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Neurology Flashcards

1
Q

Cranial nerves

A

I - Smell
II - vision
III, IV, VI - eye movement
V - facial sensation and jaw movement
VII - facial expression
VIII - Hearing and balance
IX, X, XI - swallowing and PNS
XII - tongue movement

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2
Q

Oh, Oh, Oh, To Touch And Feel A Guy’s Vein And Hotdog

A

I Olfactory Nerve

II Optic Nerve

III Oculomotor Nerve

IV Trochlear Nerve

V Trigeminal Nerve

VI Abducens Nerve

VII Facial Nerve

VIII Vestibulocochlear Nerve/Auditory Nerve

IX Glossopharyngeal Nerve

X Vagus Nerve

XI Accessory Nerve/Spinal Accessory Nerve

XII Hypoglossal Nerve

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3
Q

What is the role of the neuro exam

A

History
Neuro exam
Localisation
DDX - general exam
Diagnostic tests
Diagnosis
Treatment

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4
Q

Forebrain lesion

A

Altered mental state
Central blindness/deafness
Inattention
Normal to paretic gain - large circles towards lesion
Abnormal postural reactions - contralateral
Abnormal movements/postures - head pressing, head yaw
Seizures

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5
Q

Cerebellum lesion

A

Ataxia
Wide base stance
Dysmetria - normal strength
Intention tremour - generalised and eyes
Extensor hypertonus
Absent menace reflex?
Opisthotonus?
Vestibular - flocculonodular lobe?

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6
Q

Vestibular lesion

A

Head tilt - down towards lesion - central and peripheral
Asymmetric ataxia - central and peripheral
Nystagmus - fast away from lesion - central and peripheral
Positional nystagmus - central
Decreased proprioception
Paresis
Horners
Facial paralysis
Other cranial nerve deficits

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7
Q

Pontomedullary lesions

A

UMN signs in all 4 limbs - ipsi or contralateral
Postural reaction deficits
Cranial nerve IV - XII deficits
Altered mental state

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8
Q

Midbrain lesion

A

UMN signs in all four limbs or contralateral
Mental depression
Ipsilateral oculomotor signs
Hyperventilation?
Head pressing?

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9
Q

Diencephalon lesion

A

UMN signs in al four limbs or contralateral
Mental depression
Optic nerve deficits
Endocrine/autonomic deficits
Inappetence

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10
Q

What is LMN

A

Final common pathway for voluntary motor activity
Needed for reflexes
Needed to maintain tone

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11
Q

What is UMN

A

Need for voluntary motor activity
Not needed for reflexes
Not needed to maintain tone

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12
Q

Lesions along spinal cord signs

A

Cranial lesion - UMN deficits in fore and hind
C1-C5 lesion - UMN deficits in fore and hind
C6-T2 - LMN fore, UMN hind deficits
T3-L3 - normal fore, UMN deficits hind
L4-S3 - normal fore, LMN deficits hind

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13
Q

Different types of spinal cord pathologies

A

Transection,
atrophy,
haemorrhage,
acute compression,
neoplasia,
ascending myelomalacia,
concussion,
degenerative,
focal ischemia,
compression and concussion,
inflammatory,
global ischaemia,
fracture,
malformation,
chronic compression

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14
Q

Ophthalmology exam

A

Coat, iris, and fundus colour are related

Hands off
Hands on
Schirmer tear test
Cranial nerve test
Anterior segment with pen torch in dark
Ophthalmology - distant direct, close direct, indirect
Fluorescein stain
Swabs/scrapes
tonometry

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15
Q

History for eye exam

A

Vaccination, worming, diet
Other pets in house? Especially relevant for cats
Cats – indoor versus outdoor
Travel history – exotic diseases becoming more common/relevant
General health
Other medical conditions
Appetite, thirst, urination/defaecation, demeanour
Current medication(s)

Previous ocular problems?
Unilateral or bilateral?
Duration and progression of signs
Presenting complaint:
Ocular pain - blepharospasm, increased tearing
Change in appearance - redness, discharge, swelling
Decreased vision - day vs night, any change in unfamiliar surroundings

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16
Q

Examination

A

Behaviour
Painful - eyes open or closed, discharge
Symmetry of face and eyes
Eyelid conformation
Size of palpebral fissure
Position of third eyelid

Hands on
External anatomy
Palpation
Look under upper eyelid
Examine anterior surface of third eyelid
Retropulsion

Schirmer tear test
- With any discharge, conjunctivitis, lacklustre cornea - at start of exam before drops
But not with deep ulcer or risk pf perforation
Measures aqueous tear film
Position in middle to lateral third of eye - contacting cornea not third eyelid - basal and reflex tear production
Open or closed eyelid
15-25mm/min is normal

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17
Q

Ocular reflexes

Vision tests

A

Palpebral reflex
Menace response
Dazzle reflex
Pupillary light relflexes - weak light in daylight - false negative. Scared/stressed - high level sympathetic tone. Iris atrophy - positive not always consistent with vision
Vestibulo-ocular reflex

Tracking - drop cotton wool infront and see if they track it
Maze test - can they maneuver around things
Visual placing - bring up to edge of table and see if they place feet

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18
Q

What cranial nerve does palpebral reflex test?

A

Afferent - trigeminal (V)
Efferent - Facial (VII)
Perform before menace to check eye can actually blink

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19
Q

What cranial nerves does menace response test?

A

Afferent - optic nerve (II)
Efferent - Facial (VII)
Learned response - 12-14 weeks in puppies - involves visual cortex

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20
Q

What cranial nerves does dazzle reflex test?

A

Afferent - optic nerve (II)
Efferent - Facial nerve (VII)
Subcortical reflex

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21
Q

What cranial nerves does pupillary light reflex test?

A

Afferent - optic nerve (II)
Efferent - Oculomotor nerve (III) - parasympathetic
False negatives common
Positive does NOT = vision

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22
Q

Test of corneal sensation

A

Corneal reflex
Use if suspect disorder of blinking/trigeminal dysfunction
Wisp of cotton wool touched to lateral cornea outside line of vision - V - trigeminal
Normal response - globe retraction (VI) and blink (VII)

Afferent: trigeminal n (V)
Efferent: abducens n (VI) and facial n (VII)

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23
Q

How to examine anterior segment with focal light source

A

Pen torch or similar in dark room +/- magnification if available
Be systematic – e.g. examine from outside to inside and superficial to deep
Eyelids – eyelashes, nasolacrimal puncta
Third eyelid
Conjunctiva, sclera, limbus
Cornea
Anterior chamber
Iris and pupil

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24
Q

Ophthalmoscopy

A

Distant direct
Essential – one of the most useful parts of routine exam
0 dioptre setting, arms length
Uses tapetal reflex to highlight visual axis
Compare pupil size
Opacities in visual axis
Nuclear sclerosis versus cataract - cataract blocks tapetal reflex

Close direct
0 dioptres, lower the rheostat, use brow rest, get close to patient (2-3cm)
Practice makes perfect!
Dilate pupil with tropicamide if needed
“Key-hole” effect:
Small, highly magnified field of view
Hard to examine whole fundus

+20D for eyelids and cornea
+10D for lens
0D for retina

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25
Q

Fluorescein staining

A

Orange dye that turns green in alkaline conditions
Stains corneal stroma green
No uptake by intact corneal epithelium or by Descemets membrane

Jones test - doe it appear at both nostrils within 3-5 mins

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26
Q

Swabs and scrapes of eyes

A

Conjunctival microbiology - sterile swabs
Suspect bacterial - charcoal medium
- Cats - chlamydophila felis, feline herpes 1 - PCR - dry sterile tube
Melting ulcers, or neoplasia - cytology

Use local first

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27
Q

Tonometry

A

End of exam before dilating pupil
IF reduced vision, red eye, blue eye (corneal oedema), dilated pupil, buphthalmic globe, exophthalmos, suspect lens luxation

Raised IOP - glaucoma
Lowered IOP - suspect uveitis
Difference >8mmHg between eyes is abnormal

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28
Q

How many drops to give per eye

A

One drop at a time - any more will spill over eyelid margins

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29
Q

How many minutes between different topical eye drugs?

A

5-10 mins

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30
Q

Topical ophthalmic antibiotics

A

Fusidic acid - first line for minor ocular surface imperfections - conjunctivitis

Chloramphenicol - prophylaxis for ulcers and ocular surgery, bacterial conjunctivitis - not licenced - not pseudomonas

Ofloxacin and ciprofloxaxin - broad spec - infected/melting ulcers , not licenced

Gentamycin drops - infected melting - broad spec - licenced - epitheliotoxic to corneal epithelium

Chlortetracycline - broad spec - chlamydial conjunctivitis - licenced

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31
Q

What to use to treat melting ulcers

A

Anti-collagenases - serum form same or another animal - leave to clot and spin down - extract plasma - keeps in fridge for one week
Stromease

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32
Q

Oral antibiotics for ophthalmology

A

Clindamycin
Doxycycline

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33
Q

Ocular toxic oral antibiotics

A

Sulphonamides - TMPS
Enrofloxacin

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34
Q

Antiviral drugs for ophthalmology

A

For feline herpesvirus 1
Ganciclovir or acyclovir ointment
Oral - famiciclovir tablets or oral paste

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35
Q

Topical antiinflammatories

A

Prednisolone
Diclofenac (NSAID)

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36
Q

How to treat glaucoma

A

Reduce aqueous humour production
Increase aqueous humour drainage
No licenced drugs in dogs/cats
Prostaglandin analogues - induce miosis and increase outflow
Carbonic anhydrase inhibitors - brinzolamide - reduce formation
Beta blockers - timolol - also reduce formation

Latanoprost - will reduce IOP
- Contraindicated in uveitis and anterior lens luxation

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37
Q

Mydriatic

A

Dilate pupil
Examining lens and fundus
Treating anterior uveitis and aiding intraocular surgery
Atropine - treat anterior uveitis - long duration
Tropicamide - much shorter onset and duration of action

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38
Q

Topical local for eye

A

Proxymetacaine
Rapid onset
Lasts 45 mins
Repeat application over 2-3 mins increases depth and duration
Epitheliotoxic

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39
Q

IVDD - intervertebral disk disease

A

Two types: Extrusion and protrusion. Onset can be acute, chronic or acute on chronic.

Extrusion – when the disc erupts and disc material escapes and compresses the spinal cord.
Protrusion – Disc gets compressed and changes shape, compressing spinal cord.

Pain on palpation of spinal column. Paralysis of limbs depending on point of compression.

Treatment is either conservative or surgical. Conservative cage rest can do well for a lot of dogs and is worth trying unless in emergency cases with severe compression. Severe extrusion would be a case of this.
Keeping the dog still is very important to prevent further compression or extrusion of fluids.
Breed predisposition: Dachshunds

40
Q

FIbrocartilaginous embolism

A

Microscopic blood clot in the spinal column. Can cause unilateral or bilateral paralysis.
Diagnosis is based on exclusion of other differentials.

Clinical signs: Acute onset, not painful, paralysis. Absent lower motor neurone signs.

Treatment is conservative cage rest. Analgesia where necessary however not painful after 24 hours. Bladder control. Most dogs will recover.

41
Q

Neospora infection

A

Can pick up in utero so if one puppy presents with condition, be worried about the rest of the litter.
Can show signs at around 4 weeks of age but paralysis develops over several weeks as the parasites invade the muscles. Results in lots of scar tissue that causes stiffness and restriction of movement in limbs.

Clinical signs: Hindlimb extensor rigidity, inability to walk, difficult to demonstrate reflexes, resents limb flexion.
Can turn cases around if caught early enough however delayed treatment means prognosis is poor.

42
Q

Feline infectious peritonitis - FIP

A

The dry form of the disease causes granuloma formation. These can cause granulomatous change in the spinal cord. Could be multifocal or a singular lesion however rapidly progressive.

Clinical signs: paraparesis with increased tone. Uncomfortable on spinal palpation. Reflexes and pain sensation present. Absent tail movement.

43
Q

Atlantoaxial subluxation

A

Cervical pain with non-ambulatory tetraparesis.

Treatment: Need to immobilise the neck. Difficult to do. Don’t GA as the neck is being held together by muscle spasm so GA will relax the only support however GA required to fully appreciate problem and position correctly.

Breed predisposition: Toy breeds – chihuahuas, Yorkshire terriers

44
Q

Bacterial meningitis

A

Bacterial infection of the meninges.

45
Q

Discospondylitis

A

Abscess/infection of an intervertebral disc. Treat with antibiotics.
Could use a blood culture to try and culture bacteria present but depends on stage of infection. If unable to culture, use broad spectrum - Amoxicillin/TMPS

46
Q

Steroid responsive meningitis arteritis

A

Non-infectious meningitis. Giving an immunosuppressive course of steroids should treat the meningitis. If no response, see MUO.
Diagnosis via a CSF spinal tap BEFORE trialling steroids. High levels of neutrophils in the sample.

47
Q

Meningitis of unknown origin - MUO

A

Non-infectious meningitis that doesn’t respond to steroid treatment.

48
Q

Idiopathic polyradiculoneuritis

A

Unknown pathology – multiple uncoordinated limbs due to nerve inflammation.

49
Q

Tetanus

A

Dirty wound

50
Q

Botulism

A

Ingested toxin

51
Q

Syringomyelia

A

CSF in the spinal cord due to expansion of the central canal.
Breed predisposition: Cavalier King Charles Spaniel

52
Q

Define spastic, ataxia, and weakness

A

Spastic – Abnormal increased muscle tone or stiffness of muscles
Ataxia – Uncoordinated movement, can’t position legs underneath body
Weakness – Not strong enough to pull legs underneath the body and push to stand up

53
Q

Causes of being off limbs

A

IVDD
Fibrocartilaginous embolism
Neospora infection
Feline infectious peritonitis
Atlantoaxial subluxation
Bacterial meningitis
Discospondylitis
Steroid responsive meningitis arteritis
Meningitis of unknown origin
Idiopathic polyradiculoneuritis
Tetanus
Botulism
Syringomyelia

54
Q

Conjunctiva

A

Freely mobile apart from attachements at limbus and eyelid margins - free movement of ocular structures
Contibutes to tear film - goblet cells produce mucin
Provides lymphatic drainage to eye - CALT - conjunctival assocaited lymphoid tissue

55
Q

Acute conjunctivitis

A

Unilateral or bilateral
Hyperaemia - redness
Chemosis - oedema
Swelling/thickness
Discharge - lacrimation vs mucoid, purulent, mucopurulent or haemorrhagic
Mild irritation/blepharospasm
Occasionally pruritis - allergic conjunctivitis

56
Q

Chronic conjunctivitis

A

Thickening d/t squamous metaplasia of epithelium
Hyperpigmentation
Follicular hyperplasia – especially posterior third eyelid and in conjunctival fornices
NB follicular conjunctivitis is common in young dogs; may need treatment but often resolves spontaneously

57
Q

Causes of canine conjunctivitis
Treatment

A

Treatment
Treat/remove underlying cause
Topical antibiotic therapy
Fusidic acid (Isathal®)
Licensed product in UK – first choice
Treats Gram +ve organisms most commonly found in canine conjunctivitis (Staph spp, Strep spp)
Chloramphenicol drops/ointment
Other antibiotics based on culture & sensitivity

Infectious – primary or secondary

Non-infectious – irritants, FBs, allergies

Secondary to
- Adnexal disease (eyelids, tear film, nasolacrimal duct)
- Local ocular disease - corneal ulcers, blepharitis, orbital disease
- Other ocular disease – uveitis, glaucoma, episcleritis/scleritis

Conjunctival involvement in systemic disease

FBs (check under third eyelid!)
Important in small furries e.g. GPs
Irritants e.g. smoke, sand, neomycin
Allergic e.g. atopic dermatitis
Adnexal disease
Eyelid and eyelash problems
Tear film problems e.g. KCS (dry eye)
Tear duct infection (dacryocystitis)

Entropion: inversion (inward turning) of the eyelid margin
Treatment: Hotz-celsus surgery: removal of elliptical piece of skin

Ectropion: eversion/outward turning of eyelid margin
Treatment: wedge resection

Ectopic cilia - surgical excision - eyelash at right angle into cornea
KCS - keratoconjunctivitis sicca - local immune mediated destruction of lacrimal gland and third eyelid
- WHWT, pug, Shih tzu, bulldog, CKCS, english cocker spaniel - young-middle aged - bilateral
Can be congenital, neurogenic (unilateral), toxic (sulphonamide drugs), endocrine (diabetes mellitus, hypothyroid), iatrogenic (removal of third eyelid gland)
Schirmer tear test
Tear substitutes, stimulants, broad spec abx if secondary infection

Epiphora - poor tear drainage - overflow
Congenital atresia or obstruction

58
Q

Canine infectious conjunctivitis

A

Primary infectious conjunctivitis: uncommon in dog
Viral infection, e.g. canine herpesvirus-1
Bacterial infection
Parasitic infection e.g. Thelazia or Leishmania spp – imported dogs
Fungal infection rare in UK

Secondary bacterial infection is very common
Commensal Gram +ve organisms, e.g. Staphylococcus spp, Streptococcus spp
Less commonly: E. coli, Bacillus spp, Proteus spp, Pseudomonas spp

59
Q

Dacryocystitis in rabbits

A

Cause of most conjunctivitis in rabbits
Treatment must include nasolacrimal duct flushing (NB single lower nasolacrimal puncta)
Underlying cause: overlong molar roots pressing on nasolacrimal duct
Often recurrent, aiming to manage rather than cure

60
Q

What can cause red eye

A

Conjunctivitis
Uveitis
Glaucoma
Scleritis/episcleritis

Haemorrhage
Most commonly due to blunt trauma
Check carefully for intraocular damage
Other differential diagnoses include coagulopathies, systemic hypertension and vasculitis

61
Q

Feline conjunctivitis

A

Infectious: common

Non-infectious: as for dogs but less common
E.g. entropion – less common, may be acquired in older cats
KCS much less common, hard to diagnose (normal STT values highly variable), can see qualitative tear film problem

Extension from local ocular disease
Secondary to another ocular disease
Conjunctival involvement in systemic disease

Primary infectious conjunctivitis is common (unlike in dogs):
Chlamydophila felis (bacterium)
Feline herpesvirus-1 (FHV-1) (virus)
Feline calicivirus (FCV)
Mycoplasma felis (bacterium)
Bordetella bronchiseptica (bacterium)
Secondary bacterial infections common
Usually secondary to primary infection (cf dogs – secondary infections also common but usually secondary to underlying problem e.g. adnexa/tear film)

62
Q

Chlamydophila felis

A

Obligate intracellular bacterium
Common cause of feline conjunctivitis

Clinical signs
Unilateral conjunctivitis, becomes bilateral within a few days
Chemosis often marked, hyperaemia
No corneal signs
Absent or mild upper respiratory disease

Diagnosis: clinical signs +/- conjunctival swab for PCR test:
Sterile swab rolled in conjunctival sac, placed in sterile, dry tube

Systemic treatment indicated as organism affects respiratory tract, GIT and reproductive tract as well as eye
Doxycycline antibiotic of choice
10mg/kg daily for 3-4 weeks to eradicate organism (treat in-contacts too)
NB may cause teeth discolouration in young animals
NB can cause oesophagitis – give with food/syringe water afterwards
Amoxycillin-clavulanate in pregnant queen or kittens

63
Q

Feline herpes virus 1

A

Important ocular pathogen
Clinical signs vary according to age:
Kittens and young cats
Bilateral conjunctivitis in conjunction with upper respiratory signs (cat flu)
+/- corneal ulceration
Adult cats
Unilateral ocular discharge with mild conjunctivitis
History of previous upper respiratory infection
Wide range of other conditions, e.g. corneal ulceration, sequestrum, entropion, eosinophilic keratitis

Diagnosis
History and clinical signs
Conjunctival swab for PCR test
Same technique as for C felis
Swab site of interest i.e. swab cornea, conjunctiva and/or oropharynx
PCR has superseded culture (like C felis)
Care with interpretation:
False negatives common d/t intermittent shedding
False positives common – many cats have been exposed to FHV-1, so positive result could reflect FHV-1 reactivation that is coincidental or secondary to the ocular disease

Treatment
Nursing
Cleaning eyes, nutrition, rehydration
Broad-spectrum antibiotic to prevent/treat secondary bacterial infection
Topical for eyes (e.g. fusidic acid, chloramphenicol)
Systemic for respiratory involvement e.g. amoxycillin-clavulanate
Anti-virals
Topical e.g. ganciclovir 4x daily
Systemic e.g. famcyclovir (expensive) 90mg/kg BID recommended dose

64
Q

Corneal pathology - oedema

A

Breach of or dysfunctional barrier layers - epithelium and endothelium
- Increased water content
- Distorts collagen fibrils - creating opacity

65
Q

Corneal pathology - vascularisation

A

Superficial or deep ingrowth of blood vessels
Promotes healing but can increased scarring

66
Q

Corneal pathology - pigmentation

A

Non specific response to corneal insult

67
Q

How does corneal epithelium self renew?

A

Proliferation at basal epithelial cells at limbus - mitosis
Movement of peripheral cells towards centre of cornea
Epithelial cells lost from corneal surface into tear film

68
Q

Stromal wound healing

A

Stromal wound healing
Starts once re-epithelialisation is complete
Fibroblasts migrate in & lay down new collagen
Requires vascularisation
Results in scar tissue: remodelling over time

69
Q

Causes of corneal ulcers

A

Many possible causes
Trauma
Tear film problem – KCS
Adnexal conditions i.e. involving eyelids, eyelashes and conformation
Primary corneal disease – SCCEDs – more on later
Infection - bacterial keratitis/feline herpes virus 1
Neurological disease - neuroparalytic keratitis - facial nerve paralysis - unable to blink
Careful eye examination necessary – examine both eyes for clues as many conditions are bilateral

70
Q

Clinical signs of corneal ulceration

A

Pain - classic TRIAD of ocular pain
Increased lacrimation (high STT)
Blepharospasm - closing eye
Photophobia - avoiding bright light
Conjunctival hyperaemia - a “red eye”
Ocular discharge
Corneal oedema
Reflex uveitis

71
Q

SCEDD - spontaneous chronic corneal epithelial defect

A

SCCED: spontaneous chronic corneal epithelial defect
Aka non-healing ulcer, indolent ulcer, ‘Boxer ulcer’
Superficial ulcer that affects middle-aged dogs (>7 years old)
Can affect any breed (esp Boxers and corgis)
Usually unilateral (but can be bilateral, recurrent)

Epithelium loss only
NO stromal involvement
Characterised by lip of loose epithelium – epithelium grows across but cannot adhere to underlying stroma

SCCED:
Indistinct, irregular border which under-runs with fluorescein
Variable inflammatory response – from no neovascularisation to granulation tissue ++

Diagnosis based on
Signalment: older dogs
Clinical appearance: superficial, non-adherent epithelium
Ruling out other underlying causes e.g. ectopic cilium, foreign body, eyelid mass, KCS…

Treatment
Debride, keratotomy, medical treatment - local drops, cotton bud
Chloramphenicol
Systemic NSAIDs
Treat reflex uveitis - atropine
Bandage contacct lens
Check weekly

72
Q

Stromal ulcer

A

Loss of epithelium and stroma
Acute or chronic
Fluorescein stains walls and floor of ulcer
Superficial stromal or deep stromal
Anterior uveitis common

Loss of stroma will distort contours of cornea – visible crater

73
Q

Superficial corneal ulcer

A

Epithelial loss only
Acute onset
Painful (higher density of nerve endings in superficial layers of cornea)
Sharp distinct borders
Minimal corneal inflammatory response
+/- Reflex uveitis

Treatment
Identify and treat underlying cuase
Prevent secondary infection - chloramphenicol drops
Systemic NSAIDs
Treat any reflex uveitis - atropine
Recheck 3-5 days

74
Q

Descemetocoele

A

Acute or chronic
Complete stromal loss - defect down to Descemet’s membrane
Walls of ulcer/crater usually obvious
Descemet’s membrane is 10-15μm – similar to cling film

Walls stain positive (exposed stroma)
Descemet’s membrane does not stain with fluorescein
Floor/base of ulcer looks black or clear

Make sure to flush fluorescein - false negative as base will stain until flushed

75
Q

Melting corneal ulcers - keratomalacia

A

Beware the animal with an acute closed painful eye with copious discharge – probably “melting”

Acute, painful
Lots of gelatinous “gloopy” discharge
Ill-defined, rounded, soft edges – like melting butter/candle wax…

Variable appearance – varying amounts of stromal involvement
Ill-defined, rounded, soft edges
Marked corneal oedema
Marked anterior uveitis (pain, miosis, hypopyon, low IOP)
Can progress rapidly and perforate within hours: ophthalmic emergency

Enzymes (proteinases and collagenases) break down or ‘digest’ corneal stroma
Two origins
Cornea itself: epithelial cells, stromal fibroblasts, WBCs
Bacterial infection, e.g. Pseudomonas sp, β-hemolytic Streptococcus sp
Topical steroids cause local immune suppression and potentiate collagenase activity

Corneal cytology
Gently scrape margin of ulcer (not base)
Corneal swab
Bacterial culture and sensitivity
Swab margin of ulcer (not base)
Care with very deep lesions – procedure can cause corneal perforation!

Treat as infected
Ideally C&S - enrofloxacin
Anticollagenase - serum every 1-2 hours
Systemic antibiotics
Systemic NSAIDs and opiates
Atropine to effect
May need surgery - monitor closely/hospitalise

76
Q

Treatment of complex corneal ulcers

A

Deep stromal
Descemetocoele
Perforated ulcer
Melting ulcer

Intensive treatment +- surgery
All good referral options

Grafting surgery
Provide immediate tectonic support
Provide blood supply
Enucleation

77
Q

Cat corneal ulcers

A

Common causes are:
Infection: feline herpesvirus infection (FHV-1)
Trauma (cat fight injuries, FB)
Corneal sequestrum

Gentle debridement with cotton bud and contact lens fine
Keratotomy techniques for SCCEDs predispose to sequestrum formation

78
Q

Seizure control

A

Remove the primary cuase
Treat the rest of the brain to isolate it from the effects of the primary cause

Control not cure!

1st line - phenobarbital, imepitoin
KBr or Levetiracetam
Gabapentin
Zonisamide

79
Q

What is status epilepticus?

A

Seizure of more than 5 minutes
Or
More than 1 seizure in 5 minute period

Treat with
IV diazepam
IV phenobarbital
IV propofol

Rectal diazepam
IV levetiracetam
Intranasal midazolam
IV pentobarbital

80
Q

What is an ocular emergency?

A

Condition that threatens vision and/or the globe itself

Traumatic globe prolapse
Retrobulbar abscess
Acute glaucoma
Anterior lens luxation
Corneal emergencies
Sudden onset blindness

81
Q

What is globe prolapse?

Replace or enucleate?

A

Acutely displaced beyond plane of eyelids

Immediate oedema of conjunctiva and orbital soft tissue – further exacerbated by the eyelid spasm (obstructs venous drainage leading to more swelling…)
Traction on optic nerve likely to result in permanent blindness
Desiccation of ocular surface – potential for corneal ulceration
Rupture of extraocular muscles

Brachycephalic - Shallow orbits impart very little protection for eye
Very little force required to cause prolapse
Easy to replace, better prognosis

Feline
Cats have deeper orbits and therefore better protection
Large amount of force required to prolapse globe
Head trauma in an RTA

In theory, better prognosis if:
Brachycephalic
Positive PLR
Eye that attempts to move

Worse prognosis if:
Cat or dolicocephalic breed
Hyphaema
Corneal/scleral rupture

If in doubt, attempt replacement – can enucleate later if needed
Enucleate immediately if attachments almost all severed or if optic nerve is severed

Needs treating immediately: by you rather than by referral
Rapid treatment will improve prognosis for vision and globe
Distressing to animal and owner
Painful

Keep globe moist – lubricating ointment (if animal allows)
Prevent self-trauma with buster collar
Provide analgesia/sedation
GA for globe replacement once stable
+/- clip hair
Prepare area with aqueous povidine-iodine solution or sterile saline

Lateral canthotomy
Make eyelid opening larger by cutting skin at lateral canthus
Reduces pressure on globe and makes replacement much easier
Wrap eyelids back around and push globe in with swab
Repair lateral canthotomy
Double layer closure with figure of 8 at eyelid margin
4/0 – 6/0 polyglactin (Vicryl)

Temporary tarsorraphy (suture eyelids together)
To prevent re-prolapse and tamponade haematoma and oedema within orbit
5/0 vicryl
3-4 simple interrupted or mattress sutures +/- stents

Systemic antibiotics and anti-inflammatories
Broad spectrum topical antibiotic
Buster collar
Re-evaluate after 10-15 days to remove sutures and decide if enucleation required

82
Q

What is globe prolapse?

Replace or enucleate?

A

Acutely displaced beyond plane of eyelids

Immediate oedema of conjunctiva and orbital soft tissue – further exacerbated by the eyelid spasm (obstructs venous drainage leading to more swelling…)
Traction on optic nerve likely to result in permanent blindness
Desiccation of ocular surface – potential for corneal ulceration
Rupture of extraocular muscles

Brachycephalic - Shallow orbits impart very little protection for eye
Very little force required to cause prolapse
Easy to replace, better prognosis

Feline
Cats have deeper orbits and therefore better protection
Large amount of force required to prolapse globe
Head trauma in an RTA

In theory, better prognosis if:
Brachycephalic
Positive PLR
Eye that attempts to move

Worse prognosis if:
Cat or dolicocephalic breed
Hyphaema
Corneal/scleral rupture

If in doubt, attempt replacement – can enucleate later if needed
Enucleate immediately if attachments almost all severed or if optic nerve is severed

Needs treating immediately: by you rather than by referral
Rapid treatment will improve prognosis for vision and globe
Distressing to animal and owner
Painful

Keep globe moist – lubricating ointment (if animal allows)
Prevent self-trauma with buster collar
Provide analgesia/sedation
GA for globe replacement once stable
+/- clip hair
Prepare area with aqueous povidine-iodine solution or sterile saline

Lateral canthotomy
Make eyelid opening larger by cutting skin at lateral canthus
Reduces pressure on globe and makes replacement much easier
Wrap eyelids back around and push globe in with swab
Repair lateral canthotomy
Double layer closure with figure of 8 at eyelid margin
4/0 – 6/0 polyglactin (Vicryl)

Temporary tarsorraphy (suture eyelids together)
To prevent re-prolapse and tamponade haematoma and oedema within orbit
5/0 vicryl
3-4 simple interrupted or mattress sutures +/- stents

Systemic antibiotics and anti-inflammatories
Broad spectrum topical antibiotic
Buster collar
Re-evaluate after 10-15 days to remove sutures and decide if enucleation required

Must manage owner expectations
Prognosis for vision:
Guarded
Most eyes are blind (80% dogs, ?100% cats)
Prognosis for retaining globe
Reasonable (most owners prefer blind eye to no eye)
Other complications: lagophthalmos, neurotrophic keratitis, dry eye, permanent strabismus…

83
Q

Retrobulbar abscess

A

Abscess or cellulitis behind globe
Clinical signs
Acute onset
Unilateral
Exophthalmos (proptosis)
Pain, especially on opening the mouth
Third eyelid protrusion and swelling
Ocular discharge
Pyrexia, lethargy

Ultrasound: look for fluid-filled cavity
Look in mouth (recall close proximity of upper dental arcade to soft tissue floor of orbit)

Drain abscess under GA
Access to soft tissue floor of orbit via mouth
Scalpel incision, insert artery forceps blindly into retrobulbar space
Recall that most eyes are 2cm from cornea to sclera
Release pus…

Pressure around and traction on optic nerve can cause temporary blindness and, if not treated urgently, permanent blindness
Medical management
Systemic NSAIDS
Systemic antibiotics
May need IV fluids and injectable medications if not eating
Topical lubricants until normal blinking returns

84
Q

Acute glaucoma

A

Ocular pain (classic triad):
Blepharospasm
Increased lacrimation
Photophobia
Head shy, yelping, dull/quiet
Vision loss
Change in appearance…

Two groups of dogs predisposed to acute glaucoma:
Purebreed dogs with hereditary primary glaucoma (Spaniels, retrievers, Bassets, huskies…)
Terrier breeds with acute lens luxation and secondary glaucoma
How to differentiate?
Is it a predisposed breed?
Can you see an underlying cause? (Uveitis, lens luxation)

Tonometry
Normal range in dogs and cats:
10-25mmHg
Acute glaucoma:
Often >40mmHg
May see IOPs of 60-80mmHg

Reduce IOP – choice of medications depends on underlying cause
Prostaglandin analogue (latanoprost) if suspect primary
Carbonic anhydrase inhibitors (brinzolamide, dorzolamide) always ok
IV mannitol if not responding to drops
Analgesia
Seek referral advice/offer referral ASAP
Primary glaucoma is a bilateral condition
Consider referral assessment of other eye

85
Q

Anterior lens luxation

A

Acutely painful eye
Glaucoma (episcleral injection, raised IOP, diffuse oedema, vision loss)
Focal corneal oedema
Lens outline may be visible in anterior chamber

Is it a predisposed breed?
If a terrier, assume anterior lens luxation until proven otherwise!

Lens luxation or primary glaucoma?
Does the dog have a history of either problem?
If very cloudy
Take a photo with a flash
Consider ultrasound
Look at the other eye for clues – bilateral condition

Offer referral: emergency surgical removal of lens or “couching” to push lens backwards
Analgesia e.g. oral NSAID and opioid

Bilateral condition: contralateral eye likely to be affected but at an earlier stage i.e. subluxation
Consider referral assessment/prophylactic treatment
If eye is enucleated, send for histopathology

86
Q

Corneal emergencies

A

Chemical injury
FB
Melting ulcer
Severe lacerations

Acid and alkali injuries cause immediate loss of epithelium
Cornea and eyelids
Acid injuries
Bleach, toilet cleaner
Spirit-based skin preparation
Alkali injuries
Caustic solutions
Lime burns (e.g. cement, plaster)
Washing detergents

IMMEDIATE irrigation of ocular surface
If at home, tap water is fine
Tap water or saline or Hartmann’s solution if animal in the practice
Flush copiously e.g. 500ml to 1 litre until pH normal (7.5); sedation likely to be necessary
Test pH of conjunctival sac to determine nature of chemical e.g. urine dipstick
Early specialist advice
Medical management for corneal ulceration
Alkalis may induce ‘melting’ or liquefactive necrosis, intensive medical management indicated

Urgent attention indicated for all FB but most are not true emergencies
Emergency only if large and painful

The following require urgent treatment but are not true emergencies
Deep corneal ulcers
Descemetocoeles
Perforated corneal ulcer +/- iris prolapse
‘Melting’ ulcer is however a true emergency

Crater appearance: loss of stroma
Descemetocoele: dark/clear base is hallmark sign
Perforated ulcer with iris involvement – site of perforation “plugged” by iris tissue, anterior chamber has re-formed

Corneal lacerations
Sharp corneal trauma carries better prognosis than blunt trauma

87
Q

Sudden onset blindness

A

Acute glaucoma
Acute uveitis
Intraocular haemorrhage
Retinal detachment
Optic neuritis
SARD (Sudden Acquired Retinal Degeneration)
Toxicity (ivermectin, enrofloxacin in cats)
Intracranial lesion

88
Q

Head tilt causes

A

Idiopathic vestibular disease
Otitis interna
Oto-toxic drugs
Inflammatory polyp
Trigeminal neuritis
Trigeminal nerve sheath tumour
Brucellosis
Rabies

89
Q

Idiopathic vestibular disease

A

Treat with time. May need antiemetics to deal with nausea.
Can also get Horner’s syndrome as can affect sympathetic pathway.
Clinical signs: Sudden onset, head tilt, stumbling, circling, nystagmus, nausea. More commonly affects the older animal.
Occurs alongside idiopathic facial paralysis as inflammation through the foreman so multiple nerves effects.
Prognosis: good to excellent

90
Q

Otitis interna

A

Involves fluid in the inner ear: Vestibular cochlear organ – can be secondary to otitis media or tympanic rupture.

Can be sterile or infectious.

Use otoscope to check for inflammation through the tympanic membrane.

Clinical signs: Head tilt, spontaneous horizontal or rotary nystagmus, circling

Most common bacteria are pseudomonas spp and staphylococcus spp. .

Oblique skyline and lateral oblique radiograph can be used to view tympanic bullae and to check for fluid however difficult. Can use MRI or CT.

Treatment – otitis media: Broad spectrum

91
Q

Oto toxic drugs

A

Anything administered local has the risk of rupturing the tympanic membrane.

Metronidazole -> OD or abnormal reactions can cause vestibular syndrome.

Aminoglycosides (gentamicin, amikacin) and cisplatin are of the highest concern for ototoxicity.

92
Q

Inflammatory polyp

A

Benign growths mainly seen in cats. Develop in the middle ear and Eustachian tubes. Depending on which path the polyps take, patients may present with otitis, nasopharyngeal signs or both. Condition may be acute or chronic.

May be related to the inflammation caused by a respiratory virus however polyp signs often don’t appear until months after infection.

Clinical signs if in middle ear: Abnormal balance, changes in pupil sizes, head tilt, nystagmus.

Treatment: Ventral bulla osteotomy/ removal by traction. Can cause nerve damage.

93
Q

Trigeminal neuritis

A

Sudden onset dropped jaw. Mickey muzzle and analgesia. Diagnosis by exclusion. Ability to manually shut jaw.
Clinical signs: Inability to close jaw, difficulty taking food into mouth, may have difficulty swallowing.
Idiopathic, bilateral, non-suppurative and affects all motor branches of the trigeminal nerve. Can be accompanied by Horner’s syndrome and/or sensory disturbances to some regions of the head.

94
Q

Trigeminal nerve sheath tumour

A

Chronic slow growth of tumour. Causes progressive atrophy. Many dogs outlive tumours. Risk of going into brain and cause neurological signs.
One side of the head is sunken in, atrophy to muscles of mastication.

Clinical signs: Facial asymmetry, reduced facial sensation, absent palpebral reflex with normal menace response. Reduced unilateral corneal sensation and enophthalmos. Horner’s syndrome.
As it progresses, signs of brainstem compression develop.

95
Q

Brucellosis

A

Not in the UK however being brought in from Romania. Zoonotic. CSF culture and sensitivity. Can cause discospondylitis.

96
Q

Rabies

A

Has the dog been abroad – if suspicious, call for help and get advice. Don’t perform neurological exam for risk of getting bitten. Isolate and keep behind bars.

Small animal (11 decks)

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