Case of the Month – Oct 2012

Octobers Case of the Month stars Jasper – a 5 year old male Pekingese with an unusual case of Dry Eye. Dry eye is a medical condition where tear production is reduced or even stops completely.  This results in chronically dry cornea (the clear surface of the eyeball).  The technical name for Dry Eye is Kerato-Conjunctivitis Sicca (KCS).  The photograph below shows a typical case – the eye has a matt appearance with a thick sticky discharge and small dimples can be seen on the corneal surfaceDry Eye ImageNatural tears have many important functions which are lost in KCS: they carry vital nutrients, oxygen and lubricate and cleanse the eye which helps protect against infection.  Without tears the eye becomes very dry and uncomfortable.  As bacteria and day to day debris (pollen/dust etc) builds up, infections naturally develop and a chronic Conjunctivitis ensues. If left over time the chronic irritation results in scarring on the corneal surface.  This has a dense black appearance which cannot be seen through. Once this scarring develops it is permanent so every effort must be made to stop it from occurring.  Worse case scenarios result in the cornea becoming weak and thin and ulcers can develop which run the risk of the globe (eyeball) itself rupturing. Dry eye is caused by the immune system destroying the tear glands and certain breeds can be predisposed.  English Cocker Spaniels, Westies, Cavaliers and Shih-Tzus are especially prone.  KCS is diagnosed by performing a Schirmer Tear Test – a link showing this test can be found here. Schirmer Tear TestEffectively we place a small sterile piece of filter paper under the eyelid and measure the moisture absorbed over a 30-60 second period depending on how wriggly the patient is! Poor Jasper at his initial presentation had a Schirmer Tear Test reading of 0mm in the Right eye – basically the eye was completely dry and the tear test did not absorb any moisture at all.  The left eye was a little better with a reading of 6mm.  Still far too low to keep his eyes adequately moisturised.  Both eyes were showing evidence of a secondary infection as there were no tears to flush away any bacteria or debris on his eye surface.  Scarring was also present in both eyes although still visual through his left eye.  A major concern was that both eyes had evidence of ulcers developing in the dry corneas.  Despite having sore eyes though he was impeccably well behaved for his lengthy examination. Although we could not be 100% sure what had caused the KCS to develop Jasper had been born with very impressive facial folds as most Peke’s do.  However in Jasper’s case these folds were so large that they both touched his corneal surfaces all the time.  This obviously will cause the eye to water and over time could easily exhaust his tear production.  This problem was compounded by having very large eyelids.  When Jasper blinks or sleeps his eyelids did not meet in the middle resulting in part of his eyeball being exposed continually.  This obviously puts a strain on tear production and increases the risk of his eyes drying out thus causing an acceleration of scarring. An intensive course of eye drops was instigated using a combination of Optimmune (to stimulate tear production), antibiotics (to fix the secondary infection) and fake tears (to lubricate the eye).  A nervous 10 days passed as we waited to see if Jasper had any healthy reserves left that could still produce tears.  Thanks to the owners very hard work applying multiple drops throughout the day (and Jasper being good and not wriggling) within 10 days we had success with his tear production.  The right eye was now measuring 6mm and the left eye a whopping 16mm. Now that we knew Jasper was able to still produce tears it was decided to give him a doggy ‘face lift’.  His nasal folds were removed under a general anaesthetic and his eyelids shortened to allow them to close and protect his eyeball surface when blinking.  The surgery went very well and Jasper recovered incredibly quickly.  Photographs of his surgery can be found for the non squeamish below.  To give you an idea how large his nasal folds touching his eyeballs were, we removed over 20mm of skin on both sides!  His eyelids were shortened on both sides by 10mm too. What a result!  Although we joke about face lifts this was in no means a ‘cosmetic’ procedure – even though he does look very handsome now his hair is growing back.  Now that there is no irritation to his corneas and the demands placed on his glands producing tears is so much reduced we have seen a vast increase in his tear production.  Jaspers last Schirmer Tear Test was 16mm in right eye (initially 0mm) and 26mm in the left eye (initially 6mm).  This is a normal reading for the left eye and although not quite there for the right is enough to provide adequate lubrication.  We are now starting to wean Jasper off his eye drops in the hope that he can continue without anything but only time will tell.  Even if he needs to continue with the optimmune drops for life it will only be once daily or possibly every other day applications. As far as Jasper is concerned, he thinks its great.  He has a new lease of life and seems to love having his drops as he always gets a treat and a cuddle.  Without this treatment Jasper would have undoubtedly become blind so it’s great to see him so happy!