EYE ULCERS

Some time ago I wrote this article in lay man terms to cover eye ulcers in Boxers and Pugs - due to the fact that there were many remedies circulating on cod liver oil, milk (!), serum etc being used to heal these conditions.

I then sent to Dr Chloe Hardman (Animal Eye care specialist vet). She has made her additions and audited what I wrote.

Below is the edited version....

Having owned pugs for a while now, I have become a little more knowledgeable on eye ulcers. Unfortunately pugs and boxers have quite a bulbous eye shape, and are both an energetic type of dog.

Pugs and Boxers (and other dogs prone to eye problems) seem to get ulcers from scratches (plants/sticks/playing with another dog), or a bit of soap in the eye from bathing, from heat and the eye drying out, dust, eye lashes rubbing on the surface etc.

First signs to watch for:

The very first sign is generally excessive 'blinking' of the eye with some excess tears. A trip to the vet and staining of the eye with a green dye will reveal the ulcer in its various forms.

(There are eight layers to the eyeball - a bit like an onion with its layers upon layers.)

The cornea is 0.7mm thick in the dog and has several layers – the epithelium (surface) (7 cell layers thick), the stroma = collagen in about 100 layers (like an onion), the endothelium and Descemet’s membrane. A very shallow ulcer (often just epithelial depth) can be barely visible, but may develop a clouding over a portion of the eye – due to fluid retention (oedema) due to inflammation. Sometimes ulcers can look like a whiter pin prick, a white scratch, or even a larger white area as big as a flattened cotton tip bud. Deeper ulcers can look like a hole (these involve the stoma). Very deep ulcers look like a deep hole, and the inner membrane can bulge = Descemetocoele. These can perforate (pop) resulting in collapse of the eye.

The major, very serious problem with ulcers is that they can get infected, and then they eat through the surface layers of the cornea and result in perforation. (thus reaching the (gelatinous) watery filling of the eye - which can then leak out of the ulcerated hole. The eyeball loses pressure and all sorts of problems arise.)

Here in Melbourne we are incredibly fortunate to have an Animal Eye Care specialist veterinary clinic - whose vets are all specialists in their field. Being only an hour away, their clinic is my first port of call, and I have learnt a tremendous amount during my pug apprenticeship.

In the case of ulcers, their first treatment is as follows:

1. Diagnosis of the ulcer with staining
2. Prescription of antibiotics to prevent infection. These antibiotics are to be given in two forms -
   
   

   Tricin (triple) antibiotic ointment and Vibravet (doxycycline) tablets (antibiotics).
   
   

   The Vibravet tablets are the best form of antibiotics to use in eye injuries as they are concentrated in the tears so flush over the eye all day long, and also promote healing of the surface layers. Tricin eye cream is good (3 x daily) as it lubricates the surface and is broad spectrum - however only stays in the eye a short period of time as is washed away by tears. (The Vibravet is excellent as it comes out in the tear ducts of the eye, therefore providing 24 hour cover.)
   
   

3. Rimadyl tablets are also prescribed - they are an anti-inflammatory and also give pain relief
4. Optimmune ointment 3 times daily - which (acts like false tears and) lubricates and protects the eye, has anti-inflammatory properties, and promotes normal tear production/healthy tear film.
5. If there is a lot of pain, and a small pupil, atropine will dilate the pupil and relieve pain.

You take the dog home, put on an Elizabethan collar (to prevent rubbing the eye) and keep inside out of the wind and dust, in a darkened room, or at least until blinking has stopped.

One week later (providing the eye looks like it is healing and not getting worse) you go back for a check up and staining, to see if the ulcer is diminishing in size.

Grid Keratotomy

Sometimes the position of the ulcer is so central, that blood vessels are not reaching out to fix it. Often Pug ulcers get worse despite the correct treatment and surgery is needed e.g. third eyelid flap. Pekes, Pugs and Shih Tzu’s all have prominent eyes and for some reason they often need more intensive treatment.

Some ulcers can then become an 'indolent' ulcer - meaning that although it is not necessarily getting bigger - it is not healing either. The longer the ulcer is around, the bigger chance of infection occurring - so it needs to be fixed.

To encourage healing - vets can put anesthetic drops on the eyeball - and then lightly debride (rub) the surface of the ulcer with a cotton tip bud to see if the edges peel back. If they do – it is an indolent ulcer and surgery is needed – grid keratotomy. This should only be done to VERY SUPERFICIAL ulcers. It needs to be performed under general anaesthetic and then a third eyelid flap can be done. Eye specialists may be able to perform this under topical anaesthetic in the consult room depending on how large the ulcer becomes when the edges are peeled off/unhealthy epithelium (skin layer) is removed.

[make it a bit worse (to encourage the blood vessels to heal it – Belinda – we actually want the ulcer to epithelialise – hopefully without blood vessels).

If that does not work after a few days, then they will actually scrape the surface layers of the eyeball, then pull the third eye lid up to protect the area, and promote healing.

They generally leave a small corner of the third eye flap open, so that Tricin and Optimune can still be administered - along with the Rimadyl and Vibravet.]

I have found through experience, that it is best to have the eye checked under the stitches weekly - as sometimes the eye does not heal as expected despite all the correct treatment. It can even become infected under the third eye lid flap ... which is bad news - and if left undiagnosed - causes greater problems.

Symptoms

Initial symptoms of ulcer can be blinking and excess tears.

Initial symptoms of greater eye injuries: inflamed eye area, redness, dog averting its head, pulling its head away from the eye area as if trying to escape pain, sleeping a lot (an excellent sign to watch for when the third eye lid is sewn up - the dog gets so tired from the pain that it actually sleeps far more than you would expect).

Another excellent indicator is to compare pupils - an eye in pain will generally have a pin prick pupil - as the eye actually spasms in pain.

In spasm cases, vets will administer Atropine hourly for a few hours to relieve the spasms (on top of all the other treatments). Atropine causes the pupil to dilate to its fullest for 24 hours or more, making the eye extremely sensitive to light (as it cannot contract) so it is most important that when Atropine is being administered, you keep you dog in the dark.

Important note

Eye injuries, especially after surgery has been done, need to be monitored closely.

I had a grid keratotomy done and the third eye lid sewn up to protect it by a local veterinary clinic. The eye became infected, and the only thing preventing the eye collapsing completely was the pupil plugging the hole! (Don't ask me for the technical details, still unsure as to what happened). The point is, I couldn't see all this happening under the sewn up area. This would have been avoided with more frequent trips to the vet or specialist clinic.

Theories/alternative remedies

I have discussed at length with the Animal Eye Care team the alternative remedies used by owners - the two that come to mind immediately:

Cod liver oil, and serum taken from blood from the dog. Whilst Animal Eye Care did not discount these remedies - they did make a good point - which is that ulcers easily become infected - which means they MUST be treated with antibiotics. Cod liver oil and serum may help with healing - but only after the danger of infection has been cleared up.

If corneal ulcers become infected, more potent antibiotics should be used. e.g. fortified gentamicin drops (gentamicin ointment and drops not strengthened by adding extra gentamicin drug are of little use). These drops need to be used 10+ times daily initially until the infection has resolved (may take 7 days +).

An alternative is Ocuflox (ofloxacin) that is even more potent.

Ulcers – a final note

Ulcers really are pretty common (unfortunately) in the breeds with more prominent eyes - these dogs do not seem to close their eyes as quickly, they dry out, are scratched etc - and providing you get the best advice - you can prevent really serious consequences (loss of sight/eye) and reduce your dogs discomfort levels.

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Belinda – this is very good – fantastic in fact – especially as you are a "lay" person. I have told you before and will say it again that your treatment of corneal ulcers and understanding of the monitoring is better than most vets I deal with! I have put some things you wrote in brackets – probably not needed. I have made suggestions/corrections in bold.
Dr Chloe Hardman