University of Pennsylvania University of Pennsylvania

ScholarlyCommons ScholarlyCommons

Departmental Papers (Vet) School of Veterinary Medicine

1-1-2000

Hyphema Part II Diagnosis and Treatment Hyphema Part II Diagnosis and Treatment

Andraacutes M Komaacuteromy

David T Ramsey

Dennis E Brooks

Cynthia C Ramsey

Maria E Kallberg

See next page for additional authors

Follow this and additional works at httpsrepositoryupenneduvet_papers

Part of the Eye Diseases Commons Ophthalmology Commons and the Veterinary Medicine

Commons

Recommended Citation Recommended Citation Komaacuteromy A M Ramsey D T Brooks D E Ramsey C C Kallberg M E amp Andrew S E (2000) Hyphema Part II Diagnosis and Treatment Compendium on Continuing Education for the Practicing Veterinarian 22 (1) 74-79 96- Retrieved from httpsrepositoryupenneduvet_papers52

Dr Komaacuteromy was affiliated with the University of Pennsylvania from 2003-2012 Part I can be found at httprepositoryupenneduvet_papers51

This paper is posted at ScholarlyCommons httpsrepositoryupenneduvet_papers52 For more information please contact repositorypoboxupennedu

Hyphema Part II Diagnosis and Treatment Hyphema Part II Diagnosis and Treatment

Abstract Abstract The clinical appearance of hyphema is variable and is influenced by the volume of blood and the amount of time erythrocytes are present in the anterior chamber When hyphema is evident a complete history should be obtained and a thorough physical examination performed to direct the initial selection of diagnostic tests Secondary complications of hyphema include glaucoma synechiae cataract formation blood-staining of the cornea and blindness Frequent measurement of intraocular pressure is recommended The two primary management issues in animals with hyphema are prevention of secondary hemorrhage (by treating the underlying disease) and control of secondary glaucoma

Disciplines Disciplines Eye Diseases | Medicine and Health Sciences | Ophthalmology | Veterinary Medicine

Comments Comments Dr Komaacuteromy was affiliated with the University of Pennsylvania from 2003-2012

Part I can be found at httprepositoryupenneduvet_papers51

Author(s) Author(s) Andraacutes M Komaacuteromy David T Ramsey Dennis E Brooks Cynthia C Ramsey Maria E Kallberg and Stacy E Andrew

This journal article is available at ScholarlyCommons httpsrepositoryupenneduvet_papers52

l

Vol 22 No1 January 2000

Article 4 (15 contact hours)CE Refereed Peer Review

FOCAL POINT

Hyphema is frequently associated with iridocyclitis and generally implies severe intraocular or systemic disease

KEY FACTS

The prognosis for animals with hyphema depends in large part on the identification of underlying diseases institution of proper treatment and careful long-term follow-up p 74

Athorough ophthalmic and systemic diagnostic evaluation should be performed when hyphema is present p 75

The two primary management issues in animals with hyphema are preventing secondary hemorrhage (ie rebleeding) and controlling secondary glaucoma 77

Frequent measurement of intraocular pressure is required in patients with hyphema p 78

reclll ofa ic di

TI is PI [ clini diffe exanHyphema Part II coag takeDiagnosis and Treatment whe

Un iversiry of Florida

Andras M Komaromy Drmedvet

Dennis E Brooks DVM PhD

Maria E Kallberg DVM Stacy E Andrew DVM

med lar tJ

Michigan Stare 0niversiry also David T Ramsey DVM pher

Cynthia C Ramsey DVM MS PH~ TI

an aJ not I ed e

ABSTRACT The clinical appearance of hyphemais variable and is influenced by the volume of e1im blood and the amount of time erythrocytes are present in the anterior chamber When hypheshy pruc ma is evident a complete history should be obtained and a thorough physical examination that performed to direct the initial selection of diagnostic tests Secondary complications of hypheshy ocul ma include glaucoma synechiae cataract formation blood-staining of the cornea and blindshy 109 ness Frequent measurement of intraocular pressure is recommended The two primary manshy unn agement issues in animals with hyphema are prevention of secondary hemorrhage (by ougrtreating the underlying disease) and control of secondary glaucoma

Pamll tect syste art I of this two-part presentation reviewed the pathophysiologic mechashyorrhnisms that most frequently result in hyphema in animals this article covshybraners diagnostic and treatment considerations The prognosis for animals

with hyphema depends on identifYing the underlying cause initiating proper muo sa) ( treatment and careful long-term follow-up sent tope Intrd

HISTORY When hyphema is evident a complete history should be obtained and a thor~

IrIS Iough physical examination performed to direct the initial selection of appropriate hyp ldiagnostic tests Recent health and vaccination statlls should also be ascertained AbdTrauma or ingestion of toxins (eg anticoagulant todenticide) should be considshytionered if an animal has access to the outdoors regardless of whether a traumatic inshyvealcident or rodenticide ingestion was witnessed by the owner Living in or travel to a thregiom in which enzootic infectious disease (eg ehrlichiosis Rocky Mountain rhagspotted fever) is common should alert clinicians to consider infectious agents as a menpotential cause of hyphema Recent drug administration or past illness may be tivel)important factors in determining the cause of hyphema A recent history of abshyintrnormal vision or behavior before the onset of hyphema may signifY preexisting or shouunderlying ocular (e g iridocyclitis glaucoma retinal detachment) or central idennervous system (eg hemorrhage retrobu1bar optic neuriris) disease Hisrory of

Parr I of this [Wo-parr presentation appeared in the November 1999 (Vol 21 gtNo 11 ) OPH issue of Compendium Tf

I

Compendium January 2000 Small AnimalExotics 75

recurrent hyphema is suggestive detailed ophthalmic examinashyof a persistent ocular or systemshy tion of both the anterior and ic disease posterior segments of the afshy

The time at which hyphema fected and contralateral eye Inshyis first observed may also assist direct pupillary light response clinicians in developing a list of allows the evaluation of retinal differential considerations For function even with a bloodshyexample hyphema from antishy filled anterior chamber as long coagulant rodenticide toxicity as the contralateral pupil is visshytakes 5 to 7 days to develop ible Iridocyclitis manifests as whereas hemorrhage occurs imshy conjunctivitis corneal edema mediately in patients with ocushy miosis and hyporony Glaucoshylar trauma Ocular neoplasia may ma and retinal detachment areFigure 1A also cause an acute onset of hyshy generally associated with a myshyphema driatic pupil When hyphema2

is aruibutable to a systemic disshy3PHYSICAL EXAMINATION ease process the contralateral The physical examination of eye may also have clinical siglls

an animal with hyphema should suggestive of the disease Funshynot be limited only ro the affectshy 1 duscopic examination allows ed eye Vhen trauma has been direct visualization of delicate eliminated as a likely cause the vascular structures (retinal and prudent approach is ro assume choroidal vasculature) and censhythat a serious sight-threatening tral nervous tissue (optic nerve ocular disease or life-rhreatenshy head retina) Ocular signs sugshying systemic disease is present gestive of systemic vasculitis are until proven otherwise A thor- Figure 1B frequently detected during exshyough and detailed physical exshy Figure 1-Photograph (A) and photomicrograph (B) amination of the fundus amination is indicated to deshy showing inrrastromal hemorrhage of rhe iris (1) in a Depending on the cause and tect any underlying evidence of dog (cornea (2J anterior chamber (3J posrerior chamshy severity of blood-ocular barrier systemic disease Petechial hemshy ber (4j) (Hematoxylin amp eosin srain original magnishy breakdown and the presence of orrhages of the mucous memshy iridocyclitis aqueous flare (preshyficarion x40)

branes (ie conjunctiva oral dominantly proteins) hypopyshymucosa preputialvulvar m ucoshy on or hyphema may appear in sa) or skin are frequently preshy the anterior chamber The clinshysent along with thrombocyshy ical appearance of hyphema is topenia or thrombocytopathy influenced by the volume of Intrastromal hemorrhage of the erythrocytes in the anterior iris may also be present before chamber and by how long they hyphema occurs (Figure 1) have been present and may difshyAbdominal and thoracic palpashy fer substantially from case to tion and auscultation may reshy case The term complete or toshyveal physical signs suggestive of tal h)phema is used to describe a third-compartment hemor- hemorrhage filling the entire

anterior chamber and is usuallyrhage or vital organ involve- Figure 2-Complere (toral) hyphema in a dog memo Unless trauma is defmi- a result of acute fulminant or tively identified as the cause of recurrent hemorrhage (Figure 2) intraocular hemorrhage every cat with hyphema Complete hyphema obstructs the examiners ability to should have its arterial blood pressure measured to visualize intraocular structures identify systemic hyperrension 1 The blood in a complete hyphema may change color

from red to black as a result of altered aqueous dynamshyOPHTHALMIC EXAMINATION ics indicating the cessation of aqueous circulation 2 If

The physical examination should always include a hemorrhage was initially minimal and transitory hy-

I R I DOCYC LlTI S FUNDUSCOPIC EXAMINATION COMPLETE HYPHEMA

l

l I

76 Small AnimalExotics

phema is light red in appearshyance This type of hyphema may develop a shallow line of demarshycation (ie gravity line) when erythrocytes settle due to gravity in a homogeneous layer in the ventral anterior chamber (Figure 3) Extensive or persistent hemshyorrhageinto the anterior chamshyber appears bright red in color and may occlude both the pupil and iris Complete hyphema atshytributable to transient hemorshyrhage that has been present for at least 5 to 7 days appears dark red or bluish-black and is reshyferred to as eight-baff hyphema (Figure 4) 1 Decreased oxygenashytion of erythrocytes in the anteshyrior chamber is reflected by the dark color 2 Chronic active hyshyphema may appear light or dark red or bluish-black depending on when the last active hemorshyrhage occurred Occlusion of the pupil by hyphema may cause a relative pupillary block that inshyhibits aqueous circulation to the anterior chamber resulting in subsequent elevated intraocular pressure (lOP)

There are definitive circumshystances thac determine when blood in the anterior chamber mayor may not clot Hyphema

Compendium January 2000

currently (eg bone-marrow disshyease) If bone-marrow disease is suspected based on CBC results aspiration cytology with or withshyout core biopsy is indicated 4

Serum biochemical profile and urinalysis may help identify such underlying abnormalities as liver disease renal insufficiency or hyshyperadrenocorticism

Indications for selecting more specific diagnostic tests are deshytermined by history physical ex-3mination findings and initial diagnostic test results Evaluashytion for infectious diseases should

Figure 3-Hyphema wirh gravity line Eryrhrocytes be performed if suggested by geshy

sertle due (0 gravity in a homogeneous layer in rhe ographic location travel history ventral anterior chamber or exposure to other risk factors

Toxoplasma gondii feline leukemia virus (FeLV) feline immunoshydeficiency virus (FIV) and FIP infection and possibly systemic fungal diseases should be considshyered when hyphema is evident in a cat 5 The seroprevalence of T gondii in cats with iridocyclitis was reported to be as high as 7855 However serologic evishydence of infection by T gondii FeLV FIV or FIP does not necshy

Figure 4-Dark red or bluish-black appearance of essarily correlate with clinical eighr-ball hyphema disease induced by these causashy--------------------------------------- rive agents When a systemic

TREA Prir

ma 111

bleedi treati glauclt amon from

Irido

Bloo(

Secor

middotSee rl bUnd lV= il

caused by trauma vasculitis (eg feline infectious perishytonitis [FIP]) or iridocycliris may clot whereas hypheshyrna attributable to immune-mediated thrombocytopeshynia or warfarin toxicity generally will not dot Hyphema attributable to rubeosis iridis (new vascular proliferation of the iris) intraocular neoplasia or conshygenital ocular anomalies may occasionally clot

EXPANDED DATABASE Laboratory tests should be performed based on findshy

ings from the history and physical examination A dishyrect blood smear permits rapid estimation of platelet and megathrombocyte numbers and the detection of erythrocyte and leukocyte involvement (eg presence of schistocyrosis or Haemobartonella) Platelets leukoshycytes and erythrocytes should be evaluated by a comshyplete blood count (CBC) the three cell lines may be afshyfected individually (eg thrombocytopenia) or con-

bleeding disorder is suspected a coagulation profile should be completed4

Sampling of aqueous humor to determine local inshytraocular antibody production is not indicated in pashytients with hyphema because the sample will be conshytaminated with systemic blood When hyphema prevents visualization of intraocular structures transcorneal B-mode ultrasound (75- to 12-MHz transducer) is indicated to determine whether retinal detachment or intraocular tumors are present or to identify other oCLIlar lesions (eg luxated lens intraocshyular foreign body)G Skull radiographs computed toshymography or magnetic resonance imaging may also reshyveal an intraocular foreign body depending on the type or composite When a metallic intraocular foreign body is suspected magnetic resonance imaging should be avoided and computed tomography performed Retinal function can be evaluated using electroretinogshyraphy7

EIGHT-BALL HYPHEMA INFECTIOUS DISEASES IMAGING TECHNIQUES

Compendium January 2000 Small AnimalExotics 77

TREATMENT Primary management issues in animals with hypheshy

rna include preventing secondary hemorrhage (ie reshybleeding) by (1) treating the underlying disease (2) treating iridocyclitis and (3) controlling secondary glaucoma (Table I) There is considerable variation among specific treatment regimens to eliminate blood from the anterior chamber bur the hallmark of hypheshy

rna treatment is management of the iridocyclitis that is frequently present Erythrocytes exit the anterior chamshyber primarily through the iridocorneal drainage angle The iris produces enough fibrinolytic enzymes in most instances to prevent blood from cloning so that it can more easily exit the anterior chamber via the aqueous humor outflow pathways Uncomplicated hyphema should resolve within 7 to 21 days3 Hyphema that

TABLE I Treatment of HyphemaIJ

Disorder

Iridocyclitis)

Blood or fibrin clot 9

Secondary glaucoma O 11

See rexr for derails

Drug Class

Topical parasympatholytics

Topical corticosteroids

Topical NSAIDs

y temic corticosteroids

Systemic NSAIDs

Fibrinolytics

Systemic carbonic anhydrase inhibitors

Topical carbonic anhydrase inhibitors

Topical sympathomimetic drugs

Topical sympatholytic drugs Osmotic agents

Drug

Atropine 1 (use ointment in cats)

Prednisolone acetate suspension 1 dexamethasone solution 01

Dexamethasone ointment 005

Flurbiprofen 003 suprofen 1 indomethacin 1 diclofenac 01

Prednisone

Aspirin

Flunixin meglumine

Carprofen

Tissue plasminogen activator

Dichlorphenamide

Methazolamide

Dorzolamide 3

Epinephrine 1 dipivefrin HCI 01

T imolol maleate 05

Mannitol

Underlying diseases should be rreared firsr in cases ofhyphema

IV = inrravenously PO =orally

FrequencyDose

1-4 times daily

4-6 times daily

3-4 times daily

4 times daily

1-2 mgkgday in divided doses

Dogs 10-15 mgkg PO 2-3 times daily

Cats 80 mg PO every 48-72 hr

Dogs 025-05 mgkg IV single dose

Dogs 2 mgkg PO tvice daily

25-75 flg intracamerally

Dogs 2-4 mgkg PO 2-3 times daily

Cats 1 mgkg PO 2-3 times daily

2-4 mgkg PO 2-3 times daily

3 times daily

2-3 times daily

2-3 times daily

05-10 gkg IV

I

Compendium January 2000 Small AnimalExotics 75

recurrent hyphema is suggestive detailed ophthalmic examinashyof a persistent ocular or systemshy tion of both the anterior and ic disease posterior segments of the afshy

The time at which hyphema fected and contralateral eye Inshyis first observed may also assist direct pupillary light response clinicians in developing a list of allows the evaluation of retinal differential considerations For function even with a bloodshyexample hyphema from antishy filled anterior chamber as long coagulant rodenticide toxicity as the contralateral pupil is visshytakes 5 to 7 days to develop ible Iridocyclitis manifests as whereas hemorrhage occurs imshy conjunctivitis corneal edema mediately in patients with ocushy miosis and hyporony Glaucoshylar trauma Ocular neoplasia may ma and retinal detachment areFigure 1A also cause an acute onset of hyshy generally associated with a myshyphema driatic pupil When hyphema2

is aruibutable to a systemic disshy3PHYSICAL EXAMINATION ease process the contralateral The physical examination of eye may also have clinical siglls

an animal with hyphema should suggestive of the disease Funshynot be limited only ro the affectshy 1 duscopic examination allows ed eye Vhen trauma has been direct visualization of delicate eliminated as a likely cause the vascular structures (retinal and prudent approach is ro assume choroidal vasculature) and censhythat a serious sight-threatening tral nervous tissue (optic nerve ocular disease or life-rhreatenshy head retina) Ocular signs sugshying systemic disease is present gestive of systemic vasculitis are until proven otherwise A thor- Figure 1B frequently detected during exshyough and detailed physical exshy Figure 1-Photograph (A) and photomicrograph (B) amination of the fundus amination is indicated to deshy showing inrrastromal hemorrhage of rhe iris (1) in a Depending on the cause and tect any underlying evidence of dog (cornea (2J anterior chamber (3J posrerior chamshy severity of blood-ocular barrier systemic disease Petechial hemshy ber (4j) (Hematoxylin amp eosin srain original magnishy breakdown and the presence of orrhages of the mucous memshy iridocyclitis aqueous flare (preshyficarion x40)

branes (ie conjunctiva oral dominantly proteins) hypopyshymucosa preputialvulvar m ucoshy on or hyphema may appear in sa) or skin are frequently preshy the anterior chamber The clinshysent along with thrombocyshy ical appearance of hyphema is topenia or thrombocytopathy influenced by the volume of Intrastromal hemorrhage of the erythrocytes in the anterior iris may also be present before chamber and by how long they hyphema occurs (Figure 1) have been present and may difshyAbdominal and thoracic palpashy fer substantially from case to tion and auscultation may reshy case The term complete or toshyveal physical signs suggestive of tal h)phema is used to describe a third-compartment hemor- hemorrhage filling the entire

anterior chamber and is usuallyrhage or vital organ involve- Figure 2-Complere (toral) hyphema in a dog memo Unless trauma is defmi- a result of acute fulminant or tively identified as the cause of recurrent hemorrhage (Figure 2) intraocular hemorrhage every cat with hyphema Complete hyphema obstructs the examiners ability to should have its arterial blood pressure measured to visualize intraocular structures identify systemic hyperrension 1 The blood in a complete hyphema may change color

from red to black as a result of altered aqueous dynamshyOPHTHALMIC EXAMINATION ics indicating the cessation of aqueous circulation 2 If

The physical examination should always include a hemorrhage was initially minimal and transitory hy-

I R I DOCYC LlTI S FUNDUSCOPIC EXAMINATION COMPLETE HYPHEMA

l

l I

76 Small AnimalExotics

phema is light red in appearshyance This type of hyphema may develop a shallow line of demarshycation (ie gravity line) when erythrocytes settle due to gravity in a homogeneous layer in the ventral anterior chamber (Figure 3) Extensive or persistent hemshyorrhageinto the anterior chamshyber appears bright red in color and may occlude both the pupil and iris Complete hyphema atshytributable to transient hemorshyrhage that has been present for at least 5 to 7 days appears dark red or bluish-black and is reshyferred to as eight-baff hyphema (Figure 4) 1 Decreased oxygenashytion of erythrocytes in the anteshyrior chamber is reflected by the dark color 2 Chronic active hyshyphema may appear light or dark red or bluish-black depending on when the last active hemorshyrhage occurred Occlusion of the pupil by hyphema may cause a relative pupillary block that inshyhibits aqueous circulation to the anterior chamber resulting in subsequent elevated intraocular pressure (lOP)

There are definitive circumshystances thac determine when blood in the anterior chamber mayor may not clot Hyphema

Compendium January 2000

currently (eg bone-marrow disshyease) If bone-marrow disease is suspected based on CBC results aspiration cytology with or withshyout core biopsy is indicated 4

Serum biochemical profile and urinalysis may help identify such underlying abnormalities as liver disease renal insufficiency or hyshyperadrenocorticism

Indications for selecting more specific diagnostic tests are deshytermined by history physical ex-3mination findings and initial diagnostic test results Evaluashytion for infectious diseases should

Figure 3-Hyphema wirh gravity line Eryrhrocytes be performed if suggested by geshy

sertle due (0 gravity in a homogeneous layer in rhe ographic location travel history ventral anterior chamber or exposure to other risk factors

Toxoplasma gondii feline leukemia virus (FeLV) feline immunoshydeficiency virus (FIV) and FIP infection and possibly systemic fungal diseases should be considshyered when hyphema is evident in a cat 5 The seroprevalence of T gondii in cats with iridocyclitis was reported to be as high as 7855 However serologic evishydence of infection by T gondii FeLV FIV or FIP does not necshy

Figure 4-Dark red or bluish-black appearance of essarily correlate with clinical eighr-ball hyphema disease induced by these causashy--------------------------------------- rive agents When a systemic

TREA Prir

ma 111

bleedi treati glauclt amon from

Irido

Bloo(

Secor

middotSee rl bUnd lV= il

caused by trauma vasculitis (eg feline infectious perishytonitis [FIP]) or iridocycliris may clot whereas hypheshyrna attributable to immune-mediated thrombocytopeshynia or warfarin toxicity generally will not dot Hyphema attributable to rubeosis iridis (new vascular proliferation of the iris) intraocular neoplasia or conshygenital ocular anomalies may occasionally clot

EXPANDED DATABASE Laboratory tests should be performed based on findshy

ings from the history and physical examination A dishyrect blood smear permits rapid estimation of platelet and megathrombocyte numbers and the detection of erythrocyte and leukocyte involvement (eg presence of schistocyrosis or Haemobartonella) Platelets leukoshycytes and erythrocytes should be evaluated by a comshyplete blood count (CBC) the three cell lines may be afshyfected individually (eg thrombocytopenia) or con-

bleeding disorder is suspected a coagulation profile should be completed4

Sampling of aqueous humor to determine local inshytraocular antibody production is not indicated in pashytients with hyphema because the sample will be conshytaminated with systemic blood When hyphema prevents visualization of intraocular structures transcorneal B-mode ultrasound (75- to 12-MHz transducer) is indicated to determine whether retinal detachment or intraocular tumors are present or to identify other oCLIlar lesions (eg luxated lens intraocshyular foreign body)G Skull radiographs computed toshymography or magnetic resonance imaging may also reshyveal an intraocular foreign body depending on the type or composite When a metallic intraocular foreign body is suspected magnetic resonance imaging should be avoided and computed tomography performed Retinal function can be evaluated using electroretinogshyraphy7

EIGHT-BALL HYPHEMA INFECTIOUS DISEASES IMAGING TECHNIQUES

Compendium January 2000 Small AnimalExotics 77

TREATMENT Primary management issues in animals with hypheshy

rna include preventing secondary hemorrhage (ie reshybleeding) by (1) treating the underlying disease (2) treating iridocyclitis and (3) controlling secondary glaucoma (Table I) There is considerable variation among specific treatment regimens to eliminate blood from the anterior chamber bur the hallmark of hypheshy

rna treatment is management of the iridocyclitis that is frequently present Erythrocytes exit the anterior chamshyber primarily through the iridocorneal drainage angle The iris produces enough fibrinolytic enzymes in most instances to prevent blood from cloning so that it can more easily exit the anterior chamber via the aqueous humor outflow pathways Uncomplicated hyphema should resolve within 7 to 21 days3 Hyphema that

TABLE I Treatment of HyphemaIJ

Disorder

Iridocyclitis)

Blood or fibrin clot 9

Secondary glaucoma O 11

See rexr for derails

Drug Class

Topical parasympatholytics

Topical corticosteroids

Topical NSAIDs

y temic corticosteroids

Systemic NSAIDs

Fibrinolytics

Systemic carbonic anhydrase inhibitors

Topical carbonic anhydrase inhibitors

Topical sympathomimetic drugs

Topical sympatholytic drugs Osmotic agents

Drug

Atropine 1 (use ointment in cats)

Prednisolone acetate suspension 1 dexamethasone solution 01

Dexamethasone ointment 005

Flurbiprofen 003 suprofen 1 indomethacin 1 diclofenac 01

Prednisone

Aspirin

Flunixin meglumine

Carprofen

Tissue plasminogen activator

Dichlorphenamide

Methazolamide

Dorzolamide 3

Epinephrine 1 dipivefrin HCI 01

T imolol maleate 05

Mannitol

Underlying diseases should be rreared firsr in cases ofhyphema

IV = inrravenously PO =orally

FrequencyDose

1-4 times daily

4-6 times daily

3-4 times daily

4 times daily

1-2 mgkgday in divided doses

Dogs 10-15 mgkg PO 2-3 times daily

Cats 80 mg PO every 48-72 hr

Dogs 025-05 mgkg IV single dose

Dogs 2 mgkg PO tvice daily

25-75 flg intracamerally

Dogs 2-4 mgkg PO 2-3 times daily

Cats 1 mgkg PO 2-3 times daily

2-4 mgkg PO 2-3 times daily

3 times daily

2-3 times daily

2-3 times daily

05-10 gkg IV

l

l I

76 Small AnimalExotics

phema is light red in appearshyance This type of hyphema may develop a shallow line of demarshycation (ie gravity line) when erythrocytes settle due to gravity in a homogeneous layer in the ventral anterior chamber (Figure 3) Extensive or persistent hemshyorrhageinto the anterior chamshyber appears bright red in color and may occlude both the pupil and iris Complete hyphema atshytributable to transient hemorshyrhage that has been present for at least 5 to 7 days appears dark red or bluish-black and is reshyferred to as eight-baff hyphema (Figure 4) 1 Decreased oxygenashytion of erythrocytes in the anteshyrior chamber is reflected by the dark color 2 Chronic active hyshyphema may appear light or dark red or bluish-black depending on when the last active hemorshyrhage occurred Occlusion of the pupil by hyphema may cause a relative pupillary block that inshyhibits aqueous circulation to the anterior chamber resulting in subsequent elevated intraocular pressure (lOP)

There are definitive circumshystances thac determine when blood in the anterior chamber mayor may not clot Hyphema

Compendium January 2000

currently (eg bone-marrow disshyease) If bone-marrow disease is suspected based on CBC results aspiration cytology with or withshyout core biopsy is indicated 4

Serum biochemical profile and urinalysis may help identify such underlying abnormalities as liver disease renal insufficiency or hyshyperadrenocorticism

Indications for selecting more specific diagnostic tests are deshytermined by history physical ex-3mination findings and initial diagnostic test results Evaluashytion for infectious diseases should

Figure 3-Hyphema wirh gravity line Eryrhrocytes be performed if suggested by geshy

sertle due (0 gravity in a homogeneous layer in rhe ographic location travel history ventral anterior chamber or exposure to other risk factors

Toxoplasma gondii feline leukemia virus (FeLV) feline immunoshydeficiency virus (FIV) and FIP infection and possibly systemic fungal diseases should be considshyered when hyphema is evident in a cat 5 The seroprevalence of T gondii in cats with iridocyclitis was reported to be as high as 7855 However serologic evishydence of infection by T gondii FeLV FIV or FIP does not necshy

Figure 4-Dark red or bluish-black appearance of essarily correlate with clinical eighr-ball hyphema disease induced by these causashy--------------------------------------- rive agents When a systemic

TREA Prir

ma 111

bleedi treati glauclt amon from

Irido

Bloo(

Secor

middotSee rl bUnd lV= il

caused by trauma vasculitis (eg feline infectious perishytonitis [FIP]) or iridocycliris may clot whereas hypheshyrna attributable to immune-mediated thrombocytopeshynia or warfarin toxicity generally will not dot Hyphema attributable to rubeosis iridis (new vascular proliferation of the iris) intraocular neoplasia or conshygenital ocular anomalies may occasionally clot

EXPANDED DATABASE Laboratory tests should be performed based on findshy

ings from the history and physical examination A dishyrect blood smear permits rapid estimation of platelet and megathrombocyte numbers and the detection of erythrocyte and leukocyte involvement (eg presence of schistocyrosis or Haemobartonella) Platelets leukoshycytes and erythrocytes should be evaluated by a comshyplete blood count (CBC) the three cell lines may be afshyfected individually (eg thrombocytopenia) or con-

bleeding disorder is suspected a coagulation profile should be completed4

Sampling of aqueous humor to determine local inshytraocular antibody production is not indicated in pashytients with hyphema because the sample will be conshytaminated with systemic blood When hyphema prevents visualization of intraocular structures transcorneal B-mode ultrasound (75- to 12-MHz transducer) is indicated to determine whether retinal detachment or intraocular tumors are present or to identify other oCLIlar lesions (eg luxated lens intraocshyular foreign body)G Skull radiographs computed toshymography or magnetic resonance imaging may also reshyveal an intraocular foreign body depending on the type or composite When a metallic intraocular foreign body is suspected magnetic resonance imaging should be avoided and computed tomography performed Retinal function can be evaluated using electroretinogshyraphy7

EIGHT-BALL HYPHEMA INFECTIOUS DISEASES IMAGING TECHNIQUES

Compendium January 2000 Small AnimalExotics 77

TREATMENT Primary management issues in animals with hypheshy

rna include preventing secondary hemorrhage (ie reshybleeding) by (1) treating the underlying disease (2) treating iridocyclitis and (3) controlling secondary glaucoma (Table I) There is considerable variation among specific treatment regimens to eliminate blood from the anterior chamber bur the hallmark of hypheshy

rna treatment is management of the iridocyclitis that is frequently present Erythrocytes exit the anterior chamshyber primarily through the iridocorneal drainage angle The iris produces enough fibrinolytic enzymes in most instances to prevent blood from cloning so that it can more easily exit the anterior chamber via the aqueous humor outflow pathways Uncomplicated hyphema should resolve within 7 to 21 days3 Hyphema that

TABLE I Treatment of HyphemaIJ

Disorder

Iridocyclitis)

Blood or fibrin clot 9

Secondary glaucoma O 11

See rexr for derails

Drug Class

Topical parasympatholytics

Topical corticosteroids

Topical NSAIDs

y temic corticosteroids

Systemic NSAIDs

Fibrinolytics

Systemic carbonic anhydrase inhibitors

Topical carbonic anhydrase inhibitors

Topical sympathomimetic drugs

Topical sympatholytic drugs Osmotic agents

Drug

Atropine 1 (use ointment in cats)

Prednisolone acetate suspension 1 dexamethasone solution 01

Dexamethasone ointment 005

Flurbiprofen 003 suprofen 1 indomethacin 1 diclofenac 01

Prednisone

Aspirin

Flunixin meglumine

Carprofen

Tissue plasminogen activator

Dichlorphenamide

Methazolamide

Dorzolamide 3

Epinephrine 1 dipivefrin HCI 01

T imolol maleate 05

Mannitol

Underlying diseases should be rreared firsr in cases ofhyphema

IV = inrravenously PO =orally

FrequencyDose

1-4 times daily

4-6 times daily

3-4 times daily

4 times daily

1-2 mgkgday in divided doses

Dogs 10-15 mgkg PO 2-3 times daily

Cats 80 mg PO every 48-72 hr

Dogs 025-05 mgkg IV single dose

Dogs 2 mgkg PO tvice daily

25-75 flg intracamerally

Dogs 2-4 mgkg PO 2-3 times daily

Cats 1 mgkg PO 2-3 times daily

2-4 mgkg PO 2-3 times daily

3 times daily

2-3 times daily

2-3 times daily

05-10 gkg IV

Compendium January 2000 Small AnimalExotics 77

TREATMENT Primary management issues in animals with hypheshy

rna include preventing secondary hemorrhage (ie reshybleeding) by (1) treating the underlying disease (2) treating iridocyclitis and (3) controlling secondary glaucoma (Table I) There is considerable variation among specific treatment regimens to eliminate blood from the anterior chamber bur the hallmark of hypheshy

rna treatment is management of the iridocyclitis that is frequently present Erythrocytes exit the anterior chamshyber primarily through the iridocorneal drainage angle The iris produces enough fibrinolytic enzymes in most instances to prevent blood from cloning so that it can more easily exit the anterior chamber via the aqueous humor outflow pathways Uncomplicated hyphema should resolve within 7 to 21 days3 Hyphema that

TABLE I Treatment of HyphemaIJ

Disorder

Iridocyclitis)

Blood or fibrin clot 9

Secondary glaucoma O 11

See rexr for derails

Drug Class

Topical parasympatholytics

Topical corticosteroids

Topical NSAIDs

y temic corticosteroids

Systemic NSAIDs

Fibrinolytics

Systemic carbonic anhydrase inhibitors

Topical carbonic anhydrase inhibitors

Topical sympathomimetic drugs

Topical sympatholytic drugs Osmotic agents

Drug

Atropine 1 (use ointment in cats)

Prednisolone acetate suspension 1 dexamethasone solution 01

Dexamethasone ointment 005

Flurbiprofen 003 suprofen 1 indomethacin 1 diclofenac 01

Prednisone

Aspirin

Flunixin meglumine

Carprofen

Tissue plasminogen activator

Dichlorphenamide

Methazolamide

Dorzolamide 3

Epinephrine 1 dipivefrin HCI 01

T imolol maleate 05

Mannitol

Underlying diseases should be rreared firsr in cases ofhyphema

IV = inrravenously PO =orally

FrequencyDose

1-4 times daily

4-6 times daily

3-4 times daily

4 times daily

1-2 mgkgday in divided doses

Dogs 10-15 mgkg PO 2-3 times daily

Cats 80 mg PO every 48-72 hr

Dogs 025-05 mgkg IV single dose

Dogs 2 mgkg PO tvice daily

25-75 flg intracamerally

Dogs 2-4 mgkg PO 2-3 times daily

Cats 1 mgkg PO 2-3 times daily

2-4 mgkg PO 2-3 times daily

3 times daily

2-3 times daily

2-3 times daily

05-10 gkg IV

I

I

78 Small AnimalExotics

continues to bleed may indicate that the underlying disease is still present Surgical removal of a blood clot with or without iridectomy is discussed in the human medicalliterature2

bull12 and is rarely necessary in human or

veterinary patients Prevention of a posterior synechiae and iris bombe is

achieved with the use of topical parasympatholytics (eg atropine) to dilate the pupil and topical corticoshysteroids to suppress anrerior uveitis (Table I) In addishytion to prevenring synechiae topical atropine (a topical mydriatic and cycloplegic drug) also relieves some pain associated with spasm of the ciliary musculature and helps to stabilize the blood-aqueous barrier II- 1gt If an increase in lOP is noted after the initiation of mydriatshyic treatment atropine should be discontinued immedishyately and glaucoma treatment initiated

Topical use of parasympathomimetic drugs (eg pishylocarpine) to treat hyphema has been advocated to conshytract the ciliary musde which hypothetically facilitates drainage of blood from the anrerior chamber through the iridocorneal angle I Parasympathomimetic drugs also cause miosis which increases iris surface area thereby hypothetically exposing iris surface fibrishynolysins to the clot and blood in the anrerior chamshyber 1( We do not recommend using topical parasympashythomimetic drugs to treat hyphema they dilate iris blood vessels and increase iridal intravascular pressure which may exacerbate hyphema Because these drugs induce miosis the risk of posterior synechiae formashytion iris bombe and peripheral anrerior synechiae forshymation is increased

Nonspecific reduction of ocular inflammation to preshyserve the transparency and function of ocular structures and stabilize the blood-aqueous barrier can be achieved with topical corticosteroids andlor NSAIDs (Table I) Ll1 7 Topical corticosteroids are contraindicated when corneal ulceration is present Systemic administration of NSAIDs can further decrease inflammation but should also be used very cautiously because of their inshyterference with platelet function Systemic corticoshysteroids (eg prednisone prednisolone) should be used cautiously and only when systemic infectious disease has been ruled out or is being treated concurrently Sysshytemic immunosuppressive doses of corticosteroids and systemic carbonic anhydrase inhibitors may help to reattach retinas in patients wmiddotith exudative detachshyments IHl~

Although the use of anrifibrinolytic agents in the managemenr of hyphema is conrroversial intracameral injection of tissue plasminogen activator (tPA) to inshyduce fibrinolysis can be performed to reverse a pupilshylary block when the iris is adhered to the lens by a blood or fibrin clot (Table I) 1~ 12 tPA is most effective

Compendium January 2000

when injected within 48 hours of clot formation but it can also be effective tn dissolving clots of longer durashytion However tPA injections may also induce hypheshyrna or result in more severe hyphema from dissolution of a blood clot when given within 24 hours of the inishytial hemorrhage or when recurrent bleeding is Iikely19

Surgical intervention and concurrent systemic and topical treatment with antibiotics should be considered when hyphema results from penetrating ocular injury or blunt trauma with eyeball rupture Restricted exershycise or even cage rest is recommended to prevent reshybleeding Animals with hyphema may need to be hosshypitalized for close monitoring of possible secondary hemorrhages and elevation of rOp lOP should be meashysured at least daily during the hospital stay and freshyquently after discharge 12

IG We do not recommend Schiotz tonometry in animals with weakened corneas caused by penetrating trauma

If secondary glaucoma develops due to anterior or posterior synechiae of the iris treatment can be atshytempted (eg intracameral tPA and antiglaucoma drugs) but the prognosis to save vision is poor When the eyeball is irreversibly blind or painful from secshyondary glaucoma enucleation should be performed Medical treatment of secondary glaucoma consists of a combination of systemic or topical carbonic anhydrase inhibitors topical sympathomimetic drugs and sympashytholytic drugs (Table I) Osmotic agents are less effecshytive with a leaky blood-ocular barrier Because of the risk of posterior synechiae parasympathomimetic drugs (eg pilocarpine) are contraindicated

COMPLICATIONS Mild hyphema may resolve without significant seshy

quelae The main complications of persistent hyphema are increased lOP peripheral anterior and posterior synechiae development of cataracts and an increased risk of corneal bllood staining attributable to endotheshylial damage and breaks in Descemets membrane 12 If an underlying disease persists and hemorrhage is recurrent atrophy of the eyeball (phthisis bulbi) and blindness are usually the long-term results

PROGNOSIS Prognosis for vision in geriatric dogs with hyphema

secondary to retinal disease is grave 20 In cases of unexshyplained unresponsive or recurring hyphema the diagshynosis must be reassessed Prognosis is grave for any hyshyphema in which an unknown underlying systemic disease persists In such cases enucleation is recomshymended if the lOP rises to levels that cause pain When intraocular neoplasia is known or strongly suspected as the cause for hyphema the affected eye should be enushy

clea If tl 101 oft onc Intr er h

1

2

3

4

5

6

7

8

9

10

I 1

12

3

14

15 1

16 1

17

18

PARASYMPATHOMIMETIC DRUGS TISSUE PLASMINOGEN ACTIVATOR SURGICAL INTERVENTION

cleared and submiued for histopathologic evaluation l

If the underlying cause is nonrec urring or treated and

lOP does nor increase an accurate prognosis for return of the eye to cosmetic and visual normalcy can be made

once resorption of the hemorrhage allows a complete intraocular examination It is difficult to predict whethshy

er hyphema will resorb

REFERENCES I Henik RA Sysremic hyperrension and irs managemem Vet

Cin North Alii SmaIL Anim Pract27(6) 1355- 1372 1997 2 Folberg R Parrish RK G laucoma following trauma in Tasshy

man W Jaeger EA (cds) Duanes Ophthalmology Clil1iCtlI Volume 3 CD-ROM Edition Hagersrown MD LippinconshyRaven 1998

3 Collins BK Moore CP Diseases and surgery of rhe canine amerior uvea in Gelan KN (cd) Veteril1fl1) Ophthalmology ed 3 Baltimore Lippincorr Williams amp Wilkins 1999 pp 75 5-795

4 Hackner SG Approach ro rhe diagnosis of bleeding disorshyders Compend Contin Educ Pract Vet 17(3)33 1-349 1995

5 Chavkin MJ Lappin MR Powell Cc er al Seroepidemioshylogic and clinical observarions of 93 cases of uveiris in cars Prog Vet Comp OphthalmoI2(l)29-36 1992

6 Williams J Wilkie DA Ulrrasonography of rhe eye Comshypend Contin Educ Pract Vet 18(6) 667-676 1996

7 Komaromy AM Smirh PJ Brooks DE Elecrrorerinography in dogs and cars Parr If Technique imerprerarion and inshydicarions Compend Contin EclIe Pract Vet 20(3)355-366 1998

8 Wilkie DA Uvea in Bi rcha rd SJ Sherding RG (eds) Saunshyders ManuaL of SmaLl Animal Practice Philadelphia WB Saunders Co 1994 pp 1213-1216

lt) Marrin C Kaswan R Grarzek A er al Ocular use of ri ssue plasminogen acrivaror in companion animals Prog Vet Comp OphthalmoI3(l)29-361993

10 Wilkie DA G laucoma in Birchard SJ Sherding RG (eds) Saunders ManuaL ofSma Animal Practice Philadelphia WB Saunders Co 1994 pp 121 7-1222

1I Gelan KN Brooks DE The canine glaucomas in Gelarr KN (ed) Veterinary Ophrhalmology ed 3 Balrimore Lippinshyco rr Williams amp Wilkins 199 9 pp 70 1-754

12 GortSch JD H yphema Diagnosis and managemenr Retina 10(S uppl 1)S65-S7 1 1990

13 Bisrner S Allergic- and immunologic-mediared diseases of rhe eye and adncxae Vet Clin North Am Small Anim Pract 24(4)7 ll-734 1994

14 Swan KC Har r WM A compararive srudy of rhe effecrs of mecholyl doryl eserine pilocarpine arropine and epinephshyrine on rhe blood-aqucous bar rier A m j Ophthamol 23( 12) l311-1319 1940

15 Van Alphen GWHM Macri FJ Enrrance of fluorescein inro aqueous humor of cat eye Arch OphthaLmoI75(2)247-253 1lt)66

16 W imton SM Ocular emergencies Ver CLin North Am Small A nim Ptlct 11(1) 59-76 1981

17 Ward DA Ferguson DC Ward SL er al Comparison of rhe blood-aqueous barrier stabilizing effecrs of sreroidal and nonshysreroidal anti-inflammatory agenrs in rh e dog Prog Vet Comp OplnhaLmoI2 (3) 11 7-124 1992

18 Ki m M Marmor MF Reri nal adJles ive force in living rabbir

car and monkey eyes Normarive dara and enhancemenr by manni ro l and ace razo lamide Invest Ophthalmol Vi Sc i 33(6) 1879- 1882 1992

19 Andrew SE Abrams KL Brooks D E Kuhili s PS Clinical features of sreroid respo nsive rerinal derachmenrs in twenryshyrwo dogs Prog Vet Comp OphrhaLmoI7(2)82-87 1997

20 Nelms SR Nasisse MP D avidson MG Kirschner SE H yshyphem a associared wi rh rer inal disease in dogs 17 cases (1 986-199 1) jAVMA 202(8) 1289-1 292 1993

About the Authors Drs Komaromy Brooks Kallberg and Andrew are affilishy

ated with the Department of Small Animal Clinical Scishyences College of Veterinary Medicine University of Florishyda Gainesville Florida Drs David and Cynthia Ramsey

are affiliated with the Department of Small Animal Clinical

Sciences College of Veterinary Medicine Michigan State University East Lansing Michigan Drs David Ramsey

Brooks and Andrew are Diplomates of the American Colshy

lege of Veterinary Ophthalmologists Dr Cynthia Ramsey is a Diplomate of the American College of Veterinary Inshy

ternal Medicine and thwAmerican College of Veterinary Emergency Medicine and Critical Care

ARTICLE 4 CE TEST The article you have read qualifies for 15 conshy

tac t hours of C ontinuing Education Credit from the Auburn Unive rsity College of Veterinary

M edici ne Choose only the onl best answer to each of the following questions then mark your anshy

swers on the test form inserted in Compendium

1 The dark red or bluish-black color of eight-ball hypheshyma indicates decreased a oxygenation of the animal b ocular blood flow e oxygenarion of erythrocytes in rhe antnior chamber d none of the above

2 Which of the following must be co nsidered 111 cats with intraocular hemo rrhage a FIr b sysremic hypertension e T gondii d all of the ahove

3 Sampling of aqueous humor from an eye with hypheshymlt1 to derermine intraocular antibody producrion 15

not indicared because a rhere is no inrraocular anribody producrion h the aqueous humor is conraminared wirh antibodshy

ies from sysremic circularion c possible complicarions (eg a dramaric drop in lOP) d Sampling of aqueous humo r is indicared in eyes

with hyphema (COilTin lies on page 90)

96 Compendium January 2000

Hyphema (ru lllinuedfro1lpage 79)

4 When hyphema is presenr a complete hisrory should include questions regardi ng l geographic location of res idencelrravel history b recent admin is tratio n of medicati on c pas t illnesseslrecenr visual impairment d all of th e above

5 In an eye with hyphema the condition of the re[Ina can be assessed with a indirect pupillary light respo nse (if the contralateral

pupil is vis ible) b transcorneal B-mode ultrasound c elect roretinography d all of the above

6 _______ is not caused by topical atropine l Mydriasis b Cycloplegia c Mios is d Stab ilization of the blood-aqueous barrier

7 Use of topical corticosteroids is contraindicated in pashytiems with a antenor UV CltlS c corneal ulcer b cataract d conjunc[Ivltls

8 How fas t does uncomplicated hyphema generally resolve a 1 day c 3 months b 7 to 2 1 days d 6 monrhs

9 is no t a complication of hyphema a Optic neu ritis b G laucoma c Anterio r and posterior synechiae of the iris d Corneal blood staining

lO should nor be used to trea t iridocyclitis ltl T opical pilocarpine b T opical atropi ne c T opical prednisolone acetate d Systemic prednisolone

Index to Advertisers Small Animal

Hayer Agricultu re Division An imal Hca lr h Acivanragc 43 O ro mal Pl us 15

Classic M ed ical Supply h rlsoli lld Eguip menr 59

Fo rr D odge Animal H ealth DUramllJ1 C V~l cc i n cs Cor r 4 Pain NlJn1gCnlcllt f-acr Sheer In sert

rnnovH ive Ve[crina ry Dicts Iimircd In grcdicnr Diets 4- 5 Xcs tc rn Vere rinary Conrerence Sym posium 60

Mark ~il o r rL~ Insr itut( Small Animnl Clinicnl lVutrition 34

lVlt rck Puhlishing Group Mack Veterinary Mall ual CD-ROM 53

Ntrures Form lib H Cl lrh Prod ucts Iiquid Herha l Remedies 16

NOVlrtis

C lomicalm Coer 2- 1 Progrln 26--27

N utralnmiddotLX L~lborJ l ori (s Coscquin 6

Pfizer Animall-l calrh 0 ughG uard B Va nguard 5B N3aGuard-IJ 8

Revolurion 6~li 7 48 Zeniqu in 22- 23 28

Schcri nu- Pl ollgh An imal H ealth Gexy Pa~vo 67 Orb 3132- 33

Synhioric) Wi rns HW 11

Vee~~h~~~~~~l~~ ~ ~~~ ~~~l~ bullbullbullbull Cover 3

Vecrin l ry Prodllcrs Labo ramri ts FlexlS Plll ~ 71

Equine Fo[[ Dodge An imal Health

Pinnacle l N 80 Ve[sn eam

CD-Eq uis 85

Food Animal Ve[crinary Learning Systems

Compendillm Reprillts 524 E11Ieryency 11edicille in Smnll l illimal Prnaice 52

OCTOBER 1999 QUIZ ANSWERS

ARTICU i 1 Rena l Effect of Nonste roida l Ant iinflammatory Drugs-S D Fo rrester G C Troy I c 2 d 3 b 4 5 a 6 c 7 lt1 8 b 9 10d

ARTlCLH2 Ac ute T horaco lumbar Disk Extrusion in Dogs Part (-R II Jerrol1l e lV f) () r nmiddot

I h 2 1 J 4 5 c 6 h 7 c R J 9 e 10 a

ItRlICLE 3 The Avian ReIp iralOry S ysl~ nl-S L OHZ I a 2 e 3 4 d 5 b 6 e 7 d R a 9 h 10 a

ARTICLE 4 Basic fl lepharoplasly Techlliqllcs-H L Hamilron R D Whilley S t M(u(l~h lil1 S F Swoilll I b 2 d 3 d 4 5 a 6 d 7 b 8 e 9 a 10 c

tRTICLE 5 A Practilio ne r s Guide In Nccrop y-I b 2 a 3 6 d 7 d 8

ARTICLE 6

E A Sartil 1 S Spalla T L Halhcock c 4 d 5 d a 9 e 10 d

Diagnosing Equ ine P rotozoal M yclol llcepha liti s Complica [ing Fac[o rs shyB C Bell I W G Cner T Tobill l d 2 a 3 b 4 5 a 6 e 7 d ~ b 9 10

ARTICLE 7 Agric ul[ unl l Economics fo r Vetcrin arians Marketi ng Becf Cow Herds-R L La rson V L Pierce I d 2 e 3 e 4 a 5 e 6 a 7 b 8 d 9 a 10 c

ARTICLE 8 Cryplosporidiox i - G L SkklJ 1 D InBOellill~ fi Ridlev D Van )1elre R Falkner I d 2 a 3 d 4 d 5 e 6 d 7 b 8 d 9 a 10 d

cleared and submiued for histopathologic evaluation l

If the underlying cause is nonrec urring or treated and

lOP does nor increase an accurate prognosis for return of the eye to cosmetic and visual normalcy can be made

once resorption of the hemorrhage allows a complete intraocular examination It is difficult to predict whethshy

er hyphema will resorb

REFERENCES I Henik RA Sysremic hyperrension and irs managemem Vet

Cin North Alii SmaIL Anim Pract27(6) 1355- 1372 1997 2 Folberg R Parrish RK G laucoma following trauma in Tasshy

man W Jaeger EA (cds) Duanes Ophthalmology Clil1iCtlI Volume 3 CD-ROM Edition Hagersrown MD LippinconshyRaven 1998

3 Collins BK Moore CP Diseases and surgery of rhe canine amerior uvea in Gelan KN (cd) Veteril1fl1) Ophthalmology ed 3 Baltimore Lippincorr Williams amp Wilkins 1999 pp 75 5-795

4 Hackner SG Approach ro rhe diagnosis of bleeding disorshyders Compend Contin Educ Pract Vet 17(3)33 1-349 1995

5 Chavkin MJ Lappin MR Powell Cc er al Seroepidemioshylogic and clinical observarions of 93 cases of uveiris in cars Prog Vet Comp OphthalmoI2(l)29-36 1992

6 Williams J Wilkie DA Ulrrasonography of rhe eye Comshypend Contin Educ Pract Vet 18(6) 667-676 1996

7 Komaromy AM Smirh PJ Brooks DE Elecrrorerinography in dogs and cars Parr If Technique imerprerarion and inshydicarions Compend Contin EclIe Pract Vet 20(3)355-366 1998

8 Wilkie DA Uvea in Bi rcha rd SJ Sherding RG (eds) Saunshyders ManuaL of SmaLl Animal Practice Philadelphia WB Saunders Co 1994 pp 1213-1216

lt) Marrin C Kaswan R Grarzek A er al Ocular use of ri ssue plasminogen acrivaror in companion animals Prog Vet Comp OphthalmoI3(l)29-361993

10 Wilkie DA G laucoma in Birchard SJ Sherding RG (eds) Saunders ManuaL ofSma Animal Practice Philadelphia WB Saunders Co 1994 pp 121 7-1222

1I Gelan KN Brooks DE The canine glaucomas in Gelarr KN (ed) Veterinary Ophrhalmology ed 3 Balrimore Lippinshyco rr Williams amp Wilkins 199 9 pp 70 1-754

12 GortSch JD H yphema Diagnosis and managemenr Retina 10(S uppl 1)S65-S7 1 1990

13 Bisrner S Allergic- and immunologic-mediared diseases of rhe eye and adncxae Vet Clin North Am Small Anim Pract 24(4)7 ll-734 1994

14 Swan KC Har r WM A compararive srudy of rhe effecrs of mecholyl doryl eserine pilocarpine arropine and epinephshyrine on rhe blood-aqucous bar rier A m j Ophthamol 23( 12) l311-1319 1940

15 Van Alphen GWHM Macri FJ Enrrance of fluorescein inro aqueous humor of cat eye Arch OphthaLmoI75(2)247-253 1lt)66

16 W imton SM Ocular emergencies Ver CLin North Am Small A nim Ptlct 11(1) 59-76 1981

17 Ward DA Ferguson DC Ward SL er al Comparison of rhe blood-aqueous barrier stabilizing effecrs of sreroidal and nonshysreroidal anti-inflammatory agenrs in rh e dog Prog Vet Comp OplnhaLmoI2 (3) 11 7-124 1992

18 Ki m M Marmor MF Reri nal adJles ive force in living rabbir

car and monkey eyes Normarive dara and enhancemenr by manni ro l and ace razo lamide Invest Ophthalmol Vi Sc i 33(6) 1879- 1882 1992

19 Andrew SE Abrams KL Brooks D E Kuhili s PS Clinical features of sreroid respo nsive rerinal derachmenrs in twenryshyrwo dogs Prog Vet Comp OphrhaLmoI7(2)82-87 1997

20 Nelms SR Nasisse MP D avidson MG Kirschner SE H yshyphem a associared wi rh rer inal disease in dogs 17 cases (1 986-199 1) jAVMA 202(8) 1289-1 292 1993

About the Authors Drs Komaromy Brooks Kallberg and Andrew are affilishy

ated with the Department of Small Animal Clinical Scishyences College of Veterinary Medicine University of Florishyda Gainesville Florida Drs David and Cynthia Ramsey

are affiliated with the Department of Small Animal Clinical

Sciences College of Veterinary Medicine Michigan State University East Lansing Michigan Drs David Ramsey

Brooks and Andrew are Diplomates of the American Colshy

lege of Veterinary Ophthalmologists Dr Cynthia Ramsey is a Diplomate of the American College of Veterinary Inshy

ternal Medicine and thwAmerican College of Veterinary Emergency Medicine and Critical Care

ARTICLE 4 CE TEST The article you have read qualifies for 15 conshy

tac t hours of C ontinuing Education Credit from the Auburn Unive rsity College of Veterinary

M edici ne Choose only the onl best answer to each of the following questions then mark your anshy

swers on the test form inserted in Compendium

1 The dark red or bluish-black color of eight-ball hypheshyma indicates decreased a oxygenation of the animal b ocular blood flow e oxygenarion of erythrocytes in rhe antnior chamber d none of the above

2 Which of the following must be co nsidered 111 cats with intraocular hemo rrhage a FIr b sysremic hypertension e T gondii d all of the ahove

3 Sampling of aqueous humor from an eye with hypheshymlt1 to derermine intraocular antibody producrion 15

not indicared because a rhere is no inrraocular anribody producrion h the aqueous humor is conraminared wirh antibodshy

ies from sysremic circularion c possible complicarions (eg a dramaric drop in lOP) d Sampling of aqueous humo r is indicared in eyes

with hyphema (COilTin lies on page 90)

96 Compendium January 2000

Hyphema (ru lllinuedfro1lpage 79)

4 When hyphema is presenr a complete hisrory should include questions regardi ng l geographic location of res idencelrravel history b recent admin is tratio n of medicati on c pas t illnesseslrecenr visual impairment d all of th e above

5 In an eye with hyphema the condition of the re[Ina can be assessed with a indirect pupillary light respo nse (if the contralateral

pupil is vis ible) b transcorneal B-mode ultrasound c elect roretinography d all of the above

6 _______ is not caused by topical atropine l Mydriasis b Cycloplegia c Mios is d Stab ilization of the blood-aqueous barrier

7 Use of topical corticosteroids is contraindicated in pashytiems with a antenor UV CltlS c corneal ulcer b cataract d conjunc[Ivltls

8 How fas t does uncomplicated hyphema generally resolve a 1 day c 3 months b 7 to 2 1 days d 6 monrhs

9 is no t a complication of hyphema a Optic neu ritis b G laucoma c Anterio r and posterior synechiae of the iris d Corneal blood staining

lO should nor be used to trea t iridocyclitis ltl T opical pilocarpine b T opical atropi ne c T opical prednisolone acetate d Systemic prednisolone

Index to Advertisers Small Animal

Hayer Agricultu re Division An imal Hca lr h Acivanragc 43 O ro mal Pl us 15

Classic M ed ical Supply h rlsoli lld Eguip menr 59

Fo rr D odge Animal H ealth DUramllJ1 C V~l cc i n cs Cor r 4 Pain NlJn1gCnlcllt f-acr Sheer In sert

rnnovH ive Ve[crina ry Dicts Iimircd In grcdicnr Diets 4- 5 Xcs tc rn Vere rinary Conrerence Sym posium 60

Mark ~il o r rL~ Insr itut( Small Animnl Clinicnl lVutrition 34

lVlt rck Puhlishing Group Mack Veterinary Mall ual CD-ROM 53

Ntrures Form lib H Cl lrh Prod ucts Iiquid Herha l Remedies 16

NOVlrtis

C lomicalm Coer 2- 1 Progrln 26--27

N utralnmiddotLX L~lborJ l ori (s Coscquin 6

Pfizer Animall-l calrh 0 ughG uard B Va nguard 5B N3aGuard-IJ 8

Revolurion 6~li 7 48 Zeniqu in 22- 23 28

Schcri nu- Pl ollgh An imal H ealth Gexy Pa~vo 67 Orb 3132- 33

Synhioric) Wi rns HW 11

Vee~~h~~~~~~l~~ ~ ~~~ ~~~l~ bullbullbullbull Cover 3

Vecrin l ry Prodllcrs Labo ramri ts FlexlS Plll ~ 71

Equine Fo[[ Dodge An imal Health

Pinnacle l N 80 Ve[sn eam

CD-Eq uis 85

Food Animal Ve[crinary Learning Systems

Compendillm Reprillts 524 E11Ieryency 11edicille in Smnll l illimal Prnaice 52

OCTOBER 1999 QUIZ ANSWERS

ARTICU i 1 Rena l Effect of Nonste roida l Ant iinflammatory Drugs-S D Fo rrester G C Troy I c 2 d 3 b 4 5 a 6 c 7 lt1 8 b 9 10d

ARTlCLH2 Ac ute T horaco lumbar Disk Extrusion in Dogs Part (-R II Jerrol1l e lV f) () r nmiddot

I h 2 1 J 4 5 c 6 h 7 c R J 9 e 10 a

ItRlICLE 3 The Avian ReIp iralOry S ysl~ nl-S L OHZ I a 2 e 3 4 d 5 b 6 e 7 d R a 9 h 10 a

ARTICLE 4 Basic fl lepharoplasly Techlliqllcs-H L Hamilron R D Whilley S t M(u(l~h lil1 S F Swoilll I b 2 d 3 d 4 5 a 6 d 7 b 8 e 9 a 10 c

tRTICLE 5 A Practilio ne r s Guide In Nccrop y-I b 2 a 3 6 d 7 d 8

ARTICLE 6

E A Sartil 1 S Spalla T L Halhcock c 4 d 5 d a 9 e 10 d

Diagnosing Equ ine P rotozoal M yclol llcepha liti s Complica [ing Fac[o rs shyB C Bell I W G Cner T Tobill l d 2 a 3 b 4 5 a 6 e 7 d ~ b 9 10

ARTICLE 7 Agric ul[ unl l Economics fo r Vetcrin arians Marketi ng Becf Cow Herds-R L La rson V L Pierce I d 2 e 3 e 4 a 5 e 6 a 7 b 8 d 9 a 10 c

ARTICLE 8 Cryplosporidiox i - G L SkklJ 1 D InBOellill~ fi Ridlev D Van )1elre R Falkner I d 2 a 3 d 4 d 5 e 6 d 7 b 8 d 9 a 10 d

96 Compendium January 2000

Hyphema (ru lllinuedfro1lpage 79)

4 When hyphema is presenr a complete hisrory should include questions regardi ng l geographic location of res idencelrravel history b recent admin is tratio n of medicati on c pas t illnesseslrecenr visual impairment d all of th e above

5 In an eye with hyphema the condition of the re[Ina can be assessed with a indirect pupillary light respo nse (if the contralateral

pupil is vis ible) b transcorneal B-mode ultrasound c elect roretinography d all of the above

6 _______ is not caused by topical atropine l Mydriasis b Cycloplegia c Mios is d Stab ilization of the blood-aqueous barrier

7 Use of topical corticosteroids is contraindicated in pashytiems with a antenor UV CltlS c corneal ulcer b cataract d conjunc[Ivltls

8 How fas t does uncomplicated hyphema generally resolve a 1 day c 3 months b 7 to 2 1 days d 6 monrhs

9 is no t a complication of hyphema a Optic neu ritis b G laucoma c Anterio r and posterior synechiae of the iris d Corneal blood staining

lO should nor be used to trea t iridocyclitis ltl T opical pilocarpine b T opical atropi ne c T opical prednisolone acetate d Systemic prednisolone

Index to Advertisers Small Animal

Hayer Agricultu re Division An imal Hca lr h Acivanragc 43 O ro mal Pl us 15

Classic M ed ical Supply h rlsoli lld Eguip menr 59

Fo rr D odge Animal H ealth DUramllJ1 C V~l cc i n cs Cor r 4 Pain NlJn1gCnlcllt f-acr Sheer In sert

rnnovH ive Ve[crina ry Dicts Iimircd In grcdicnr Diets 4- 5 Xcs tc rn Vere rinary Conrerence Sym posium 60

Mark ~il o r rL~ Insr itut( Small Animnl Clinicnl lVutrition 34

lVlt rck Puhlishing Group Mack Veterinary Mall ual CD-ROM 53

Ntrures Form lib H Cl lrh Prod ucts Iiquid Herha l Remedies 16

NOVlrtis

C lomicalm Coer 2- 1 Progrln 26--27

N utralnmiddotLX L~lborJ l ori (s Coscquin 6

Pfizer Animall-l calrh 0 ughG uard B Va nguard 5B N3aGuard-IJ 8

Revolurion 6~li 7 48 Zeniqu in 22- 23 28

Schcri nu- Pl ollgh An imal H ealth Gexy Pa~vo 67 Orb 3132- 33

Synhioric) Wi rns HW 11

Vee~~h~~~~~~l~~ ~ ~~~ ~~~l~ bullbullbullbull Cover 3

Vecrin l ry Prodllcrs Labo ramri ts FlexlS Plll ~ 71

Equine Fo[[ Dodge An imal Health

Pinnacle l N 80 Ve[sn eam

CD-Eq uis 85

Food Animal Ve[crinary Learning Systems

Compendillm Reprillts 524 E11Ieryency 11edicille in Smnll l illimal Prnaice 52

OCTOBER 1999 QUIZ ANSWERS

ARTICU i 1 Rena l Effect of Nonste roida l Ant iinflammatory Drugs-S D Fo rrester G C Troy I c 2 d 3 b 4 5 a 6 c 7 lt1 8 b 9 10d

ARTlCLH2 Ac ute T horaco lumbar Disk Extrusion in Dogs Part (-R II Jerrol1l e lV f) () r nmiddot

I h 2 1 J 4 5 c 6 h 7 c R J 9 e 10 a

ItRlICLE 3 The Avian ReIp iralOry S ysl~ nl-S L OHZ I a 2 e 3 4 d 5 b 6 e 7 d R a 9 h 10 a

ARTICLE 4 Basic fl lepharoplasly Techlliqllcs-H L Hamilron R D Whilley S t M(u(l~h lil1 S F Swoilll I b 2 d 3 d 4 5 a 6 d 7 b 8 e 9 a 10 c

tRTICLE 5 A Practilio ne r s Guide In Nccrop y-I b 2 a 3 6 d 7 d 8

ARTICLE 6

E A Sartil 1 S Spalla T L Halhcock c 4 d 5 d a 9 e 10 d

Diagnosing Equ ine P rotozoal M yclol llcepha liti s Complica [ing Fac[o rs shyB C Bell I W G Cner T Tobill l d 2 a 3 b 4 5 a 6 e 7 d ~ b 9 10

ARTICLE 7 Agric ul[ unl l Economics fo r Vetcrin arians Marketi ng Becf Cow Herds-R L La rson V L Pierce I d 2 e 3 e 4 a 5 e 6 a 7 b 8 d 9 a 10 c

ARTICLE 8 Cryplosporidiox i - G L SkklJ 1 D InBOellill~ fi Ridlev D Van )1elre R Falkner I d 2 a 3 d 4 d 5 e 6 d 7 b 8 d 9 a 10 d