Corneal Endothelial Degeneration
Q: Dear Dr. Richards,
Let me first thank you for a very insightful site on Cushing's disease. My dog's symptoms and initial blood tests strongly indicated Cushing's. After reading your material, I became convinced that the cause was cortisoids in eye drops. I stopped all medication and she started to get better, and the "resistance" (I forgot the name) came back negative. Now the question. I have a 7-year old Boston Terrier called Missy. A Veterinary Ophthalmologist diagnosed her condition as corneal endothelial degeneration and gave the following medication: Indomethacin and 5% saline. I would be very grateful if you could give me a broad walk around on your views and experiences with this condition. Thank you once again, Riitta.
The cornea is the clear portion of the eye. In order to be clear, it has to be very specialized. It can't contain blood vessels, for instance --- because then it would be red or the vessels would at least be visible in it. If you think of it as clear skin without blood vessels it might be helpful. The endothelium is the innermost layer of the cornea. It is a very thin layer that has the major task of keeping the fluid in the eye from entering into the clear cornea. The reason for this is that any water that gets into the corneal layers tends to make them swell. When they swell they get cloudy or develop a bluish haze. This can be focal, occurring in discrete spots, or it can be generalized and the cornea can become cloudy or blue instead of clear.
In some dogs this will lead to corneal ulcers or a condition that is referred to as bullous keratopathy (blistering of the cornea). In Boston terriers there is an inherited form of endothelial degeneration that is referred to as endothelial dystrophy. It usually starts out as haziness or cloudiness of the cornea towards the outside side of the eye and then gradually over time spreads towards the nasal side of the eye. It can lead to blindness. Older dogs of all breeds can have a degeneration of the endothelium that is just a function of age and perhaps some underlying weakness (since it doesn't occur in a lot of dogs it can't be just age). I'm not sure how to tell these conditions apart since the problem in Boston terriers tends to start in middle age (or older).
The inherited condition is more common in females, though. There is a surgical treatment for endothelial degeneration, thermokeratoplasty, but I do not know if it is useful in the inherited form of this disease in Boston terriers. 5% Sodium chloride drops are used because they are hyperosmotic (more salt in the drops than in the cornea) which causes fluid to move out of the cornea. This is beneficial in reducing the accumulation of fluid in the cornea. I was not aware that there was evidence that anti-inflammatory drops were helpful but I'm absolutely certain that your ophthalmologist knows more about this condition that I do so I'm going to remember this for future reference.
Indomethacin is a non-steroidal anti-inflammatory medication and I'm assuming it is being used to reduce pain and/or inflammation in the cornea. My experiences with this condition are actually pretty limited. I think we have had less than five patients with this condition over the years in our practice. Unfortunately, most of them have eventually had to have either permanent conjunctival flaps (where the pink conjunctiva is undermined and then pulled over the cornea to act as kind of a permanent bandage) or their owners eventually decided the situation was hopeless and just ignored it -- even though this is not really an acceptable option if you are thinking about the dog's comfort. I can't recall having a patient with this since the advent of thermokeratoplasty but this is reported to work well. This is a URL for an article on this: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12619840
I am hoping that the ophthalmologist has seen lots more cases of this than we have and has had good luck with treatment. This is entirely possible because we may have treated patients thinking they just had corneal ulcers or keratopathy and just missed the underlying condition. If that has happened we may have treated some of these guys with good success without even knowing it.
Mike Richards, DVM
Q: My dog Thor recently became quite passive and didn't eat normally. He is a 9 year old diabetic that takes 14 units of insulin twice a day. I get worried easily so I took him to the vet. The vet determined he needed a blood transfusion as his red blood count was 21. I hope this is a valid number. He also said his previous tests showed 43. Thor did get the transfusion and a drug baytrol 60 #14 because the vet does not know what is wrong. It has only been one day....but Thor is still very quiet and doesn't eat as normal...but he does eat something. He goes back to the vet tomorrow to do more tests for his diabetes, red blood counts, etc.
Let me say one more thing. Thor recently had cataract surgery at a surgical center for this type of work and was on a massive amount of eye drugs because one eye was not responding to the drugs. It has been several months of the massive drugs. As of now he only gets prednisone acetate. Could these drugs be the problem? Can you recommend anything to try to help Thor? I recently lost my beloved 14 year old german shepherd and I don't want to lose Thor. thank you so much for being there. Sherrie
I think that it is possible that the medications for the eye may be linked to the anemia. Many medications can induce either immune mediated thrombocytopenia (platelet deficiency) or immune mediated hemolytic anemia (IMHA). If one of these diseases is present, there should be recognizable clinical signs pretty quickly. In the case of the immune mediated thrombocytopenia a platelet count is often all that is necessary to confirm the presence of this problem. This is often done as part of the complete blood count but may have to be specifically requested at some laboratories. If would be a good idea to ask if a platelet count has been done and if so, what the results were. Immune mediated hemolytic anemia is a little harder to diagnose as this diagnosis is often based on the appearance of red blood cells in a blood smear and the presence or absence of reticulocytes, or developing red blood cells. Reticulocyte counts almost always have to be requested separately from complete blood counts because they require different staining techniques. If there are high numbers of reticulocytes and unusually shaped red blood cells referred to as spherocytes, it is very likely that IMHA is present.
The reason that I started with those two diseases is simply that they are sometimes involved in drug reactions. The diagnosis of the cause of anemia can be a little complicated because there are a number of disorders that can lead to anemia, including intestinal parasites, blood loss from undetected trauma, gastric or intestinal ulcers, kidney failure, liver failure, cancers (several), chronic illness (including diabetes) and probably at least a hundred other known causes. This makes it necessary to make a pretty thorough diagnostic effort to determine the cause of anemia. I'm not sure that I understand why a blood transfusion was given prior to making at least a tentative diagnosis with a hematocrit of 21 unless it was clear that there was a serious ongoing loss of blood. This may complicate making a diagnosis slightly. Things like this are always a judgment call and your vet was able to see your dog's overall condition so it is possible that this was the best option at the time.
The hematocrit is the percentage of the blood which is made up of red blood cells. The normal range varies from lab to lab but generally runs around 32 to 50. If the last hematocrit of 43 was recent this may give you some idea why your vet felt that a transfusion was necessary first. The first step in making a diagnosis when anemia is present is to determine if the anemia is regenerative or not. A regenerative anemia is one in which the body is attempting to respond to the loss of blood by releasing young red blood cells (reticulocytes) and/or making new blood. A non-regenerative anemia is one in which there is no apparent effort by the body to respond to the blood loss. In general, regenerative anemias tend to be more of a crisis situation and non-regenerative anemias tend to cause slow loss of red blood cells over a long period of time. There is a three day (minimum) period of time in which the body can't respond to blood loss very well. It takes about this length of time to start making new red blood cells and for high numbers of reticulocytes to make it into the blood stream from the bone marrow. This time period can confuse the differentiation between regenerative and non-regenerative anemias -- but only for a few days.
The most common cause of regenerative anemia in older dogs is probably IMHA. Sometimes the IMHA is secondary to another disease process like ehrlichiosis or cancer, though. Hookworms, severe flea infestation, severe tick infestation, gastric ulcers, traumatic blood loss, toxic damage to blood (onion poisoning, zinc poisoning, acetaminophen toxicity, others) and damage to red blood cells from diseases such as heartworms, other heart diseases, cancer and vasculitis.
Non-regenerative anemia occurs when something is stopping or inhibiting the production of red blood cells. Because there is no way for the body to respond to this problem a slowly developing anemia occurs as the red blood cells are used up. The average red blood cell in dogs probably lives a little more than 100 days but due to the continuous overlap of red blood cell production it may only take 60 days or so for anemia to develop with even small amounts of continuous blood loss that the body can not respond to. Unfortunately, there are hundreds of causes of non-regenerative anemia because almost any chronic disease can inhibit red blood cell production if it goes on long enough. Vitamin B deficiencies and iron deficiencies can cause failure to produce red blood cells. Kidney failure causes anemia because the kidneys produce the hormone that stimulates red blood cell production (erythropoietin) and because red blood cells don't live as long when the kidneys aren't doing their job of removing blood toxins well.
Anemia occurs with hormonal diseases such as hyperadrenocorticism and hypothyroidism. Some drugs directly suppress bone marrow, including sulfa-trimethoprim antibiotics, chloramphenicol, toxic levels of estrogen and chemotherapeutic agents. Cancer can cause non-regenerative anemia by suppressing red blood cell production, robbing the body of essential nutrients, causing organ damage and in several other ways. We have seen anemia in several of our patients with diabetes, especially when we have trouble getting good regulation of their insulin dosage. So far this has always been non-regenerative anemia that has improved as we gained better control over the diabetes management or at least reached a point where the anemia became stabilized even though we couldn't make it go away completely, as long as there weren't other complicating factors like kidney failure. Hopefully it is apparent why it is so important to know which type of anemia is present. Once this is known, it is possible to narrow the search for a cause in a more systematic way. It also helps in planning appropriate therapy, including the timing of treatments such as blood transfusions.
There is a big difference between giving a blood transfusion for a one-time blood loss with a normally functioning bone marrow and giving blood transfusions to patients who are not making blood, where multiple transfusions may be necessary and careful cross-matching of the blood as well as matching the patient's and donor's blood types becomes necessary due to the potential need for multiple transfusions. I can't tell from the information that you know so far what the most likely diagnosis is. Hopefully as your vet does more testing it will be possible to come to an understanding of why this anemia is present. It can take a great deal of testing to rule out all the possible diseases that can cause anemia, especially when non-regenerative anemia is present. Keep working with your vet and don't rule out things like X-rays, ultrasound examination, gastroscopy or other tests designed to look for underlying causes if it is not readily apparent why the anemia is present. Good luck with this. Make sure that your vet has a complete list of all medications that Thor has had recently, including an over-the-counter medications. If he isn't eating a commercial dog food be sure to mention that, as well. Think about the possibility of toxins, such as toy ingestion or eating metal (zinc is in pennies and was in some of the bolts used on older pet carriers -- probably ones from at least 15 to 20 years ago if you still have one of those). Watch him urinate to make sure that there is no blood in the urine and consider bringing a stool sample to your vet's in case it is hard to get one from him at the office.
Mike Richards, DVM
Giving Bulldogs Tums for Tear Stains on Face
Q: Dear Dr. Mike,
I've been a subscriber since Sept, and this is my second of 2 important questions I have. One of our pets is a wonderful 4 month old English Bulldog, "Ruby". An online group of Bulldog enthusiasts share experieneces and suggestions on raising bulldogs. I had asked about the tear stains Ruby is developing on the white side of her face. At least a dozen people replied that they give their bulldogs "tums" on a daily basis. It apparently neutralizes protein or acid in the tears and eliminates staining.
I am aware of the numerous risks of elevated calcium and I assume that the tums are pretty potent as a supplement, considering that post-menopausal women are often prescribed just one Tums/day. Ruby only weighs 18 lbs, so a little bit of anything goes a long way. With so many other health considerations in Bulldogs, I don't want to introduce one more, for the purpose of a clean face. I also heard that many people who show their bullies administer a round of antibiotics for a week or so before a show. Ruby is a princess, not a show dog. She can live with a dirty face. If, however, the tums are unquestionably harmless, I'd like to know that, and what you recommend. Thank you! Sincerely, Pam
This was actually the question that made me think I should come back to your questions later. I have had a hard time researching this but I think that I can help some. I had two questions when I got your question, 1) does this work? 2) would it cause problems?
I really can't answer the first question. I had not actually heard of using Tums (tm), which I think have 0.5mg of calcium carbonate as their active ingredient, for tear staining. There are several topical treatments for this condition sold in pet stores (Diamond Eyes (tm), is one name I remember) and some people have used tetracycline antibiotics in low doses because this has been reported to help, as well, but does raise questions about the proper use of antibiotics. When I researched your question I did find several anecdotal references to the use of Tums to control tear staining, so there is at least some indication that it might be helpful.
If one or less Tums tablet per day was sufficient to control tear staining then it is unlikely that there would be a problem with the calcium supplementation from the tablets in an adult dog but I would be reluctant to use calcium supplementation during the growth period in a puppy. The recommended calcium levels in puppy foods is higher than the requirements for most puppies and over-supplementation of calcium has been linked to some orthopedic conditions. I really think it might be best to wait until Ruby is a little older before trying this.
Mike Richards, DVM
Q: Dear Dr. Mike,
I'm Liz from Vermont and I have a senior pug (we are not sure of her age because she is a rescue, but we believe she is between 8 & 10 years old). I think I should give you some background on Dixie since she has had many problems. First, she is a special needs dog since she only has 1 eye and on Optimunne and Gentocin with Durafilm for dry eye and PK in the other. I have had my vet cut her eyelid back so the lashes wouldn't rub on her eye like they were doing and also she has had infected back teeth that had to be removed a couple of times. She is also on soloxine for her thyroid and has arthritis in her front elbows and shoulders. My vet had taken x-rays and said her third spine disc is compressed. Recently, she had a bad case of pancreatitis, but is fully recovered from that. I have been giving her gloucousamine and chrondroitin sulfate for her arthritis along with coated ecotrin for pain.
My question is I have been thinking of ordering an herb supplement for her made up of alfalfa, acadia and marigold from Natural Herbal Remedies out in California. Joel Hyman is the herbalist who owns the company. Ever heard of him? But my main question is what do you think of herb supplements and if I try this, can I continue to give her the gloucousamine and chrondroitin sulfate? Or should I stop giving her those two supplements? Any opinions you have would be greatly appreciated. Thanks for your time and please excuse the typos on the medicinal names, Liz
Before getting to the herbal question I think that I should say one thing about the KCS problem. There do seem to be times when a corticosteroid eye drop is helpful in conjunction with cyclosporin (Optimmune Rx) for this problem but there may not be a need to use the antibiotic gentamicin. Since Gentocin Durafilm (Rx) contains both the steroid and the antibiotic, using a cortisteroid only drop might be advisable. Sometimes the antibiotic is not helping or can even be irritating to the eye and it probably isn't necessary at this time.
On herbal medicine, I think that there are lot of of times when herbs can be effective, or partially effective, in the treatment of medical conditions in dogs and cats. However, it is hard to find exact dosing information and often hard to understand the rationale behind various combinations of herbs in products or in recommendations for herbal use.
I am not very familiar with Joel Hyman, although I have seen his name mentioned on a couple of web sites about herbal medicine.
In the "PDR for Herbal Medicines" alfalfa is listed as having unproven use for diabetes and thyroid disease, marigold is listed as having positive effects in the treatment of HIV and other viral illnesses, and I can't find acadia. There is a section for acacia, though. If that it is the third medication, then it is used for oral inflammation and diarrhea based on the information in the PDR. Not being an herbalist, I can not say that there are not other uses, or that combinations may have effects not listed under the individual herbs. There do not appear to be contraindications for using these herbs in combination with glucosamine and chondroitin or the other medications you mentioned in your note.
Hope this helps some.
Mike Richards, DVM
My name is Amanda, and I am doing a science fair, and I am going to do it on the eye cells of my dog. He is a pug, and he only has one eye, we are trying to find information on why his eye just shrunk and if the eye cells are dead. If you have any information about this kind of stuff, if you have any other related information to this anything will do. Thank you! Amanda Junior High student
Collapse of the eye is referred to as "phthisis bulbi" and the appearance of a sunken eye is referred to as exophthalmoses, so as you search for information, it might help to search on these terms.
The most common causes of phthisis bulbi are traumatic penetrating injury to the eye, corneal ulcers that are severe enough to cause collapse of the eye and degenerative diseases that destroy the function of the eye and eventually lead to collapse. Examples of the last set of causes would include glaucoma and cancer of the eye. Some dogs are born with smaller than normal eyes. If they eye has normal function this is referred to as nanopthalmos and if the eye has defects the condition is referred to as microphthalmos. I do not believe that either of these conditions is common in pugs.
My guess is that most pugs that have collapse of an eye probably have this due to a corneal ulcer or perforation of the eye due to trauma because their eyes are very prominent and are more easily injured due to this. Sometimes there are problems with the lids shutting completely in pugs due to the prominence of the eye, or irritation to the eye from folds of skin on the face rubbing the eye surface, which lead to corneal irritation (keratitis) and then eventually a corneal ulcer.
It is sometimes possible to determine the cause of collapse of an eye with ultrasound examination or removal of the collapsed globe and histopathologic examination of the eye tissues. These tests would not give any hope of a return in function of the eye and would be most appropriate when cancer is the suspected cause of the collapse, probably.
I hope that this helps some.
Mike Richards, DVM
Q: Dr. Richards,
In February I wrote with questions about my 5 year old Golden Retriever who had just been diagnosed with Horner's syndrome. Our Vet said it would take up to 4 months for the symptoms to go away and he was right. It took every bit of four months. By the end of June, the eye was looking perfectly normal again. But then another problem developed. He developed skin lesions, some hair loss and seborrhea. I initially thought it was allergies since Goldens are so prone to skin allergies. But after battling for most of this summer with medicated baths, Benadryl and antibiotics for his skin, our Vet suggested we test his Thyroid gland to see if his T4 level was low. It was 1.3 (normal range = 1 - 4). So we started him on Soloxine twice a day and the sores, seborrhea, and allopecia have improved remarkably.
As we were leaving the office following our recheck visit, our Vet mentioned that they (Veterinarians) are taught that if a dog develops Horner's Syndrome you should consider checking the thyroid gland function. I was just wondering what the correlation is between Horner's Syndrome and Hypothyroidism? Does one tend to lead to the other?
In a study of 100 dogs with Horner's syndrome, 9 of the dogs had concurrent hypothyroidism (Jaggy, et al, 1994). It has been argued that this is a higher than expected number of dogs with hypothyroidism than would be expected, so there must be a correlation between hypothyroidism and Horner's syndrome. It has also been argued that this is about the number of dogs who are expected to have hypothyroidism in a population of 100 dogs, especially when age is factored in. At the present time, I think that all that can be said is that there is a weak link between hypothyroidism and Horner's syndrome. Facial paralysis has also been linked to hypothyroidism, in a similar manner and sometimes facial paralysis and Horner's syndrome occur together, too.
I know that doesn't clear things up very much but there doesn't seem to be a really clear answer to your question based on a review of the literature, at this time.
Mike Richards, DVM
Q: I wrote to you recently about my dog, Dandi, who had a hemangioma taken out, and everything went well. My dog is an 11 year old mix breed, and is never sick. After this I found two more small lumps on my Dandi one on his front left leg and one on his hind leg. My vet said the one on front was probably just fatty tissue and the one on the back was like a wart. That thrilled me. I did forget to mention he does have a couple of these wart like things around his left eye (tiny little warts), and he once had like a little sty removed from his right eye which grew back but does not seem to bother him.
I noticed something new last night too. His eyes are reflecting in the pupil area like they never had (kind of like cataracts). I am very paranoid about this, because my very loved Irish Setter had diabetes and then cataracts and went blind. I taught her all the blind dogs stuff around the house and she was doing great when she all of a sudden got acute glaucoma with high pressures in both eyes causing her a lot of pain. They were able to bring the pressure down in one eye but not the other I brought her to a ophthalmologist and surgery was not an option, and because she was so ill I had to put her to sleep.
A: Most dogs develop hardening of the lenses of their eyes as they age. This causes the lens of the eye to become slightly opaque in the center region, changing the way the eye looks when light hits it by producing a bluish tinge where the color was previously bright green (usually). This process is called nuclear sclerosis and becomes noticeable on close examination around eight to ten years of age and becomes more obvious with time. In most cases it will never become severe enough to cause loss of vision but it probably does reduce visual acuity. You should mention noticing this change on the next visit to your vet, so that you can be sure this is the problem. It is important to remember that this is a process that affects the lenses, inside the eye. If the surface of the cornea (the clear outer portion of the eye) is getting cloudy, that is a much more serious thing and does require immediate attention from your vet.
Hope this helps.
Mike Richards, DVM
Q: Dr. Mike,
My 8 1/2 year old Dalmatian "Mugs" recently started to "rust". His eyes are weepy and rusty under the eye area as well as around his mouth. Of course every where he licks becomes rusty from his saliva. He hasn't experienced any environmental changes which might have triggered an allergic reaction. Earlier this summer he was treated with antibiotic drops for an eye infection. His eyes were very mattery at the time of treatment but not "rusty". He has never experienced this type of rusty condition. I'd like to know if parasites or mites of some type could be the cause. He is otherwise in healthy condition. He does take daily doses of soloxine for his thyroid condition. Please reply with any info you may have.
Thank you, Kathleen
The bronze or rust color in the tears and around the mouth are due to bacteria breaking down porphyrins, which are part of the heme molecule that carries the iron in the blood stream. This can happen in tears or in saliva. For this reason, tetracyclines will often help to control the staining. This is probably not the best use of an antibiotic, though.
When there is discoloration around the mouth, it is important to look for dental problems, for infections in the folds around the mouth and for disorders that cause generalized itchiness and lead to secondary bacterial infections. Allergies are very common in Dalmatians. Most commonly these are inhaled allergies (atopy) but Dalmatians also get food allergies and they seem to be more prone to this than many breeds.
For discoloration around the eyes, it is best to look for changes in the anatomy of the eyelids that sometimes occur with age and allow tear flow over the eyelids, disorders that irritate the eyes, such as glaucoma, allergies and uveitis and to also check for tear deficiency which can actually cause periods of increased tearing early in the disorder. Since allergies appear on both of these lists, they have to be strongly considered. I do not know how common allergies are in Alaska, though.
Sometimes, resistance to bacterial infection drops with hypothyroidism. If it has been awhile since thyroxine levels have been checked, to be sure they are in the normal range with the supplement, it might be a good idea to check on those levels.
Hope this helps some.
Mike Richards, DVM
Q: I had a question about Neuclear Ventricullar Sclorosis.
I am not familiar with the term nuclear ventricular sclerosis. There is a condition referred to as nuclear lenticular sclerosis, which affect the eyes of pets and I have seen the term ventricular sclerosis used to describe scarring associated with heart muscle damage, though.
I suspect you are looking for information on nuclear sclerosis of the lens of the eye, though. This is a normal age related change that occurs in the lens of the eye. At about 8 years of age in dogs and about 10 years of age in cats it is usually possible to see cloudiness in the lens of the eye and the reflection from the eye may change from green (or red) to a hazy blue color. This happens because the lens is a very special tissue. In order to be clear so that light can pass through it, the cells in the lens have be oriented just right and there can not be a blood supply -- or you would see red all the time. The lens adds new cells from the edges, making the center cells get more compact as time goes on. Eventually they become compact enough that cloudiness occurs. This would be more of a problem if dogs had to read or if they were strongly dependent on central vision but they don't read and they don't lose the ability to see movement which is more of a peripheral vision ability. So most dogs with lenticular nuclear sclerosis will continue to see well enough to get around for the remainder of their lives. The same is true for cats, although we do have a few cat patients who live long enough that this change does eventually seem to affect their vision some. When I am not sure if a problem is a cataract or nuclear sclerosis I send the patient to an ophthalmologist but this doesn't happen very often.
Hope this helps some. If this reply is way off the mark and you are looking for information on an entirely different condition that I don't know about I'll be glad to look into it for you.
Mike Richards, DVM
Q: I just heard about retinal folds and PPM's being present in some belgian pups. Marked weight loss in the mother was present during early pregnancy. I'm unfamiliar with both retinal folds and PPM's. Please discuss retinal folds & PPM's as they might relate to maturation. Also please give info on the heritability of these conditions in respect to belgians as a breed. Thanks.
Persistent pupillary membranes are present as a congenital abnormality in many dog breeds on an occasional basis and are known to be inherited in Basenji's. I am not aware of evidence of inheritance in Belgian shepherds but could not be sure it wasn't a problem. Most of the time persistent pupillary membranes cause no harm but most ophthalmologists do advise against breeding dogs with this condition, just to be cautious. If a dog was very good and had many other attributes that would be beneficial to its breed this would be a hard decision to make, though.
I am not sure if you are referring to retinal dysplasia when referring to retinal folds as a problem. Retinal dysplasia is abnormal development of the retina and can include folds and other defects in the retina. This is a condition that is thought to be inherited in a number of dog breeds. There may be no visual defect discernible in affected dogs, so this may be a problem that is only found when the eye is examined. Despite this, since it is an inherited defect that is thought to be an autosomal recessive trait, a case can be made for avoiding breeding. This is especially true in Labrador retrievers, samoyeds and English springer spaniels, since the condition in these breeds is associated with other genetic abnormalities (according to Wheeler, in Morgan's Handbook of Small Animal Practice). I do not know the situation in Belgians.
This condition can also be acquired as an injury or due to viral infections, toxins and nutritional disorders (probably a rare cause).
If I run across anything specific to Belgians, I will try to remember to post it online.
Mike Richards, DVM
Q: Hi Dr. Mike!
Well it's me, the infamous pug rescue lady again..doing her deal. Actually, we have affiliated with a rescue in Missouri where the puppy mill horrors of the world are, and recently were contacted by a breeder who had a litter of puppies with horrid eyes, the breeder referred to them as "sick" eyes. She added that the bubble-like cysts in the eyes either go away in three weeks, or the puppies die. Apparently the mother has the same looking eyes, but there were other breed puppies nursing nearby who appeared to be fine. My question...could this be a herpes type infection - we cannot seem to find adequate information to point us elsewhere. If so what it the prognosis...is this contagious, and is treatment possible?
Thanks Dr. Mike. Pam
It is supposed to be possible for dogs to have herpes virus corneal infections but they are supposed to be pretty rare. I didn't find any references to outbreaks among litters.
There seem to be a fair number of pugs who develop tear deficiencies or who have an inability to completely close their eyes due to the bulging nature of their eye anatomy and sometimes multiple members of a single litter are affected by this combination of problems. The current approach to this problem is to close the eyelid margin surgically, just enough to allow these puppies to close their eyes. Using artificial tears or a tear production stimulant like cyclosporin might also help, if this is the problem. Measuring the tear production is pretty easy and most veterinary hospitals can do this. Evaluating whether there is a problem with the lids closing is a little harder and it may take observation by a veterinary ophthalmologist. Problems like distichiasis (eyelashes arising from the lid margin which irritate the eye) can also lead to early signs of corneal damage.
If I find anything more about herpes causing eye problems in dogs I'll try to remember to send it to you or post it on the site.
Mike Richards, DVM
Q: Dear Dr. Richards,
I recently subscribed to vetinfo and would like to ask a question. For several months now, my five-year old female German Shepherd has been having greenish-yellow discharge in her eyes, especially her right eye. Also, the pigment on her nose was very dry and chapped for a while and now is a dry pink. I took her to my regular vet who gave me some type of cortisone pills to be given to her for a about a month and a half. It helped a little but now her eye seems to be even worse. My vet referred me to an animal dermatologist who could possibly check her for allergies. He said that the nose problem may be some type of lupus and he gave me an ointment to try and see if that helps. Well, as soon as I put it on she just licks it off so I can't tell whether it is working or not. I am more concerned about her eye, however. He said he suspected it was an allergy and gave me some drops to put in her eye but it is extremely difficult for me to get the drops in her eye. Her eye is very red and the discharge is constant. I wipe her eye with a wet towel but I have been very unsuccessful with the drops. My question is: can you suggest anything else that I can do for her and also, is there any danger in her having this infection for so long?
Thank you so much for your help.
German shepherds get several disorders that can lead to chronic runny eyes. Allergies are probably the most common cause of conjunctivitis in dogs. This is irritation of the pink tissues of the eyes which can lead to eye discharges. However, German shepherds get a pannus, which is an immune mediated condition that can lead to eye pain, corneal damage and conjunctival signs. There are also some dogs with discoid lupus or phemphigus that develop conjunctivitis. This sounds possible in your dog's case due to the history of nasal problems as well. Due to the potential need to treat dogs with discoid lupus or phemphigus for life, it is usually better to get a biopsy sample and try to confirm that one of these illnesses is present if it is necessary to go to systemic medications (oral medications, injections).
Topical corticosteroids will sometimes work well despite the fact that dogs lick a lot of the medication off of their noses. They do not always work, though. Eye drops are sometimes very hard to administer. It helps to remember that it is the upper lid that has most of the motion, so that is the one to gently press upwards in order to administer the drops. If you can't use drops it may be necessary to use pills. This does mean that you are treating the whole dog to get the eye problem under control, though.
I have a number of clients who have trouble with eye drops and I have a canine patient who I can not successfully administer eye drops to, so you have a lot of company in this difficulty.
If cortisones did not help the eyes it would be a really good idea to get a veterinary ophthalmologist to look at your dog. I know that it gets old running around to different specialists, but sometimes it really does help a great deal.
You might also want to ask your vet's technician to show you how to administer eye drops. Sometimes, seeing how someone else does this can help a great deal.
I wish I could help more.
Mike Richards, DVM
Buttons Update - Not Blind
Update: It's been a long road, but finally some good news about Buttons. We thought he was blind after having an ulcer on his eye, but it has healed and he is seeing just fine. After having nausea with Lysodren for Cushings, our vet told me to give him half the dose for twice as long. Buttons is a strong willed dog and I had a gut feeling that he could do this with a lot of TLC, so I didn't do what I was told. Instead I gave him half the dose one day, 3/4 the next, and followed with the full dose and he has been taking it ever since with no side effcts. His last dose will be this Sunday, then we'll start on the Prednisone.
Buttons is beautiful, his eyes are big and bright, he looks better than I have seen him in about 2 years. We were able to have him groomed for the first time in 3 mths. today. We are beside ourselves with wonder at how he has come out of all the problems, just keeping our fingers crossed that there is no relapse, time will tell! I hope that you have printed all the letters I sent so that others can read them and realize that there is hope, it just takes a very firm commitment on the owners part to do everything necessary for the welfare of the animal. Being a retired RN, I never had a problem with all the meds and treatments, I was just very determined to get this dog well. It has taken myself, our Vet and you to accomplish what looked like an impossible task at the beginning. I include you because it was your recommendation to test for Cushings that motivated our Vet to do just that, I thank you very much for that and also for being there and listening and encouraging me. It's been a tough battle, after spending many nights in tears over Buttons, finally, all is well. Thank you again, Joan
I am glad to hear that Buttons is doing better and that you were able to help him get through all the problems. He is lucky to have a dedicated owner!
Q: Dr. Mike,
It's been a while since I wrote last, there's been a lot going on with Buttons. The Demodectic mange seems to be improving with Ivermectin. He was tested for Cushings with positive results, he was started on Lysodren 500 mg., 1/3 tab daily, gave him one pill and he became nausious the next morning, gave him Prednisone 10 mg. and he improved shortly, called the vet and stopped the Lysodren. This was a week ago, still waiting to see what we are going to do. In the meantime, his left eye became runny and closed, took him to the vet (we had already had an appt. for that day), he has an ulcer on that eye, vet stained it and gave us Triple abx oint. to apply 3 times daily, also Vitamins and Iron as he did a CBC and found he was still anemic. We're very concerned as he doesn't seem to be able to see very well, he has to nudge with his nose to locate his food and water bowls. He manages to get around okay, but of course, he knows the house well. It seems like there is a drama unfolding day by day. Can you give me any encouraging words about all of this? Thanks, Joan
One more thing that is very strange, Buttons eyes are now opened very big, what I want to say about that is that the only time w have ever seen his eyes so big is during a thunderstorm when he's upset, don't know what to think about this?
The wide open pupils may be an indication that Buttons has become blind, especially with the other signs you have observed. There is some chance that this could be due to hypertension, as that is a common problem in dogs with Cushing's disease. Hypertension can cause retinal hemorrhaging and sudden onset of blindness. This is more common in cats, although the hypertension is usually due to renal failure in cats. An ophthalmic exam to see what is happening with Button's eyes would be a really good idea. Blindness from hypertension will respond to therapy for the hypertension in many cases.
There are times when administration of Lysodren (Rx) will bring on a sudden onset of neurologic problems that are actually due to the Cushing's disease. I don't think this occurs very often with the first treatment, but I couldn't be sure it wouldn't happen that way, either.
Sudden acquired retinal degeneration (SARDs) is a condition in which the retinas deteriorate very rapidly for reasons that are not entirely clear. However, this condition is seen more often in dogs with hyperadrenocorticism than in dogs that do not have Cushing's disease. This is actually the most likely problem, probably. It is not a treatable condition. It can be difficult for dogs to adjust to the blindness in these cases because it comes on so suddenly. However, most dogs do adjust and if their environment is kept pretty constant (don't move the furniture much) they do well.
I know that wasn't a very encouraging note.
If Buttons can't tolerate treatment with Lysodren, there is selegiline (Anipryl Rx), which is also approved for the treatment of Cushing's disease. It doesn't work as fast and it doesn't work as often, but it doesn't cause as many side effects. It is especially worth considering in a dog in which Lysodren is known to be problematic.
I know that this is all pretty discouraging. It doesn't seem fair when you do the right things and find out what is going on, treat it properly and problems still occur. If you hang in and keep working towards getting the hyperadrenocorticism under control there still is a chance that Buttons could have a good quality of life, even with persistent blindness. The next few days will tell you if he is able to cope with this new problem, too.
Mike Richards, DVM
Q: Hi Dr. Mike,
I am a former Veterinary Technician and a new subscriber to Vetinfo Digest. I am writing because my 5 year-old Golden Retriever, Midas, was recently diagnosed with Horner's Syndrome. A few weeks ago we arrived home to find his lower left eyelid was drooping and his eye appeared smaller than usual --almost to the point where you could hardly tell there was an eye there at all. With no history of injury or illness, we assumed that our other dog may have scratched the cornea since they play together often. Of course, this occurred on a weekend, so I rushed him to the only place where I could get an appointment, an Emergency Clinic. They diagnosed him with Uveitis (no scratch evident with staining) and prescribed a Triple Antibiotic Ointment with a steroid for a few days.
Three days later, with no improvement we took him to our regular Vet for a recheck. He diagnosed him with Horner's Syndrome, an eye disorder that he says is common among male Goldens of his age. He recommended we continue applying the ointment and also prescribed Atropine eye drops twice a day. Unfortunately, he said the symptoms could take up to 4 months to go away. Although he doesn't seem in pain or uncomfortable, I am concerned about how this may effect his sight and any long term neurologic problems that may be ahead. Do you recommend we seek an eye specialist to treat this kind of disorder? Will this be a chronic problem that will continue throughout his life? I would appreciate any information you could offer or recommend.
It can be pretty hard to differentiate Horner's syndrome from uveitis when it first occurs, so I can easily understand the EVC vet's initial diagnosis.
Goldens do seem to be prone to Horner's syndrome. Most of the time it occurs for no discernible reason and most of the time it eventually clears up but it may take months, as your vet has said. It isn't actually necessary to treat for Horner's syndrome but it may make the eye more comfortable and it usually makes it look more normal to treat.
I don't think that it is necessary to see an ophthalmologist for treatment of this condition but it may be worth a visit to an ophthalmologist if it doesn't clear up.
Horner's syndrome occurs due to damage to the sympathetic nervous system (part of the autonomous nervous system). The damage can occur in the brain, in the spinal cord or along the path of the sympathetic nerve after it exits the spinal cord, travels through the chest, under the front leg, along the neck, past the middle ear and back to the eye. This makes it possible for the damage to the pathway to occur in a number of ways. Head trauma, brain tumors, other brain damage, hormonal illnesses affecting the brain (hypothyroidism and hyperadrenocorticism have both been implicated), damage to the spinal cord, chest injuries, chest tumors, injuries causing pressure on the area of attachment of the front leg to the body, neck injuries and middle ear infections can all lead to Horner's syndrome. Thinking about all these possibilities is necessary even though lots of times Horner's syndrome occurs for no discernible reason.
The most common complicating illness is probably inner ear infection. Some vets advocate using antibiotics or doing diagnostic testing (X-rays or even MRIs) to rule out inner ear infection as a cause.
I don't personally believe there is a strong correlation with hypothyroidism but this is common in goldens, too. So it might be worth considering testing for this problem.
If, after a careful exam, none of the above problems seems likely, the best thing to do is wait and see what happens. I think that most of the time Horner's syndrome does improve on its own. It can take several weeks to several months.
Medicating the eye is supposed to be unnecessary unless the degree of third eyelid elevation or globe retraction seems to interfere with vision. I have mostly seen recommendations to use phenylephrine long term when treatment is necessary.
It is possible to partially localize the point of damage to the sympathetic nervous system by placing phenylephrine (usually 10%) drops in both eyes and then watching the dilation of both eyes, checking every few minutes for about an hour. Rapid dilation of the affected eye and slower dilation of the normal eye is suggestive of a lesion along the path of the nerve returning to the eye (postganglionic lesion). This can guide further testing in cases in which there is not a reasonably rapid return to normal. Ophthalmologists have the most experience evaluating this test and may have access to imagining equipment that can help to localize the lesions.
Hopefully, Midas will have the self correcting version of this problem. If he does develop balance problems or other signs of neurologic disease affecting his face, try to rule out inner ear disease. The facial nerve also is sometimes affected in inner ear disease.
Mike Richards, DVM
Q: Dr. Mike Richards,
About six weeks ago, my peekapoo, Bitzi, had eye removal surgery. She had developed glaucoma. She had been blind from cataracts due to diabetes for about two years. We also believe that her diabetes developed from Cushings disease. Bitzi was treated for the Cushings with Lysodren. After her initial dosing phase, she was given an maintenance dose for awhile. After a routine ACTH Stim test, her vet recommended stopping the Lysodren altogether because Bitzi was in danger of becoming Addisonian.
So, anyway, after her eye surgery she developed a severe itchy sore on her chin. When this sore did not respond to treatment we did a biopsy on it. The results of the biopsy were that the sore was calcinosis cutis. Bitzi's vet said that calcinosis cutis was caused by Cushings so we did a dex suppression test to confirm. The dex suppression test came back negative. Can you think of any reason that my dog should have calcinosis cutis? Her kidney values are good. She has not been exposed to any chemicals. The only thing that I can think of that has been different for her is she no longer has her eyes. The opthomoligist who did the surgery inserted silicone prosthesis before he stitched her eyelids shut.
Also, after her surgery she had a really bad reaction to the morphine type pain-killer she was prescribed. We are treating her neck with DMSO applications once a day and there seems to be a little improvement. This problem has been very uncomfortable for her and I would like to make it go away. She needs to have some peace and pain-free comfort after all she has gone through. If you have any suggestions I would really appreciate them. I would do about anything to help her. Our veterinarian is very open to suggestions, also.
Thanks for anything you can offer, Carol
I think with the history that the most likely problem is that the Cushing's disease (hyperadrenocorticism) is still the problem. Lysodren (Rx) kills adrenal gland tissue. If enough of it is given, it will destroy the adrenal gland's ability to produce cortisol and the patient will develop Addison's disease (hypoadrenocorticism). When a dog has hyperadrenocorticism the adrenal glands continue to hypertrophy (to grow) throughout the course of the disease, either in response to a stimulating hormone (ACTH) being produced by the brain or because the adrenal glands are affected directly by cancer. Most vets in the United States try to give enough Lysodren (Rx) to kill just enough of the adrenal gland at a time to keep it functioning at a normal level --- so as the brain stimulates the adrenal gland more, the medication destroys its ability to respond, keeping a balance. In some countries and in some cases in the United States, vets just give enough Lysodren (Rx) to destroy the ability of the adrenal gland to function and then treat the patient for hypoadrenocorticism (Addison's disease).
Your vet elected to stop short of killing the adrenal gland. The adrenal gland was very suppressed but would still be stimulated by the brain or cancer to grow and produce more hormone. Even though it has taken some time, it is likely that she now has hyperadrenocorticism again. Of course, there is no way to be sure of this except by repeating the lab tests (dex suppression or ACTH stimulation). It seems to me that would be a good idea at this point. If the tests do not support a diagnosis of Cushing's disease it may be necessary to think through the problem again.
To the best of my knowledge, calinosis cutis only occurs in response to Cushing's disease. So it is a pretty good hint that the problem has returned.
Mike Richards, DVM
Q: Hi -
I got into the cybervet because I have a 13 year old westie who is now crying after she eats. She walks around with her pillow in her mouth wailing for @ 15 minutes, no matter how much food I give her (tsp or plate). She has been to the dog psychiatrist in the past for faking limping, but I would never forgive myself if she had a stomache problem and I dismissed it for that. Also, she has a malignant tumor in her arm pit 1.5 years ago, so I wanted her checked out. My regular vet is on vacation until 8/11 so I took her to the associate who said she was faking for attention. I am not comfortable with this, so I am taking her to the regular doctor when he returns. Do you think this is a real problem? Please help!!!
You should watch very very carefully for signs of swelling around either eye with the symptoms you are seeing. There are a number of potential causes for pain around the time of eating but the most serious one is a retrobulbar abscess, or an abscess that forms in the space behind the eye. These can cause serious problems fairly quickly, including blindness and in severe cases, death. In most cases, dogs with retrobulbar abscesses are really pained by having their mouths opened -- some dogs refuse to allow this and others just scream when someone attempts to open the mouth beyond a certain point.
Our dog had a retrobulbar tumor and had similar signs -- but she would open her mouth part way before it hurt. She continued to eat but sometimes acted as if she was in pain afterwards. So this would be a concern, too.
Dogs that have periodontal disease will sometimes have pain but I can't recall a patient having severe pain for fifteen minutes after eating.
Dogs with marginal liver function can have behavioral changes associated with the period immediately after eating. In severe cases this can cause severe neurologic signs, including stupor or seizures.
Older dogs get a condition known as canine cognitive dysfunction that can cause odd behavioral signs. We have one patient in our practice who wailed for ten to fifteen minutes at a time, several times a day who responded well to selegiline (Anipryl Rx), the medication approved to treat this condition.
Gastric problems are conceivable, as well.
Westies are prone to craniomandibular osteopathy. If she had difficulty with this as a puppy, there is some chance that she has arthritis in the mandibular joints now. This can happen without having the craniomandibular osteopathy, too. Recognizing TMJ in dogs isn't easy, since they can't complain effectively.
I think that it is worth continuing to look for a medical cause of this problem, personally. I am sorry that the list of differential diagnoses for the symptoms is long enough to make it difficult to search through. Please keep checking to be sure she can comfortably open her mouth and that there is no visible swelling around one eye. If these signs develop, don't wait for your regular vet.
Mike Richards, DVM
Michael Richards, D.V.M. co-owns a small animal general veterinary practice in rural tidewater Virginia. Dr. Richards graduated from Iowa State University's College of Veterinary Medicine in 1979, and has been in private practice ever since. Dr. Richards has been the director of the PetCare Forum...