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2010/5/12
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老年犬貓常見眼科疾病
胡俊琨 DVM, MS
經歷
• 2004~2007 台大動物醫院 外科住院醫師
• 2006~2007 台大動物醫院 眼科專科門診
• 2008 遠見動物醫院 眼科醫師
• 2008~now 台大動物醫院 外科總醫師
Outline
• Anatomy of eyes 解剖構造
• Dry eye 乾眼症
• Cataract 白內障
• Glaucoma 青光眼
• Retinopathy 視網膜病變
• Neoplasia 腫瘤
• Others (asteroid hyalosis, iris atrophy) 其它
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Anatomy of Eyes
Anatomy of Eyes
Anatomy of Eyes
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Dry Eye
Dry Eye
• Pre‐corneal tear film (PTF)
– Lipid, aqueous, and mucin
Tear’s Function 淚水功能
• Antibacteria 抗菌– Globulins, growth factors…
• Cornea’s metabolic needs 供給角膜養份O2 glucose electrolytes water– O2, glucose, electrolytes, water
• Lubricate cornea, conjunctiva, and nictitating membrane 潤滑角膜、結膜、第三眼瞼
• Remove and flush metabolites, particulate and bacteria 移除代謝廢物、細菌
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Breed Disposition to Keratoconjunctivitis Sicca (KCS)
Breed Relative Risk of KCS
Cavalier King Charles Spaniel 11.5
English Bulldog 10.8
Lhasa Apso 9.8
Shih Tzu 6.2
West Highland White Terrier 5.5g
Pug 5.2
Bloodhound 4.5
American Cocker Spaniel 4.1
Pekingese 4.0
Boston Terrier 2.0
Miniature Schnauzer 1.8
Samoyed 1.7
All breeds 1.0
(Vet Clin North Am Sm Anim Pract, 1990)
Etiology of KCS 乾眼成因
• Congenital alacrima 先天無淚腺
• Neurologic (VII) 神經性傷害
• Drug induced (atropine, sulfonamide) 藥物引起
• Viral infection (CD Herpes) 病毒• Viral infection (CD, Herpes) 病毒
• Removal of the third eyelid gland 移除第三眼瞼
• Autoimmune‐mediated adenitis 自體免疫疾病
• Endocrine disease (hypo T) 內分泌疾病
• Senile atrophy 老年萎縮
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Therapy 治療
• Artificial tears 人工淚液
• Antibiotics 抗生素
• Topical cyclosoprine 環孢靈點眼
• Topical tacrolimus
• Surgery 手術
– Parotid duct transplantation 耳下腺移植術
Cataract
Lens
• 65% water and 34% protein
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Nuclear Sclerosis 核硬化
• Normal aging changes (older than 7 years)
• Progressive fiber formation and internal compression
N i i l• No vision loss
Inherited Cataract in Dogs
• Cocker Spaniel
• Boston Terrier
• Golden Retriever
• Poodle (miniature, toy)
• Siberian Husky
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Therapy
• Ignore ? 忽視?
– Lens induced uveitis 葡萄膜炎
– Lens luxation 水晶體異位
Glaucoma 青光眼– Glaucoma 青光眼
• Surgical removal 手術移除
– Should be performed by a specialist! 由專科醫師執行
– 69%~93% success rate regain vision 成功率69~93%
• PRA, retinal detachment, optic nerve disease
• ERG, ultrasound 視網膜電波圖、超音波
Complications 併發症
• Retinal detachment 視網膜剝離
• Posterior capsule opacification 水晶體後囊混濁
• Corneal edema 角膜水腫• Corneal edema 角膜水腫
• Glaucoma 青光眼
– Hypermature cataract (25%) 過成熟白內障
• Patient compliance and rechecks are critical!! 病患配合度及回診很重要!
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Medical Treatment ?
• N‐Acetyl Carnosine N-乙醯肌肽
– Free radical scavenger– Anti-oxidant effects
• Veterinary research– 30 dogs, 58 eyes
– Some marginal reduction in lens opacification
– Immature cataract or nuclear sclerosis(Veterinary Ophthalmology, 2006)
• Human research– Does not support the 'promising potential‘ in cataract reversal
– More robust data will be required
(Royal College of Ophthalmologists, 2008)
Glaucoma
Primary Closed‐Angle原發性封閉型青光眼
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Clinical Signs 臨床症狀
• Ocular pain 眼部疼痛
• Retinal and optic nerve changes 視網膜及視神經病變
• Vision loss 失明
• Increased intraocular pressure 眼壓上升– Dog 19 (11‐29) mmHg, Cat 20
(14‐26) mmHg
• Dilated pupil 散瞳• Lens subluxation 水晶體異位
• Uveitis 葡萄膜炎
• Dilated pupil 散瞳
• Episcleral and conjunctivalvessels congestion 鞏膜及結膜鬱血
• Bulphthalmos 牛眼症
• Corneal edema 角膜水腫
Dilated Pupil & Vessels Congestion
Bulphthalmos & Corneal Edema
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Primary Closed‐Angle
• 6 ~ 8 years of age
• Predisposed breed – Basset Hound
– American/English Cocker Spaniel
– SamoyedSamoyed
– Siberian Husky
– Chow Chow
– Shar Pei
– Welsh Springer Spaniel
– Bouvier des Flandres
– Flat Coated Retriever
Therapy
• Antiglaucoma medications 抗青光眼藥物
– Decrease aqueous humor production 減少前房液產生
• β blockers
• Carbonic anhydrase inhibitorsCarbonic anhydrase inhibitors
– Increase aqueous humor outflow 增加前房液流出
• Cholinergic agents
• Prostaglandin analogues
• Hyperosmotic agents
Therapy
• Surgery
– Cryotherapy, transscleral lasers, endoscopic cyclophotocoagulation
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Therapy
• Surgery• Gonioimplants, Cullen frontal sinus shunts
• Enucleation, intrascleral prosthesis, chemical ablation
全眼球摘除、人工義眼全眼球摘除 人工義眼
Therapy
• Prophylactic medical treatment 預防性藥物
– 0.5% betaxolol twice/day
– 0.25% demecarium bromide once/day and topical corticosteroid once/daycorticosteroid once/day
– Delay or prevent the onset of glaucoma in 2nd eye
• 8 months vs. 31 months
(JAAHA 2000)
Sudden Acquired RetinalDegeneration Syndrom
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Sudden Acquired Retinal Degeneration Syndrom (SARDS) 突發後天性視網膜退化
• Occur in mid‐life to older animal, mean of 8‐10 years of age 好發8-10歲中老年動物
• Acute 急性
Bli d f d dil t d il l f d– Blind, confused, dilated pupils, normal fundus
• Chronic 慢性
– Tapetal hyperreflectivity, vascular attenuation
• Polyphagia, ployuria, and polydipsia 多吃、多尿、多喝
Progressive Retinal Atrophy (PRA)
Retinal Detachment
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Retinal Detachment視網膜剝離
• Neurosensory retina separates from the underlying retinal pigmented epithelium
• The most common cause
– infiltration of the subretinal space with fluid or exudate
• Risk factor 危險因子– hypertension from chronic renal insufficiency or hyperthyroidism in older animals 高血壓、甲狀腺機能亢進
Ocular Tumor
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Eyelid 眼瞼
• The common eyelid mass
– Meibomian adenoma 瞼板腺瘤
– Papilloma 乳突瘤
Histocytoma 組織細胞瘤– Histocytoma 組織細胞瘤
– Melanoma 黑色素瘤
– Squamous cell carcinoma (cat) 麟狀上皮細胞瘤
• Predisposed breeds
– Beagle, Siberian Husky, English Setter, Labrador Retriever, Golden Retriever, Toy Poodle
• Surgical excision
+/‐ plastic surgery
• Cryosurgery
Conjunctiva & Nictitating Membrane結膜和第三眼瞼
• Conjuctiva
– Squamous cell carcinoma 麟狀上皮細胞瘤
– Hemangioma, hemangiosarcoma, melanoma 血管瘤、惡性血管瘤、黑色素瘤
• Nictitating membrane
– Squamous cell carcinoma 麟狀上皮細胞瘤
– Lymphoma, adenocarcinoma, hemangioma, melanoma 淋巴瘤、惡性腺瘤、血管瘤、黑色素瘤
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Cornea 角膜
• Primary cornea tumor 原發角膜腫瘤
– Rare
• Limbus 異色邊緣
S ll i– Squamous cell carcinoma
• Risk factors: pigmentary keratitis, keratoconjunctivitissicca
– Melanoma
• Treatment
– Keratectomy, Nd:YAG photocoagulation, diode laser, cryotherapy
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Uvea 葡萄膜
• Anterior uvea
– Iris, ciliary body
• Melanoma (60%), adenocarcinoma、adenoma lymphoma (secondary)adenoma, lymphoma (secondary)
Melanoma Canine Feline
Age 9 y/o 11 y/o
Predisposing breed LR, GR, mixed, Schnauzer,Cocker Spaniel
‐‐‐‐
Tumor characteristics Nodular growth Diffuse infiltration
Differential diagnosis Iris cyst, limbal melanoma,Iridociliary epithelial tumorStaphyloma
Benign nevussenile pigment change
Prognosis < 10% metastatic rate 63% died from metastatic disease
• Therapy
– Sector iridectomy/ iridocycyclectomy
– Enucleation / orbit exenteration
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Degenerative Changes
Iris Atrophy 虹膜萎縮
• Frequently seen in older dogs and blue‐eye cat
• Two forms
– Sphincter iris atrophy
M t i Mi i t P dl• Most common in Miniature Poodle
– Stromal iris atrophy
• Toy breeds
Asteroid Hyalosis 星狀玻璃體症
• Degenerative condition, unknown cause
• No correlation with ocular disease
• Common in older and diabetic cataract ipatients
• Asteroid bodies:
– liquid crystals
