Bilateral keratoconjunctivitis sicca in a horse

Episcleral cyclosporine A implants for the management of unilateral keratoconjunctivitis sicca in an 8-year-old mare

An 8-year-old mare was presented for investigation of a 1-month history of blepharospasm, eyelid swelling, corneal edema, and ocular discharge of the right eye (OD). Ophthalmic examination confirmed mucopurulent ocular discharge, conjunctival hyperemia, and a dry, dull appearance to the cornea OD. Schirmer tear test results confirmed an absence of tear production OD (0 mm/min) consistent with keratoconjunctivitis sicca. Treatment with topical 0.2% cyclosporine A resulted in an improvement in clinical signs. An episcleral cyclosporine A implant was placed under standing sedation 5 days after initial presentation. Re-examination 9 days post-operatively confirmed that the mare's tear production in the right eye had improved and no further clinical signs had been observed. Topical medications were gradually discontinued. Re-examinations performed up to 12 months postsurgery showed no recurrence of clinical signs and no adverse effects of the implant. To our knowledge, this is the first report of the use of a cyclosporine A implant in the management of KCS in a horse and highlights its potential as an effective, alternative therapy in the management of KCS in horses.

Bilateral parotid duct transposition for keratoconjunctivitis sicca in a Connemara stallion

A 7-year-old Connemara stallion was presented with a 4 month history of blepharospasm, recurrent corneal ulcerations, mucopurulent ocular discharge, and keratoconjunctivitis sicca (KCS) in both eyes unresponsive to medical therapy. Ophthalmic examination revealed lackluster corneas, axial corneal scarring and pigmentation with associated neovascularization, and absolute KCS in both eyes. Computed tomography scan and endoscopic evaluation of the upper airway and guttural pouches revealed no structural abnormalities to indicate neurogenic KCS. The stallion was diagnosed with immune-mediated dacryoadenitis as all other causes of KCS were excluded. Parotid duct transposition (PDT) was performed in the right eye followed by PDT in the left eye 4 weeks later. The right PDT was functional 2 years post-operatively with significant improvement in ocular comfort and reduced corneal fibrosis and neovascularization. The left PDT developed a salivary-cutaneous fistula over the left masseter muscle post-operatively due to avascular necrosis of the distal parotid duct (PD). Surgical reconstruction of the PDT using an expanded-polytetrafluoroethylene (e-PTFE) tube graft, an e-PTFE tube graft to autogenous caudal auricular vein graft, and an autogenous saphenous vein graft were all unsuccessful. Tear production in the left eye improved at 1 year post-surgery as a result of long term lacrostimulant therapy, and a permanent PD-cutaneous fistula was performed on the left PD at the level of the ventral mandible. Bilateral PDT in the horse is effective in resolving clinical signs associated with KCS; however, morbidity associated with avascular necrosis of the transposed PD may be significant and can result in surgical failure.

Keratoconjunctivitis sicca attributable to parasympathetic facial nerve dysfunction associated with hypothyroidism in a horse

CASE DESCRIPTION

A 6-year-old 680-kg (1,496-lb) German Warmblood gelding was evaluated because of bilateral blepharospasm and head shaking.

CLINICAL FINDINGS

Moderate blepharospasm was evident bilaterally, and both eyes had hyperemic and edematous conjunctivas and lusterless corneas. For each eye, the Schirmer tear test value was only 7 mm/min. The horse's nasal mucosa was dry. Abnormal behaviors included mild repetitive vertical movement of the head, snorting, and flehmen response (classic signs of head shaking). Touching the horse's nostrils and face revealed paresthesia and dysesthesia with slight nasolabial muscle hypertrophy bilaterally. Cranial nerve examination revealed no other abnormalities. Serum thyroxine concentration was low, and results of thyrotropin-releasing hormone and thyroid-stimulating hormone stimulation tests were negative, indicating that the horse had hypothyroidism. The diagnoses included keratoconjunctivitis sicca and dry nares attributable to parasympathetic facial nerve dysfunction, head-shaking syndrome with paresthesia and dysesthesia of the face attributable to sensory trigeminal nerve disorder, and hypothyroidism. The 2 nerve dysfunctions were considered peripheral neuropathies that were most likely caused by hypothyroidism.

TREATMENT AND OUTCOME

Treatment of both eyes was initiated with topical applications of cyclosporine, 0.5% sodium hyaluronate, and vitamin A ointment. Levothyroxine (20 microg/kg [9.1 microg/lb], PO, q 24 h) was administered. Within 3 weeks to 4 months, serum thyroxine concentration was within reference range, and clinical signs and Schirmer tear test values improved.

CLINICAL RELEVANCE

Hypothyroidism should be considered as a differential diagnosis in horses with peripheral neuropathy or keratoconjunctivitis sicca. In affected horses, administration of levothyroxine may lead to resolution of neurologic signs.

The precorneal tear film in horses: its importance and disorders

The precorneal tear film (PTF) is of critical importance in the physiologic and pathologic findings of the cornea. Clinicians should recall that quantitative and qualitative disorders of the PTF can be a cause of corneal diseases as well as a clinical sign of ocular surface diseases. It is also important to consider that some systemic and topical treatments may affect the PTF volume and composition. Not all interactions are known at this time. There is a continued need for basic research into PTF components in healthy and diseased equine eyes, because much remains unknown. Until additional basic information about the biochemical composition and pH of the PTF as well as the interactions between equine corneal pathogens and specific PTF deficits becomes available, it will not be possible to define the cause and effect relations precisely between the various ocular surface diseases and deficiencies,excesses, and imbalances of PTF components. It is quite possible that a number of equine corneal diseases may be manifestations of qualitative PTF disorders.

A comparative approach to topical cyclosporine therapy

Topical cyclosporine has been used by veterinary ophthalmologists since 1989 for the treatment of ocular surface inflammatory disease and keratoconjunctivitis sicca (KCS). As well as ameliorating clinical signs of ocular surface lymphocyte-driven inflammation in the dog, cat and horse, topical cyclosporine significantly raises tear production in both normal and KCS-affected animals. A licensed ointment preparation of 0.2% cyclosporine, Optimmune (Schering-Plough), is now available for administration to dogs. In this paper we examine the mechanisms by which cyclosporine exerts both its immunomodulatory and its lacrimogenic actions. The pharmacokinetics of topical cyclosporine are examined to determine whether these effects are truly local or are influenced by generalised immunosuppression caused by systemic absorption of topically applied drug. The paper reviews the few side effects of cyclosporine preparations in the experience of veterinary ophthalmologists and the experimental evidence which appears to implicate the vehicle rather than the active agent cyclosporine as causing many of these effects. Given that topical cyclosporine has been so widely accepted as a valuable ophthalmic preparation in the veterinary world and licensed as such, it is surprising that human ophthalmologists have not employed the drug to the same extent for conditions from vernal keratoconjunctivitis to Sjögren's syndrome.