Treatment for Emma’s neonatal conjunctivitis.
In this case, since Emma was only 9 days old, we wanted to avoid surgery at all cost. A vet can use anesthesia to open the eyelids in cases where they are still closed, flush the eye, instill eye drops and suggest home treatment afterwards. Because the eyelids are not meant to be open that early mechanically (before they are ready on their own), tear gel or artificial tears will need to be applied every 2-4 hours in the eyes because puppy have limited tear production abilities.
But, because I wanted to avoid any type of surgery and anesthesia on Emma, we elected to try lukewarm compress on her eyelids. We took cotton balls with lukewarm water and gently applied it to left eyelid (about 2 minutes of compress). Then we gently did a small left to right movement with the cotton ball and pus stared to come out from what we call the medial canthus area (the area where the left eye corner is the closet to the nose). We did this 4-5 times a day and after 72 hours, pus stopped coming out. We also applied over the counter polysporin eye drops every 4 hours (even if her eyelids were closed). We aimed to get in the same area where the pus would come out. If pus can drain, that means there is a hole and hopefully eye drops will get in from that same hole. About 5 days later, she opened her eyelids naturally. She reacted with a tiny yelp when polysporin was applied, so we discontinued that. She was now 14 days old. We switched from polysporin eye drops to fucithalmic gel and we kept doing artificial tears for a few days.
A few days later, her eye took a turn for the worst. Basically, the epithelium of her cornea detached itself from the stroma of the cornea (formed a liquid bubble). The eye looked mushy like what we see in a burst eye (perforated eye) or uveitis, but it looked bigger like we see in glaucoma cases (bupthalmia).
Once her left eye started to bulge out to the point her eyelids would not close over it, it seemed painful. This happened in under 24 hours, going from an almost-normal looking cornea to an abnormal looking eye that looked like it had ruptured. She started to whine constantly and had to be rushed to the vet hospital for emergency eye surgery (and of course this always happens during a huge snowstorm when the clinic is closed). Emma was put under general gas anesthesia and I was mentally preparing myself to remove an eye the size of an eraser pencil tip, thinking for sure her eye had ruptured for some unknown reason at this point.
While under anesthesia, I used a q-tip to investigate the origin of what I suspected was a hole in her cornea, trying to determine the cause of all of her trouble. Suddenly the bubble popped and liquid started to come out, exactly like we see in ruptured eyes, but imagine my surprise when I saw an intact stroma hidden behind that bubble. Basically, with the q-tip, I tore a hole in what was the epithelium part of the cornea and the stroma underneath was intact!
So, if you look at these pictures, the entire epithelium had detached itself from the stroma and stuck in between was fluid with blood and pus. That meant that the eye itself was not leaking fluid which also meant NO EYE REMOVAL!
After doing some research, the closest thing I found that would come close to describing this condition is a condition called Keratoconus in people. Emma had a condition that I had never seen before and that I could not find documented cases of in dogs. You can see on this image that the cornea is bulging out, so if you try to close your eyelids, well technically that bulge would get squeezed in between them.
We still had a chance to save her eye. So, I debrided the entire epithelium part of the cornea (usually we would do a grid technique on deep ulcer). In this case, the entire superficial layer of the cornea was stretched out, abnormal looking and hiding a pocket of infection/fluid that I suspect came from her original neonatal conjunctivitis. I removed as much of the epithelium as I could, but even under anesthesia the exam of the eye was hard since it was tiny. Looking at her eye, we could see a line when I suspect the infection got in between the lawyers of the cornea (between 10-12 o’clock there was a 3-4 mm line where the sclera and the cornea joined). I suspect this is the tear that allowed the infection to set in. Usually, I would do serum drops in cases where we have deep ulcers, but since this looked superficial and because this was a 1 lbs puppy, we elected not to take blood from any veins to make serum drops. We did a third eyelid flap similar as what you can see in this Youtube video. This protects the eye in hopes to allow the cornea to heal itself. It brings vessels and nutrition to the sick and injured cornea. It keeps the eye moist and allows us to apply medication to the eye with less of a struggle. I usually use a human contact lense more often now days then a third eyelid flap but finding a contact lense that tiny would have been a challenge. So, as a last resort, we had to do a third eyelid flap under anesthesia.
She was put on Artificial tear gel every 4 hours, Oflaxacin (my favourite for Boxers with indolent ulcers) twice a day, Diclofenac twice a day and Atropine twice a day. The third eyelid flap was removed 7 days later and it seems that her cornea is slowly healing. She was also put on a probiotic called Fortiflora.
Emma had a third eyelid flap surgery on December 18th. This is her on December 22th. On the upper left eyelid, there are 3 tiny purple stitches.
December 22th: Emma getting tear gel. We see the purple stitches on her eyelid flap on her upper eyelid.
December 23rd: Emma is drinking from a bottle. Her third eyelid flap still holding well.
December 24th: This is a few minutes after we removed her eye flap. There is still a lot of swelling and corneal edema (blueness on her eye).
December 25th, a lot less swelling
December 26th: Note the eye cornea seems to be healing!
December 26th: Note the cornea is intact and it is beautiful to see this after we thought her eye had ruptured!
December 29th: Her cornea is showing signs of healing!
December 29th: This is about 11 days after her ulcer was noted and debrided, and about 5 days after her third eyelid flap was removed.
December 30th: There is still a lot of swelling with her third eyelid, but once her cornea is fully healed up we will start her on Maxitrol to reduce all that. Her cornea is almost ready, it will be 14 days post-ulcer on January 1st 2014. A few days later, she was started on Maxitrol twice a day for 7 days once we tested her eye with a fluorescine stain to make sure the ulcer was healed up! This will reduce any scaring left on her cornea and allow what we hope is a full return to normality.
January 4th, 2014. Left eye looking a lot better and almost normal!
January 7th, you can barely see a scar in her left eye!
Last update: January 22th, barely not scar visible in her left eye! We will be looking into each herbs and the Immunity support formula that we will be using on these puppies as the immunity series blog progresses. This is more a case presentation so that we may see how she and the rest of the litter progress as we move into re-balancing their immune system. Sometimes even very sick puppies can be supported to make them healthier long term and this is our goal with herbs and natural supplements. Integrative Veterinary medicine means that we combine conventional therapies with natural therapies in order to try and promote a more a healthier life! The goal is to nurse these sick puppies back to health in hopes that we will not have complications related to their immune system as they grow older.
Written by Dr Cindy Lizotte, DVM, MBA, CVFT (CHI institute), CVA (IVAS), Grad Dip Vet Western Herb Med (CIVT) Cert CVHM (IVAS)