Orbit Module 1

Monona

9 year old, female spayed DSH

Start

Created by: Seth Eaton, VMD, DACVO

Where Do You Want To Start?

History &Client Interview

Ocular Examination

Ancillary Diagnostics

Ocular Examination

Patience, patience ...

Ocular examination is the foundational tool a veterinarian uses to assess the eye, develop a problem list, and develop a diagnostic and therapeutic plan.

However, exam findings are most meaningful in the context of a complete history.

So, let's take a beat and reconsider how we want to begin our case.

Let's go back ...

Ancillary Diagnostics

We'll get there ...

Ancillary ophthalmic diagnostic tests like the Schirmer tear test, corneal fluorescein staining, and tonometry are essential components of ocular assessment.

However, it would be premature to jump to these tests without doing some other things first.

Let's take a step back and maybe consider checking some other boxes off first.

Let's go back ...

History & Client Interview

"Let's start at the very beginning, a very good place to start ..." - Maria

What do you, the clinician, want to know?

Why are you bringing Monona in today?

Can you tell me more? How long has this been going on?

How is she otherwise? Any other problems?

What is her past medical history? Any prior eye problems?

Read more ...

Taking Ocular Histories

Next - Let's Begin to Form Our Problem List

Why are you bringing Monona in today?

What is the chief complaint?

"Monona's right eye has been really red and irritated over the past 2 months. Over the past two weeks or so, it's been kind of puffy looking, too. There's been some stuff coming out of the eye, too - goopy stuff."

Can you tell me more? How long has this been going on?

What is the history of the chief complaint?

What was the first thing you noticed as abnormal and when?

Did this always involve one eye?

Are the signs episodic or more persistent?

Is the eye ever normal?

Have you noticed any changes/abnormalities in her vision?

Has she received any medications or other treatment for this?

Return

Has she traveled recently?

How is she otherwise? Any other problems?

Review of systems

Is she eating normally?

Drinking a normal amount of water?

Urinating normally?

Any coughing, sneezing, nasal discharge, breathing issues?

Any vomiting, diarrhea, dietary indiscretion?

Any lethargy or changes in activity?

Return

What is her past medical history? Any prior eye issues?

Past/pertinent medical history

Is she up to date on vaccinations?

Has she ever been treated for any illnesses before?

Has she ever had major surgery? Any complications?

Any known drug allergies or sensitivities?

Is she receiving any medications now?

Does she have a history of prior eye problems?

Return

Building a problem list ...

What is on our problem list after obtaining a full history?

f. polyuria

A. OCULAR REDNESS - RIGHT EYE

G. Nasal discharge

B. OCULAR REdNESS - LEFT eye

H. ocular discharge - right eye

C. vomiting

i. ocular discharge - LEFt eye

D. DIARRHEA

J. ocular swelling - right eye

E. POSSIBLE LETHARGY

To move on, you need to enter the Secret Code. The Secret Code will be the letters of the items above in Monona's problem list, based on her history. NOTE: The letters in the code must be entered in alphabetical order.

Enter the Secret Code Here

Enter the code's letters in alphabetical order.

NOTE: Use ALL CAPS to enter the code.

Great! What do you want to do next?

History &Client Interview

Ocular Examination

Ancillary Diagnostics

Current Problem List

1. Ocular redness - Right eye
2. Possible lethargy
3. Ocular discharge - Right eye
4. Ocular swelling - Right eye

Ancillary Diagnostics

We'll get there ...

Ancillary ophthalmic diagnostic tests like the Schirmer tear test, corneal fluorescein staining, and tonometry are essential components of ocular assessment.

However, the results of these tests are most accurately interpreted in the context of ophthalmic examination findings.

Let's take a step back and try to build our problem list by performing an examination first.

Let's go back ...

The Ocular Examination

The ophthalmic examination is the single most important component of ocular assessment in animals. The examination includes:

Subjective assessment of vision, comfort and symmetry

Neurophthalmic assessment

Structural evaluation of the:

Anterior segment

Posterior segment

adnexa

A complete ophthalmic examination requires the correct equipment. Hover over the images at the right to learn more about how these tools are used to assess the eye.

Next

Ocular Examination

Subjective Evaluation

Neurophthalmic Evaluation

Right Eye (OD)

Left Eye (OS)

General PE

Hold up a second ...

It might be worth trying to complete a subjective evaluation before we dive into the other assessments.

Subjective Evaluation

Subjective Evaluation

Monona's owner brings her out of the carrier and places her on the exam table. She seems timid, and quickly lays down with her head tucked behind her legs and tail. She looks to be in reasonable body condition. You do see that her right eye looks more closed than her left and it's not completely normal. You can also see that there discharge below her right eye and possibly some blood. She's very stoic but overall, you don't see anything else that's particularly abnormal.

Back

Index

Ocular Examination

Subjective Evaluation

Neurophthalmic Evaluation

Right Eye (OD)

Left Eye (OS)

General PE

Maybe ...

It might be worth making the neurophthalmic evaluation before we dive into the other eye exam and PE.

Neurophthalmic Evaluation

Neurophthalmic Evaluation

Let's see how Monona's ocular innervation is working.

Pupils are dilated at rest but symmetrical Palpebral reflex = intact in both eyes (OU), but incomplete in the right eye (OD) Menace response = absent OD, but intact and complete in the left (OS) Dazzle reflex = intact OU but incomplete eyelid closure OD Pupillary light reflex = slightly slow but complete and symmetrical Vestibuloocular reflex = abnormal OD (reduced ocular movement), normal OS

Let's update our problem list ...

Back to exam ...

Ocular Examination

Subjective Evaluation

Neurophthalmic Evaluation

Right Eye (OD)

Left Eye (OS)

General PE

Ophthalmic Examination - Adnexa

Right eye (OD)

Left eye (OS)

You can get a good look at Monona's right eye now that she's becoming more relaxed.

Describe to yourself what you see. NOTE: On palpation of the head, there are no overt asymmetries but you do notice that Monona's right eye is sitting back in the orbit slightly and does not retropulse as well as the left eye. Monona tolerates oral examination and retropulsion but does seem slightly uncomfortable when both are performed.

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Ophthalmic Examination - Anterior and Posterior Segment

Anterior Segment Examination Slightly hazy cornea in the right eye (OD) No aqueous flare in either eye (OU) Normal iris OU Clear lens (no cataract) OU

Posterior Segment Examination Normal non-myelinated optic disk OU Normal retinal vessels OU No identifiable lesions OU

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General Physical Examination

Hydration status: mildly decreased skin turgorOral: mild dental calculus but otherwise normalEars: clear in bothRespiratory: clear nares, normal respiratory effort, 48 breaths per minute, normal bronchovesicular sounds on auscultation, intact air passage through both naresCardiovascular: HR 196 with regular rate and rhythm, pulses strong and synchronous, no murmur auscultedIntegument: normalPeripheral lymph nodes: moderately increased mandibular lymph node size on the rightAbdomen: normal palpationTemperature: 101.9 FNeurologic status: quiet, but alert and appropriate

Let's update our problem list one more time ...

Next

Let's finish that ocular assessment while we're at it ...

It might be worth completing the eye exam before we do the PE.

Ophthalmic Evaluation

Good job. Let's complete our ocular assessment.

History &Client Interview

Ocular Examination

Ancillary Diagnostics

Ancillary Diagnostics

Ancillary Ophthalmic Tests

Schirmer Tear Test

Fluorescein Stain

Tonometry

You elect not to perform a Schirmer tear test as this is not routinely performed in cats.

21 mmHg in the right eye

Positive in the central cornea in the right eye

17 mmHg in the left eye

Negative in the left eye

Why not?

Next

Let's take a moment to put some things together ...

What makes sense and what doesnt?

Can you attribute the items in your problem list to your eye examination findings?

1. Ocular redness - Right eye 2. Possible lethargy 3. Ocular discharge - Right eye 4. Ocular swelling - Right eye 5. Incomplete eyelid closure - Right eye 6. Absent menace response - Right eye 7. Reduced ocular movements - Right eye 8. Enophthalmia - Right eye 9. Decreased retropulsion - Right eye 10. Corneal haze - Right eye 11. Mild dehydration 12. Increased right-sided mandibular lymph node size 13. Positive fluorescein stain uptake - Right eye

Next ...

What could be going on with Monona?

Based on examination and diagnostic findings, which of the following could explain Monona's problems involving her right eye?

Note: More than one answer may apply.

E. ORBITAL ABSCESS/CELLULITIS

A. HORNER's SYNDROME

F. ANTERIOR UVEITIS

B. HERPESVIRAL CONJUNCTIVITIS

G. ORBITAL NEOPLASIA

C. GLAUCOMA

H. OPTIC NEURITIS

D. CORNEAL FOREIGN BODY

To move on, you need to enter the Secret Code. The Secret Code will be the capital letter(s) (i.e. A. B. C., etc.) of the item(s) you choose as possible clinical diagnoses. Note: Make sure you enter the letters in alphabetical order on the next screen.

Enter the Secret Code Here

Case sensitive. Make sure to enter the password as a capital letter(s.

Enter letters in alphabetical order.

Great!!

There's definitely something going on in Monona's orbit.

What's next?

Identify a diagnostic and treatment plan

Narrow down the clinical diagnosis

Communicate a plan and prognosis to the owner

Start

Socks first. Then shoes.

In order to come up with a meaningful diagnostic and treatment plan, we have to first try to figure out the cause and nature of the orbital disease.

Let's go back ...

We still don't have a diagnosis or plan yet.

So before we communicate with the client, let's get a plan together so we can discuss it.

Let's go back ...

Some clinical signs/findings tend to differentiate between orbital infections (abscess/cellulitis) and orbital neoplasia. Below is a list of clinical signs/findings that are either more characteristic of infection or neoplasia.

MATCH THE CHARACTERISTIC CLINICAL FEATURE TO ORBITAL NEOPLASIA OR ABSCESS

Usually slower to progress [1]

Tends to affect older animals [9]

More likely to cause dorsal or ventral exophthalmia [20]

More likely to be painful on retropulsion [43]

ORBITAL ABSCESS

ORBITAL NEOPLASIA

Tends to present more acutely [4]

Pain on opening of the mouth [16]

Once you're finished, add up each number in brackets at the end of the items you matched to ORBITAL NEOPLASIA. Enter that sum as the Secret Code to advance to the next step.

SOLUTION

Click here when ready.

Enter sum of the bracketed numbers from signs of ORBITAL NEOPLASIA.

Enter the sum here.

Good call.

Taken in summary, Monona's age, gradual disease progression, lack of severe pain on opening of the mouth and/or retropulsion, and reduced retropulsion collectively support the presence of orbital neoplasia.

exophthalmia,

But wait ...orbital neoplasia should produce right? Why does Monona have ?

enophthalmia

What should I do next?

Identify and recommend a diagnostic and treatment plan

Narrow down the clinical diagnosis

Communicate a plan and prognosis to the owner

Almost there.

We should probably have an idea of what our recommended plan will be before we discuss our findings and impressions with the client.

Let's go back ...

Working up Orbital Neoplasia

What should we recommend diagnostically for Monona?

What diagnostic tests should I recommend?

CBC/chemistry/UA

Thoracic Radiographs

Lymph Node FNA

Abdominal ultrasound

Orbital ultrasound

Skull radiographs

MRI scan

CT scan

Next ...

Communicate Your Recommended Plan and Your Expectations

You: "I'm suspicious that Monona has a tumor growing in the orbit behind her right eye. Though less likely, it's possible that it could be an infection. The only way to really formulate a prognosis and determine possible treatment options is to perform some diagnostic tests and advanced imaging, like a CT scan." Monona's owner: "Ok. Wow ...that sounds kind of expensive. I want to do everything I can for her but how much is that gonna cost?" You: "The cost of the tests, including anesthesia for the CT scan falls betwee $2000-2500. Our hospital requires 75% of the high end of the estimate at drop-off for the CT scan since it requires anesthesia." Monona's owner: "Oh my. That's a lot of money. Do you think that, if we do the scan, we'll be likely to find something that's treatable?" You: "That's hard to say. To be honest, most tumors that grow in the orbits of cats tend to be very malignant or at least locally aggressive and can be difficult to cure. We indeed could find something with limited treatment options. I'm sorry - I wish I had more encouraging news. Monona's owner: "Thank you for your honesty. I want to do this for her, but it's a lot of money and I'm a little overwhelmed by the news. I don't want her to be in pain. Is there something you can do for her while I decide what I want to do?"

What can/should we consider for Monona in the meantime?

What can/should we consider for Monona in the meantime?

What are our priorities for her while the owner decides whether she'd like to pursue diagnostic testing?

Topical ophthalmic antibiotics

Broad-spectrum systemic antibiotics

Systemic corticosteroids

Systemic non-steroidal anti-inflammatories

Adjunctive analgesia (e.g. buprenorphine, gabapentin)

Topical ophthalmic NSAIDs or corticosteroids

Next ...

Supportive care measures

For starters, let's make sure any treatment won't make things worse for Monona ...

Do any of the parameters out of range concern you?

Next

Conservative Medical Management

There are a number of different ways that a clinician could choose to proceed with symptomatic care for a patient with suspected orbital neoplasia like Monona. Some of it may depend on the client, some on the animal, some on the suspected diagnosis, and of course the presence/absence of co-morbidities.

If an owner is considering pursuing a diagnostic workup, medical treatment should seek to manage pain while avoiding any unsubstantiated treatment that could mask underlying disease and prevent eventual diagnosis.

If an owner is looking for palliation, then more aggressive empirical medical therapy can be pursued as long as that client is aware that eventual diagnosis could be complicated should they later decide to pursue a workup.

Next

Monona's Treatment

Since Monona is still eating and drinking water, only presents with mild dehydration, has relatively unremarkable laboratory tests, does not seem remarkably painful, and has an owner that may pursue advanced diagnostic testing, you prescribe the following symptomatic treatment:

• 75 ml of subcutaneous fluids
• Robenacoxib, 6 mg PO once daily for 3 days
• Gabapentin, 15 mg PO twice daily
• Ophthalmic erythromycin ophthalmic ointment in right eye, 4-6 times daily

Next

1 week later ...

Monona's owner calls and says that she had really started to rub at her right eye over the past few days and, this morning, she noticed a small pool of blood on the floor after Monona had scratched at her face a few times. The owner does not think it's a reaction to the topical eye ointment since she has tolerated it without any problems until the last day or so. Though she feels like Monona had otherwise been doing fine, she's decided that she'd like to pursue the chest x-rays, abdominal ultrasound, lymph node aspirates, and CT scan. There is availability for a CT scan your hospital the following day. At presentation the next day, most examination findings are the same. However, Monona no longer has an intact dazzle reflex in the right eye and no direct PLR in the right eye or indirect PLR from right to left.

Next ...

Diagnostic Workup Results

Click on each item for Monona's diagnostic results.

Abdominal ultrasound

Thoracic radiographs

CBC/chemistry/UA

US-guided orbital FNA

CT scan

Lymph node FNA

Next ...

Diagnostic Workup Results

Click on each item for Monona's diagnostic results.

Abdominal ultrasound

Thoracic radiographs

CBC/chemistry/UA

US-guided orbital FNA

CT scan

Lymph node FNA

Return ...

Are we more convinced now that Monona has orbital neoplasia?

Yes

No

Soo ....what do we do now?

Our working diagnosis is orbital neoplasia but we don't know what type.

Based on Monona's clinical presentation and CT findings, which tumor types should we consider of highest likelihood? Hint: If you want to go back and review the diagnostic results, click

here.

Lymphosarcoma

Nasal adenocarcinoma

Next ...

Conjunctival adenocarcinoma

Squamous cell carcinoma

Myofibroblastic sarcoma

What can we offer Monona's owner?

You: "I'm afraid I don't have the best news based on our diagnostic testing. Based on the samples we collected from Monona's orbit, I'm confident we're dealing with a tumor in the orbit. However, I can't yet tell what kind of tumor as the aspirates were non-conclusive. So, I can't give you and Monona a definitive diagnosis, prognosis, or treatment plan yet. I wish I could tell you exactly what was going on. Monona's owner: I was afraid of this, but I think you prepared me well for this possibility. Let's put it this way - whatever the tumor is, is it likely to be something bad? You: Well, the literature about orbital tumors in cats is not favorable. In general, most tumors carry a poor prognosis as they can become locally invasive in the head, or even spread to other areas of the body. Fortunately, the rest of Monona's body is healthy at this time with no evidence of active spread. Monona's owner: Ok, well, this cat is important to our family. We at least want to do something to get the diagnosis and maybe figure out what our options are for her; and we really want her to be comfortable. I think she's in pain.

What could we do now?

Re-aspirate?

Biopsy?

enucleate?

Exenterate?

Exenteration

Exenteration is surgical removal of all of the orbital contents, including the globe. It is indicated for treatment of orbital neoplasia or orbital infection/cellulitis that is non-responsive to medical therapy.

In the case of neoplasia, it offers the opportunity to debulk the malignancy in anticipation of possible adjunctive radiation therapy; or in less common scenarios, it may offer the chance to resect the neoplasm in its entirety in an attempt to cure surgically.

After discussion of the options, Monona's owner elects for exenteration. She would like to make Monona more comfortable and may elect for adjunctive radiation therapy depending on the diagnosis.

Next ...

Monona's Diagnosis

Feline restrictive myofibroblastic sarcoma (FROMS)

Formerly known as orbital pseudotumor, FROMS is an insidious orbital neoplastic disease of cats with a progressive clinical course over weeks to months. Clinically, the characteristic features develop due to gradual fibrous neoplastic infiltration of the eyelids and orbital tissues. Over time, this leads to severe corneal exposure and desiccaiton with ulceration and, if chronic enough, often results in globe rupture. Histologically, there is no discrete "mass". Instead, the orbital tissues are invaded along their collagenous connective tissue planes by a fibrous and mixed but predominantly lymphocytic and plasmacytic neoplastic infiltration. Occasional intraocular disease (uveitis, retinal detachment) develops secondary to the orbital diease. FROMS affects middle-aged to older cats (mean age 10.8 y). Surgical cure is largely not possible as most affected cats progress to bilateral involvement with or without migration of disease to the face and lips.

Gelatt, Feline Ophthalmology in Veterinary Ophthalmology, 2016

Next ...

Click here for a histologic image of FrOMS

Monona Follow-Up

There is no treatment proven to discourage progression of FROMS. While the following treatment modalities have been attempted, none have successfully prevented eventual spread of the neoplasm along tissue planes:

• Systemic/topical corticosteroids
• System/topical NSAIDs
• Systemic/topical chemotherapy
• Radiation therapy
• Antiviral agents (famciclovir)

Click on the papers below to learn more about FROMS

Monona's owner opts to forego pursuing any adjunctive therapy given the prognosis, electing instead to continue to monitor at home for progression and to provide symptomatic care as needed.

next ...

Monona Follow-Up

Unfortunately, Monona's condition worsens over the course of 6 months following exenteration as the disease progresses in the skin at the base of the right pinna and restricts movement of the right side of the mouth. Eventually the malignancy spreads to the other side of the face and affects the contralateral eye. The owners eventually elect euthanasia.

5 months postop

6 months postop

Proceed to case summary ...

Case Summary (1 of 2)

Diagnosis and treatment of orbital disease in animals can be a clinical challenge, and given the poor prognoses often associated with orbital neoplasia it can be very difficult for pet owners. Owners are often faced with the difficult dilemma of whether to pursue expensive diagnostic tests to identify a potentially untreatable disease, or one that will end up leaving their pet requiring expensive treatment with no guarantees. There were a number of ways that this case could have gone, depending on the owners' goals for the animal and their comfort level with the diagnostic process. Below are some notes reviewing different aspects of the case: Monona's Problem List: In this case, all of the problems on Monona's list were easily attributed to the orbital disease process and her eventual diagnosis of FROMS (ocular redness, discharge, and conjunctival swelling, incomplete eyelid closure and reduced ocular movements, decreased retropulsion, corneal haze [secondary to ulceration], and mild right-sided lymphadenopathy). In addition, the lethargy and mild dehydration could have been explained by possible low-grade pain associated with the orbital malignancy. To reiterate, most orbital neoplasms in dogs and cats cause exophthalmia, though in cats anterior neoplasms such as those originating from the conjunctiva can actually push the eye back (enophthalmia). In the case of FROMS, the tumor is fibrotic in nature and actually spreads along connective tissue planes, pulling the eye back in the orbit with progression. Note: There were some additional abnormalities revealed as Monona's diagnostic plan progressed. On CBC, there was a very mild circulating eosinophilia which could have been tumor-associated; and on chemistry, there was mild hypercholesterolemia and hyperalbuminemia. The mild hyperalbuminemia could have been attributed to mild dehydration but the cause for the elevated cholesterol could not be easily linked to the primary disease process. She also had evidence of lower airway disease (allergic/inflammatory) which, while unrelated to her neoplasia, could have been linked to the eosinophilia. Note: Though there was no evidence of intraocular disease on Monona's exam, she eventually lost her menace response and dazzle reflex, indicating loss of optic nerve function. This is presumed to be due to the progressive destruction of orbital tissue associated with FROMS.

Next

Case Summary (2 of 2)

Would systemic prednisone/prednisolone have been a bad choice in this case? It would not have adversely affected the FROMS and may have decreased some inflammation and improved comfort in the short-term. Again, the choice of systemic corticosteroids is best chosen when an infection has been ruled out and when the owner is unlikely to pursue diagnostic testing or treatment in the near future, instead electing for palliative care. Why not try to biopsy before moving to exenteration? This is really client/owner dependent. It would have been very reasonable to try an ultrasound-guided orbital biopsy following the inconclusive results from fine needle aspiration. Recent literature ( click ) has demonstrated that biopsy of orbital tissue is more likely to verify a diagnosis when compared to fine needle aspirate. In the case of Monona, the owners elected to maximize the chance for reaching a diagnosis while also trying to ensure long-term comfort.

here

Nice work!

Kind of a bummer of a case, though. If you have any additional questions about Monona's case, orbital disease, or this content, feel free to email me at: jseaton2@wisc.edu