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  Discussion on Corneal Ulcer Not Healing
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New Member:
Nwalken

Posted on Tuesday, Jul 15, 2003 - 10:59 am:

I have a 12 year old Appendix Quarter Horse that my daughter shows on the A Hunter Circuit. Four weeks ago he came in from the pasture in the morning with a slightly puffy eye. I was hauling him to my vet clinic that morning to have his hocks and stifles injected anyway, so he was seen that morning. The eye was stained and revealed a 2mm ulcer on the cornea. The vet gave me triple antibiotic ointment to use in the eye 3 times a day, but I like to be more aggressive with an ulcer early on, so I treated him every 2-4 hours until bedtime. After 3 days I left town and my barn help DrOpped back to treating him 4 times a day. I might note that my vet clinic is 2 hours from my house so my vet often allows me to do simple things myself to save me the 2 hour drive. I am a former critical care nurse and nurse educator, and have had horses all my life. I stained the eye after one week of treatment and I was shocked to see that the ulcer was no smaller. The vet speculated that a fungus may be the culprit so he overnighted me myconizole ointment for the eye to use 3 times a day along with the triple antibiotic ointment 4 times a day, administered at least 2 hours apart. After one week I could see no improvement in the eye and could see the ulcer, without staining, as a white spot on the cornea. I took him back to the clinic where they scraped the cornea to examine it for fungal spores. There were none. The ulcer appeared about 2.5mm at this point. They sent me home with gentamicin ointment to apply every 6 hours. The eye did not appear particularly painful, but the spot was still clearly visible, and there was a slight mucoid drainage in the corner of his eye. After one week I stained the eye again and the ulcer was no smaller. Five days ago we added Adequan eye DrOps every 12 hours along with the gentamicin every 6 hours. I became more concerned yesterday because his eye appeared more painful. Other than the two times he had been to the clinic, he had received no Atropine. I spoke with the vet and he had me administer Banamine along with some Atropine ointment I told him I had. This morning the eye is open and I can evaluate it better. It is cloudy, tearing slightly, and the ulcer still appears the same as a white spot on his cornea. I have several concerns. I spoke with my vet this morning and I am taking the horse to the clinic tomorrow morning, but the only new suggestion from him was systemic antibiotics if necessary. We have been at this for 4 weeks. Is it time to seek out an equine opthamologist or should I give my vet more time? This is a valuable horse, not to mention a beloved pet whose vision is of the utmost importance to me because of my daughter's safety. From what I have been reading I wonder if the ulcer needs to be debrided at this point? I would really appreciate Dr. O's thoughts on this, along with anyone else that might have a suggestion.
Thanks, Nancy
Moderator:
DrO

Posted on Wednesday, Jul 16, 2003 - 8:25 am:

Hello Nancy,
Yes I think it is time. Besides fungi, some serovars of both pseudomonas and good old strep can create melting ulcers so proper id is critical. I would expect both scrappings and culture repeated as these things can change over time. There is a pretty high resistance rate to both the neomycin and gentamycin among the pseudomonas and strep is not really targeted by the aminoglycosides. If it does turn out to be fungal we have had good luck with itraconazole with DMSO to aid penetration, I think the percentages are in the article on corneal ulcers. All of he -conazoles penetrate the cornea poorly by themselves.
DrO
Member:
Nwalken

Posted on Thursday, Jul 17, 2003 - 12:05 am:

I took the horse to my vet this morning, and remarkably when he stained the eye it did not take up any stain. I asked why it had appeared so painful two days ago and he suggested that the gentamicin and/or the Adequan DrOps could have been irritating the eye since it was at the end of the healing process. Is that possible? The eye is open, but cloudy, and the white spot is still visible as a scar. He wants me to leave things alone for two weeks and see if the cloudiness resolves on its own. He said that he hesistates to start any steroid at this point when the ulcer has been so difficult to heal. Do you still vote for going to the opthamologist, or should I give this a chance? Thank you so much for your help.
Nancy
Moderator:
DrO

Posted on Thursday, Jul 17, 2003 - 10:42 am:

Hello Nancy,
I am not familiar with the Adequan used intraocularly. Gentamicin may be mildly irritating but it sounds to me like the eye is healing. Deep wounds of the eye are slow to heal and until they do the eye remains inflamed: this may be normal healing but an intracorneal abscess may lok this way also.

I too would be afraid of a steroid at this point, but believe I would be keeping the pupil dialated, using a systemic antiinflammatory (Bute), and using a intraocular antimicrobial based on my best guess of what caused the problem. I do not know if an opthamologist should be consulted now as things seem to be doing better: how confidant are you the veterinarians have a handle on the problem?
DrO
Member:
Nwalken

Posted on Thursday, Jul 17, 2003 - 12:27 pm:

Hi Dr.O,
I have always had great trust in this clinic (there are actually two vets involved) as they have an active, equine only practice. I have used this clinic for 10 years, and these particular doctors for about 4 years. The Adequan DrOps were prescribed to strengthen the cornea. The addition of the Adequan DrOps was the
only change last week, so if the ulcer has healed, I guess that may have made a difference. The eye is still very dialated, but there was no discussion about keeping it that way. I guess I will keep a close eye on him, and watch for any return of symptoms over the next few days. My sense is that they have dealt with intractable ulcers before, so I feel ok with waiting things out since there has been this improvement. I think they trust me to keep a close eye on things. No pun intended. I wish they had done a culture along the way, but beyond looking for fungal spores under the microscope, they did not. I would have no idea what antimicrobial to use at this point. If anything goes wrong down the road, I think I will ask them for a referral to an opthamologist. Hopefully that won't happen. Thank you so much for your time. It has really helped to get your thoughts on things.
Nancy
Member:
Nwalken

Posted on Friday, Jul 18, 2003 - 12:36 am:

Hi Again-
I have been doing more research on this, especially since you mentioned that you were not familiar with the Adequan used intraocularly. I always like to get to the bottom of these things. I found a very informative website that described what was going on with my horse perfectly. It is a site started by a veterinarian opthamologist called animaleyecenter.com. The discussion about the management of slow healing corneal ulcers addresses the indolent ulcer, and that particular description fits perfectly. The problem is not infection, but a defect in the way the regenerating epithelial cells anchor to the corneal stroma. There are several medications mentioned to handle this, with Adequan being one of them. I hope you find it interesting if you have time to check it out. Go to the FAQ section and click on the last FAQ about Journals. I would post the link but I didn't know if that was proper protocal.
Nancy
Moderator:
DrO

Posted on Friday, Jul 18, 2003 - 6:47 pm:

The problem with your diagnosis is your eye does not stain and indolent ulcers do. We encourage publishing useful links and this sounds like one worth exploring.
DrO
Member:
Nwalken

Posted on Friday, Jul 18, 2003 - 9:52 pm:

https://www.animaleyecenter.com/Journals/V1N3.html

Here is the link for the article on slow healing ulcers. As far as the staining is concerned, now I am confused. The ulcer did stain up until this week. If the white spot is still there and not staining, does that rule out an indolent ulcer, even if it stained for 4 weeks? The important thing is the eye looks better every day. Thanks for your guidance.
Nancy
Moderator:
DrO

Posted on Sunday, Jul 20, 2003 - 3:30 pm:

Pretty much yes and this time frame for healing of a serious melting ulcer with extensive stromal involvement is not unusual.
DrO
Member:
Nwalken

Posted on Monday, Jul 21, 2003 - 5:22 pm:

Well thankfully, I think we have turned the corner on this one. The cloudiness is diminished, there is no tearing, and the white spot while still present, is less distinct. He appears very comfortable, so I am relieved. I appreciate your time and advice so much Dr. O. This is a great service for members.
Nancy
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