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CORNEAL OPACITIES IN
DOGS & CATS
Ann R. Strom, DVM, MS, and David J. Maggs, BVSc, Diplomate ACVO
University of California–Davis
The cornea is transparent, densely innervated, appropriate diagnostic tests and prompt initiation of
avascular, and the major refractive structure of optimal therapy are required to maximize the chance
the eye. a healthy cornea achieves and maintains of saving vision, producing a comfortable globe and,
transparency due to the organization of constituent occasionally, saving the patient’s life.
cells and collagen fibers, as well as its relatively The following questions should be asked when
dehydrated state. anything that alters this a patient with a corneal opacity is presented for
organization or deturgescence leads to development evaluation.
Tools for
of a corneal opacity.1 Ophthalmic
as the outer and most exposed structure of the QUESTION 1. WHAT IS THE Examinations
globe, the cornea is not only at risk for trauma, but APPEARANCE OF THE OPACITY? Fortunately,
also often receives close attention from clients. as causes of corneal opacities, which are often seen diagnosis of
such, a presenting complaint of corneal opacity is in various combinations, are listed in Table 1.2 corneal opacities
common in veterinary practice. each of these pathologic changes is associated with is possible with
correct interpretation of corneal changes is critical a specific appearance—especially color. however, just a few pieces
for diagnosing corneal disease as well as many of inexpensive
other ocular and some systemic diseases. Therefore, equipment. Among
these, a dark room,
magnification,
TABLE 1.
and a bright and
Causes of Corneal Opacity & Appearance focal light source
CAUSES OF CORNEAL APPEARANCE are key for a
CORNEAL good ophthalmic
OPACITY examination.2
Edema Blue “cobblestoned” appearance
Inflammatory Yellow, green, or tan corneal
cell infiltration stromal opacity
Lipid/mineral Silvery white, crystalline, sparkly FIGURE 1. Focal corneal edema secondary
deposition opacities; sometimes coalescing to corneal ulceration in a dog. The pupil has
creamy or shiny opacities been pharmacologically dilated. Note the loose
Fibrosis epithelial edges of the corneal ulcer suggestive
Grayish white, sometimes feathery
or wispy opacity of a superficial chronic corneal epithelial
defect (SCCED). Resolution was achieved by
Melanosis Dark brown to black, variable debridement (using a sterile cotton-tipped
density; often with blood vessels applicator) and topically applied antibiotics and
Vascularization Variably perfused blood vessels atropine. Courtesy University of California–Davis
extending from corneoscleral limbus Comparative Ophthalmology Service
Edema
a blue, “cobblestoned” appearance of the cornea—
whether focal or diffuse—is indicative of corneal
stromal edema, and results from loss of corneal
epithelial or endothelial cell function.
Focal Edema. specific causes of focal edema
include focal corneal epithelial dysfunction (due to
corneal ulceration), or focal endothelial cell damage FIGURE 2. Diffuse corneal edema in a dog with a
(due to blunt corneal trauma, lens luxation, or penetrating corneal cat claw injury and secondary
keratic precipitates) (Figure 1, page 105).2 uveitis. The wound from the cat claw can be
Diffuse Edema. diffuse corneal edema (Figure seen on the ventromedial paraxial cornea.
Courtesy University of California–Davis Comparative
2) is more consistent with intraocular disease,
Ophthalmology Service
such as glaucoma or uveitis, but may also indicate
breed-related endothelial dystrophy or age-related
endothelial degeneration. These conditions can
usually be differentiated by assessing for signs of
pain or inflammation: the latter 2 conditions are
nonpainful and noninflammatory, whereas glaucoma
and uveitis are painful and associated with other
signs of inflammation.
Whenever possible, treatment for diffuse corneal
edema should always be directed at the underlying
disease process, especially since both glaucoma and
uveitis are vision-threatening diseases, and some
causes of uveitis can even be life-threatening.2,3
FIGURE 3. Feline acute bullous keratopathy.
When no cause is found or the underlying disease is Note the large corneal stromal bulla protruding
untreatable, symptomatic treatment with hypertonic outwards. The lack of corneal vascularization
sodium chloride (nacl) ophthalmic ointment may confirms the acute nature of the disease.
be attempted, but it often has little to no effect, may Mucous discharge covers some of the
irritate the eye, and requires administration at least 4 dorsomedial cornea and bulla. Courtesy University
of California–Davis Comparative Ophthalmology Service
to 6 times daily.
Diffuse Edema in Cats. cats are rarely affected
with endothelial dystrophy or senile endothelial
degeneration. instead, severe, diffuse corneal
edema in cats is typically seen with acute bullous
keratopathy (Figure 3). This condition, which is
more common in younger cats, has no recognized
predisposing cause and an extremely acute onset
that leads to massive stromal edema and, sometimes,
corneal rupture. The dysfunction may involve
the stroma itself rather than the endothelium or
epithelium. Treatment involves emergency surgical
support—either conjunctival grafting or placement FIGURE 4. Infectious keratitis with
of a third eyelid flap.4,5 keratomalacia (“melting”) and stromal loss in
a dog. The patient also has an eyelid tumor
on the lateral aspect of the superior eyelid.
Inflammatory Cell Infiltration
Courtesy University of California–Davis Comparative
a yellow, green, or tan corneal stromal opacity
Ophthalmology Service
suggests white blood cell (Wbc) infiltration, which
• Active lesions usually have more irregular, or fuzzy, intraocular disease include diffuse TABLE 3.
outlines due to corneal edema and/or cellular corneal edema and deep corneal Determining Whether a Corneal
infiltrates. vessels; often in association with Ulcer Is Complicated
• Chronic, inactive lesions, such as corneal fibrosis or episcleral injection.
A corneal ulcer is considered
melanosis, often have more distinct borders with referral to a veterinary complicated if one or more of the
the surrounding cornea. ophthalmologist should take place following is noted:
as early as possible, in order to • Corneal blood vessels
QUESTION 5. WHEN SHOULD YOU increase the chance of saving the • Corneal stromal loss (If > 50% is
REFER A PATIENT WITH A CORNEAL eye, including its vision. lost, surgical stabilization is typically
OPACITY TO A VETERINARY recommended.)
• Corneal WBC infiltration (greenish
OPHTHALMOLOGIST? csK = chronic superficial keratitis; yellow cornea)
although individual practitioners have different FeK = feline eosinophilic keratitis; • Failure to heal within 1 week
comfort levels regarding diagnosis and treatment of FhV-1 = feline herpesvirus type 1; • Indolent ulcers (ie, SCCEDs)
ocular conditions, certain conditions warrant referral Kcs = keratoconjunctivitis sicca; • Infection
• Keratomalacia (“melting”)
to a veterinary ophthalmologist. Veterinarians KP = keratic precipitates; • Marked or persistent corneal edema
should refer patients when: scced = superficial chronic
1. They do not feel comfortable managing the corneal epithelial defect; sTT = schirmer’s tear test;
ophthalmic condition UV = ultraviolet; Wbc = white blood cell
2. referral is specifically requested by clients
3. intraocular disease, a complicated (deep or References
chronic) corneal ulcer (Table 3), or vision 1. Torricelli aa, Wilson se. cellular and extracellular matrix
modulation of corneal stromal opacity. Exp Eye Res 2014;
impairment is present2
129c:151-160.
4. Patients require corneal microsurgery. 2. gelatt Kn, gilger bc, Kern TJ (eds). Veterinary Ophthalmology,
corneal opacities that are suggestive of 5th ed. Wiley-blackwell, 2013.
What color
Creamy or sparkly white Gray
is the Yellow/green (WBCs) Blue (stromal edema)
(lipid/mineral) (fibrosis)
lesion?
Unilateral
Bilateral,
Diffuse, marked Focal, mild or bilateral,
symmetric,
asymmetric,
not inflamed
inflamed
• Cytology & aerobic bacterial • Check for pain, • Apply flu- • Apply fluores- • Monitor for • Check for other
What cultures flare, redness, or orescein cein stain secondary ocular abnor-
± Fungal cultures lens luxation stain • Consider ulceration malities
test(s) to ± Viral PCR • Measure IOP • Perform systemic hy- with fluores- • Perform STT
perform? • Fluorescein stain • Apply fluorescein STT perlipidemia, cein stain • Apply
• Identify causes of corneal stain hypercalce- • Rule out fluorescein
ulcers & perform STT • Consider mia, & pri- chronic top- stain
US if unable mary corneal ical steroid
to examine disease use
intraocular
structures
If cornea
Negative Positive Nonpainful, Painful, ulcerated, Corneal Corneal Prior corneal
Why is cultures/no cultures/ no inflam- inflamed, look for degeneration lipid/mineral damage
the lesion organisms cytology: mation or flare, cause, dystrophy
there? on cytology: Support flare, abnormal such as
Immune- diagnosis normal IOP: eyelid ab-
mediated or of IOP: Glaucoma, normalities
viral (herpetic) infection Endothelial uveitis, or dysfunc-
keratitis degener- or lens tion, tear
ation or luxation film defi-
dystrophy ciencies,
foreign
body,
trauma, or
SCCED
Treat with • Intensively treat Consider • Treat Monitor for • No treatment
antivirals with topical treating underlying ulceration required unless
Treatment or anti-in- antimicrobials with Treat with systemic underlying
flamma- (guided by hypertonic prophylac- disease and/ cause found
tories cytology and (5%) NaCl tic topical or primary • Monitor
C/S results) ointment ≥ antibiotics keratitis
• If keratomalacia Q6H and atro- • Monitor for
present, use pine ulceration
serum topically
• If > 50% stro-
mal loss, con-
sider surgical
stabilization
When to Refer Refer if progres- Refer if Refer as Refer if • Refer for keratectomy or Referral usually
refer to a if poor sive, recurrent, or bullae or soon as progressive, chelation if opacity is marked not needed
veterinary response notable stromal secondary possible recurrent, • Refer if ulcer is progressive,
ophthal- to loss ulceration or notable recurrent, or involves notable
mologist? therapy occur stromal loss stromal loss
The corneal opacities described in this diagram are often seen in various combinations, sometimes with other corneal color changes (such as black,
tan, or red). As such, the flowchart is simplified. If the reader has doubts about management of an ophthalmic case, they should consult with a
veterinary ophthalmologist.
C/S = culture & sensitivity; IOP = intraocular pressure; NaCl = sodium chloride; PCR = polymerase chain reaction; SCCED = superficial chronic
corneal epithelial defect; STT = Schirmer’s tear test; US = ultrasound; WBC = white blood cell
3. Townsend WM. canine and feline uveitis. Vet Clin North Am feline eosinophilic keratitis with topical 1.5% cyclosporine: 35
Small Anim Pract 2008; 38(2):323-346, vii. cases. Vet Ophthalmol 2009; 12(2):132-137.
4. Moore Pa. Feline corneal disease. Clin Tech Small Anim Pract 8. barrientos ls, Zapata g, crespi Ja, et al. a study of
2005; 20(2):83-93. the association between chronic superficial keratitis and
5. glover T, nasisse MP, davidson Mg. acute bullous keratopathy polymorphisms in the upstream regulatory regions of
in the cat. Vet Comp Ophthalmol 1994; 4(2):66-70. dla-drb1, dla-dQb1 and dla-dQa1. Vet Immunol
6. Wang l, Pan Q, Xue Q, et al. evaluation of matrix Immunopathol 2013; 156(3-4):205-210.
metalloproteinase concentrations in precorneal tear film from 9. Maggs dJ, Miller P, ofri r. Slatter’s Fundamentals of Veterinary
dogs with Pseudomonas aeruginosa-associated keratitis. Am J Vet Ophthalmology, 5th ed. elsevier, 2013.
Res 2008; 69(10):1341-1345. 10. sansom J, blunden T. calcareous degeneration of the canine
7. spiess aK, sapienza Js, Mayordomo a. Treatment of proliferative cornea. Vet Ophthalmol 2010; 13(4):238-243.