This patient is a 9 yo MN Schnauzer who was diagnosed recently with diabetes. He lost vision overnight and has been keeping both eyes closed and having copious discharge. He presents to you looking like this…

Holy painful fire-eyeballs! Now this is a bit extreme, but what is going on here?

Remember that cataracts have 4 stages of development. Incipient, immature, mature and hypermature are the stages in order of severity and how much of the lens is affected.

Incipient cataracts are early and may not even be detected due to the lack of notable vision limitation. As they progress through the immature stage to the mature stage, the opacity is often noticed and the vision declines. This process can happen VERY quickly in diabetic dogs and juveniles. The hypermature stage is the end-stage and is associated with breakdown of the lens material and protein leakage into the anterior chamber resulting in an inflammatory response called lens-induced uveitis.

In this breed, the Schnauzer, they often develop quickly and cause severe inflammation as a result.

This dog’s cataracts have become hypermature. In some pets, the lens-induced uveitis is more of a smoldering inflammatory response but in this breed and in many diabetics, a more severe inflammatory response called phacoclastic uveitis is present. Some even refer to this degree of inflammation as phacoanaphylaxsis due to the severity of the inflammation and sequelae.

This severe inflammation often results in synechia (anterior and posterior), secondary glaucoma and retinal detachment. As a result of the severe lens-induced uveitis, many of these patients are not surgical candidates, even if rapid intervention is pursued.

For this reason, most ophthalmologists consider diabetic cataracts somewhat of a surgical urgency. I recommend referral at the initial onset of cataract development and in very motivated owners, at the diagnosis of diabetes. At minimum, please start these dogs on topical anti-inflammatory therapy (I like prednisolone acetate or ketorolac) and educate these owners on their options. The ideal option is referral for cataract surgery but if that is not an option, referral for management of sequelae or just education on possible sequelae should be performed.

Many of dogs this bad off require enucleation for comfort.

Don’t let your diabetic (or non-diabetic for that matter) patients turn into fire-eyeballs!

Here are some photos of these eyes after removal. Inside of the eye you can see the cataract and the inflammatory changes. In the second picture, at the limbus there is an area where the globe actually ruptured as a result of that horrible endophthalmitis caused by these cataracts!

 
This eye has a hypermature cataract with marked lens induced uveitis and keratic precipitates on the endothelium.

#coolcases 

About the Guide: Kristin Miller Fischer, DVM, DACVO

Dr. Kristin Fischer is a board-certified veterinary ophthalmologist. She graduated from the University of Tennessee College of Veterinary Medicine in 2007 and completed a rotating general internship at VCA Alameda East Veterinary Hospital in Denver, CO. She then returned to Knoxville in 2009 to complete her ophthalmology residency at UTCVM. Dr. Fischer practices in South Carolina and works at Animal Eye Care of the Lowcountry. She loves the challenge of the complicated cases and the frequent connection between ophthalmology, internal medicine and neurology. Her favorite thing is returning sight to blind animals and then seeing them greet their families post-op!