It is a Wednesday morning, and you are halfway through your appointments. Next up is a 9-year-old cat with "sore eyes again".
Think you can help? Grab a pen and paper, set a timer (so you can record your CE!) and settle down with our clinical case. We expect it to take an hour or two to work through properly, but you can always pause and return if you need to.
You quickly review the recent history. The cat is a neutered male domestic shorthair. He lives with three other cats, and was adopted after the owner found him as a stray about 5 years ago. He is estimated to be around 9 years old. His last appointment was his vaccination about eight months ago, when a dental procedure was recommended. Before that, he has a general history of cat bite abscesses and recurring upper respiratory tract symptoms.
The owner reports that his "URI is back." Both eyes have been "weepy and irritated" for around five days. The discharge was initially clear, but has become slightly thicker over the last 24-48 hours. The cat has been squinting intermittently, especially in bright light, and has been rubbing his face on the sofa more than usual. He is snuffly too, with some discharge around his nose.
The owner is not especially worried. He has had occasional mild flare-ups of sneezing and watery eyes in the past, usually settling without treatment or with oxytetracycline/polymyxin B ophthalmic ointment. The owner suspects this is another episode. She is a bit annoyed that the receptionist would not give her any more medicine without the cat being seen.
You start with a general clinical examination before looking more closely at the eyes.
The cat is quiet but responsive in the exam room. He resents handling around his head but is not fractious. He is underweight compared with previous records: today he weighs 4.1 kg, compared with 4.5 kg at his vaccination appointment eight months ago. Body condition score is 4/9.
|
Parameter |
Finding |
|
Temperature |
38.8 C |
|
Heart rate |
180 beats/min, regular |
|
Respiratory rate |
32 breaths/min |
|
Mucous membranes |
Pink and moist |
|
Capillary refill time |
<2 seconds |
There is a small amount of dried serous discharge around both nares. Airflow appears present bilaterally, and there is no stertor or increased respiratory effort. Thoracic auscultation is unremarkable.
Oral examination is limited, but there is moderate calculus, halitosis, and gingivitis. No obvious oral mass, fractured tooth, draining tract or marked focal oral pain is identified.
Both submandibular lymph nodes are moderately enlarged and mobile. The prescapular lymph nodes are also palpable bilaterally and feel mildly enlarged.
Abdominal palpation is unremarkable. No obvious abdominal mass, organomegaly or discomfort is detected. The skin and coat are unremarkable, and no fresh wounds, abscesses or bite marks are noted.
The cat is sitting hunched in the carrier with both eyes partially closed. He is more comfortable in the dimmer part of the exam room and resists being turned toward the window. Both eyes have mild watery to mucoid discharge, with some dried discharge at the medial canthi.
There is bilateral conjunctival hyperemia, slightly worse on the right. Mild chemosis is present, but there is no marked swelling of the eyelids and no obvious periocular wound or facial asymmetry.
There is no obvious corneal opacity, vascularization, or ulcer/injury visible without staining. The anterior chambers are not easily assessed at this stage, but the pupils appear smaller than expected for the room lighting, with the right pupil slightly more miotic than the left.
There is no obvious iris mass, marked color change or gross distortion of the pupil shape noted. Both globes appear to be in a normal position, with no exophthalmos, enophthalmos, third eyelid protrusion or obvious globe enlargement.
Considering the above, you'll need to explain the change in concern to the owner, start treatment, and do some further investigations to get to the bottom of the problem.
Your test results for the cat are waiting when you get in the next morning.
At the recheck in the afternoon, the owner reports he is brighter and eating small amounts, but the right eye looked more closed this morning. She assumed this was because the drops were "stinging". On examination, the right eye is more painful, the cornea is slightly hazy, and the pupil is larger than the left.
While you are doing that, your test results come in...
The following morning, the cat is even more comfortable. The IOP in the right eye is 18 mmHg, and the left eye remains 11 mmHg. It is time to phone the owner with an update on her cat and a management plan. You will also need to talk her through the recent results, and the next steps of investigation.
You relay the latest test results to the owner, and present her with some treatment options.
Once you have completed the case, consider what you've learned. This reflection is an important part of the CE cycle. Is there anything you'd do differently in future? Have you identified any knowledge gaps that need filling?