C10004853 / invoice 10000

Recheck corneal ulcer post debridementUlcer healedPlan: lubricate OD BID x2wks. 'DIAGNOSTICS:Fluorescein staining: Negative. A small, healed lesion is visible on the cornea.ASSESSMENT:The corneal ulcer has healed completely. A small scar is present, which is not expected to impact vision. The patient is comfortable.DIAGNOSIS:Corneal ulcer, HEALED, RIGHT eye

Primary care: Camden Valley Veterinary HospitalREASON FOR PRESENTATION:Non-healing corneal ulcer in the left eye for approximately two weeks.HISTORY:Chloe is a four-year-old, nearly five-year-old, female. She presented for a corneal ulcer in the left eye that has not healed over the past two weeks. The owner reports the ulcer appears unchanged and is not worsening or improving. Chloe has been rubbing the affected eye with her paws and tends to keep it more closed than the right eye. There is no history of witnessed trauma to the eye. She has no previous history of ocular issues. She has a history of three snake bites in the last year, but these were not facial injuries. Current treatment consists of Chlorsig ointment. The owner reports she is fed chicken and renal diet biscuits.OPHTHALMIC EXAMINATION:Neuro-ophthalmic exam (both eyes): intact menace response, dazzle reflex, direct & consensual pupillary light reflex. Intact palpebral reflex. Intact vestibulo-ocular reflex.RIGHT: held open. Eyelids and adnexa unremarkable. Cornea clear except for a linear superficial ulcer with surroindign well defined area of mineral-like deposits. AC clear. Iris unremarkable. Pupil mobile. Lens clear. Fundus unremarkable.LEFT: held open. Eyelids and adnexa unremarkable. Cornea clear. AC clear. Iris unremarkable. Pupil mobile. Lens clear. Fundus unremarkable.DIAGNOSTICS:Schirmer tear test: 20 mm/60seconds (right eye)Intraocular pressure: Not performed.Fluorescein staining: Positive uptake in a linear pattern in the left cornea.ASSESSMENT:The presentation is atypical for a spontaneous chronic corneal epithelial defect (SCCED) given the patient's age and the presence of mineral-like deposits within the ulcer bed. The ulcer is superficial and linear, suggestive of a scratch, but no foreign body or structural cause was identified. The mineral deposits may be primary (causing the ulcer) or secondary (resulting from the non-healing ulcer). The differential diagnoses include an indolent ulcer with secondary mineralisation or a primary corneal degeneration.Options discussed with the owner included referral to a specialist, medical management with drops to dissolve calcium deposits, or mechanical debridement of the affected area under topical anaesthetic. The owner elected to proceed with debridement.DIAGNOSIS:Non-healing superficial corneal ulcer with suspected secondary mineralisation.TREATMENT:Motorised diamond burr debridement of the affected area of the left cornea was performed under topical anaesthetic. A D4 bandage contact lens was placed in the left eye. A single dose of topical atropine was applied to the left eye to provide comfort.PLAN:Continue Chlorsig ointment three times daily (owner may switch to drops for ease of administration). An Elizabethan collar is to be worn to prevent rubbing. Recheck scheduled in one week to assess healing and check the contact lens. The owner was advised to return sooner if there is any worsening of squinting or discomfort.

recheck ulcer - not healingsame amoutn of stain uptake as previousMD also looked at ulcer and reccommended to recheck with KG on wednesay