TAKE A CLOSER LOOK: The Importance of Patient and Client Compliance in the Management of Eye Problems

By Michelle Willis, DVM, Diplomate, ACVO, Ophthamology Dept. Head

A positive outcome for many ophthalmic surgical procedures may rely considerably on the medications prescribed post-operatively to counteract inflammation, infection and pain. If a patient does not tolerate frequent medicating, or if client disability or lack of availability precludes the timely administration of medications, the surgical outcome can be compromised.

A recent case provides an example underscoring the importance of both patient and client compliance. “Fred” (an alias is used to protect the patient’s identity), a geriatric neutered male domestic shorthaired cat, presented for evaluation of blindness. Fred’s human, truly one of the nicest clients to cross my path in a long time, was intent on having the cataracts removed. Fred had been blind for several months and although he seemingly tolerated his blindness, his human felt compelled to intervene. In contrast to the delightful personality of his human,
Fred was a veterinarian’s nightmare – four sets of claws, a mouthful of teeth and an amazing aim considering his lack of vision. The initial exam was aborted after 5 minutes of flying fur and open mouth breathing (by patient, client and veterinarian!). Sedation was required to complete baseline ophthalmic and physical examinations. Bilateral chronicactive anterior uveitis with secondary mature cataracts was diagnosed.

While it is the goal of most ophthalmologists to improve or restore vision in every case possible, I speculated that Fred’s behavior was going to pose a problem in his case management from the get go. I strongly discouraged Fred’s human from the pursuit of surgery. From a purely medical standpoint, the eyes were in rough shape, and not good surgical candidates for standard phacoemulsification – cats with cataracts secondary to uveitis rarely are. The uveitis was active and the eyes were very inflamed. I even went so far as to discuss the option of bilateral enucleation with Fred’s human, as a means of providing Fred “an out” from a life of medications and possible suffering, albeit not a visual outcome. Fred’s human was not ready for eye removal, and she elected to try to give him eye medications to improve the overall status of the eyes, and assess Fred’s tolerance to treatment. Topical steroid and anti-glaucoma drops were prescribed bilaterally several times daily. A recheck appointment was scheduled several weeks later.

Fred was no more enthusiastic about the next examination. Unfortunately, a new problem had developed – in the right eye, the cataractous lens had luxated into the anterior chamber. This event poses two additional risks to the health of the eye – first, the intraocular pressure (IOP) of the eye can increase pathologically, due to several mechanisms. Secondly, the anterior position of the lens can abut the corneal endothelium, sometimes with permanently damaging results. At that time, the options were outlined – the anterior lens luxation would most likely eventually compromise the long-term health of the eye and if it were to be salvaged, surgery to remove the luxated lens (an intracapsular lens extraction or ‘ICLE’) was advised.

For Fred, the decision to pursue ICLE surgery was not an easy one. Although not technically a very difficult surgery for an ophthalmologist, ICLE requires a very large limbal corneal incision to remove the lens from the eye. This incision is closed with very fine gauge suture, typically 8-0 or 9-0 dissolvable material, and effective healing is supported by multiple medications given with as little restraint as possible. An Elizabethan collar is a given component in the post-operative management of all eye surgeries that I perform, and it is undoubtedly a point of considerable concern of for most pet owners – how can an animal possibly eat, drink and sleep with one of those things on? Barring the occasional skin irritiation or exacerbation of a pre-existing ear infection, most patients do just fine with their “e-collars” and after a few days,
most become oblivious to their constant presence. The protection of their investment is usually enough to convince owners of the essential role the e-collar plays in the post-operative regime.

Fred’s human, although over the top with excitement that ICLE could potentially restore Fred with some functional vision, was worried. I was equally concermed. Over the prior last few weeks, Fred had reportedly “tolerated” the daily eye medications, but on closer questioning scrutiny, I learned that Fred’s human had actually hired a veterinary technician neighbor to help with the treatments, and it took the two of them typically 15 minutes to corral, restrain and medicate Fred. Was ICLE and its management aftermath really the best option for Fred, who had had plenty of time to adjust to his blindness, or would he be better off having the eye enucleated? Although an e-collar is typically recommended following this procedure as well, the postenucleation drug protocol is usually a short course of systemic analgesics. The uveitis in Fred’s other eye, also non-visual, could potentially be controlled with daily or every other day topical steroids, or, as previously discussed, both eyes could be removed and permanently negate the need for any eye medication.

Fred’s human was still convinced that vision was integral to his happiness (or hers?), so we proceeded forward. The ocular ultrasound and IOP were within normal limits and an electroretinogram revealed normal retinal photoreceptor function. ICLE was performed in the right eye without complication. Fred went home later that day with an e-collar and a suitcase full of drugs. I always try to treat with a minimalistic approach, only using what I feel is necessary so as not to overwhelm clients and patients – but the reality is that some problems require a lot of therapy to prevent, control or eliminate a disaster. Fred’s medication list was long, consisting of topical and systemic anti-infective, anti-inflammatory and anti-glaucoma drugs.

The first phone call came before I left the hospital that night – Fred was “freaking out” with the collar and had managed to get it off; I insisted it was required and they said they would have their veterinary technician neighbor come over to help. Fred came back for a recheck 3 days post-operatively – the e-collar was not on, and Fred looked at me smugly as I kindly but firmly counseled his human on the risks associated with not keeping the collar on. The eye looked remarkably good, and there was evidence of vision. Fred actually let me check his eye pressure and replace the ecollar. The past few days had been hard for the family, but the eye drops were being given, although Fred effectively spit out all oral medications. I thought we were on a roll. I was wrong.

One week later, Fred returned for the next follow-up exam. The e-collar was not on and Fred’s human was sheepish – she and her husband had decided the collar was too stressful for Fred and it was impairing their ability to treat him. I gasped when I saw the eye – the cornea was very edematous and cloudy, and Fred looked uncomfortable. He would not allow even a cursory exam, so sedation was again required. Examination revealed a yellow-white infiltrate and a deep stromal pitting along the entire corneal incision. The one positive finding was an acceptable low-normal IOP. I surmised that had Fred engaged in typical cat ocular grooming behavior without the protection of the e-collar and contaminated the incision with the bugs that like to live on cat feet and in their saliva. Floors, litter boxes and the patio deck contain plenty of bacteria, and with a less than steady-state antimicrobial level in Fred’s ocular tissues, the susceptibility to bacterial contamination was high. The serious nature of the infected and degenerating corneal incision forced the discussion again toward enucleation, but neither myself nor Fred’s human were willing to give up so soon.

We replaced the e-collar, added a high-powered topical antibiotic and a hypertonic saline ointment, to address the infection and the marked edema, respectively. Steroids were discontinued but the importance of NSAIDS and analgesics was re-iterated. I gave Fred an ultimatum – show some improvement ASAP or enucleation was around the corner. To make an already long story shorter, Fred’s eye did eventually take a positive turn, but it was not without considerable effort on everyone’s part. Medicating remained a challenge, as did his follow-up exams, but he came through the incisional infection crisis and started back on the path to vision. Cat corneas can take a significant hit and rebound, and I hope that in Fred’s case, this will prove true. Remarkably, Fred ended up tolerating continuous wear of the e-collar for 3 weeks during the corneal crisis period. If he had just worn that collar for the first two weeks after surgery, could this all have been prevented? Would Fred ultimately be better off blind, but without eyes requiring constant medicating or proving a source of chronic pain?

This case review exemplifies the importance of patient selection as a factor in the success rate of an ocular surgery. Client compliance is as important – medication dosing should be adhered to and e-collars need to stay on. In this case, the client was always determined to do what was needed during discussions in the exam room, but carrying out the requests at home proved to be beyond her abilities much of the time, primarily because of Fred’s tenacious nature. Regardless of the ultimate outcome Fred’s eye may have, he will remain an example of what can happen when the rules are not followed – be it because of patient or client compliance, or both.