This is Teddy’s story, written by his adopter Barrie, who is a long term PDWRA supporter. We are very grateful to Barrie for writing Teddy’s story in considerable detail for us, so that we can spread the word about the eye condition known as PK via the Pug Health section on our website.
“Teddy is a 7 year old brindle male. He was surrendered in December 2018 due to long term health issues which his owner was unable to deal with. When we collected him we were given the medication he was receiving for his eyes and a skin condition.
As part of the routine PDWRA rescue procedure we arranged for a health assessment by our local vet. Records obtained from the previous vet showed he had a history of issues with his eyes, and skin. He had been prescribed two types of eye drops to be administered daily in each eye; one type twice and the other three times. The drops were to be administered over a roughly twelve hour period. This treatment regime was to be continued long term and thus an onerous commitment for any adopter. Due to this condition we applied to adopt Teddy and this was granted.
Note: His skin condition which required a daily tablet and weekly bathing is not a life changing condition and other than adding to the daily treatment routine is not particularly troublesome and will not be discussed in this article.
The health assessment confirmed Teddy had pigmentation on both his eyes which was the reason we noticed he had very limited vision. Based on this diagnosis we requested a referral to a specialist ophthalmic veterinary practice.
The purpose of this article is to alert owners to the eye condition which if left untreated can have serious consequences. We have kept pugs for over 30 years and had never (knowingly) experienced the condition.
A referral was made to an ophthalmic specialist and an appointment made for 22/01/2019.
The ophthalmologist confirmed Teddy had the advanced stages of pigmentary keratitis (PK) in both eyes.
What is PK?
PK is a condition that results in progressive inflammation and pigment deposition over time on the corneal tissue (the clear surface of the eye). This usually starts at the area of cornea closest to the nose, but if left untreated can spread over the entire cornea. As the corneal pigmentation spreads over the cornea, it results in a gradual reduction of vision (like someone wearing glasses that are becoming progressively more dirty) and in extreme cases can result in complete blindness. The condition is not painful, though pain can occur if there is associated corneal ulceration. The condition can develop at any age and has been seen in puppies as young as 12 weeks of age.
Fortunately it is known that flat faced breeds e.g. Pugs, French Bulldogs, Bulldogs, Pekinese, Shih Tzus, and Lhasa Apso are predisposed to this condition. Thus owners of these breeds can take preventative steps to stop the disease developing.
There is no treatment available at this time to completely reverse this disease but there is medication which is known to suppress the progression.
What causes the condition to develop?
The cause of PK is not yet fully understood, but there is a strong correlation between genetic makeup, trauma to the eye (such as chronic irritation, corneal ulcers, or scarring), and the development of pigmentation. Chronic irritation is usually caused by a congenital defect of the eyelids that results in the eyelids rolling inwards making the eye lashes rub against the eye ball.
Readers will find the following link useful to get a better understanding of this disease, its causes and treatment:
Teddy’s Assessment 22/01/2019
This is the key extract from Teddy’s assessment: “The corneal pigmentation was covering almost the entirety of both corneas other than the ventral left cornea and was consistent with poor visual acuity observed. Both eyes had evidence of lower lid conjunctival hyperaemia and the right eye had an ongoing superficial corneal ulcer.“
In simple terms the pigmentation (a brown/black film) was preventing light getting into his eyes, which if not treated can ultimately lead to blindness. After discussion with the ophthalmologist it was decided the pigmentation had progressed too far to achieve any significant improvement using the suppressive medication, and surgery would be the best option to significantly improve Teddy’s vision and quality of life.
This possibility had been anticipated when making the referral appointment and surgery proceeded immediately.
Laser ablation successfully removed the majority of the pigmentation. As a result the ophthalmologist was optimistic that the vision from both eyes would improve. In effect what the surgery does is like scraping the ice off a car windscreen (cornea) on a frosty morning. Once the ice is removed the windscreen can be kept clean with the wipers and antifreeze solution.
In addition plastic surgery was performed to restructure the eye lids to reduce the aperture size and eliminate any rolling in of the lower eyelids to prevent irritation from the eye lashes.
Teddy was ready to leave for home at about 5.00 pm.
Post-operative care for first 10 – 14 days
- There are small sutures in the corner of the eyes which will dissolve over several weeks.
- Expect some swelling around the eyelids.
- There may be some bloody discharge around the incisions over the next 24 hours.
- Bathe away any discharge with cooled boiled water and pat dry with tissue.
- Keep collar on at all times.
- Topical Exocin, one drop to both eyes 4 times daily.
- Topical Atropine, one drop to both eyes once daily for 3 days then discontinue. May cause transient salivation following application.
- Topical Maxitrol, one drop to both eyes three times daily.
- Topical Tacrolimus 0.02% apply one drop to both eyes twice daily. Wear gloves when handling. Discard after six weeks.
- Topical Remend, apply one drop to both eyes four times daily.
- Oral Ronaxan 100mg, give one tablet once daily with food.
- Oral Rimadyl 20mg, give one tablet once daily with food. Start 23/01/19. Stop if any sickness or diarrhoea.
Teddy did not experience any bloody discharge from the incisions and none of the possible side effects of the medication occurred.
Post-op check 13 days after operation 04/02/2019
This confirmed the laser surgery had significantly reduced the pigmentation and his vision had improved. This was good news and for the next phase of rehabilitation his medication was greatly reduced to a more manageable level:
- Topical Tacrolimus one drop both eyes twice daily.
- Topical Exocin, one drop both eyes four times daily for ten days, then stop.
- Topical Remend, one drop both eyes four times daily (apply last).
The next check is scheduled in 3 months’ time, sooner if any concerns arise.
Progress to date (40 days after surgery)
Teddy’s sight has improved considerably and will continue to do so through the application of medication known to suppress the progression of any new pigmentation. When Teddy joined us and our three other rescued pugs he was only visually aware of objects and people within a range of approximately 3 feet. Now he is aware of everything going on around him within a range of approximately 20 yards. He’s gained confidence and shows no signs of visual limitations.
The first 2 weeks were difficult for him but from then on the turnaround has been wonderful to see. In early May he will go for his 3 months’ check-up which should confirm he has fully recovered from surgery. But this will not be the end of his journey. What the surgery does is give him the chance of starting afresh with clear eyes which can be treated with the suppression medication to stop the pigmentation developing again. He will require a long term maintenance dose of the suppression medicine 2 times daily.
WATCH THIS SPACE FOR HIS 3 MONTH REPORT!
Summary of what is known about PK
The good news is that:
- A lot is now known about PK and how it can be treated.
- It is known that the pigmentation starts from “small beginnings” and progresses very slowly so it may go unnoticed for a long time and become much more difficult to deal with.
- It is known that a major contributor to the cause of the disease is physical damage to the outer surface of the eye, e.g. ulcers, eyelids and skin folds in the vicinity of the eyes irritating the surface through contact, and dry eye.
- It is known there are medications which suppress the progress of pigmentation.
- It is known surgery will significantly help severe established conditions by resetting the baseline condition and allow medication to be more successful.
The not so good news is that pugs are a vulnerable breed. BUT KNOWING THIS IS A BIG PART OF THE BATTLE AGAINST THIS CONDITION.
What can Owners do?
The essential message from this article is “CATCH IT EARLY”. PK is a progressive disease and when caught in the early stages is much more manageable.
- It is recommended that pugs should be checked for the presence of PK every 6-12 months.
- If you have a reason to visit your vet soon, ask for an eye examination for the presence of pigmentation.
- If you don’t have an early visit planned, make an appointment.
- If the whites of the eyes look red and sore, make an appointment.
A general practice vet should be able to see the early signs and definitely see established pigmentation with their standard equipment. If any is found your vet should be able to advise whether referral to a specialist ophthalmic practice is necessary. Specialist ophthalmic practices only work on a referral basis.
For those interested in photography, below is a mobile phone camera picture of Tina’s eye (one of Teddy’s new friends). The purpose of taking the photograph was that it looked to be a nice clear eye to compare with how Teddy’s eye looked before surgery. However note the pyramid shaped dark area encroaching from the inside corner. Based on information in this article we were concerned it is the early sign of PK. To be sure we sent the photograph to the ophthalmologist who had treated Teddy and he verified it does look like she has evidence of relatively mild pigmentatation. We will now be taking Tina with us when Teddy goes for his 3 month check and hope to report this is a good example of “catching it early”and what the treatment will be.
In contrast, below is how Teddy’s right eye looked before surgery.
None of the essential exterior features of the eye are visible, i.e. pupil, iris and cornea. They are completely covered with a layer of pigmentation which prevents light reaching the vital internal parts of the eye that enable vision.
When pigmentation reaches this level surgery has to be considered to give the patient an opportunity to regain a reasonable level of vision. The procedure is expensive, and anyone considering it must have the time available to provide the necessary intensive post-operative management.
For us it has been a very rewarding experience taking Teddy from being practically blind to having a good level of vision to enjoy fun and games with the rest of the grumble – what a wonderful result!”
On 2nd May we visited our ophthalmologist for Teddy’s 3 month post op check, and Tina’s initial assessment to confirm our suspicion that she had the beginnings of PK.
Summary of findings from Teddy’s 3 month post op examination
On re-examination today both eyes were open, comfortable and had evidence of good vision. The left corneal pigmentation continues to disperse well, with a clear view of the posterior segment* permitted. The right corneal pigment has cleared well in the lateral 2/5 of the cornea but the central and medial cornea remains pigmented.** I would be hopeful that this will clear further in time with continued use of the Tacrolimus.
Owner noted some intermittent hyperaemia of the lower eyelid skin and I suspect that this is the result of tear run-off being trapped within the nasal fold. I have advised that this area is kept as dry as possible in order to reduce the risk of any moist dermatitis developing.
I have requested re-examination in six months.
* The posterior segment is the back two-thirds of the eye that includes the anterior hyaloid membrane and all of the optical structures behind it: the vitreous humor, retina, choroid, and optic nerve. In cases of advanced PK this part of the eye is not visible and critically prevents light getting to the optic nerve thereby causing loss of vision.
**The right eye has not cleared as well as the left due to an ulcer being present at the time of surgery.
From an owner’s perspective we would add this has been a great experience and Teddy is now enjoying a full puggy life style.
Summary of findings from Tina’s initial assessment
Slit lamp biomicroscopy confirmed the presence of pigmentary keratitis in both eyes. I suspect that this has developed as a result of chronic irritation of the cornea from the lower eyelid and nasal skin fold and I discussed surgical intervention (bilateral medial blepharoplasty surgery and combined laser pigment ablation) in order to control the pigmentation. Owner was keen to consider the treatment in the future and I have initiated treatment with topical Remend and Tacrolimus in the interim period in an attempt to controlling the current level of corneal pigmentation.
I have requested re-examination in six months at which time surgery may be opted for.
We are hoping the next six months will demonstrate that use of medication alone can make a difference in controlling PK. The Tacrolimus is aimed at the pigmentation and Remend will counter the irritation caused by lower eye lid.
That’s it for now. We will be continuing the story in 6 months’ time.