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Ophthalmology - Related Articles
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Anterior Uveitis
What is uveitis?
The word uveitis means inflammation of the uvea or vascular tissue inside the eye. The iris, ciliary body and choroid make up the uvea. Inflammation of the iris and ciliary body is called anterior uveitis. Inflammation of the choroid is called posterior uveitis. Inflammation of all three structures is panuveitis.
What causes uveitis?
In many cases, the cause of uveitis is never determined and is believed to be immune- mediated. Bacterial or viral infections in other parts of the body can show up as inflammation inside the eyes. Diseases carried by ticks and trauma are other potential causes. Blood tests may be performed to rule out any underlying disease.
What are the signs of uveitis?
Mild uveitis can be very difficult to detect without specialized equipment like an ophthalmoscope or a slit-lamp. Moderate to severe uveitis is more obvious. Owners often notice a red eye, a change in the color or cloudiness of the eye, sensitivity to light, excessive tearing or discharge, squinting or other signs of pain or loss of vision. In severe cases the front of the eye may fill with blood or fibrin.
How is uveitis diagnosed?
A veterinary ophthalmologist with specialized equipment can see changes inside the eye consistent with inflammation. A glaucoma test should be performed and other tests may also be used to rule out other diseases. Blood and urine samples should also be collected and submitted to the lab to help rule out any underlying cause.
How is uveitis treated?
Uveitis can be difficult to treat and is often a life-long condition that can be controlled but not cured. Initial treatment typically involves the use of anti-inflammatory eye drops and oral medications. In some cases injections around the eyes can be given to more rapidly ameliorate signs. After the inflammation is well controlled, the medication can be reduced in dosage and frequency. In some cases the uveitis is resolved and never returns. In most cases the pet will need some medication for future episodes or may need to stay on low-dose treatment in order to prevent future attacks.
What if the uveitis is not treated?
Uncontrolled inflammation inside the eyes will result in adhesions and disruption of fluid flow. This results in secondary glaucoma causing vision loss and/or chronic pain. It is important to follow the recommended treatment and re-evaluation schedule to avoid these complications.
Blind Pet Care
Blind dogs and cats can be very happy pets. Here are a few bits of advice that will make the transition easier:
1. Avoid changing your pet's environment, such as moving the furniture.
2. Encourage your pet to use his other senses to compensate for vision loss.
a. Provide toys that are noisy or have a recognizable odor.
b. Get a companion pet that your blind pet can follow around using hearing and smell.
3. If your pet is blind due to cataracts, it is wise to observe his eyes daily for changes that may be indicate glaucoma or uveitis, which are painful. These changes include bloodshot eye, increased size of eye, pawing a or rubbing the eyes and change in position of the cataract.
4. Encourage exercise, whether in a fenced yard or on a leash.
5. Teach your pet the location of the food and water bowls and keep their location constant.
6. Some behavior changes (aggression, depression, fear, etc.) accompany sudden blindness. Avoid stressing or startling your pet. Inform family members (especially children) of the new condition.
7. Please feel free to contact Animal Eye Specialists for advice regarding your specific circumstances.
Below are some resources that contain additional support and information about how to help you and your pet adapt:
Living With Blind Dogs by Caroline D. Levin, RN
Canine Entropion
What is entropion?
Entropion is an abnormal rolling in of the eyelid. This causes the hairs of the eyelid to abrade the surface of the eye.
What causes entropion?
Entropion is usually due to an inherited faulty eyelid conformation that manifests in young adult dogs. Occasionally, entropion results from an eyelid spasm due to some other painful eye condition.
Are certain breeds of dogs prone to entropion?
Yes. The Bloodhound, Bulldog, Retrievers, Chow Chow, Rottweiler, and Shar Pei are prone to entropion, although any breed may be affected.
How do I recognize that my dog has entropion?
Most pet owners notice that the affected eye is partially held shut and has excessive tearing. Both eyes are usually affected simultaneously. Breed-related entropion usually affects dogs under 1 year of age.
How is entropion diagnosed?
A thorough examination of the eye is performed to make certain there are no other painful conditions present that are causing an eyelid spasm. If the eye has no other problem, then a diagnosis of inherited entropion is made.
How is entropion treated?
Most dogs with entropion require surgical correction. This surgery involves removing a small portion of the skin to tighten the eyelid. Temporary eyelid tacking may be used in very young dogs. Definitive surgical correction is often delayed until the dog has a more mature head conformation at 6 months of age. If uncorrected, subsequent corneal ulceration, pigmentation, and scarring may produce vision loss.
Should I show my dog if it has had entropion?
No. The American Kennel Club considers entropion surgery a cosmetic surgery and prohibits these animals from participating in AKC sanctioned shows and events.
Should I breed my dog if it has had entropion?
If a dog has had entropion due to an eyelid spasm, there is no restriction placed on breeding. The American College of Veterinary Ophthalmologists, in conjunction with the Canine Eye Registration Foundation (CERF) have made breed-specific breeding recommendations with inherited entropion. Ideally, no dog with inherited entropion should be bred, since this may result in offspring with entropion.
Will entropion recur?
In most cases, no. Some breeds of dogs such as Shar Pei may have severe and complex entropion that requires several corrective surgeries.
Canine Glaucoma
What is glaucoma?
Glaucoma is an increase of pressure within the eye. If the pressure within the eye is elevated for more than several hours, permanent damage or blindness can result.
What causes glaucoma?
Glaucoma is due to an obstruction to the drainage of aqueous humor from the eye. Continued fluid secretion into the sealed eye elevates the intraocular pressure.
Are certain breeds of dogs prone to glaucoma?
Yes. The American Cocker Spaniel, Basset Hound, Siberian Husky, Samoyed, and Shar Pei are prone to glaucoma, although any breed of dog may be affected.
How do I recognize that my dog has glaucoma?
Most dogs with glaucoma will suddenly have a red, painful eye. Many dogs exhibit eye pain by a loss of appetite, excessive sleeping, or a decrease in activity. A decrease in vision is usually not recognized unless both eyes are affected. Some breeds of dogs will not have a red, painful eye but will have only a slow loss of vision.
How is glaucoma treated?
Glaucoma that has been present for less than 48 hours requires emergency treatment. Although only a small percentage of dogs regain vision in an eye that has glaucoma, emergency treatment helps relieve the extreme pain associated with this condition. If your dog has had glaucoma for more than 48 hours, emergency treatment may not be effective. Emergency treatment generally requires one day of hospitalization. Long term treatment is often needed to control glaucoma requiring oral medication and/or eye drops for the rest of your pets life. A surgery to relieve increased eye pressure is frequently recommended instead of long term medication if the eye is permanently blind.
Do the medications have side effects?
Occasionally, the oral medication used for glaucoma, Daranide, may produce a loss of appetite and lethargy. On rare occasions, vomiting and/or diarrhea may occur. The eye drops may cause temporary redness and tearing immediately after instillation.
What surgeries are available for glaucoma?
The Eye With a Potential for Vision
Laser: Laser energy can be directed into the eye to selectively destroy the fluid producing cells. This "turns down" the flow of fluid into the eye and subsequently reduces intraocular pressure. Laser surgeries are about 75% effective in keeping an eye comfortable, amount of vision restored to the eye is dependent on the amount of damage done during the pressure spike.
The Blind Eye
Eye Removal (enucleation): Although this surgery seems drastic, enucleation is the most reliable way to alleviate the source of your pet's pain. The eyeball is removed, a silicone ball is placed in the eye socket, and the eyelids are permanently sutured over the ball. The ball prevents the skin over the eye socket from sinking in.
Intraocular Evisceration & Implantation: The inner contents of the eye are removed and replaced with a black silicone ball. The outer portions of the eye remain. The eye is sutured shut for 4 weeks while the eye heals. This surgery is often chosen by pet owners who cannot tolerate eye removal. The resulting eye does not look exactly like the dog's original eye but may be more cosmetically appealing than enucleation.
Can I prevent glaucoma in the fellow eye?
Unfortunately, no. Regardless of treatment, glaucoma usually occurs in the fellow. Treatment of the normal eye may delay glaucoma from occurring an average of thirty months. If glaucoma medications are instituted prior to the onset of glaucoma, glaucoma may be postponed beyond 1 year.
How often should I return for eye exams?
While your dog is on preventative glaucoma treatment, you should have his/her eyes examined 4-6 times each year.
What do I do if glaucoma occurs in the normal eye?
If you notice redness, irritation, or a decrease in vision in the normal eye, you should seek veterinary assistance immediately! Your veterinarian or local emergency clinic will begin emergency treatment.
Canthoplasty: Nasal and Temporal
What is a canthoplasty?
A canthoplasty is a surgery performed to shorten the length of the eyelids. It closes down the eyelid space and protects the eye. This surgery can be performed on the nasal (nose) side of the eyes and/or the temporal (ear) side of the eyes. Occasionally, both sides of the lids need surgery to best help your pet.
What conditions may require a canthoplasty?
Prevention of corneal scarring is usually the reason a canthoplasty is performed. Corneal scarring may be the result of several different conditions. Many pets are unable to fully close their eyes when blinking. Pets may sleep with their eyes partially open. In some breeds, the prominent nasal folds touch the eyes. Some pets either lack or have poor tear film coverage on their corneas. Another reason a canthoplasty may be recommended is if your pet is at risk for pushing his eye in front of his eyelids (a proptosis). A canthoplasty can be performed as a preventive surgery. Whatever the reason, a canthoplasty is performed to improve overall eye health for the life of your pet.
What happens if you choose to have canthoplasty for your pet?
Before surgery:
When you decide canthoplasty is the best option for your pet, we will schedule a date for surgery, usually within one week of the exam day. Your pet will need complete blood work and a urinalysis prior to the day of surgery. These tests are important in reaching an accurate pre-operative evaluation, assuring our goal of a safe anesthesia, and leading to the best possible recovery for your pet.
The day of surgery:
This surgery often is performed on an outpatient basis, which means your pet will go home the same day. You will be asked not to feed your pet breakfast and to bring all of his medications with you. Phone us with any questions, and refer to our anesthesia handout for your pet's specific pre-operative instructions.
When your pet is admitted for surgery, he will be given a sedative to help him relax. Later, an IV catheter will be placed for medication and fluid administration. General anesthesia will keep your pet asleep and pain-free during surgery. Our surgical team will be monitoring your pet before, during and after surgery.
The operation:
While under general anesthesia, a local block (like a dentist gives) will be placed in the eyelids to keep your pet comfortable after surgery. A "V" shaped section of eyelid and skin is will be removed along the nasal or temporal side of the eyes. The incisions are closed with 2 layers of sutures. This closure makes the lid opening smaller, protecting the globe.
After surgery, an Elizabethan collar will be placed on your pet to prevent him from rubbing at the sutures. Your pet will recover under the supervision of our team. Once he is alert enough to walk, he is transferred to a hospital kennel. There, he can quietly rest on a fleece bed until he is ready to go home.
After surgery:
When your pet is awake and comfortable, he can go home. This is usually 3-5 hours after surgery. We will provide you with written instructions regarding medications and restrictions after surgery. Please schedule a courtesy appointment for your pet 12-14 days after surgery for skin suture removal.
What complications can occur?
Successful canthoplasty surgery requires care and attention by both owner and ophthalmologist. Complications after canthoplasty are incredibly infrequent, but can include: infection at the incision, premature suture removal by the pet, and, very rarely, hair growth in irregular directions that may necessitate a second procedure. It is to be stressed that these are very seldom seen and almost all patients recover from surgery without any complications.
What are the other options?
Diligent application of topical tear-promoting medication or lubricants is a second option for some pets. For most pets and owners, canthoplasty offers a high surgical success rate, convenience of requiring less long-term medical treatment, and the ability to protect the eye for the life of your pet.
What is a cataract?
A cataract is cloudiness of the normally clear lens of the eye. The lens is the structure within the eye behind the iris and pupil that helps us focus. When the lens turns cloudy from a cataract, it impairs vision. There are different types of cataracts; some lead to blindness, some do not. A skilled ophthalmologist will be able to diagnose and classify the type of cataracts your pet has. The rate of progression of cataracts may be impossible to predict.
What causes cataracts?
Most commonly, cataracts are genetically passed from parents to offspring. Other cataracts are due to diabetes, ocular injuries and chronic ocular inflammation.
How are cataracts treated?
Surgery is the only way that cataracts can be removed. There are no medications or dietary supplements that have been shown to prevent, slow progression or cure cataracts. Surgical removal of the cataract entails removal of the entire lens. This surgery is performed with your pet under general anesthesia using an operating microscope, microsurgical instruments, and a phacoemulsification unit. While not all patients are candidates for cataract surgery, and not all cataracts require surgery, it may still be a good idea to seek the opinion of a veterinary ophthalmologist. Because cataracts may cause secondary problems, visiting with a veterinary ophthalmologist may help maintain the health of your dog's eyes.
What is phacoemulsification?
Cataract surgery is performed in dogs similarly to the way it is performed in human beings. Phacoemulsification is the technique by which the lens is broken into tiny fragments with ultrasonic power. An ultrasound probe is introduced into the eye through a small incision, the lens is broken apart and the lens fragments are aspirated from the eye. This restores an optically clear window through which your dog can see.
What is an intraocular lens?
An intraocular lens implanted at the time of surgery replaces the focusing power of the natural lens that was removed. Dogs with artificial lenses implanted at the time of cataract surgery have better vision than dogs without lenses. If the natural capsule that surrounds the lens is able to support an intraocular lens, one will be implanted. This is a decision that is made at the time of surgery.
What is the success rate?
Approximately 90% of dogs have good to excellent vision after surgery. Vision-threatening complications that may occur include glaucoma, retinal detachment and scar tissue formation. Thankfully, these complications are not common, and the vast majority of dogs see well after surgery.
Cataract Surgery Preparation
My dog is having cataract surgery…what do I need to know?
Having cataract surgery for your dog can be a very exciting experience. This handout is designed to prepare you and your dog for surgery as well as alleviate some of the anxieties associated with surgery.
Success Rate
Specialized training and modern equipment have drastically improved the success rate of cataract surgery. Approximately 90% of dogs have excellent long-term vision after surgery.
Potential Complications
As with any surgery, cataract surgery has potential complications. Some complications are short-term and resolve with treatment. Regrettably, some complications are severe and blinding. Very rarely eye removal or an intraocular prosthesis is necessary to resolve the complication. To minimize the complications, we request diligent administration of prescribed medications and frequent re-evaluations after surgery. Glaucoma, or increased intraocular pressure, may occur post operatively. Glaucoma may or may not be controllable with medication and can be vision-threatening. Uveitis, or inflammation within the eye, may occur and potentially require life-long medication. Retinal detachment is a possible complication due to the nature of the surgical procedure itself. Eye infection after surgery is rare because surgery is performed using sterile technique. Scar tissue formation around the intraocular lens and around the surgical incision are other possible complications. General anesthesia is also a risk. However, we take all precautions by performing complete pre-operative blood work, a thorough physical exam, employing the most current anesthetic protocols, and diligent anesthetic monitoring to ensure the safest anesthesia possible.
Getting Your Dog Ready for Surgery
After a comprehensive eye exam, electroretinogram, ocular ultrasound and complete bloodwork, we will schedule a date for surgery. In the days or weeks prior to surgery you will be administering topical and oral medications to prepare your dog for surgery. It is very important to follow all instructions on these medications as they improve the success of surgery and keep your dog comfortable until surgery can be performed.
What Happens the Day of Surgery?
Please bring all of your dog's medications with you on the day of surgery, as we will need to use them throughout the day. If your dog is a diabetic DO NOT administer insulin the morning of surgery, but DO bring the insulin with you to VRCC. We will closely monitor your dog's blood glucose before, during, and after surgery taking appropriate actions to maintain normal levels.
We will administer pain control and sedative medications before surgery to help keep your dog calm. We will place an intravenous (IV) catheter in his leg to administer intraoperative antibiotics, anti-inflammatory injections, fluids, and other necessary medications. For surgery, we will place a breathing tube in the trachea (windpipe) to administer oxygen and gas anesthesia. We will closely monitor heart rate and rhythm, blood pressure, blood oxygen levels and blood carbon dioxide levels throughout the procedure. Cataract surgery takes approximately 2 hours. After your dog recovers from anesthesia we will closely monitor his comfort and vision will be evaluated. Typically, patients go home on the afternoon of the surgery.
What Happens After Surgery?
Frequent recheck exams after surgery are necessary to ensure proper healing takes place. We will need to see your pet 1 day and approximately 1 week, and 2-4 weeks post-operatively. From there, the doctor will advise you on how frequently he would like to see your dog over the following year. At minimum, an annual exam will be recommended. For your convenience, we have practices located in Englewood and Boulder.
For two weeks post-operatively, patients should have restricted activity: no roughhousing with other dogs and leash walks only. An Elizabethan collar should be worn for two weeks to prevent self-trauma and no bathing or swimming until the surgery site has healed.
Medications are a very important part of aftercare. All instructions must be followed carefully for a successful recovery. If you have any questions regarding medications please call our office.
As patients heal from surgery, we will guide you through what is normal healing and what may require attention. It is extremely important that you call us immediately if you notice any change with the eye. For example: if the white of the eye turns bloodshot, or if the surface of the eye becomes hazy or blue in color, or if your dog suddenly starts squinting or has more discharge than normal. Any of these signs could indicate complications that require immediate medical attention.
Restoring vision to a blind dog is a very rewarding part of our job. The tail wagging and smiling that goes on when patients and clients see each other after weeks, months or years of vision loss is a delight to see again and again.
Cherry Eye
What is a prolapsed third eyelid gland?
A prolapsed third eyelid gland is when the normally hidden tear gland located behind the third eyelid flips up into an abnormal position. This tear gland is responsible for one-third to one-half of the tears needed to lubricate the eye.
What causes a prolapsed third eyelid gland?
The exact cause of this condition is unknown. It is believed that there is a weakness of the ligament that holds the gland in place. The gland is therefore free to flip up and out of its normal position.
Are certain breeds of dogs prone to developing a prolapsed third eyelid gland?
Yes. The American Cocker Spaniel, English Bulldog, Lhasa Apso, and giant breeds are prone to third eyelid gland prolapse, although many other breeds may be affected as well. Third eyelid gland usually occurs in young dogs less than 1 year of age.
How can I recognize that my pet has a prolapsed third eyelid gland?
Most pet owners will notice a pink lump near the inside corner the affected eye. Frequently, this lump will disappear and reappear without treatment before it finally remains in the abnormal position. It may occur in one or both eyes.
What should be done?
Untreated prolapsed glands may become inflamed, cause tearing and obstruct vision. Simple gland excision may cause dry eye, especially in breeds predisposed to dry eye such as the Cocker Spaniel, English Bulldog, and other small dog breeds. For this reason, the recommended treatment is surgical replacement of the gland into its normal position rather than excision.
Are there any complications associated with third eyelid gland surgery?
Approximately 1 out of 20 dogs has recurrent gland prolapse after surgery. A repeat surgery is recommended. It is uncommon for a dog to require more than 2 surgeries for this condition. Third eyelid swelling and ocular discharge is common for 5 to 7 days after surgery.
Should I breed my dog if it has had a prolapsed third eyelid gland?
Currently, the American College of Veterinary Ophthalmologists and the Canine Eye Registration Foundation (CERF) place no restriction on the breeding of dogs with prolapsed third eyelid gland.
Corneal Infections
What is a corneal infection?
When the outer layer of the cornea is injured, bacteria can take advantage of this weakness and create an area of infection. Enzymes released by the bacteria can digest the cornea creating a deep ulcer. Deep corneal ulcers may lead to a rupture of the eye. Most corneal infections are started by a minor injury to the cornea. Other possible causes include low tear production in dogs and herpes virus infection in cats.
Are certain breeds of dogs or cats prone to developing corneal infections?
Yes. Dogs and cats with prominent eyes such as the Shih Tzu, Lhasa Apso, Pug, Boston Terrier, Persian and Himalayan are more prone to corneal injuries and infections, although any breed may develop this condition.
How can I recognize that my pet has a corneal infection?
Most pet owners notice that the affected eye is suddenly red, painful, and held shut; occasionally, the eye will turn blue. The depth and severity of the corneal infection can be determined by your veterinarian. Rarely, a dog will exhibit little or no pain and will only have a slight change in the appearance of the eye.
How is a corneal infection diagnosed?
A veterinary ophthalmologist is able to determine if a corneal infection exists with specialized instruments and testing. The depth of the infection can be determined with a specialized instrument called a biomicroscope.
How is a deep corneal infection treated?
Most corneal infections are initially treated with a combination of antibiotic eye drops. To control the infection, the drops are instilled every 1-2 hours for the first day of treatment. Even with aggressive medical treatment the eye can still rupture. If the infection has created a pit or ulcer deeper than 1/2 the corneal thickness, surgical grafting is the most prudent treatment.
What is the surgery for a deep corneal infection?
The surgery for a deep corneal infection consists of grafting tissue near the eye directly onto the ulcer bed. This patch will permanently adhere to the cornea, thereby preventing rupture of the eye. The eye rapidly becomes comfortable following graft surgery. Some of the grafted tissue may be excised 6-8 weeks after the initial surgery.
Will my pet have any permanent damage or vision loss from the infection?
The potential for vision depends upon the initial severity and location of the infection. Vision is regained, to some degree, in most eyes that have had a deep infection. If the eye is ruptured or the ulcer is very large, significant scarring may lead to poor or absent vision after treatment.
How often does my pet need to be re-examined?
The frequency of re-examination is dependent upon the severity of the infection and the type of treatment needed. Ulcers treated without surgery should be examined every 1-2 days until healing is certain. Ulcers treated surgically are evaluated in 3-5 days and again in 10-14 days. If needed, the base of the graft will be excised from the topically anesthetized cornea during an office visit 6-8 weeks after the surgery was performed.
Corneal Sequestrum
What is a corneal sequestrum?
The condition is unique to cats and is characterized by an area of corneal degeneration with brown pigmentation.
Are certain breeds more likely to develop a corneal sequestrum?
Yes. Persians, Himalayans, Siamese, and Burmese cats are diagnosed with the disorder most frequently. However, any breed can be affected.
What causes a corneal sequestrum?
Although the cause is unknown, there is usually a history of corneal ulceration, irritation, and/or ocular feline herpes virus infection.
What are the signs of a corneal sequestrum?
Squinting and tearing with a brown tearstain are common. The area of corneal degeneration appears as a brown "spot" on the surface of the eye, which can vary in size and depth in the cornea.
How is a corneal sequestrum treated?
Surgical treatment is almost always necessary.
Will the condition come back?
The risk of recurrence is reduced when the entire corneal sequestrum is excised and the corneal defect is reconstructed with a grafting procedure. A sequestrum may develop in the other eye.
Dry Eye
What is keratoconjunctivitis sicca?
Keratoconjunctivitis sicca (KCS) or "dry eye" is the failure of the tear glands to produce enough liquid tears to keep the eye moist and healthy.
What causes keratoconjunctivitis sicca?
The most common cause for KCS is thought to be an autoimmune reaction. The immune system launches a misdirected attack on the tear glands; the triggering event is unknown. Occasionally, certain drugs may induce a dry eye. Additionally, KCS may be caused by an interruption to the nerve supply that tells the gland to make tears. In most instances, KCS is permanent and requires life-long treatment to prevent blindness and to avoid ocular discomfort.
Are certain breeds of dogs prone to keratoconjunctivitis sicca?
Yes. The American Cocker Spaniel, Bulldog, Lhasa Apso, Miniature Poodle, Shih Tzu and West Highland White Terrier are prone to KCS, although any breed of dog may be afflicted with KCS.
How can I recognize that my pet has keratoconjunctivitis sicca?
Most dogs with KCS will have a constant heavy, white-to-yellow discharge from the affected eye. A dry eye is more prone to bacterial infection, "pink eye" or conjunctivitis, which temporarily responds to treatment with antibiotic eye ointment.
Eyes that are dry for several months develop corneal scarring and pigmentation, resulting in loss of vision.
How is keratoconjunctivitis sicca diagnosed?
A small strip of paper is placed in the conjunctival sac, and the amount of tears soaked up by the paper in one minute is measured. This test, known as the Schirmer tear test, is used to diagnose KCS and to measure response to treatment.
What is the treatment for keratoconjunctivitis sicca?
KCS is treated with medication or surgery. Medical treatment with cyclosporine or tacrolimus in the affected eye can reverse the autoimmune reaction and stimulate tear production. Approximately 8 out of 10 dogs treated with topical cyclosporine will make more tears. If successful, medical management is usually required for the life of your dog. In patients non-responsive to tear-stimulating medications, a parotid duct transposition surgery may be recommended. Surgery involves re-routing the parotid salivary gland duct from the mouth to the eye, so that the eye is lubricated by saliva.
Regardless of the treatment chosen, KCS is a chronic problem that often requires long-term maintenance therapy.
Exposure Keratopathy
Enucleation Surgery
What is an enucleation?
Enucleation is a surgical procedure to remove the eye and the eyelids. The empty eye socket is usually filled with a silicone ball that serves as a space-filler to prevent a sunken appearance after surgery. The skin is permanently closed over the eye socket.
What are some reasons your pet may need an enucleation?
There are many reasons a pet may need an enucleation; usually, they involve a blind, painful eye. Common reasons for an eye removal include pain from a severe infection, intra- or extra-ocular tumors, medically unresponsive glaucoma, and irreparable ocular injury.
What happens if you choose to have an enucleation for your pet?
Before Surgery:
When you decide enucleation is the best option for your pet, we will schedule a date for surgery, usually within one week of the exam day. Your pet will need complete blood work and a urinalysis prior to the day of surgery. These tests are important in reaching an accurate pre-operative evaluation, assuring our goal of a safe anesthesia, and leading to the best possible recovery for your pet.
We will also discuss different methods of pain control for your pet. One option is a fentanyl patch. It is best to have the patch applied to the skin the afternoon prior to surgery. A small area of fur is shaved and a clear plastic transdermal patch is applied. After an initial uptake time of 8-12 hours, this patch will release continual pain medication to your pet for 72 hours.
The Day of Surgery:
This surgery often is performed on an outpatient basis, which means your pet will go home the same day. You will be asked not to feed your pet breakfast. Please bring all of his medications with you. Phone us with any questions, and refer to our anesthesia handout for your pet's specific pre-operative instructions.
When your pet is admitted for surgery, he will be given a sedative to help him relax. Later, an IV catheter will be placed for medication and fluid administration. General anesthesia will keep your pet asleep and pain-free during surgery. Our certified technicians will be monitoring your pet every step of the way.
The Operation:
While under anesthesia, a regional nerve block (similar to what a dentist gives) will be placed to keep your pet comfortable after surgery. The eye is then gently removed through skin incisions placed above and below the eyelids. The ocular muscles and optic nerve are cut, allowing the eye and surrounding tissues to be removed. A silicone ball usually is placed in the eye socket as a space-filler, and the incision is closed with three layers of sutures.
After surgery, an Elizabethan collar will be placed on your pet to prevent him from rubbing at the sutures. Your pet will recover under the watchful eye of our team. Once your pet feels awake enough to walk, he is transferred to a hospital kennel. There, they quietly rest on a fleece bed and are closely supervised until they are ready to go home.
After Surgery:
When your pet is awake and comfortable, he can go home. This is usually 3-5 hours after surgery. We will provide you with written instructions regarding medications and restrictions after surgery. Please schedule a courtesy appointment for your pet 12-14 days after surgery for skin suture removal.
Successful enucleations require care and attention by both owner and ophthalmologist.
Complications after an enucleation are incredibly infrequent, but do include: excessive incisional bleeding after surgery that resolves after bandage and overnight hospitalization, premature suture removal by the pet, and transient nose bleed. More serious complications include: infection within the eye socket, and in less than 1 in 100 patients, rejection of the silicone implant. Both of these complications resolve after removal of the implant. We want to stress that these complications are very rare and almost all patients recover from surgery without any problems.
For some pets, there are other options besides enucleation surgery. These options include: Intraocular Prosthesis Implant or Intravitreal Gentamicin Injection. Please ask our staff if your pet qualifies for one of these options. Please keep in mind, however, that no other surgery has the success rate and ability to relieve pain and discomfort with as few long-term, potential complications as an enucleation.
We can show you post-operative photos of both dogs and cats who have had enucleation surgery and, remember, your pet will still be the beautiful friend you have always loved.
Eyelash Diseases
What are distichia?
Distichia are misplaced eyelashes that grow from the eyelid margin. Soft distichia cause no irritation. Coarse distichia scratch and irritate the eye. Dogs with coarse distichia typically display excessive tearing.
What are ectopic cilia?
Ectopic cilia are eyelashes that originate under the eyelid and are directed directly at the cornea. They are much more irritating to the eye because they are directed perpendicular to the corneal surface.
What should be done?
The abnormal hair follicle must be destroyed to remove the hair and to prevent regrowth. Typically, sedation or a short general anesthesia and an operating microscope are necessary to permit precise visualization of the hair follicle and its permanent removal by electrocautery, cryosurgery, or microsurgical excision.
What should I expect after eyelid surgery?
There may be a small amount of blood in your pet's tears for 24 hours. The surgery site will be swollen for 5-7 days.
Will the abnormal eyelashes come back?
While the success rate is very high it is possible to have growth of hairs from the same or new follicles. It is also possible after removal of the hairs that some of your pet's symptoms will continue due to some other problem like allergies. The procedure is 90% to 95% percent successful at making your pet comfortable long-term.
Eyelid Tumors (and Cryosurgery)
What are eyelid tumors?
Older dogs very commonly develop small, slowly growing masses on their eyelids. These masses most commonly arise from the meibomian glands that line the eyelids (meibomian gland adenomas or adenocarcinomas) or from melanocytes (melanomas), although other cell origins are possible.
Should eyelid tumors be treated?
Untreated eyelid tumors are generally benign in that they are unlikely to spread to other places in your dog's body or injure the eye. However, eyelid tumors may become inflamed, producing pain like what people experience with a stye. Additionally, larger masses rub on the eye, interfere with normal blinking, and can stimulate excessive tearing.
What should be done?
Eyelid tumors may be safely excised following a mild intravenous sedation and local anesthetic injection in the eyelid. General anesthesia is not necessary in most cases. To prevent a recurrence of the eyelid tumor, the surgery site is frozen with a liquid nitrogen cryosurgery probe.
What is cryosurgery?
Cryosurgery is the local application of extreme cold in order to kill tissues. Normal eyelid structures are relatively resistant to injury by freezing; however, eyelid tumors are quite sensitive to freezing.
What should I expect after eyelid cryosurgery?
You may notice a small amount of blood in the tears for 2-3 days, and the surgery site will be swollen for 5-7 days. Within 2 weeks the surgery site will turn pink due to the loss of melanocytes. You may notice whitening of the hairs surrounding the surgery site. In most cases, the skin will repigment within 4 months, but the hair whitening may be permanent.
Will the eyelid tumor come back?
Approximately 5-10% of eyelid tumors recur after cryosurgery. If you notice a tumor on your dog's eyelid in the future, it may be a recurrence of the original tumor or it may be a completely new tumor. The treatment is the same: excision or cryosurgery.
Fatty Acids
What are essential fatty acids and where do they come from?
Essential fatty acids are necessary fats that the body does not produce on its own. They support the cardiovascular, reproductive, immune and nervous systems. There are two families of essential fatty acids: Omega-3 and Omega-6. Omega-6 fatty acids are found in animal fats and plant sources. Omega-3 fatty acids are found in marine body oils (fish and salmon). Fish oils contain eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). EPA is the powerhouse of Omega-3 fatty acids, being easily incorporated into cell membranes. While Omega-6 fatty acids are supplied in ample amounts in pet diets, most commercial pet foods contain very little Omega-3 fatty acids.
What do essential fatty acids do?
For years, essential fatty acids have been given to pets to promote skin and coat health. More recently, essential fatty acids have been found to play an important role in controlling inflammation, allergies, and auto-immune conditions.
How can essential fatty acids help the eye?
For patients with chronic dry eye, it's believed now that supplementation of Omega-3 fatty acids can provide some relief. Omega-3s work in two ways: they improve eye comfort by suppressing inflammation, and they may also provide additional beneficial nutrients to the eyelid glands that secrete the oil layer of the tear film. The oil layer of the tear film is the outermost layer that prevents evaporation of the second, watery layer.
Though few studies have been done, initial reports in humans suggest that Omega-3 dietary supplementation decreases a patient's chance of developing dry eye and also provides relief from the discomfort associated with dry eye. Because EPA, the crucial element in Omega-3 fatty acids, is incorporated into cell membranes, noticeable results can take some time. Pets often need to be on fatty acid supplements for 9-12 weeks before owners will see improvement.
And, remember, fatty acids do add calories, so fewer treats or a slight decrease in the overall amount of food can help to prevent weight gain.
What's important when buying and giving Omega-3 supplements?
Shopping for fatty acid supplements can be confusing. Different products report ingredients in different ways. While bottles are labeled according to the total milligrams of marine oil per unit (usually a capsule or a pump for a liquid), a dose of Omega 3 is determined by the amount of EPA present. These two things are not the same. It is the actual concentration of EPA in a supplement that is most important, so you must look at the nutritional label on the package
to determine the amount of EPA present in any given product. Fatty acids increase the body's need for antioxidants,
as well, so please look for supplements that are fortified with Vitamin E. Since many combinations of fatty acids are available on both the human and veterinary markets, it's up to you to read the labels carefully to ensure quality and proper dosing.
Please give your pet 180 mg of EPA per 10 pounds of body weight. Administer this dose twice daily. Some pets may need to build up to this dose. You can start by just giving one dose per day for 7 days, then increase to twice daily.
Feline Herpes
What is the Feline Herpes Virus (FHV)?
The feline herpes virus most commonly infects kittens and causes sneezing, ocular and nasal discharge, and a reluctance to eat and play. With good nursing care, the vast majority of kittens return to normal within 3 weeks. Vaccinated kittens may still develop disease, but the illness is less severe. Approximately 80% of FHV infected cats become latent carriers with a 45% chance of viral re-activation. Adult cats with eye disease due to FHV are more likely to be suffering from viral re-activation than from a primary FHV infection.
What happens when the virus is re-activated?
The feline herpesvirus can hide quietly in your cat's nerve roots. During periods of stress, the virus can travel down the nerves and injure the conjunctiva and cornea in one or both eyes. Affected cats begin squinting, tearing, and may paw at the eye(s). Some cats may also sneeze, stop eating, and feel poorly.
What stressful events may precipitate viral re-activation?
The three most common stressful events that cause FHV re-activation are:
1) a new cat or dog is brought into the household
2) your cat is moved to a new household
3) you go away on vacation
Basically, anything that alters the normal daily routine of your cat may permit viral re-activation.
How should FHV be treated?
The severity of the disease and the eye structures involved will determine the treatment. Famciclovir and Acyclovir are oral antivirals that may be used to control FHV. Topical antivirals include Idoxuridine and Betadine eye drops. Sometimes surgery is required to repair the damage done by the virus.
Will the virus come back?
Topical and systemic antiviral medications can control FHV, but they cannot completely eliminate the virus from your cat's body. Early treatment arrests the disease before it becomes severe.
Feline Uveitis
What is uveitis?
Uveitis is inflammation of the tissues inside the eye. Inflammation that affects only the front part of the eye is called anterior uveitis. Inflammation that affects only the back part of the eye is called posterior uveitis. Inflammation of the entire eye is panuveitis.
What causes uveitis?
In many cases, the cause of uveitis is never determined. It is important to attempt to determine the cause. Several serious diseases such as those caused by the Feline Leukemia virus, Feline Immunodeficiency virus, Feline Infectious Peritonitis virus, Toxoplasma gondii, and cancer (lymphoma) may cause uveitis in the cat. These diseases may lead to serious disorders in other parts of the body or even result in death, therefore, early diagnosis may alert your veterinarian to other potential problems.
How do I recognize that my cat has uveitis?
Uveitis may be difficult to recognize in cats. Caretakers often notice a red eye, a change in the color or cloudiness of the eye, a dilated pupil, or loss of vision. Your veterinarian may notice that your cat has uveitis on a routine health examination, without your having noticed prior problems.
How is a uveitis diagnosed?
A veterinary ophthalmologist can diagnose uveitis with specialized equipment: the slit lamp and the ophthalmoscope. A glaucoma test is performed since many cats with uveitis have an abnormally high eye pressure (glaucoma). Blood and urine samples are collected and examined for evidence of infection with agents that are known to cause uveitis.
How is uveitis treated?
Uveitis can be difficult to treat, and often is a life-long condition that can only be controlled but not cured. Initial treatment consists of anti-inflammatory eye drops 3-4 times a day. If the results of diagnostic testing reveal a treatable infection such as Toxoplasmosis, then specific treatment is begun. Severe inflammation necessitates more intensive anti-inflammatory therapy with an injection near the eye and oral medications. If glaucoma is present, additional medication may be prescribed to lower the eye pressure.
What if the uveitis is not controlled?
Uncontrolled inflammation and glaucoma will result in vision loss and/or chronic pain. It is important to follow the recommended treatment and re-examination schedule, so that problems can be detected and treated early.
How often does my cat need to be re-examined?
Cats on long-term medication that have controlled uveitis should be examined 3-4 times a year. If the uveitis is poorly controlled, more frequent examinations may be recommended.
German Shepherd Pannus
What is pannus?
Pannus is an nonpainful, autoimmune disease of the cornea and conjunctiva of both eyes. Affected dogs suffer from a misdirected immune response to their own corneas that manifests itself as blood vessels, pigmentation, and scar tissue in the cornea. With time, the normally clear corneas opacify, and some dogs eventually go blind.
Are certain breeds more likely to develop pannus?
Yes. approximately 90% of dogs with pannus are German shepherds. Other affected breeds include Belgian tervuerens, Siberian huskies, border collies, and greyhounds, although other breeds may be affected.
How is pannus treated?
The corneas will clear significantly after 1-2 months of diligent eye drop application. Some dogs respond best to corticosteroid eyedrops, while others respond best to cylosporine ointment. More severe cases require treatment with both types of eye drops. Additionally, your dog may require a corticosteroid injection around the eye to augment your eye drop treatments.
Can pannus be cured?
Unfortunately, no. For this reason, the key to the long-term preservation of vision is faithful, uninterrupted medication of the eyes and regular evaluations by a veterinarian.
Are surgeries available to help my dog?
If the eye drop treatments fail in spite of our best efforts, your dog may benefit from a local application of Beta-Radiation with or without surgical excision of the corneal scar tissue. With your dog under general anesthesia, a radioactive probe is placed upon the cornea, and a specified dose is delivered. The remainder of the eye and body is unaffected due to the poor penetration of the low energy beta particles. Beta radiation will not cure pannus, but in most cases will augment your efforts with the eye drops. Beta radiation slightly injures the normal cornea. Thus, a dog may withstand 2-3 applications over a lifetime. For this reason, beta radiation is reserved for the dog who fails maximal medical treatment.
The most important factor in preserving your dog's vision is diligent, uninterrupted eye drop treatments.
Horner's Syndrome
What is Horner's Syndrome?
Horner's syndrome is loss of sympathetic nerve supply to the eye, eyelids, and muscles that dilate the pupil. The sympathetic nerves are part of the nervous system that control "automatic" body functions.
How can I tell if my pet has Horner's Syndrome?
The signs associated with Horner's Syndrome are usually unilateral (one-sided). They include, drooping of the upper eyelid, constriction of the pupil, sinking of the eye, and elevation of the third eyelid.
What causes Horner's Syndrome?
In most cases, the cause of Horner's Syndrome is idiopathic, or unknown. However, anything that can create a disruption in the nervous pathway can cause Horner's Syndrome i.e. trauma/injury, infection, and tumors.
How is Horner's Syndrome Diagnosed?
Horner's Syndrome diagnosis is based upon the clinical signs found during an ophthalmic and a neurologic exam. A phenylephrine test is used to confirm the diagnosis. Causes of Horner's Syndrome due to problems within the brain, spinal cord, and chest may require further testing to find the location and cause of the problem. Treatment is then based on these test results.
How is Horner's Syndrome treated?
For most dogs, the signs associated with idiopathic Horner's Syndrome will resolve within 6 months.
Is Horner's Syndrome Painful?
Does Horner's Syndrome interfere with vision?
In some cases Horner's Syndrome will interfere with vision because the eye is covered by the third eyelid.
Lenticular Sclerosis
The canine lens is composed of three structures: the lens capsule, the cortex and the nucleus.
Lenticular sclerosis, also known as nuclear sclerosis, is a normal change within the lens that occurs with advancing age. The central zone of the lens, also known as the nucleus, becomes denser and appears as a grey haze within the eye. Humans, dogs, cats and horses are all affected by lenticular sclerosis. In humans, nuclear sclerosis results in presbyopia, which is a loss of the ability of the lens to accommodate. Accommodation is the mechanism used to maintain focus on objects that are close up. Accommodation in required hi humans for performing routine tasks such us reading. Lenticular sclerosis is the reason that most people who are "forty-something" require reading glasses.
Your pet's visual acuity will be slightly decreased secondary to lenticular sclerosis; however, these deficits are minimal. Your pet's vision will be decreased in areas with dim lighting. Lenticular sclerosis is not painful and most cases do not require medical or surgical treatment.
Lenticular sclerosis can be difficult to decipher from cataracts. Cataracts are opacities within the lens nucleus, cortex and/or capsule that can cause blindness. Fortunately, the vision loss from cataracts can be restored in most dogs and cats with cataract surgery.
Lens Luxation
What is the lens?
The lens is a structure that is located inside the eye and helps focus light onto the retina to create useful images- The lens is normally located behind the iris. When light passes through the pupil of the eye it is passing through the lens. See the following diagram for clarification.
What is luxation or subluxation of the lens?
The lens is usually held in place behind the iris by small fibers known as zonules. These zonules anchor the lens in place. When these zonules are disrupted the lens is free to move partially (subluxation) or completely (luxation) from its proper location inside the eye. As the following diagrams show, the lens may move forward (this happens in most cases) or backwards (rarely happens).
What should be done for my pet with lens luxation?
If the lens falls forward it is very painful for the pet and can be very destructive to the normal eye structures. In this case surgical lens removal is recommended. Medication is typically not effective at keeping the eye comfortable or visual. If the lens falls backwards into the vitreous, surgery may or may not be indicated.
Why did this happen to my pet?
Lenses can luxate for several reasons; trauma (trauma severe enough to cause luxation usually causes other damage to the eye), secondary to glaucoma, due to cataract formation or due to zonular breakdown caused by age or an inherited defect (most commonly seen in terriers).
Intraocular Prosthesis Implantation
What is an intraocular prosthesis implantation surgery?
Intraocular prosthesis implantation is a "cosmetic" alternative to traditional eye removal (enucleation). The tissues inside the eye are removed and replaced with a silicone implant, which maintains the normal size and shape of the eye. The cornea and eyelids are preserved and will blink over the new "fake eye."
When is Intraocular Prosthesis Implantation an option?
An intraocular prosthesis may be an option if your pet has a blind, painful eye from medically unresponsive glaucoma. Intraocular prosthesis implants should not be performed in cases of cancer, infection and corneal disease.
What happens if you choose to have an intraocular prosthesis for your pet?
Before Surgery:
When you decide intraocular prosthesis implantation is the best option for your pet, we will schedule a date for surgery, usually within one week of the exam day. Your pet will need complete blood work and a urinalysis prior to the day of surgery. These tests are important in reaching an accurate pre-operative evaluation, assuring our goal of a safe anesthesia, and leading to the best possible recovery for your pet.
We will also discuss different methods of pain control for your pet. One option is a fentanyl patch. It is best to have the patch applied to the skin the afternoon prior to surgery. A small area of fur is shaved and a clear plastic transdermal patch is applied. After an initial uptake time of 8-12 hours, this patch will release continual pain medication to your pet for 72 hours.
The Day of Surgery:
This surgery often is performed on an outpatient basis, which means your pet will go home the same day. You will be asked not to feed your pet breakfast. Please bring all of his medications with you. Phone us with any questions, and refer to our anesthesia handout for your pet's specific pre-operative instructions.
When your pet is admitted for surgery, he will be given a sedative to help him relax. Later, an IV catheter will be placed for medication and fluid administration. General anesthesia will keep your pet asleep and pain-free during surgery. Our certified technicians will be monitoring your pet every step of the way.
The Operation:
While your pet is under anesthesia, the contents of the eye are gently removed through a scleral incision made under the eyelid. A silicone ball is placed within the corneoscleral shell as a space-filler, and the incision is closed with sutures. A temporary suture is placed in the eyelid to bandage the eye.
After surgery, an Elizabethan collar will be placed on your pet to prevent him from rubbing at the sutures. Your pet will recover under the watchful eye of our team. Once he is awake enough to walk, he is transferred to a hospital kennel. He can quietly rest on a fleece bed under close supervision until he is ready to go home.
After Surgery:
When your pet is awake and comfortable, he can go home. This is usually 3-5 hours after surgery. We will provide you with written instructions regarding medications and restrictions after surgery. Please schedule a courtesy appointment for your pet 12-14 days after surgery for skin suture removal.
There will be pink blood tinged discharge for the first 48 hours, with some ongoing discharge for several weeks. The eye will gradually turn red over the first 4 weeks post-operatively. In 6 weeks, the eye will achieve its final coloration.
What complications can occur?
Successful intraocular prosthesis implants require care and attention by both owner and ophthalmologist. Both minor and serious complications after an intraocular prosthesis implantation are infrequent. However when they occur they include: low tear production, infection of the cornea or prosthesis, regrowth of unidentified intraocular neoplasms, premature suture removal by the pet, and rejection of the silicone implant. We want to stress that serious complications are very rare and most patients recover from surgery without any problems.
What are the other options?
There are other options besides intraocular prosthesis implant surgery. These options include: Enucleation or Intravitreal Gentamicin Injection. Please ask our staff if your pet qualifies for one of these options.
We can show you post-operative photos of dogs that have had intraocular prosthesis surgery. Keep in mind that every eye will look different after this surgery. This is due to the individual pet's healing.
Nasolacrimal Duct System
What is the nasolacrimal duct?
The nasolacrimal duct is involved with tear drainage from the surface of the eye to the nose. Tears are produced by lacrimal glands located around the eye. A continuous supply of tears is needed to provide nutrition and to wash away bacteria from the surface of the eye. Two small openings or "puncta" are present in the inner corners of the eyelids which allow tears to enter the nasolacrimal duct. The duct (a tube-like structure) then directs the tears through the bone and releases them inside the nose. The duct is shown in the following diagrams.
How do I know if there is a problem with the duct?
If the duct is not present or is for some reason blocked, tears will not flow into the nose. Instead, tears will spill over the lower eyelid and wet the face under the eye. This can be irritating to the pet and in some cases can lead to bacterial infections on the skin from tear saturation.
What causes an obstruction of the duct?
Most tear duct obstructions in the cat are due to chronic eye infections or conjunctivitis from the Feline Herpes Virus. In the dog, the obstruction is often caused by a foreign body (usually a seed or other plant debris from running through tall grass). It is possible but rare that the obstruction can be caused by an underlying tooth root infection or tumor.
What should be done for my pet?
A nasolacrimal flush can be performed as part of the initial examination. This flush is usually diagnostic in nature and rarely is a cure for the condition. If the tear duct can not be flushed or the excessive tearing persists shortly after the flush then a nasolacrimal catheter should be placed. This catheter is a small plastic tube that is passed under heavy sedation or general anesthesia from the eyelid puncta through the duct and into the nose. The catheter is then sutured in place for three to four weeks. The tube can then be removed under another sedation and the duct flushed at the same time. While this procedure is highly successful, some pets continue to exhibit signs of nasolacrimal duct obstruction after this procedure has been performed.
Non-Healing Corneal Ulcer
What is a non-healing corneal ulcer?
Non-healing corneal ulcers (also called indolent or Boxer ulcers) are superficial abrasions on the surface of the eye that have a characteristic non-adherent area around the edge of the ulcer. They typically fail to heal with medical management alone.
What causes a non-healing corneal ulcer?
Non-healing ulcers are due to an abnormality of the corneal epithelium of the eye. This abnormal epithelium cannot stick to the surface of the eye following a minor injury. The epithelium simply peels off like a sunburn.
Are certain breeds of dogs prone to developing a non-healing ulcer?
Yes. Boxers are commonly affected, but any dog may develop a non-healing corneal ulcer.
How is a non-healing ulcer diagnosed?
A veterinary ophthalmologist can frequently diagnose a non-healing ulcer based solely upon your pet's history and the appearance of the eye. When a cotton swab is gently wiped across of surface of the anesthetized eye, the abnormal epithelium will easily peel away.
What should be done?
Most non-healing erosions require surgery to promote healing:
Following light intravenous sedation and application of anesthetic eye drops, a corneal debridement and a grid keratotomy are performed. The abnormal corneal epithelium is gently removed from the eye, and corneal surface is lightly scratched. These light scratches serve as anchor points for the healing corneal epithelium. A local anesthetic is injected into the third eyelid and it is temporarily sutured over the eye to act as a bandage. Nine out of ten dogs will heal within 14-21 days.
Will non-healing ulcers recur?
Unfortunately, yes. Most dogs with a non-healing ulcer will develop a non-healing ulcer in the fellow eye at a later date. There are no reliable measures to prevent a recurrence.
Please schedule a re-evaluation with Dr. Chavkin, Dr. Nuhsbaum or Dr. Graham in 14-21 days.
Pilocarpine for Dry Eyes
Your pet has been diagnosed with Keratoconjunctivitis Sicca, also commonly known as "Dry Eye." The ophthalmologist has prescribed Pilocarpine ophthalmic drops. Pilocarpine given orally will stimulate the tear glands to make more tears.
If you are filling this prescription at a pharmacy, do not be alarmed if the pharmacist is not familar with using pilocarpine eye drops as an oral medication. The prescription is correct. We use pilocarpine in its eye drop form as an oral medication. This is commonly done in veterinary medicine, but it is rarely prescribed for oral use in people.
The ideal dose of pilocarpine is different for each patient; follow the instructions below to determine your pet's ideal dose.
Start your pet on Pilocarpine ___% on his food twice daily per the chart below. In the first week, give one drop on the food twice daily. In the second week, increase to 2 drops in the AM and 1 drop in the PM. Continue down the chart increasing by one drop each week.
If your dog develops symptoms of pilocarpine toxicity, such as excessive salivation, vomiting, or diarrhea, stop the medication until the side effects have resolved; this usually takes 48 hours. Then, restart pilocarpine at the previously tolerated, lower dose. This is your pet's ideal dose. Continue at this dose until your pet's next exam. Please call with concerns or questions.
Progressive Retinal Atrophy
What is progressive retinal atrophy?
Progressive retinal atrophy (PRA) is an inherited disease of the retina. The retina is the tissue in the back of the eye that senses light, similar to the film in a camera. This disorder initially causes night blindness that eventually progresses to total blindness.
What causes progressive atrophy?
PRA is an inherited disease that is passed on from parents to offspring. PRA is not caused by diet, infection, or other environmental causes. PRA is similar to the inherited disease Retinitis Pigmentosa in human beings.
Are certain breeds of dogs prone to Progressive Retinal Atrophy?
Yes. The American and English Cocker Spaniel, Labrador Retriever, Miniature Schnauzer, Miniature Poodle, and Portuguese Water Dogs are prone to PRA, although any breed may be affected.
How do I recognize that my dog has Progressive Retinal Atrophy?
Most dogs with PRA initially have poor night vision. This decrease in night vision may be manifested as an aversion to go outdoors at night, reluctance to jump up and down from furniture in dim light, or a disinclination to go down an unlit hallway. Poor night vision eventually progresses to complete blindness.
How is Progressive Retinal Atrophy Diagnosed?
If PRA is advanced, a veterinary ophthalmologist is able to diagnose the disorder by examining the retina with an ophthalmoscope. If PRA is not advanced, an electroretinogram (ERG) is required for the diagnosis. An ERG is an electronic test of the retina similar to an electrocardiogram of the heart. A special contact lens electrode is placed on the topically-anesthetized eye. A computer program measures the electrical signal produced by the retina after a light is flashed into the eye.
The OptiGen prcd-PRA test is a DNA-based test for pets that may provide caregivers with more information about one form of Progressive Retinal Atrophy (PRA). "prcd" stands for "progressive rod-cone degeneration" which is the type of PRA known in several breeds.
The following website has more information about PRA testing in certain breeds: http://www.optigen.com/opt9_test_prcd_pra.html
Is there a treatment for Progressive Retinal Atrophy?
Unfortunately, no. PRA eventually leads to blindness in all cases. The time it will take before blindness is complete will vary from dog to dog. Thankfully, PRA is not a painful condition, but dogs with PRA may develop secondary problems. Animals with PRA may develop cataracts (an opacity of the lens) that make their pupils appear white. Cataracts surgery is not recommended, since this will not improve vision.
Should I breed my dog if it has Progressive Retinal Atrophy?
No. This is a genetic disease and may be passed to offspring.
Dogs with PRA adapt well to vision loss. They are able to memorize their surroundings, recognize their families, and live happy lives.
S.A.R.D.S (Sudden Acquired Retinal Degeneration)
What is Sudden Acquired Retinal Degeneration Syndrome ( S.A.R.D.S.)?
Sudden Acquired Retinal Degeneration Syndrome is an ocular disease in dogs that is characterized by a sudden onset of blindness. The vision loss occurs over a period of a few hours to days.
Which dogs tend to be affected by Sudden Acquired Retinal Degeneration Syndrome?
The highest incidence of Sudden Acquired Retinal Degeneration Syndrome is reported in middle- to older- aged, moderately overweight, small breed, female dogs. However, cases have been described in large breed, male dogs.
How is Sudden Acquired Retinal Degeneration Syndrome diagnosed?
The diagnosis of Sudden Acquired Retinal Degeneration Syndrome is based on 1) a history of sudden blindness, 2) a normal appearing fundus in the early stages of the disease, and 3) absence of electrical activity on an electroretinogram.
In the early stages of the disease the ophthalmic examination is normal. In some early cases, subtle changes in the retinal vessels may be identified by a veterinary ophthalmologist. Advanced cases of Sudden Acquired Retinal Degeneration Syndrome display end-stage retinal disease with attenuation of retinal vessels, diffuse retinal thinning and atrophy of the optic nerve head. Advanced cases of Sudden Acquired Retinal Degeneration Syndrome may be difficult to discern from progressive retinal atrophy. Progressive retinal atrophy is an inherited retinal disease in dogs.
What causes Sudden Acquired Retinal Degeneration Syndrome?
Unfortunately, the cause of Sudden Acquired Retinal Degeneration Syndrome is not known.
What is the treatment for Sudden Acquired Retinal Degeneration Syndrome?
Since we do not know the cause of Sudden Acquired Retinal Degeneration Syndrome, we do not have a treatment for this disease yet.
Why is my dog eating more food, drinking more water and urinating more frequently?
The cause of these clinical signs in dogs with Sudden Acquired Retinal Degeneration Syndrome is speculated to be due to increased cortisol levels in the blood. Cortisol is a hormone that is released during stressful periods. Elevated cortisol levels in the blood stimulate appetite and increase thirst. In most cases these signs resolve within 4-6 months after the diagnosis of Sudden Acquired Retinal Degeneration Syndrome is made.
Is Sudden Acquired Retinal Degeneration Syndrome contagious to other dogs?
No, Sudden Acquired Retinal Degeneration Syndrome is not contagious to other dogs.
Can Sudden Acquired Retinal Degeneration Syndrome be passed on to my dog's puppies?
No, there is no evidence that Sudden Acquired Retinal Degeneration Syndrome is an inherited disease.
Will my dog's vision return?
Unfortunately, your pet's vision will not return. There are anecdotal reports of intermittent episodes of vision in dogs with Sudden Acquired Retinal Degeneration Syndrome, however, eventually all dogs with S.A.R.D.S. are permanently blind.
Is Sudden Acquired Retinal Degeneration Syndrome painful for my dog?
Sudden Acquired Retinal Degeneration Syndrome is not painful but acute vision loss is certainly unsettling for your dog. Your dog will require an adjustment period to begin compensating for vision loss with his or her other senses. These senses include smell and hearing. Fortunately, a keen sense of smell and acute hearing will allow your dog to continue to live a good quality of life. Blind dogs are excellent pets and will continue to be a wonderful companion for you and your family.
Safe Anesthesia Brochure
Surgery Information
To Prepare For Surgery
Pre-operative bloodwork
Before any surgery, it is important to rule out potential health risks. For your pet's safety, we request that blood work be done within 2 weeks of the scheduled surgery day (unless otherwise indicated by your pet's surgeon). This may be done here at VRCC or with your family veterinarian, whichever is more convenient for you.
Preoperative Medication Guidelines
Please bring a detailed list of all medications or supplements with you the day of surgery. If your pet requires any medications during their stay, please bring them with you. This applies to special food diets as well.
The night before surgery
Please take all food and snacks away from your pet after 10 p.m. the night prior to surgery. It is okay to leave a small amount of water available, even the morning of surgery. If you normally give nighttime medications, continue as normal, unless directed otherwise by our staff.
The day of surgery
Generally, it is safe to administer medications, including eye drops, the morning of surgery, but if in doubt, please call 303-874-2070 to confirm whether or not your pet should have his or her medications the morning of surgery. Your surgeon will discuss with you what will be in your pet's best interest. Diabetic patients should not have breakfast or insulin on the morning of surgery, but should bring insulin and a meal on the day of surgery unless otherwise instructed.
When you arrive at VRCC on the day of your pet's scheduled surgery, we will ask you to sign the Consent for Surgery form, verify phone numbers where you or a family member can be contacted, and briefly meet with the admitting technician to answer any of your questions. If you have any questions, please ask. We are here to help you through each step of the process.
Important Reminders:
Please make sure your pet has attempted to both urinate and defecate before admitting.
If your pet already has an Elizabethan collar (aka E. collar, lampshade, or cone) please bring it with you.
Please have an idea of any medication refills you may need for after surgery. If your pet is already taking a medication for their condition, please discuss this with your surgeon and he or she can dispense refills if needed.
It may be a good idea to have your pet groomed prior to surgery; he/she may not have another opportunity for 2-4 weeks.
Ophthalmology surgery patients usually go home the same day. If it is recommended that your pet spend the night with us, you are welcome to visit. Visiting times should be arranged prior to the visit by contacting us at 303-874-2070.
Visitation may be discouraged in excitable or anxious pets. For many procedures, it is best to allow your pet to rest quietly without disturbances that may be made by visiting.
We ask that you limit your visit to 15 minutes. This allows the technician caring for your pet to continue on schedule with his/her prescribed treatments.
Visitors are required to sign in at the front desk, wear a name ID badge, and have an escort when walking back to visit.
VRCC is open 24 hours, and a veterinary technician is always available by phone at 303-874-PETS (7387) to give you an update on your pet.
During the hours of 6 pm to 7 am, your pet is being cared for by our Specialty Patient Care Team. These technicians care for all overnight hospitalized patients, and are able to give you updates on the general well-being of your pet, but are unable to comment on surgery specifics or aftercare instructions. For that information, please call us at 303-874-2070 during the hours of 7 am and 5 pm.
Please call 303-874-2070 with any questions related to your pet's upcoming surgery.


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Daniel Mendel Harrison, MD
Assistant Professor of Neurology
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- Assistant Professor of Neurology
Multiple Sclerosis, Neurology
BiographyDr. Daniel Harrison specializes in the diagnosis and treatment of patients with multiple sclerosis and other autoimmune diseases of the brain, spinal cord, and optic nerves.
Dr. Harrisons research focuses on the evaluation of new MRI techniques that may further our understanding of multiple sclerosis pathology, better explain cognitive and physical disability, and improve clinical trial outcome measures. He is currently involved in a series of studies evaluating the utility of diffusion tensor imaging (DTI), magnetization transfer imaging (MTR), magnetic resonance spectroscopy (MRS), and high magnetic field strength MRI (7 Tesla) in multiple sclerosis. Dr. Harrison also participates in multiple clinical trials of new medications for the treatment of multiple sclerosis.
Dr. Harrison received his medical degree from the Albert Einstein College of Medicine in the Bronx, New York. He completed residency training in neurology at the Neurological Institute of New York at Columbia University Medical Center in New York City and then came to the Johns Hopkins University School of Medicine where he obtained further specialized training by completing a fellowship program in Neuroimmunology and Neurological Infections.
- English
Additional Resources
Education +
- Albert Einstein College of Medicine of Yeshiva Univ (Bronx NY ) (2004)
- Columbia University College of Physicians and Surgeons / Neurology (New York NY ) (2008)
- Johns Hopkins University School of Medicine (Baltimore MD ) (2010)
- Neurology, American Board of Psychiatry & Neurology (2008)
Research & Publications +
Academic Affiliations & Courses +
Activities & Honors +
Videos & Media +
Events +
Contact & Locations +
LocationsThe Johns Hopkins Hospital600 N. Wolfe StreetSheikh Zayed TowerBaltimore, MD 21287Appointment Phone: 410-614-1522Location MapJohns Hopkins Outpatient Center601 N. Caroline StreetBaltimore, MD 21287Appointment Phone: 410-614-1522Location Map
- Neurology

subset: commoncrawl


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Laura Matthews
Boehner's Challenger Loses Job After Rude Attack Ad
April 29 2014 1:10 PM EDT
One of House Speaker John Boehner's Republican challengers lost his job at an Ohio university after an ad parodied an erectile-dysfunction drug commercial.
Prosecutors Say US Rep. Grimm Failed To Report $1M In Income
April 28 2014 11:53 AM EDT
The New York Republican is accused of hiding more than $1 million in income from a restaurant he owned and hiring illegal immigrants.
Boehner, Heritage Action Clash Again, This Time Over Immigration Reform
April 25 2014 5:26 PM EDT
The relationship between the speaker of the House and conservative groups went south last December over a budget agreement.
Bloomberg-Backed Moms Group Set To Take On NRA
April 24 2014 5:25 PM EDT
Just days after the former NYC mayor announced a $50 million initiative to fight the NRA, one of the groups he funds is about to face the gun lobby head on.
Oklahoma, With An Oil And Gas Boom, Is Facing A Budget Crisis
April 24 2014 3:38 PM EDT
State lawmakers strapped for cash are considering even more cuts to public programs. Critics say oil tax breaks are the real culprit.
Lawmaker Drops Bid To Make Bible Louisiana's Official Book
April 23 2014 1:47 PM EDT
Republican Rep. Thomas Carmody says the controversial bill has become a distraction.
US House Still Opposed To Funding CDC's Gun Violence Research
April 22 2014 3:17 PM EDT
Republicans say the CDC's gun violence prevention research will get no funding in FY 2015, and gun control advocates aren't happy.
In South Carolina, It's Students Vs. Lawmakers On Gay-Themed Books
April 21 2014 11:52 AM EDT
South Carolina students are rebelling against lawmakers trying to cut funds because gay-themed books are on the curriculum.
Rob Ford Launches Re-election Bid With Populist Message
April 18 2014 1:51 PM EDT
Ford says he has learned his lesson since the scandals and asks for a second chance to lower taxes and fight against elitists.
Clinton's Favorability Hits 6-Year Low
April 18 2014 12:22 PM EDT
The former secretary of state's favorability rating is still higher than those of her potential 2016 presidential GOP challengers.
Republicans Sink Texas 'Boats 'N Hoes' PAC
April 17 2014 4:35 PM EDT
The Texas fundraising group's name started a political war between Republicans and Democrats vying for women voters.
Christie Ahead Among Republicans For 2016, But Barely
April 17 2014 1:00 PM EDT
The New Jersey governor is beating the Republican competition, but he loses to Hillary Clinton in a hypothetical matchup.
North Dakota's 'Heartbeat' Abortion Law Found Unconstitutional
April 16 2014 5:45 PM EDT
A U.S. district court judge says the Supreme Court has already legalized abortions up to a certain point.
Out Of Office, Bloomberg Gets Even Tougher With NRA
April 16 2014 1:35 PM EDT
Bloomberg's grassroots group will use the NRA's single-minded, single-issue strategy to take on the gun lobby.
The Bible Could Soon Become Louisiana's Official Book
April 15 2014 5:06 PM EDT
Louisiana state lawmakers want to make the Holy Bible the state's official symbol.
ACLU Sues Michigan To Recognize Same-Sex Marriages
April 15 2014 1:46 PM EDT
The ACLU of Michigan says same-sex couples who wed last month in the state's historic ceremony are being treated as "second-class" citizens.
How Senate GOP's Block Of Paycheck Fairness Act Could Haunt Party In November
April 09 2014 1:26 PM EDT
Senate Republicans say no again to a law meant to help close the gender wage gap.
Deportations Hit Minor Offenders, Not Serious Criminals, Say Immigration Advocates
April 08 2014 3:18 PM EDT
Independent studies appear to support complaints of a heavy-handed approach to deporting undocumented immigrants.
Here's Where Jeb Bush And Other GOP Hopefuls Stand On The Issues
April 08 2014 6:06 AM EDT
As Chris Christie's clout fades, several Republicans are maneuvering. From the Tea Party favorites to moderates, here's where they stand.
Obamacare Now 'Hip'? Not Quite
April 07 2014 12:06 PM EDT
However, Gallup data indicates that Republicans may have to adjust their strategy from the current all-out attack on health care reform.


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Peace with justice (and each other)
Tuesday, January 31, 2012
Two years ago I added a three to five minute speech to my Peace with Justice unit in Honors English IV. I said at the time and continue to say that the speeches made the unit. For the 10 years or so before that the unit was just lacking. It is not lacking any more and the speech featured here, by senior Logan Hill, is just one of 48 reasons why:


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Media Player
posted on Apr 19th
Supersize Me Cat, Watters Plumbing Leak Squad Drip of the Week, Kudos of the Day & ReciPippa of the Week
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©1968 Charles Portis; (P)2006 Recorded Books, LLC
"Charles Portis is perhaps the most original, indescribable sui generis talent overlooked by literary culture in America." (Esquire)
"Tom Wolfe, who worked with Portis as a reporter at the New York Herald-Tribune in the early 1960s called him – the original laconic cutup. A generation of novelists since then have simply regarded him as a writers-writer and have made his name a sort of secret password. Soon, they'll no longer have him to themselves." (Rolling Stone Magazine)
"Like Mark Twain's Huckleberry Finn and Thomas Berger's Little Big Man, Charles Portis's True Grit captures the nanve elegance of the American voice." (Jonathan Lethem)
Hello everyone
"So worth it!"
This is my first encounter with "true grit" and I was very pleasantly surprised! Wanted to listen before going to the Coen brothers version. I agree with many who have said it is a modern classic. Keeps your attention, brilliant dialogue, characters that stick with you. I completely disagree with other listeners who did not like the narrator. Her interpretation of male voices is no worse than the best male narrators attempts at female voices; while her reading of young Mattie was amazing! There would not be a better narration without a full cast. I have listened to over 500 audible books, and would rate this in the top 10% at least.
"A great rendition of a great book"
Charles Portis' book is terrific, a classic tale told well. His gift for dialogue is impressive. I can't think of a better person to read it than Donna Tartt. Certainly she was not going to capture the voice of any vision we might have of Rooster Cogburn. But this is Mattie Ross' story and she tells it wonderfully. I also enjoyed the essay at the end of audiobook. It explained well the passion that Ms. Tartt brought to her reading. This is a good investment, and a perfect companion to either movie version you prefer!
tired teacher
"Who really had True Grit?"
I really liked both of the movies made from this book, and so I really looked forward to listening to it. I was not disappointed. It was a great story, and very well written. The question remains, "Who really had True Grit?" To me the answer was #1 Maddi Ross. She was a plucky, brave and self-confident girl, and I admire her courage and presence of mind in the face of great danger and emotional upheaval. #2 One cannot say that Rooster Cogburn did not have True Grit however. I think Jeff Bridges played him a little truer to the character in the book, but I will forever love the John Wayne character as well. They were both so well done! I will never forget watching Jeff Bridges carry Maddi on his back after Little Blacky died, which is exactly what happens in the book. Now that was True Grit. #3 LeBoeff also showed that he had Grit when he was the one who in the end saved the day. Let's just say it was a Gritty cast of characters and there is much to be learned from each one. This book is well worth reading more than once.
I liked the narrator, Donna Tartt, very much, but she did go through a period of time at about the half way point where the swallowing and other non-verbal mouth sounds got to be a little annoying. I just didn't think it was necessary to have those sounds in there, what with modern recording devices and all. Other that that I thought she was very good. I especially enjoyed her comments at the end of the book.
I love reading and listening to books, especially fantasy, science fiction, children's, historical, and classics.
"Mattie Ross as Huck, Ahab, and Dorothy"
This is a concise, suspenseful, funny, philosophical, and ultimately sad novel that gives an unvarnished look at the American West and the complicated men and women who lived in it and helped to make its myth. The relationship between fourteen-year-old Mattie Ross and Rooster Cogburn, the man she hires to bring the murderer of her father to justice, is enjoyable to watch develop. For Mattie, who is narrating the story as an old woman in the early 20th century, her brief time in Indian Territory hunting outlaws with Rooster Cogburn was the most memorable moment in her life.
One reviewer was bothered by the reader Donna Tartt's audible "swallowing or breathing," and some reviewers were bothered by her "unconvincing" male voices. All I can say is that Ms. Tartt is so good at reading the story, brings it so much to life, differentiates her voice for the different characters so effectively (including the men and boys), and inhabits Mattie Ross so completely, that it's easy to ignore any trivial ancillary sounds she might make as she reads. Her obvious love for and understanding of the novel shine through her savory voice.
A final bonus of this audiobook, in fact, is the closing essay by Tartt, in which she interestingly recounts her family history with True Grit and what it meant and means to her, re-reads some of its best lines and scenes, and offers a provocative analysis of the novel, comparing it to Huckleberry Finn, Moby Dick, and The Wizard of Oz.
In conclusion, this unsentimental, brutal, humorous, moving, and spicy audiobook was a great listen.
"True Great Listen!"
I absolutely loved this narration by Donna Tartt and her essay at the conclusion was charming. Her long love affair with Charles Portis' True Grit comes shining through in the reading. I've just now discovered the sheer pleasure of this piece of fiction and plan to pass it on to everyone who loves a good story.
"I don't get what the fuss is about"
It's a good story, but short, with great, but few, characters. It's more of a novella than a novel. I enjoyed it but I wouldn't consider it a classic. The ending was a bit predictable, and the denouement whipped through several decades and left a lot of questions.
I docked a star for the poor narration. The narrator's voice was perfect, but her lip smacking, breath noises, and pregnant pauses ruined it for me. I have never heard such a clunky sound track. I don't understand why they didn't simply edit them out -- just a few hours' work in Audacity and the narration would have been smooth and professional.
"First Rate Narrator"
Donna Tart is outstanding and could not have been better suited to the task, she has a perfect understanding of the characters and brought them to life in vivid detail. The "voice" of the book is from the adult Mattie Ross and Tart's interpretation is pitch perfect.
As for Portis text, it is a classic and deserves higher praise than I can offer.
"To think I might have missed this...an epiphany."
My college age granddaughter lives (and is born and raised) in Fort Smith, AR and when the new movie version of True Grit was coming out, I asked her if she was excited about it. She said "No, why?" and I said well the setting is in Fort Smith, haven't you ever watched the (very popular and often televised) John Wayne version, "from whence" he won his Academy Award and made the eye-patch comment? No, she never heard of it. Which was just beyond my belief. And she a literature major! So, I watched the new movie, which was advertised as more closely following the original novel by author Charles Portis. Very exciting movie, very enjoyable, a real time machine. So I am looking for a book to download for my next audible selection and it occurs to me to search for the novel by Charles Portis. Now I get to my point. I was frustrated with my granddaughter for spending her life in Ft. Smith and having no awareness of True Grit, and yet I had never read any Charles Portis novels, I had to be knocked on the head. And I am almost sure that if it weren't for the movie I would have missed the novel. I will give you a tip and it won't be a spoiler, particularly if you have already watched the movie(s). The narrator has attached an essay on the novel at the end of the reading. Consider "reading" the essay before you listen to the novel. The essay is worth the price of the novel and is inspiring in itself. There are still real people in this world, away from the cities and canned education and young people working so hard to fit precise molds defining what it means to be popular and accepted. Donna Tartt is a discovery as valuable as the novel itself, and as I said, I had to be knocked on the head to find the novel and her reading. I have a prejudice, which is that I felt the only way to experience literature is to actually read the tangible book as the author intended and people have been doing for a thousand years. However, fine narrators such as Donna Tartt enhance my reading.
"Narrator was excellent, except when she wasn't"
First the book: The story is enjoyable, but I wouldn't say it's the best book I've ever known. Mattie is tough as nails and I found her pluck quite endearing, but I didn't find myself thinking about the characters when I was away from the book the way I have with other novels.
Now for the narrator: Donna Tartt is the perfect voice for the Mattie. As soon as she starts reading, the main character is 100% believable. Her male voices are ok, but a little slow in pace. I did, however, admire how she used different accents for Asians, Native Americans, and Mexicans. No easy task with a drawl as rich as Tartt's. Kudos for the diversity. However..... I kept getting drawn out of the story with Tartt's incessant swallowing and slightly-too-long pauses between paragraphs. I wonder if this was recorded in her own home studio or something. I don't ever recall hearing so much swallowing or noticeable pauses in any other books I've listened to. It was really quite annoying.
So, I guess I'd recommend this audiobook to history buffs and people who can tune out distracting noises, but if you tend to fixate on those sounds, this recording will drive you crazy.
"Yes, you should read this."
The book is a classic, some say a masterpiece. Funny, poignant, and the kind story that is so enjoyable and expertly written that it will make you want to start over again at the beginning when you finish.
Donna Tartt isn't a professional narrator (she's an accomplished author in her own right who happens to also be a big fan of this book), but she makes the absolute most of her naturally sweet Southern lilt. It fits the main character well, and ultimately, I enjoyed her read. This said, it would be nice to hear what a pro could do with characters like those in this book.
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Leviton 5604-2 Light Switch, Decora Rocker Switch, 4-Way - Brown
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About this Product
The Leviton 5604-2 4-way light switch comes standard in black. It can be paired with any standard Decora wall plate for a fast, attractive light switch installation.
This is one of our best selling switches because of its combination of elegant design, high reliability, and affordable price. Leviton created the first Decora style rocker switch and has continued to improve on their original design making one of the best switches available. This switch would look great in any home or office because its low-profile design flows with your walls keeping it from standing out to the eye. You can transform the look of your home and increase its resale value with these modern switches. With the ease of the Quickwire you need to do nothing more than push the wire into the rear of the switch and a spring action will automatically clamp the wire and insure a good electrical connection. This is a four-way switch so it can be used alone or paired with several other switches to control the same device.
Wallplate Sold Separately
Features:• 4-Way Side Wire and Rear Push Wire
• Leviton's Quickwire System
• AC Quiet Switch
• Ground Screw Terminal Attached
• Low-Profile Elegant Design
• 2 Year Warranty
Specifications:• Type: 4-Way
• Color: Brown
• Ground: Grounding
• Amperage: 15 Amp
• Voltage: 120/277 Volt
• HP Rating: 1/2HP-120V 2HP-240V-277V
• Max Amp: 12 Amp
• Termination: Quickwire Push-In & Side
• Actuator Material: Thermoplastic
• Body Material: Thermoplastic
• Strap Material: Steel
• Standards and Certifications: UL/CSA
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Leviton Light Switch, Decora Illuminated Rocker Switch, 4-Way - White
Leviton Light Switch, Decora Rocker Switch, 4-Way - Black


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United Shade Pleated Folding Door(3 Reviews) Add A Review
Catalog Item # 16310d
Reg from $34.00
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Note: Finished product will be cut shorter to allow for wall attachment.
Technical Specs
Weight: 5 lbs.
Manufacturer: United Shade Llc
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Patient Education and Counseling
Official journal of EACH, the European Association for Communication in Healthcare and AACH, the American Academy on Communication in Healthcare
Patient Education and Counseling is an interdisciplinary, international journal for patient education and health promotion researchers, managers, physicians, nurses and other health care providers. The journal seeks to explore and elucidate educational, counseling and communication models in health care. Its aim is to provide a forum for fundamental as well as applied research, and to promote the study of the delivery of patient education, counseling, and health promotion services, including training models and organizational issues in improving communication between providers and patients.
The journal welcomes unsolicited manuscripts related to the field of patient education, counseling, clinical health promotion and communication in health care.
Electronic usage:
An increasing number of readers access the journal online via ScienceDirect, one of the world's most advanced web delivery systems for scientific, technical and medical information.
Average monthly article downloads for this journal: 42,615*
* Figure is an average based on full text articles downloaded monthly via ScienceDirect between August 2008 and March 2009
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- Imprint: ELSEVIER
- 2013 Impact Factor: 2.598*