Equine Ophthalmology 1st Edition

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60522-2-FM 1/15/05 1:32 AM Page ix

Preface

Ocular disease is one of the most common health not a comprehensive clinical textbook on equine
problems in horses. Although the science of equine ophthalmology. The goal of this textbook was to
ophthalmology has grown tremendously in the past provide a fully referenced, complete guide to the diag-
10 years, our knowledge of these ocular disorders nosis and treatment of equine ocular disorders. Over
lags behind that of other domestic species. Diagnostic 400 color photographs in 13 chapters also assist in
methods and treatments for equine disorders are the identification of various ocular diseases, similar to
mostly borrowed from knowledge of the eye diseases an atlas. The textbook is written by 22 equine experts
of other species. In addition to this lack of specific from around the world. This book has both standard
knowledge, drug availability and cost of medications chapters (e.g., examination and diagnostics; diseases
has limited our ability to systemically treat most organized by anatomical location) and unique chapters
equine ocular disorders; especially inflammatory and (e.g., equine vision). The chapters range from practical
posterior segment disease. Our understanding of (e.g., management of blind horses) to scientific (e.g.,
genetic ocular disorders and how to prevent them is genetic testing). Multiple figures, diagrams, tables, and
also in its infancy. Much research is needed to over- organization of the individual disease sections assist
come these obstacles. Unfortunately, we are in a time the clinician who needs a quick reference. Extensive
of shrinking university and private foundation research text and complete references help those who need
budgets. It is imperative, therefore, that veterinarians in-depth information on the subject.
in all clinical settings use their resources wisely, plan This is a textbook intended for clinicians and clini-
appropriate basic and clinical research trials, and, most cal scientists. Anatomy, physiology, embryology, and
importantly, share their findings with their colleagues. pathology are not emphasized, except in terms of defin-
By not reporting this work, advancement in veterinary ing specific disease processes. Sources for anatomy
ophthalmology will not occur. One objective of this and normal physiology exist (and the reader is encour-
book was to provide a comprehensive basis for the aged to seek out these sources for more information);
furthering of the science of equine ophthalmology. however, comprehensive pathology and pathophysi-
I encourage those who disagree with opinions in this ology sources for equine ophthalmic disorders need to
textbook to perform studies on the subject and to be developed.
publish their results in refereed journals so that future Finally, the most important goal of this textbook is
editions of Equine Ophthalmology will include more of to help our equine patients by sharing information
this evidence-based information. on diagnoses and treatment of painful and blinding
Although there are several excellent books avail- ocular diseases that occur far too frequently in this
able regarding ocular disorders in horses, there is species.

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Acknowledgments

This book could not be possible without the sacrifice manuscripts and for contributing images. I also thank
and hard work of all the authors, who took time away my colleagues at North Carolina State University for
from their families and professions to contribute. their support during the editing of the book. Finally,
I thank Beth Hayes, Jolynn Gower, and Liz Fathman at and most importantly, I thank my wife Elizabeth for
Elsevier for their patience and willingness to make this her love, support, inspiration, and grace, without
book a reality. In addition, I thank Jacklyn Salmon for all which this project, or any other significant endeavors
the behind-the-scenes hard work; and Elaine Smith and in my life, could not have been accomplished. I also
Melissa Hamman for photography and other support. thank our daughter Katherine, whose enthusiasm for
I thank Drs. Stacy Andrew, Dennis Brooks, Michael life is unparalleled, and to our dogs who kept me
Davidson, Claire Latimer, Tammy Miller Michau, company on the couch for months helping me edit this
Riccardo Stoppini, and David Wilkie for review of textbook.

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1 Equine Ocular Examination:

Basic and Advanced
Diagnostic Techniques
Tammy Miller Michau

The ocular examination of the horse is a challenging but history, deworming schedule, presence of nasal dis-
important responsibility, because many equine ocular charge, presence of stridor, previous trauma to the
diseases can result in unsoundness. Understanding head, and whether other horses on the premises have
normal equine ocular anatomy is integral to perform- been similarly affected. Further information may be
ing the examination and detecting abnormalities. The required, depending on the specific complaint.
examination techniques, diagnostic procedures, and
modalities currently available to veterinarians and vet-
erinary ophthalmologists for use in the equine patient
ANATOMY
are discussed. Both basic and advanced ophthalmic
diagnostic techniques are described. The basic equip-
ment needed for a thorough equine ophthalmic exam- Relevant anatomy is covered in detail in subsequent
ination is listed in Box 1-1. Examination of the equine chapters relating to specific anatomic areas. Anatomy
eye includes obtaining the history and signalment, directly relevant to the common examination and diag-
inspecting the patient in a well-lighted environment, nostic techniques is touched on here. Excellent reviews
examining the ocular structures in a darkened environ- of equine ocular and head anatomy can be found in
ment, and possibly facilitating the examination with other sources,8,10-15 in addition to those found in subse-
restraint, sedation, and local nerve blocks.1-8 quent chapters.

MEDICAL HISTORY Box 1-1 Basic Equipment Needed for General

Equine Ophthalmic Examination
A thorough medical history relevant to the ocular exam- • Bright, focal light source: A Finoff transilluminator is ideal
ination should include signalment, use of the animal (halogen)
(e.g., pet or performance), environment, characteriza- • Direct ophthalmoscope
tion of the primary complaint, onset and initial clinical • Sterile fluorescein strips
signs of the complaint, any treatment and response • Sterile culture swabs
to that treatment, progression and duration of the • Kimura spatula, sterile cotton-tipped swabs, No. 10-20
complaint, current therapy, concurrent and previous sterile surgical blade—for cytology
disease, and any additional medications being used. • Glass slides
Signalment can provide an important clue as to the • Sterile eyewash
• Proparacaine (Alcaine)—topical anesthetic
cause of many ophthalmic conditions (e.g., congenital
• Tropicamide 1% (Mydriacyl)—short-acting dilating agent
stationary night blindness in the Appaloosa, heredi- • Sedation: Detomidine hydrochloride, xylazine, butorphanol
tary cataracts in the Morgan). Existing medical ther- • Mepivacaine hydrochloride (Carbocaine) or lidocaine—
apy can also greatly influence findings on ophthalmic local nerve blocks
examination. For example, topical atropine has been • Graefe fixation forceps
demonstrated to produce mydriasis for up to 14 days • Open-ended tomcat urinary catheter—for nasolacrimal
in the horse.9 Additional information that may prove irrigation
useful would include a travel history, vaccination

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1 EQUINE OPHTHALMOLOGY

the zygomatic bone and zygomatic processes of the

Orbit
temporal and frontal bones make up the zygomatic
arch.10 Frontal, lacrimal, sphenoid, and palatine bones
The equine orbit is open anteriorly and has a complete contribute to the medial orbital wall.10 The lacrimal
bony anterior orbital rim (Fig. 1-1).8,13,14,16,17 Six bones and zygomatic bones contribute to the ventral orbital
form the orbit in the horse (lacrimal, zygomatic, wall.10 Arteries, veins, and nerves pass through several
frontal, sphenoid, palatine, and temporal).10 The four foramina (i.e., rostral alar, ethmoidal, orbital, optic,
bones forming the orbital rim are the frontal, lacrimal, rotundum, supraorbital, caudal palatine, maxillary, and
zygomatic, and temporal bones.8,10,13 The frontal bone sphenopalatine) that are present in the orbital bones
forms the prominent dorsal orbital rim and wall and (Fig. 1-2). The orbital foramen is not elongated in the
contains the supraorbital fossa. The frontal process of horse, as compared with that in most domestic animals,
in which it is referred to as the orbital fissure.10 The
ventral orbital floor is predominantly composed of
soft tissues (i.e., fat).17

Globe

The equine globe, contained within the orbit, is

slightly flattened in the anterior-posterior dimension.
In the adult horse, the average horizontal dimension is
48.4 mm, the average vertical dimension is 47.6 mm,
and the average anterior-to-posterior axial diameter
A is 43.7 mm.2,10 The equine cornea is oval horizontally
(Fig. 1-3, A). The horizontal diameter ranges from 28 to
34 mm.18 The central vertical corneal diameter ranges
from 23 to 27 mm.18 The medial vertical diameter is
greater than the lateral vertical diameter.18 The cornea
represents approximately 14% of the total globe sur-
face area and is centrally located to the axis of the
globe.19 Corneal thickness varies, depending on the
state of the cornea (in vivo, enucleated, or formalin-
fixed) and the type of instrument that was used to per-
form the measurements (e.g., ultrasound biomicroscope,
pachymeter). In a recent study, corneal thickness was
reported to be approximately 0.6 mm centrally and
1 mm peripherally.20

Op E
Or
A

B
Fig. 1-1 A, Normal external appearance of the orbit in an equine Fig. 1-2 Some of the foramina in the equine orbit are shown.
skull viewed from the side. B, Normal external appearance of the Supraorbital (S), ethmoidal (E), optic (Op), orbital (Or), and rostral
orbit in an equine skull viewed from the front. alar (A).

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EQUINE OCULAR EXAMINATION: BASIC AND ADVANCED DIAGNOSTIC TECHNIQUES 1

Globe movement results from the yoke action of running anteriorly in the sclera at the 3 and 9 o’clock
six extraocular muscles (i.e., medial rectus, lateral positions.10
rectus, dorsal rectus, ventral rectus, and dorsal and
ventral oblique).10 An extremely powerful retractor
bulbi retracts the globe. The blood supply to most of
Eyelids
the eye and its associated structures arises from the
external ophthalmic artery, a branch of the maxillary
artery.10,21,22 The internal ophthalmic artery anasto- Additional extrinsic ocular muscles control move-
moses with branches of the external ophthalmic artery ment of the thin equine eyelid. Closure of the eyelid
and gives rise to the ciliary artery.10 Short posterior results from contraction of the large orbicularis oculi,
and long posterior ciliary arteries branch from the arranged concentrically around the palpebral fis-
ciliary artery. The short posterior ciliary arteries pene- sure.4,6,10 The levator anguli oculi medialis (corrugator
trate the sclera close to the optic nerve and supply the supercilii) creates a notching of the nasal third of the
retina and choroid.10 The long posterior ciliary arteries upper eyelid as a result of its insertion (Fig. 1-4).6 The
perforate the sclera anterior to the equator, and the notching can be pronounced, especially when the
lateral and medial arteries can usually be visualized horse becomes anxious. The muscles associated with
the eye and its adnexa are listed in Table 1-1.4,16 A
prominent fold can be seen on clinical examination,
parallel to the lid margin, in the upper and lower eye-
lids (see Fig. 1-3, A). The upper eyelid is larger and
more mobile than the lower eyelid.4 The palpebral
fissure is horizontally oval, and the lateral canthus is
more rounded than the medial canthus (Fig. 1-3, A).4
Numerous eyelashes are present along the lateral
two thirds of the upper eyelid, and vibrissae are
located dorsonasal to the upper lid and ventral to
the lower lid (see Fig. 1-3, A).6,23 The color of the eye-
lashes and skin of the eyelids is dependent on the
coat color of the horse. A large nictitating membrane,
situated in the medial canthus, moves laterally in a
A
horizontal and slightly dorsal action across the globe
(see Fig. 1-3, A).4,6,10 This “third” eyelid is a semilunar
fold of conjunctiva enclosing a T-shaped hyaline carti-
lage. The leading edge is usually partially pigmented
but can be devoid of pigment, and the presence or
absence of pigment is associated with coat color (see
Fig. 1-3, B).

B
Fig. 1-3 A, Normal external appearance of the equine eye. The
horse’s palpebral fissure, cornea, and pupil are oval horizontally.
The lateral canthus (L) is more rounded than the medial canthus
(M). There are prominent folds in the upper and lower eyelids.
Numerous eyelashes are present along the lateral two thirds of
the upper eyelid, and vibrissae are located dorsonasal to the
upper lid and ventral to the lower lid (arrows). The leading edge
of the third eyelid is usually partially pigmented (N). The lacrimal Fig. 1-4 The levator anguli oculi medialis can cause significant
caruncle (Lc) is prominent. B, Normal external appearance of the dorsal medial eyelid elevation and notching in the horse (arrow).
equine eye when eyelid pigment is absent. Note the lack of pig- This is more pronounced during anxiety or when the horse is
ment on the third eyelid, conjunctiva, and sclera as well. trying to focus on an object that is located to the side of its head.

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1 EQUINE OPHTHALMOLOGY

Table 1-1 Extrinsic Muscles of the Eye and Eyelids

Muscle Innervation Function Origin Insertion

Globe
Dorsal rectus CN III Upward globe rotation Around optic foramen Sclera
Ventral rectus CN III Downward globe rotation Around optic foramen Sclera
Medial rectus CN III Medial globe rotation Around optic foramen Sclera
Lateral rectus CN VI Lateral globe rotation Around optic foramen Sclera
Dorsal oblique CN IV Medial and ventral rotation Near ethmoidal foramen Passes between
of the dorsal aspect of the dorsal and
globe lateral rectus
Ventral oblique CN III Medial and dorsal rotation Medial wall of orbit Sclera near ventral
of the ventral aspect caudal to lacrimal margin of
of the globe fossa lateral rectus
Rectractor bulbi CN VI Globe retraction Around optic foramen Sclera posterior to recti

Eyelid
Levator anguli Auriculopalpebral Assists in upper eyelid Over root of the Upper eyelid
oculi medialis branch of CN VII elevation zygomatic process
Levator anguli CN VII Lateral palpebral fissure
oculi lateralis lengthening
Levator palpebrae CN III Elevates the upper eyelid Pterygoid crest Thin tendon in
superioris upper lid
Malaris CN VII Depresses the lower eyelid
Muller’s Sympathetic fibers in Elevates the upper eyelid
ophthalmic branch
of CN V
Orbicularis Auriculopalpebral Closes the palpebral Skin of the eyelids,
oculi branch of CN VII fissure medial palpebral
ligament
Retractor anguli CN VII Draws lateral canthus
oculi laterally

nasolacrimal duct follows a line drawn from the medial

Nasolacrimal System
canthus of the eye to a point just dorsal and rostral to
the infraorbital foramen (Fig. 1-5).25,26 Several dilations
The relatively large equine lacrimal gland lies just or sacculations can occur normally in the duct, with a
beneath the dorsolateral orbital rim.13,17 The innerva- prominent one being present at the level of the first
tion to this gland is poorly understood but consists premolar.13 The duct terminates in the lower punctum
of a combination of sympathetic nerve fibers and in the skin of the floor of the nostril near the mucocu-
parasympathetic fibers from the lacrimal branch of taneous junction (Fig. 1-6). Horses and mules may have
cranial nerve (CN) VII.24 The serous nictitans gland more than one nasal puncta, some of which are usually
surrounds the base of the third eyelid and is inner- blind pouches.6 The anatomy of the nasolacrimal system
vated by parasympathetic fibers from CN IX (glos- of the donkey is similar to that of the horse.27
sopharyngeal nerve).10,22 Two lacrimal puncta, located
at the margins of both the upper and lower eyelids, are
found approximately 8 to 9 mm from the medial can-
Anterior Segment
thus (Fig. 1-5).25 The lower punctum is further from the
eyelid margin than the upper punctum.6 Each punc-
tum is a roughly 2-mm–diameter, horizontal slit in the The anterior chamber volume is approximately 3.04 ±
palpebral conjunctiva.13,25 A canaliculus leads from 1.27 ml in the horse.28 The highly vascular uveal tract
each punctum toward the medial canthus, increasing is composed of the iris, ciliary body, and the choroid.10
in diameter to 3 or 4 mm and ending in the lacrimal The iris of most horses is golden to dark brown; but
sac, the expanded beginning of the approximately 22- blue, white, and heterochromia iridis may be seen (see
to 30-cm–long nasolacrimal duct.25 The lacrimal sac is Figs. 1-3, A, 1-7, and 1-8). Heterochromia iridis more
poorly developed in horses.6 The average diameter of commonly occurs in color-dilute breeds or individuals
the nasolacrimal duct is 4 to 5 mm.6 The course of the (e.g., Appaloosa, American Paint horse, palomino).

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EQUINE OCULAR EXAMINATION: BASIC AND ADVANCED DIAGNOSTIC TECHNIQUES 1

Fig. 1-5 Normal anatomy of the equine nasolacrimal duct. Two upper lacrimal puncta, one in each eyelid, are pres-
ent along the medial inner eyelid margin. A canaliculus leads from each punctum toward the medial canthus and
ends in the lacrimal sac, which is poorly developed in the horse. The lacrimal sac is the expanded beginning of the
approximately 22- to 30-cm–long nasolacrimal duct. The course of the nasolacrimal duct follows a line drawn from
the medial canthus of the eye to a point just dorsal and rostral to the infraorbital foramen.

Fig. 1-6 Normally, a single lower punctum of the nasolacrimal Fig. 1-7 Example of heterochromia iridis in the horse.
system is present and can be located in the skin of the floor of
the nostril near the mucocutaneous junction (arrow).

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1 EQUINE OPHTHALMOLOGY

A combination of white and blue iridal color with or even act as a light barrier or “shade” (Fig. 1-11).2,10
brown corpora nigra is referred to as walleye.2 A white An artery that can be seen passing circumferentially
iridal color with brown corpora nigra is referred to as around the iris is a termination of the medial and
china eye. A blue or white iris may turn yellow with lateral long posterior ciliary arteries (see Fig. 1-8).2,10
inflammation or an elevated systemic bilirubin level Each artery forms an incomplete arterial circle at the 12
(Fig. 1-9). The pupil of the adult horse is horizontally and 2 o’clock positions.2 The iridocorneal angle can be
oval and becomes more circular on dilation because directly visualized medially and laterally in the horse
of the greater vertical pull of the dilator muscle (see (Figs. 1-11 and 1-12).2,19
Fig. 1-3, A, 1-10).2 The sympathetically innervated iridal
dilator muscle of the horse is less well developed than
that of the dog, in contrast to the parasympathetically
innervated iridal sphincter muscle, which occupies
Posterior Segment
most of the stroma.2 The iris is broken down into a
central pupillary zone and a peripheral ciliary zone, The lens in a horse is very large, and normal variations,
separated by the collarette (Fig. 1-11).2 Horses have including prominent lens sutures, commonly occur.2
granula iridica (corpora nigra) arising from the dorsal Mean vitreous humor volume is 26.15 ± 4.87 ml for the
and, to a lesser extent, the ventral pupillary rim, which equine eye.28 Most horses have a triangular fibrous
may augment the effectiveness of pupillary constriction tapetum in the dorsal choroid (Fig. 1-13) that is usually

Fig. 1-8 Subalbinotic iris in a horse (walleye). It is easier to visu- Fig. 1-10 Pupil of the adult horse appears rounder when dilated.
alize the artery passing circumferentially around the peripheral
iris in a subalbinotic eye.

Ic Ip GI

Fig. 1-9 A normally blue or white iris may turn yellow with chronic Fig. 1-11 Normal anatomy of the pupil and corpora nigra in a
inflammation or an elevated systemic bilirubin level. horse. Granula iridica (GI) are present on the dorsal and ventral
pupillary margins but are normally more prominent on the dorsal
margin. The iris can be separated into a pupillary zone (Ip) and
a more peripheral ciliary zone (Ic).

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EQUINE OCULAR EXAMINATION: BASIC AND ADVANCED DIAGNOSTIC TECHNIQUES 1

some variation of green or yellow.20,29-32 The tapetum The nontapetal area is usually dark brown, but this
may be undeveloped in animals with albinotic melanin in the retinal pigment epithelium (RPE) may be
or subalbinotic coat colors.29 End-on choroidal capil- absent, depending on coat and iris coloration (Fig. 1-14).2
laries can be visualized as small dark dots throughout If the pigment is absent, the choroidal vessels can be
the tapetal fundus (i.e., stars of Winslow) (Fig. 1-13).29 visualized.
The equine retinal vasculature is paurangiotic, and
the vessels arise from the edge of the disc and extend
only a short distance.29,33 The ventral margin of the disc
at the 6 o’clock position is less vascular and normally
Tm
appears slightly whiter in this area. As in other domes-
tic mammals, there is no central retinal artery, and the
retinal arterioles arise from chorioretinal arteries.21 The
L C
optic disc is horizontally oval, usually located slightly
temporal and ventral in the nontapetal area, and is
Co Pe I P salmon pink.29 The equine disc can be differentiated
into the optic cup and neuroretinal rim regions, and
the cup-to-disc ratio is 0.61.2

Periorbital Sinuses

Several sinuses are in close anatomic contact with the

orbital bones, the frontal (conchofrontal), maxillary
(caudal and rostral), and sphenopalatine (Fig. 1-15).2,10
Sinus disease involving these sinuses may encroach on
the orbit and nasolacrimal duct.34,35 The frontal sinus is
Fig. 1-12 The attachment of the iridocorneal angle pectinate located dorsal and ventral to the orbit.17 The maxillary
ligaments to Descemet’s membrane (i.e., gray line) can be sinus is located ventral and nasal to the orbit and sep-
observed medially and laterally in the adult horse. Pupil (P), iris (I), arated from the orbit by an extremely thin bony plate.17
pectinate ligaments (Pe), attachment of pectinate ligaments to
corneal endothelium (C), trabecular meshwork (Tm), limbus (L),
and conjunctiva (Co).

Fig. 1-13 In most horses, a triangular fibrous tapetum in the dorsal Fig. 1-14 Melanin in the retinal pigment epithelium may be
choroid can be seen on ophthalmoscopic examination. End-on absent, depending on coat and iris coloration. If the pigment is
choroidal capillaries can be visualized as small dark dots through- absent, the choroidal vessels can be visualized.
out the tapetal fundus (i.e., stars of Winslow). The nontapetal
area is usually dark brown.

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1 EQUINE OPHTHALMOLOGY

Conchofrontal sinus

Frontal

Dorsal conchal

Nasolacrimal duct Caudal maxillary sinus

Rostral maxillary sinus

Fig. 1-15 Several sinuses are in close anatomic contact with the orbital bones,
including the frontal (conchofrontal), maxillary (caudal and rostral), and sphenopala-
tine sinuses.

The anterior maxillary sinus can be located just ventral should be quiet and away from major distractions.
to the intersection of a line between the medial canthus Examination of specific components of the eye requires
and infraorbital foramen and a perpendicular line the ability to darken the environment. This can be per-
from the fourth cheek tooth.6 Trephination dorsal to a formed in a darkened stall, or the horse can be placed
line between the infraorbital foramen and the medial in stocks in a room in which the lights can be dimmed.
canthus can result in nasolacrimal duct damage.25 The For accurate evaluation of the equine pupillary light
center of a line between the medial canthus and facial reflexes, a bright, focal light source and a darkened
crest indicates the location of the caudal maxillary examination area are often required. The menace
sinus.6 response and other subjective vision testing, such as
maze testing, in addition to the evaluation of the pupil-
lary light reflex (PLR), should be performed before
sedation.
GENERAL OCULAR EXAMINATION
A thorough ocular examination usually requires
restraint, tranquilization, regional nerve blocks, and
The ocular examination in the horse should proceed in topical anesthesia. Methods of restraint required to
a systematic manner.2 The general order of steps to be examine the ocular structures of the horse range from
taken in the examination is listed in Box 1-2. Before a halter and lead rope to mechanical restraint in stocks
sedation, an initial examination of the equine eye should with use of a lip twitch. Use of restraint is dependent
take place in a well-lighted area. The area of examination on temperament of the horse, availability of equipment,

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EQUINE OCULAR EXAMINATION: BASIC AND ADVANCED DIAGNOSTIC TECHNIQUES 1

Box 1-2 General Order of Steps to Take in Equine
Ocular Examination

• Medical and ocular history

• Examine horse in its environment (e.g., walking on a lead,
loose in a stall or round pen)
• Evaluation for symmetry from the front (globe, orbit,
pupils, eyelash direction, ear and lip position)
• Visual testing (menace, dazzle, PLRs)
• Palpebral reflex
• Sedation if required here or at any time during the
examination
• Auriculopalpebral nerve block
• Transillumination for gross disease (eyelids, cornea, ante-
rior chamber, iris)
• STT, if indicated (may be performed before auriculopalpe-
bral block)
• Topical fluorescein Fig. 1-16 The head (including ears and nostrils), bony orbits,
• Examination of the eyelids, cornea, anterior chamber, eyelids, globes, and pupils should be examined for symmetry
and iris with transillumination and biomicroscopy with the examiner positioned in front of the horse.
• Corneal reflex (may wait until complete corneal exam is
performed to avoid iatrogenic damage)
• Topical anesthesia (proparacaine)
• IOP (sedation can affect the IOP)
• Mydriasis (tropicamide) (e.g., buphthalmos, phthisis bulbi) should be differ-
• Transillumination, retroillumination, and biomicroscopy of entiated from changes in globe position (e.g., enoph-
the lens and vitreous thalmos, exophthalmos). Cornea globosa has been
• Direct ophthalmoscopy of fundus (± indirect) reported in the Rocky Mountain horse and may be
• Irrigate nasolacrimal duct if indicated difficult to distinguish from buphthalmos.36
The examiner should then position himself or
IOP, Intraocular pressure; PLRs, pupillary light reflexes; STT, Schirmer tear test.
herself at the side of the horse’s head to examine each
eye individually. An assistant may be required to
elevate the head of a sedated horse to the same level
and comfort level of the handlers and examiner. In as the examiner’s eyes. The examiner may need to use
addition to manual and mechanical restraint, some a stool for an extremely tall horse and may need to
form of chemical sedation can be used to smooth the kneel on the ground for an extremely short horse (e.g.,
progress of the examination. a Miniature horse). Eyelids should be examined for
position, movement, and conformation.2,4,6,8 Attempts
to forcefully elevate the upper eyelid should be avoided
if an auriculopalpebral nerve block has not yet been
Initial Examination
performed, and each eye should be examined with
minimal handling of the adnexal tissues. The orbit
The head, bony orbits, eyelids, globes, and pupils should be examined by observation, palpation of
should be examined for symmetry with the examiner the bony orbital rim, and retropulsion of the globe
positioned in front of the horse (Fig. 1-16) before through a closed eyelid.2,4,6,8 Forceful manipulation of
extensive manipulation, sedation, or blockade of the the eyelid and retropulsion should not be performed if
auriculopalpebral nerve. Comfort may be assessed by the structural integrity of the cornea or globe may be
evaluation of palpebral fissure size and symmetry, the compromised.
position of the eyelashes, ocular discharge, and blink A cranial nerve evaluation (specifically, cranial
rate.2,4,6 Any type of nasal discharge should also be nerves II, III, IV, V, VI, and VII) is then performed
noted. The upper eyelashes of the healthy horse are before any sedation is induced. These cranial nerves
nearly perpendicular to the cornea (Fig. 1-17, A).2 A are assessed through the menace response, pupillary
change in the angle between the eyelashes in the light and dazzle reflexes, globe and eyelid position and
cornea may indicate blepharospasm, enophthalmos, mobility, and sensation of ocular and adnexal struc-
exophthalmos, or ptosis (Fig. 1-17, B).2 The globes tures.2,4 Keratoconjunctivitis sicca may result from loss
should also be evaluated for symmetry of size, posi- of the parasympathetic innervation in CN VII to the
tion, and movement. Apparent changes in globe size lacrimal glands. Examination of the cranial nerves is

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1 EQUINE OPHTHALMOLOGY

A B
Fig. 1-17 A, The cornea and eyelids as viewed from the front in a healthy horse. The upper eyelashes are nearly perpendicular to the
cornea. B, The cornea and eyelids as viewed from the front in a horse with ocular pain. The eyelashes are no longer at 90 degrees
from the corneal surface but are pointed downward.

discussed in more detail in the following section. The Alcon Laboratories), which takes effect in approxi-
evaluation of the function of CN II (i.e., the optic nerve) mately 10 to 20 minutes and lasts approximately 4 to
can be challenging, but in addition to the menace 6 hours.37-39 In the case of severe intraocular inflamma-
response and pupillary and dazzle reflexes, maze test- tion or reflex uveitis caused by corneal disease or
ing can also be performed and is discussed further in trauma, a single application of tropicamide may not be
Chapter 10 (Vision and Vision Loss). sufficient to dilate the pupil. The use of atropine for
The cornea should be examined for abnormali- routine examination is not recommended because of its
ties (e.g., opacities, ulceration, blood vessels, edema) longer duration of action and potential adverse effects
by using transillumination and slit-lamp biomi- in the horse.9,40 After mydriasis has been achieved, the
croscopy.2,4,6,8 Evaluation of resting pupil size, shape clarity, position and size of the lens, the vitreous body,
and mobility of the pupil, and appearance of the the optic nerve, the retinal blood vessels, and the tapetal
anterior chamber structures should follow. The attach- and nontapetal fundus are evaluated. With full mydri-
ment of the iridocorneal angle pectinate ligaments to asis, the edge of the lens and attachment of the zonular
Descemet’s membrane (i.e., gray line) can be observed fibers are visible.19
medially and laterally in the adult horse (see Figs. 1-10
and 1-12) and allows for direct visualization of the
horse’s iridocorneal angle. Fluorescein staining of the
Cranial Nerve Examination
cornea is then performed. Examination of the naso-
lacrimal system, third eyelid, and conjunctiva is per-
formed concurrently. Fluorescein staining is followed The cranial nerve examination is an inherent and impor-
by induction of topical anesthesia with proparacaine tant part of any thorough ocular examination.38,39,41-43
(Alcaine, 0.5%, Alcon Laboratories) to perform tonom- Specifically, cranial nerves II, III, IV, V, VI, and VII are
etry. The ocular media (cornea, aqueous humor, lens, evaluated. These are assessed through the menace
and vitreous) are evaluated for clarity and transparency response; pupillary light and dazzle reflexes; globe
by transillumination and ophthalmoscopy.4,6,8 The position and mobility; eyelid position, sensation, and
anterior surface of the third eyelid can be examined by mobility (palpebral reflex); and corneal sensation
gently retropulsing the globe to produce passive pro- (corneal reflex) (Table 1-2).38,39,41
lapse of the nictitans. For evaluation of the posterior
surface, the third eyelid can be gently grasped with
Graefe fixation forceps or manipulated with a strabis-
Vision and Vision Testing
mus hook.
For complete examination of the lens and posterior
segment, mydriasis is required. The most common Vision and vision testing are discussed more extensively
mydriatic used is tropicamide (Mydriacyl, 0.5%, 1%, in Chapter 10. Vision can be subjectively assessed by

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EQUINE OCULAR EXAMINATION: BASIC AND ADVANCED DIAGNOSTIC TECHNIQUES 1

Table 1-2 Cranial Nerve Examination

Innervates: Motor (m)

CN Name or Sensory (s) Function Dysfunction Assessment

II Optic Sensory Vision (sensory) Blindness Menace response

Pupillary light reflex
Dazzle reflex
III Oculomotor Medial, dorsal, ventral rectus Globe movement Lateral Move head and watch
muscles (m) Pupillary movement strabismus eye position
Pupillary sphincter muscle (m) Upper eyelid Mydriasis Pupillary light reflexes
Levator palpebrae superioris (m) elevation Ptosis Observation
IV Trochlear Superior oblique (m) Globe movement Dorsomedial Move head and watch
strabismus eye position
V Trigeminal Maxillary branch(es):
Skin of face/eyelid
Ophthalmic branch(es):
Eye
VI Abducens Lateral rectus muscle (m) Medial strabismus Move head and watch
Retractor bulbi muscle (m) Loss of retraction eye position
Touch cornea and
watch for retraction
VII Facial Orbicularis oculi (m) Close palpebral Inability to Observation
Lacrimal gland (m) fissure blink Palpebral reflex
Stimulate tear Keratoconjuncti- STT
secretion vitis sicca
VIII Vestibulo- Equilibrium Spontaneous Observation
cochlear nystagmus

the menace response, pupillary light reflexes, and tapping the canthus before attempting to induce the
the dazzle reflex. If visual function is in doubt, the menace response again may alert the uninterested horse
horse can be subjected to a maze test and unilateral that the examiner means business. However, a fright-
blindfolding. However, horses that are depressed, ened horse may react to this lesson in an unwanted
ataxic, or vestibular may still stumble over objects that manner, such as violently startling and pulling away
they can see.4 from the handler. A pathologic lack of menace response
is the result of a lesion in the retina, CN II, the visual
cortex, or CN VII because it functions to close the
Menace Response eyelid.41-43 Cerebellar disease can cause bilateral defi-
ciency in the menace response in the absence of blind-
The menace response is a learned protective response ness or CN VII paralysis, possibly because of a loss of
in which a menacing movement toward the eye results cerebellar modulation of cerebral visual function.41-43
in closure of the eyelids and possibly retraction of the
globe or an avoidance movement of the head.38,39 The
threatening movement can be performed with the Pupillary Light Responses
examiner’s hand, but care should be taken to avoid the
vibrissae and to avoid causing an air current that could The eyes should be examined for pupillary size and
be detected even in a blind eye. For detection of a visual symmetry and for evidence of disease that might affect
deficit in one field, the menacing gesture is directed the PLR, such as synechia. The pupils and pupillary
first toward the nasal visual fields and then toward the light reflexes should be examined for symmetry in
temporal visual fields.41 However, partial visual deficits both light and dark settings to detect subtle abnor-
can be extremely difficult to detect. The afferent arm of malities.43 An indirect ophthalmoscope directed at the
the menace response is the retina and CN II, and the center of the horse’s head, with the examiner some 6 to
efferent arm is the palpebral branch of CN VII, which 8 feet in front of the horse, should illuminate both
innervates the orbicularis oculi.42,43 A horse that has tapetal reflexes and make it possible to determine pupil
intact vision but is extremely stoic, depressed, or fright- symmetry (Figs. 1-18 and 1-19).43 Anisocoria may be a
ened may have an abnormal menace response. Lightly normal finding in horses with bilateral heterochromia

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1 EQUINE OPHTHALMOLOGY

Fig. 1-18 An indirect ophthalmoscope directed at the center of

the horse’s head, with the examiner some 6 to 8 feet in front of
the horse, should illuminate both tapetal reflexes and make it
possible to determine pupil symmetry. This is easiest to perform
in a foal.

iridis or unilateral heterochromia iridis in which the

larger pupil is ipsilateral to the heterochromic eye.14
The vertical movement of the pupil is much faster
and the excursion is greater than the horizontal move-
ment. The pupil’s shape is a horizontal ellipse that
becomes rounder when dilated (see Figs. 1-10 and
1-11).44 Pupillary light reflexes can be used to simulta- Fig. 1-19 An indirect ophthalmoscope directed at the center of
neously evaluate function of the retina, CN II, midbrain, the horse’s head, with the examiner some 6 to 8 feet in front of
and CN III.41-43 Light directed into one eye should result the horse, should illuminate both tapetal reflexes and make it
possible to determine pupil symmetry. In the adult horse, a greater
in the constriction of both that pupil (direct response) distance is required to view both pupils. Supraorbital fat atrophy
and the pupil of the contralateral eye (indirect response). can also be seen in this aged horse.
This results from bilateral excitation of the parasym-
pathetic component of CN III in the pretectal region.41-43
The normal equine pupil responds somewhat sluggishly vision and a direct response in both eyes. The consen-
and incompletely to light in a biphasic manner.2,42 The sual light reflex can be extremely valuable in evalua-
first part is a brisk but small reaction, followed by the tion of problems when the posterior segment cannot be
second slower complete movement. The magnitude visualized (e.g., corneal edema, hyphema) for assess-
and time of response depends on the brightness of the ment of retinal function in the affected eye. Pupillary
light source and the mental state of the horse. A very escape, a slight dilation that follows constriction under
focal and bright light source is required to stimulate a direct light stimulation, is a normal response.43
rapid and complete response. Consensual responses
can be difficult to evaluate in the horse, because they
tend to be weaker than the direct response and because Dazzle Reflex
they can be awkward for an examiner to determine
alone. The indirect PLR is less prominent because of The dazzle reflex, in contrast to the cortically mediated
decussation at the chiasm (75%) in the horse, which menace response, is a subcortical reflex that requires
results in more efferent pupillomotor fibers that return function of the retina, CN II and CN VII, rostral collicu-
to the ipsilateral side of the brain.10,43 This is referred to lus, possibly the supraoptic nuclei of the hypothalamus,
as dynamic contraction anisocoria.19 Evaluation for the and orbicularis oculi.41-43 A very bright focal light source
consensual light reflex is unnecessary if the horse has is directed into the eye, and blinking or blepharospasm

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