A of pupillary light reflex (PLR) revealed miosis

A
32-year-old female Chilean Flamingo that is part of a captive flock at Wildlife
Safari (1790 Safari Rd, Winston, OR, USA 97496) presented an inability to enter
her night house, walking into the wall beside the entrance door. Her behavior
was otherwise normal in the exhibit and she only needed help by keepers when
going into her enclosure at night. The flock consists of 5 males and 5 females;
4 individuals between 10-11 years old and 6 individuals between 32 – 35 years.
They are locked up at night due to predation issues and given access to their
enclosure in the morning.

Physical examination revealed one small (1X1 mm)
erosion on the periocular skin cranial to the left eye. She presented adequate
proprioception and no neurological or orthopedic abnormalities were noted.
Findings upon ophthalmoscopic examination included a change in coloration of
the iris to dark yellow and a central opacity of the lens OS.  The individual was remitted to a Board
Certified Veterinary Ophthalmologist for further examination.

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On day 6 after initial presentation, the flamingo was
transported to Bliss Animal Eye Care Inc. (1217 Plaza Blvd, Central Point, OR,
USA 97502). She was manually restrained in her night house, placed in a
pillowcase and transported to the veterinary clinic of Wildlife Safari, where
she was sedated with 0.25 ml of IM Midazolam (0.5 mg/kg, 5 mg/ml, Hospira,
Inc., Lake Forest, IL 60045 USA) at approximately 8:30 AM. After induction, the
individual regurgitated a small amount of gastrointestinal content. She was
manually restrained for the duration of the trip. Her vitals during
transportation were 125 beats per minute (BPM) (102-180 BPM) for heart rate
(HR), and respiratory rate (RR) was 63 breaths per minute (BrPM) (26-100 BrPM);
there were no other abnormalities observed during transport.

A Board Certified Veterinary Ophthalmologist (CB)
performed a complete examination of the individual. Intraocular pressure (IOP)
was measured by rebound tonometry (Tonovet ®), resulting 11 mmHg OD and 7 mmHg OS. Fluorescein
staining revealed slight uptake OD, and OS was normal. Palpebral reflex was
normal in both eyes (OU). Evaluation of pupillary light reflex (PLR) revealed
miosis OU, normal direct OD and no change OS; it was difficult to assess dazzle
and menace response.

Findings on New Biomicroscopy exam OD included no
blepharospasm, normal adnexa, normal third eyelid (TEL), clear cornea, clear
deep Anterior Chamber (AC), posterior synechia from 1 to 3 o’clock, and the lens
could not be assessed. OS revealed enophthalmos, normal adnexa, dorso-temporal
fine irregular epithelium, trace edema, trace flare, fibrin clot in pupillary
aperture, orange appearance to the iris, and the lens could not be assessed
either. It was not possible to examine the fundus on either eye with indirect
ophthalmoscopy.

B-mode
ocular ultrasound was performed on each eye and the results showed: OD an antero-posterior (AP) globe length of 13.64 mm, a
hyperechoic linear opacity spanning the pupillary aperture. It wasn´t possible
to specifically identify the lens, however there was a suspect resorbed
cataract with the opacity being the lens capsule. The pecten was unremarkable
and the AP Vitreous length was 9.75 mm. OS globe AP was 13.8 mm, Lens AP is 5.07
mm, vitreous AP 4.95 mm and a hyperechoic lens consistent with a cataract was
identified.

The individual was diagnosed with an active lens
induced uveitis, cataract and corneal erosion OS; and a Hypermature Resorbed
Cataract (posterior Synechia) OD. It is considered that the left eye is painful
due to the presence of uveitis. The cause of uveitis is unknown but related to
the presence of a cataract, phacoclastic uveitis, but a systemic or traumatic
origin cannot be ruled out. Due to the significant amount of inflammation,
surgery to remove the lens is indicated. The individual was also weighed (2
kg).

Prior to surgery, for treatment of uveitis, the
flamingo was prescribed with 1.6 mg/kg32 of oral (PO) meloxicam (1.5
mg/ml Ostilox, Norbrook Laboratories Limited, Newry, Co Down, BT35 6PU,
Northern Ireland, UK) BID for 7 days; 5 mg/kg32 of Itraconazole (10
mg/ml, Itrafungol, Elanco US Inc. Greenfield, IN 46140 USA) PO SID for 7 days;
1 drop OU of Diclofenac Sodium Ophthalmic solution (0.1%, Bausch & Lomb
Incorporated, Tampa, FL 33637 USA) BID for 7 days; and 1 drop OU of Ofloxacin
Ophthalmic Solution (USP 0.3%, Akorn, In. Lake Forest, IL 60045 USA) BID for 7
days.

On day 13 after initial presentation, the Flamingo was
admitted for cataract surgery.  She was
sedated for transport with the previous protocol and no abnormalities were seen
during transport. Pre-surgical physical examination was unremarkable and
ophthalmologic examination on biomicroscopy OD showed no blepharospasm, normal
adnexa, normal TEL, clear cornea, clear deep AC, posterior synechia from 1 to 3
o’clock, and the lens could not be assessed. OS presented normal adnexa, clear
cornea and anterior chamber, irregular pigment spanning the ALC, orange
appearance to the iris and a cataractous lens.

The individual was induced for surgery with 5%
isoflurane (Fluriso, VetOne, United Kingdom) via facemask. Two minutes
post-induction she was in a working plane of anesthesia and a 4.0 mm
endotracheal tube (ET) was placed; anesthesia was maintained with isoflurane
(1-3%) and an oxygen flow rate of 1.5 L per minute. The patient was placed in
right lateral recumbency and monitored by one veterinarian throughout the
surgery. HR, RR and cloacal temperature, using an electric rectal thermometer,
were taken every 5 minutes and SP02 was monitored with a pulse-oximeter
(Nellcor PM10N, COVIDIEN Mansfield, MA 02048 USA) placed in the interdigital
membrane of the left pelvic limb. The surgical site was aseptically prepared
with Ocu-Soft Eyewash® (OCuSOFT, INC. Richmond, TX
77406 USA) and Diluted Betadine (1:10 solution).  An eyelid speculum and nylon stay suture (8-0
CaraNylon, CaraLife Inc. Edison Courd Rancho Cucamonga, CA 91730 USA) for TEL
are placed. A clear corneal incision (2.8mm) was made followed by an anterior
capsulorhexis. A routine phacoemulsification was set for 1 minute (AMO
Sovereign Compact, Abbot Medical Optics Inc., Santa Ana, CA 92705 USA). The
incision was closed with a 9-0 vicryl (Ethicon V549G, Sommerville, NJ 08876 USA)
suture in a simple continuous pattern. Subconjunctival triamcinolone (10 mg/ml,
Kenalog-10, Bristol-Myers Squibb Company, Princeton, NJ 08543 USA) and gentocin
(100 mg/ml, Gentafuse, Henry Schein Animal Health, Dublin, OH 43017 USA) were
applied (0.1mL each), as well as intracameral Tissue Plasminogen Activator
(TPA) post procedure (250 ?g/ml, Stokes Pharmacy, Mount Laurel, NJ 08054 USA).

At the end of the surgery her body temperature was at a
low point (100.6 F) and she was covered with a heated blanket (Bair-Hugger,
3M). She was recovered with oxygen at a rate of 2 L/min through the ET tube,
which was removed when she was awake, approximately 15 minutes after isoflurane
was closed. The total length of the surgery was 15 minutes.

Prior to transport back to Wildlife Safari, 0.2 ml of
Midazolam was administered IM (0.5 mg/kg, 5 mg/ml). After 90 min of transport,
the individual was placed in a room for recovery at the clinic and 0.4 ml of IM
Flumazenil (0.02 mg/kg, 0.1 mg/ml, Hikma Farmacêutica, Fervença 2705-906
Terrugem SNT, Portugal) was applied as a reversal. Recovery was uneventful. The
individual was prescribed with Meloxicam (1.6 mg/kg32 PO BID for 7
days), Itraconazole (5 mg/kg, 32 PO SID for 7 days), topical
Diclofenac (1 drop OS BID for 7 days), topical Ofloxacin (1 drop OS BID for 7
days) and 125 mg/kg 32 of clavamox PO BID for 7 days (62.5 mg/ml,
Clavamox, Zoetis, Inc, Kalamazoo, MI 49007 USA) for post-surgical therapy.

Ophthalmic examination using Biomicroscopy 7 days
post-surgery revealed a slight anterior uveitis, which was expected, and
evolution of the patient is favorable; it was decided to return the individual
to her exhibit.

Revision of the patient 22 days post-surgery showed no
abnormalities in her demeanor or physical exam. Ophthalmologic examination with
Biomicroscopy OS showed anterior uveitis with slight opacity at the suture
site, and IOP was also measured (10 mmHg OS). 
She was prescribed with the same regimen of Meloxicam, Itraconazole,
Diclofenac and Ofloxacin; 3 dosages of Ceftiofur (Naxcel 50 mg/ml, Zoetis Inc.,
Kalamazoo, MI 49007 USA) were also prescribed (0.832 ml IM SID every
4 days).

One month after surgery, examination of the eye still
showed moderate anterior uveitis, and her demeanor and physical exam were
unremarkable. IM meloxicam, topical diclofenac and ofloxacin (OS) were
continued for another week with the same dosages. The treatment was continued
for 7 more days, because at day 39 post-surgery, a mild anterior uveitis was
still perceived. 41 days after the surgery, physical and ophthalmic examination
were within normal limits.

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