Vet Clin Exot Anim 5 (2002) 223–241

Ophthalmic disease in exotic species

Nicholas J. Millichamp, BVetMed, PhD, MRCVS*
Department of Small Animal Clinical Sciences, College of Veterinary Medicine,
Texas A&M University, College Station, TX 77843, USA

Diseases of the eye are similar regardless of whether they occur in humans
or domestic or exotic animal species; however, there are unique conditions in
exotic species that reflect differences in anatomy, physiology, pharmacology,
and pathophysiology compared with domestic species. Whether the animal is
encountered in the wild or in captivity, in a zoological collection or a pet
environment may influence the types of ocular disease encountered and the
veterinary approach to the diagnosis and treatment.
This article highlights factors that must be kept in mind when dealing
with species other than cats, dogs, and horses. Several reviews have covered
different groups, and the reader is referred to these and other articles in this
issue for more details on specific conditions or groups of animals [1–5].

Environment of the animal

Exotic species with ocular disease in the wild present a significant chal-
lenge, which may preclude any attempts at diagnosis or therapy. Ocular
developmental abnormalities can be caused by teratogen exposure. Infec-
tious diseases can occur in epizootics (eg, Chlamydophila psittaci infection
in koalas in Australia [see article by Stanley elsewhere in this issue] and out-
breaks of keratoconjunctivitis [resembling infectious bovine keratoconjunc-
tivitis] in reindeer and other hoofstock in wild populations in Europe) [6].
Environmental change (eg, caused by human influence) can precipitate cer-
tain ophthalmic conditions. The spread of fire ants into Texas was accom-
panied by a marked increase in the number of deer fawns with corneal
ulceration and blepharitis from fire-ant bites [7]. In most wild populations
of animals, it is not practical, and, aside from endangered species, not desir-
able to intervene. For effective diagnosis and treatment, the animal often

* E-mail address: njm@tamu.edu (N.J. Millichamp).

1094-9194/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved.
PII: S 1 0 9 4 - 9 1 9 4 ( 0 2 ) 0 0 0 0 5 - 1
224 N.J. Millichamp / Vet Clin Exot Anim 5 (2002) 223–241

would need to be captured and maintained in captivity for at least the dura-
tion of therapy, which in most instances is not practical.
In situations in which exotics actively are managed in their wild environ-
ments (eg, large game parks), the prospects for capture, evaluation, and
treatment are better. Useful data can be obtained that have relevance to
the diseases seen in captivity. Whether an animal can survive in the wild
with significant ocular disease in one or both eyes needs to be considered.
Although most animals can live in a monocular state, animals that rely
heavily on some degree of stereoscopic vision when hunting (particularly
some birds and reptiles) do not. These animals may never be able to capture
food and compete if released back into the wild [8].
In the captive environment of a large public or private zoological collec-
tion, it is generally easier to approach the diagnosis and treatment of ocular
disease. Animals in these environments are used to some degree of human
interaction and intervention. Restraint is provided more easily, and repeated
therapy, although difficult, can be managed with less overall stress to the
animal. Inevitably, an ocular problem occurs that cannot be treated effec-
tively, and loss of the eye (enucleation) is the best choice for the animal and
for the safety of those involved in its care. The type and severity of ocular
disease, however, has to be balanced against the value of the animal and its
use in the captive collection. In a valuable or rare breeding animal, the risks
of stress and injury from repeated restraint and handling for therapy must be
weighed against the partial loss of vision. Conversely, if the animal is of value
more for exhibition, loss of the eye may be less cosmetically acceptable.
In the captive environment, abnormal population densities, inbreeding,
and the stress of captivity can affect the types of diseases seen. Congenital
ocular defects may seem magnified by captive breeding from a small gene
pool. Microphthalmia and other facial deformities are common in captive
collections of snakes and are especially evident in situations in which large
numbers of offspring are produced at one time [9]. Although the same con-
ditions are reported for wild populations, the incidence seems to be lower in
captive populations. Certain congenital defects have been reported in par-
ticular species. Eyelid and optic-nerve colobomas have been seen in snow leo-
pards on two continents [10], and although the cause is uncertain, a genetic
predisposition seems likely.
Nutritional problems in captivity result in many types of disease, includ-
ing ocular problems. In kangaroos and wallabies, galactosemic cataracts are
caused by feeding cow’s milk to young animals (see article by Stanley). Vita-
min A deficiency results in lacrimal gland disease in chelonians and possibly
conjunctivitis in some avian species. Lipid keratopathy—one of the most
common ocular diseases of captive amphibians—seems to be associated with
abnormally high fat levels in the captive diet.
The types of ocular disease encountered in the pet environment closely
mirror the types of disease seen in large zoological collections—particularly
because captive breeding of exotic species in the zoos enabled the spread of
 N.J. Millichamp / Vet Clin Exot Anim 5 (2002) 223–241 225

exotics into pet households. The same genetic and husbandry-related prob-
lems also are expected.
In the pet environment, the monetary value of the animal often has be con-
sidered when choosing diagnostic and treatment options. Although a pet
mouse may have little monetary value, humanitarian issues of pain and suf-
fering and family attachment to the pet significantly can affect how an eye dis-
order is treated. The family pet may receive more frequent and devoted care
than do the valuable and rare exotic species in large zoological collections.

Evaluating vision in exotic species

Animals present with ocular disease because the owner has noticed a loss
of vision or because the eye looks abnormal. It is often difficult to demon-
strate reduced vision because animals can compensate for severe visual dis-
ability. Often, it is not until total blindness occurs that the animal is noted to
have an eye problem. By this time, any medical intervention to restore sight
may be futile.
Observation of visual behavior should occur in the animal’s wild or cap-
tive environment and in unknown surroundings. Animals in small enclo-
sures can learn their environment well enough to seem to have normal
vision. The same animal in a strange environment may behave in a different
manner. Behavioral observations should be performed in reduced and
bright lighting. An animal with reduced vision in one eye may bump into
objects more often on that side. The animal may be reluctant to allow an
observer to get on the side with impaired visual, and it may hold its head
at an odd angle or sideways to maximize use of its normal visual fields.
Apart from having a tendency to collide with objects in their path, ani-
mals with bilaterally reduced vision may be very wary—especially in strange
environments. Vision may be totally lost or some light perception, but not
object perception, may be retained. Some animals are hesitant to move
around, whereas other, more nervous animals blunder around, attempting
to seek escape, and may injure themselves if not restrained. An animal with
retinal degeneration may see well in bright light and become disoriented in
dim lighting. Quiet and careful observation may reveal signs that suggest
poor vision, such as more obvious use of their senses of smell and hearing.

Ocular examination
The general principles and methods of ocular examination differ only
slightly between species. Ocular examination should start with observation
of the eye and assessment of the ocular reflexes and proceed with a detailed
examination of all structures, from the outer adnexa inward and posteriorly.
In the wild or zoo setting, binoculars and viewing telescopes are useful in
226 N.J. Millichamp / Vet Clin Exot Anim 5 (2002) 223–241

allowing an initial cursory examination of the eye before formulating a plan

to perform a thorough eye examination.
The ophthalmic examination initially should be carried out in a well-lit
room to allow general examination around the eye and to perform tests such
as Schirmer tear tests (where appropriate) and tonometry to measure intra-
ocular pressure. Biomicroscopic and ophthalmoscopic examination of the
eye is best accomplished in a darkened room with adequate restraint. A
sedated animal in the wild can be examined by covering the patient’s head
and the examiner with a dark cloth to mimic a darkened room.

Restraint
Small animals (eg, rodents, rabbits, guinea pigs), most birds, reptiles, and
amphibians can be restrained manually for ocular examination without
resorting to anesthesia. For more prolonged procedures, including acquiring
diagnostic specimens, some degree of sedation or general anesthesia is
needed. Sedation or anesthesia is recommended when large hoofstock, carni-
vores, or semiaquatic species are being examined. This sedation is especially
important to reduce stress in animals that are handled rarely, which in a
worst-case scenario may have fatal consequences. Restraint and chemical
immobilization are needed to protect the patient, handlers, and veterinarian.
A thorough examination of the eye includes mydriasis to evaluate the
fundus of the eye. Short-onset mydriatic agents may take 20 minutes to
dilate the pupil. The ocular examination may have to be performed in two
stages: initial examination of the anterior segment followed by mydriasis to
allow examination of the posterior segment. A lengthy period of restraint
and sedation to complete the examination can occur.
Chemical immobilization reduces the risk for iatrogenic injury during the
restraint and examination process. The author has seen retinal hemorrhages
in zoo animals that were restrained forcefully for ocular examination with-
out sedation. Struggling with an nonsedated animal can have severe conse-
quences for the eye. Thinned, ulcerated corneas are prone to perforation if
restraint is too vigorous.
General anesthesia can keep the animal still and reduce tendency to eyelid
closure, although rotation of the eye or nictitans prolapse at intermediate
stages of anesthesia can render examination more difficult unless the eye
is rotated manually. Anesthetics reduce tear production and can reduce
(many anesthetics) or increase (ketamine) intraocular pressure. Because little
is known about the normal range of values for either parameter across a
wide range of species, these anesthetics may complicate the diagnosis of ker-
atoconjunctivitis sicca or glaucoma.
Some drugs result in miosis (barbiturates), whereas others result in mydria-
sis (dissociative anesthetics like ketamine). The chosen sedatives or anes-
thetics significantly can influence how effectively the fundus can be examined.
 N.J. Millichamp / Vet Clin Exot Anim 5 (2002) 223–241 227

For larger mammals and species in which closure of the eyelids is difficult
to overcome manually without potential injury to the eye, sedation and local
or general anesthesia are recommended. In many larger exotic species, and
particularly in large mammals, the use of regional nerve blocks to paralyze
the motor innervation to the muscles that close the eyelids (particularly the
lid-encircling orbicularis oculi muscle) is essential. The innervation of this
muscle is well known in domestic species and is usually necessary to extra-
polate domestic experience to exotic relatives.
Practitioners working with exotic species should have a working knowl-
edge of sedation and anesthetic protocols or should defer to exotic animal
practitioners who have experience in this field [11].

Visual reflexes
Little is known of the significance or value of visual reflexes in exotic spe-
cies. The menace reflexes seem to be present in some but not all vertebrate
species; in birds, the responses are inconsistent. The blink response to a
bright light (dazzle reflex) is a useful test of retinal function in species with
moveable eyelids. The pupillary light reflexes vary considerably between spe-
cies, partly because of differences in the extent of decussation of the optic-
nerve fibers (total decussation in fish, amphibians, reptiles, and birds; and
partial decussation in most mammals—with the most noncrossed lateral ret-
inal fibers in primates that have the most frontally located eyes). In species
with totally crossed fibers, the consensual light reflex is not expected to be
present, although light that reaches a nonstimulated eye through the thin
interosseus septum between the eyes may result in pupillary constriction
in the nondirectly stimulated eye.
The pupillary light reflex also is influenced by the presence of skeletal mus-
cle in the iris in reptiles and birds. In many species, the pupil responses can be
overcome to some extent by adrenergic dilatation in a frightened animal; in
birds, the pupillary light reflex has to be evaluated bearing in mind that some
of the pupil motility seems to be under voluntary control. In some species
with large lenses, such as chelonians and mammals that live entirely noctur-
nal or diurnal lives (with little overlap), the pupil motility is slight [12].

Eyelids and adnexa

The eyelids differ between species to a considerable extent. Apart from
the obvious reduction or complete lack of third-eyelid structures in primates
and species with spectacles, there are variations in the extent of development
of upper or lower lids in different species. In mammals, the upper eyelid tends
to be most mobile, whereas in many lower vertebrates, this trend is reversed.
Larval amphibians and most fish (except cartilaginous fish) lack eyelids.
Metamorphosed amphibians have poor lid development. Most reptiles
228 N.J. Millichamp / Vet Clin Exot Anim 5 (2002) 223–241

have mobile lower lids, although some species, such as crocodilians, have
well-developed upper lids with bony tarsal plates. Birds have a tarsal plate
in the lower lid and a mobile and almost transparent nictitans that can cover
the entire cornea. Eyelids in some reptiles have peculiar modifications that
form a small palpebral aperture constricted around the cornea (as seen in
chameleons) or have complete fusion of the upper and lower lids to form
a spectacle that covers and is separated from the cornea by a narrow (poten-
tial) corneospectacular space. The spectacle in snakes and geckos is a source
of various ocular disorders that are associated with abnormal ecdysis and
blockage of the nasolacrimal duct [13].
Congenital defects of the eyelids occasionally are seen, including eyelid
agenesis in felids and birds. Inflammatory disease of the lids is common in var-
ious species; causes include trauma, viruses (eg, avian poxvirus, contagious
ecthema in sheep), bacteria, fungi (reported occasionally in reptiles), and
parasites (eg, Knemidokoptes eyelid lesions in birds). Eyelid neoplasia occurs
sporadically in exotic and domestic species (eg, eyelid sarcoids in zebra).

Nasolacrimal system
The nasolacrimal duct is absent in aquatic, lower vertebrates, including
fish, amphibians, and all chelonians. In some species, such as tortoises, over-
flow of tears does not represent epiphora in a true sense but indicates exces-
sive lacrimation that is associated with ocular inflammation. Many crocodile
species have multiple inferior nasolacrimal puncta lining the inner margin of
the lower lid [12]. Lacrimal glands vary considerably between species—in
many species, true Harderian glands, small nictitans glands, and lacrimal
glands are present. Little is known of the normal tear composition in most
exotic species. Empirical evaluation of tear production can be attempted
using filter paper or Schirmer tears test strips that are modified in size to suit
the species (Fig. 1). Comparison with normal animals is essential. In some
species (particularly chelonians), vitamin A deficiency results in squamous
metaplasia and enlargement of the orbital glands and their ducts, resulting
in considerable orbital swelling [14].

Conjunctiva
The conjunctiva of exotic species seems to be similar to that of domestic
animals in morphology and in the types of disease encountered. Conjuncti-
vitis commonly is seen in exotic species with various ocular problems. Out-
breaks of conjunctivitis associated with viral, bacterial, mycoplasmal, and
chlamydial infections and parasitic infestations have been described in birds
and occasionally in other groups. Cultures and cytology (conjunctival scrap-
ings) that are taken with these specific causes in mind may be diagnostic,
and techniques that are used in domestic species (polymerase chain reaction
 N.J. Millichamp / Vet Clin Exot Anim 5 (2002) 223–241 229

Fig. 1. Some procedures (such as Schirmer tears tests) that have been borrowed from human
ophthalmology have as much value in exotic and domestic animal ophthalmology.

for herpesvirus in felids) may be useful in diagnosing the cause of conjunc-

tivitis in exotic animals; however, there are still many examples of idiopathic
conjunctivitis for which an etiologic diagnosis never is reached.

Anterior segment
The anterior segment can be examined with a bright, focused light source
(eg, a Finhoff transilluminator) or a slit-lamp biomicroscope to provide
magnified optical sections across the ocular structures. Corneal morphology
is similar in most species, and corneal diseases in exotic species strongly mir-
ror those in domestic animals. Keratitis, both nonulcerative and ulcerative,
is common seen in all species, with the usual expected causes (Fig. 2). Fluor-
escein staining of the corneal stroma is indicated in cases in which corneal
injury or ulceration is suspected.
Several surveys have examined the normal external ocular flora in birds
and some mammalian species [15–17]. Some forms of keratitis in exotic spe-
cies may be identical to those in domestic species (eg, chronic superficial ker-
atitis or pannus in exotic canids). Ulcerative keratitis and corneal injuries
are good examples of eye lesions that should be treated surgically in exotic
species whenever possible to minimize stress to the patient and to improve
prognosis.
There may be differences between species in the inflammatory response of
the cornea, particularly in the tendency of some species to heal with minimal
230 N.J. Millichamp / Vet Clin Exot Anim 5 (2002) 223–241

Fig. 2. Corneal ulceration in a llama. Corneal ulcers are common in all exotic species.

scarring, whereas others are more prone to poor outcomes after keratitis
and ulceration (eg, feline and bovine corneas seem to be more robust than
canid and equid corneas).
The pathogens involved in exotic species often show notable species and
regional variations that are similar to those in domestic species. Fungal ker-
atitis is not common in domestic dogs and cats but occurs frequently in
horses in the southern United States. Similar regional differences can occur
in various infectious diseases (eg, systemic mycoses in mammalian species).
Corneal dystrophies occasionally are seen in exotic species (especially
stromal lipid dystrophies and less commonly endothelial decompensation,
resulting in corneal edema). Corneal degenerations are not uncommon in
aged, captive canids.
The anterior chamber morphology varies considerably between species
[18]. The depth of the anterior chamber shows more variation in exotic ani-
mals than between domestic mammals, which is partly a reflection of the size
and shape of the lens. In fish, the lens may appear to almost touch the cor-
nea. The iridocorneal angle morphology also shows much variation between
different species, ranging from a well-developed ciliary cleft in many mam-
mals to a poorly developed structure in many lower vertebrates [18]. The
significance of iridocorneal angle structure to the development of glaucoma
is poorly understood in mammals and in species with significantly differ-
ing morphology. Except for few species, there are little data about the nor-
mal range of intraocular pressure. These data are difficult to collect because
of the various effects of restraint or anesthesia on the pressure inside the eye
(see article by Ofri elsewhere in this issue). Although glaucoma and
 N.J. Millichamp / Vet Clin Exot Anim 5 (2002) 223–241 231

buphthalmos have been reported with some frequency in New Zealand

white rabbits [19] and Russian hamsters [20], occurrence in other species is
more sporadic and possibly secondary to uveitis in some cases. Intraocular
pressures can be measured in small rodents using an applanation tonom-
eter (such as the Tono-Pen [Oculab, Glendale, CA]).
There is tremendous variation in size and shape of the lens in different
species [12]. Cataracts of diverse causes (age, inheritance, parasites, nutri-
tional deficiency or excess) seem to be the one degenerative eye disease that
occurs commonly in many exotic species (Fig. 3) [3,7]. Spontaneous lens
luxation seems to be rare in exotic species, although traumatic luxations
occasionally are seen in birds [8].
In different species, the anterior uvea (iris and ciliary body) shows differ-
ences in the extent of its development and in its response to disease. The iris’
appearance (especially vascular patterns and pigmentation) has been the
subject of various monographs about different groups of animal [21]. The
ciliary-body morphology is related to the role this structure has in accom-
modative movements and changes in the shape of the lens [12].
Well-documented studies show that among several mammalian species
there is considerable variation in the eye’s neurologic reflex response to
injury. This variation seems to be caused by anatomic differences and by dif-
ferences in the pharmacologic mediators of inflammation in the species stud-
ied [22]. Clinically, there seems to be species variations in the eye’s response
to injury and capacity for repair with regard to maintenance of vision. These
variations may explain the clinical spectrum of surgical response seen in
exotic species.

Fig. 3. Cataracts occur frequently in many exotic species and can be treated surgically.
232 N.J. Millichamp / Vet Clin Exot Anim 5 (2002) 223–241

Uveitis is common in exotic species, although it may be difficult to recog-

nize, especially in small eyes. In many cases, the presence of uveitis, particu-
larly bilateral uveitis, should signal the need for evaluation of underlying
systemic ailments.

Posterior segment
Examination of the posterior segment is best performed with an indirect
opthalmoscope through a dilated pupil using a 20D or 28D to 60D plano-
convex lens. Achieving adequate mydriasis is often the limiting factor in
these examinations. In species with skeletal muscle in the iris sphincter
(eg, birds, reptiles), the unusual parasympatholytic drugs (tropicamide) are
ineffective in dilating the pupil. Voluntary control of the iris muscles also
can affect the examination. Although nondepolarizing neuromuscular block-
ing (curare-like) drugs can be used topically or injected into the anterior
chamber, the effects are variable and may have systemic side effects (regional
paralysis) in small animals. Drugs such as nondepolarizing neuromuscular
blocking agents have been used for this effect diagnostically [23,24]. When
spectacles cover the cornea, the only effective way to achieve mydriasis is
by intracameral injection of the neuromuscular blocking agent or use of gen-
eral anesthesia to induce centrally mediated mydriasis. Pigmented rodents
dilate poorly with topical tropicamide and may need the addtion of 10%
phenylephrine [25]. The funduscopic appearance of the posterior segment
varies between species, and there are few references regarding the normal
appearance of the exotic fundus [26–28]. In the diagnosis of retinal disease,
knowledge of what is normal is sometimes difficult to interpret. Although
the same principles or changes in fundus pigmentation and reflectivity in
tapetal fundi apply in most species, subtle differences may exist between spe-
cies. It is recommended that when presented with an exotic animal with
visual impairment, a visual representative of the same species be examined
for comparison of funduscopic appearance (Fig. 4).

Globe and orbit

The shape of the globe in many lower vertebrates (especially birds and
lizards) is determined in part by the presence of scleral hyaline cartilage and
a ring of bony ossicles in the clear over the ciliary region (scleral ossicles)
[12,29]. Ossicles over the ciliary region are present in in birds and in all rep-
tiles except snakes and crocodilians. Cartilage is present in the sclera of
metamorphosed amphibians, reptiles other than snakes, and birds, but not
in fish or mammals. These anatomic characteristics have relevance for
intraocular surgical procedures (eg, incisions in the eye for cataract removal
have to be made in clear perilimbal cornea), but otherwise preserve the shape
of the globe better in an incised eye, which is true for most of the domestic
 N.J. Millichamp / Vet Clin Exot Anim 5 (2002) 223–241 233

Fig. 4. The fundus of an alligator. Tremendous normal fundus variation is seen between exotic
species.

species that the author deals with. Passing a needle through the sclera for vitre-
ous paracentesis can be more challenging. The avian eye may require collapse
of the globe before enucleation to allow the globe to pass through a limited
orbital opening [30].
Histologically, the eye of the lower vertebrates with ossicles requires care-
ful decalcification before sectioning. Overzealous decalcification can destroy
ocular tissues. In some species, structures around the orbit and eye can pre-
dispose to unique ocular disease. Air sacs, uniquely present in birds, are
commonly the site of bacterial infections, with extension to the periorbital
sinuses. Affected birds (and especially captive psittacines) develop periocular
swelling and keratoconjunctivitis.

Medical therapy of ocular disease in exotic species

Reducing animal contact, which reduces stress and injury, requires a well-
devised plan when instituting ocular disease therapy in exotic species. When-
ever possible, techniques should be used that minimize handling, restraint,
and especially contact with the head. Long-acting drug formulations,
remote delivery systems, or parenteral therapy (to avoid actual contact with
the eye) should be used whenever possible. Domestic species also become
234 N.J. Millichamp / Vet Clin Exot Anim 5 (2002) 223–241

head shy when the eye is painful and repeated attempts are made to apply
topical medications.

Remote delivery systems

Ocular lavage systems have been widely used in horses as a means of de-
livering drugs and minimizing the risk of ocular injury. Various approached
have been described in horses, including nasolacrimal lavage and subpalpe-
bral lavage (SPL). The former involves placement of lavage (usually silastic)
tubing in the nasolacrimal duct and has several disadvantages in horses or
exotic species. This tubing can be difficult to place and is displaced easily
by rubbing or sneezing. Large volumes of medications may required to
reach the eye through the nasolacrimal duct. In some exotic species, the
absence of nasolacrimal duct or distal openings in the mouth rather than
near the external nares make these systems difficult to install.
Subpalpebral lavage systems can be used in a wide range of species. With
sedation and local or general anesthesia, silastic tubing is implanted surgi-
cally into the conjunctival sac at the fornix (to avoid contact with the cornea)
and is run a variable distance away from the eye to an injection port, through
which liquid medications are given. SPL systems have single or double
entries. In the single-entry system, the silastic tubing ends in a small footplate
that fits in the conjunctival fornix and serves to anchor the tubing in the for-
nix. The footplate is designed so the tubing does not irritate, traumatize, or
erode into the underlying bulbar conjunctiva or sclera. In the double-entry
system, there is no footplate and the silastic tubing passes into the conjunc-
tival sac and out again at a reasonable distance form the first entry point
(Fig. 5). Medications access the conjunctival sac through small holes placed
in the silastic tubing where it traverses the conjunctival sac [31,32].
The factors limiting the use of SPL include the size of the animal (and
thus size of the eye and conjunctival sac) and the animals’ potential ability
to dislodge the tubing. Various diameters of silastic tubing are available and
can be used in small species—double-entry SPL systems could be used in
most land mammals and in larger reptiles and birds (they are especially use-
ful in ratites). The single-entry system is limited by the size of footplate,
which can fit into the conjunctival sac without corneal or globe irritation.
SPL cannot be used in species that can remove the system (other than by
rubbing it out, which is always a potential complication). These species
include primates (which use their hands), elephants (which can use their
trunks), and other species that can use the feet to scratch at the eye.
Subpalpebral lavage systems are limited to the use of liquid medications
and work better with solutions than with suspensions (which tend to sedi-
ment in the tubing and block the openings in the conjunctival fornix). SPL
systems can be placed in the upper or lower conjunctival sac, and the silastic
tubing runs to various points on the body (usually to a spot behind the
head) and connects to a PRN for easy administration of medications. In
 N.J. Millichamp / Vet Clin Exot Anim 5 (2002) 223–241 235

Fig. 5. Subpalpebral lavage systems can be used in many larger species for delivering ocular
medications.

hoofstock, the author has run the silastic tubing to be attached to a halter or
has passed it back down the neck to be attached near the withers (tubing can
be taped to the mane if present) or to be sutured to the skin at a location
away from the eye and head. SPL systems can remain in place for several
weeks, but need to be attended to carefully, because failure to correctly
maintain the system during use can result in various complications (includ-
ing corneal ulcer and eyelid infections) [33]. Special care should be taken to
ensure that medications do not leak into the subcutis between the eyelid epi-
dermis and palpebral conjunctiva, resulting in severe irritation. This prob-
lem can occur with double-entry systems if the openings in the silastic
tubing are dislodged from the fornix. SPL systems also need to be kept clean
and flushed regularly with sterile saline to ensure patency. Ulcers can occur
if the SPL is not placed far enough into the conjunctival fornix, allowing the
tubing to abrade the corneal surface.

Long-acting formulations and sustained-release devices

Most ocular medications that are used in humans and animals are
applied directly to the eye as aqueous solutions, suspensions, or ointments.
The concentrations of the various eye medications at the target site (eg, con-
junctiva, cornea or anterior chamber) are affected by the formulation of the
drug. Higher concentrations at target sites are achieved with higher concen-
trations of the drug formulation. Therapeutic levels can be maintained with
frequent application or use of formulations that prolong the contact time of
236 N.J. Millichamp / Vet Clin Exot Anim 5 (2002) 223–241

the drug with the eye or slowly release the drug to the ocular tissues over an
extended period of time [31].
Ointments have longer contact times with the eye compared with solu-
tions, whereas solutions are easier to fortify to higher concentrations. Some
medications are available in long-acting formulations, which can minimize
the number of applications that are needed per day (eg, timolol gel); how-
ever, these formulations may need to be applied more frequently than is
practical in many species. Care must be taken not to increase the concentra-
tion of a medication at the ocular surface to such an extent that it has an
irritating effect. Gel inserts have been used experimentally to deliver antibio-
tics [34]. Various ocular inserts (collagen and hydrophilic contact lenses)
have been used to release antibiotics to the ocular surface in cattle [35,36].
Subconjunctival injections of various drugs can be used to treat ocular
infections and inflammation. The injected drugs should be the parenteral
form, not the ophthalmic form, of the drug. Subconjunctival injections
(beneath the bulbar rather than the palpebral conjunctiva) of agents, in-
cluding parasympatholytics (atropine), antibiotics or antifungal agents, or
corticosteroids, are drugs that can be especially useful when given by sub-
conjunctival injection [37,38].
Evidence indicates that some ocular inflammatory disease may be suscep-
tible to sustained-release devices that are implanted in the vitreous humor.
In horses, sustained-release cyclosporine implants have been used to treat
equine recurrent uveitis [39,40], and these devices may be useful with corti-
costeroids for long-term control of uveitis in other species [41].
Parenteral medications can be useful in some situations. In cattle with
infectious bovine keratoconjunctivitis, long-acting tetracycline that is given
as an intramuscular injection has been found to be effective treatment; the
same principle may apply to the use of antibiotics in other hoofstock species
[42]. Tetracyclines are concentrated in the lacrimal gland and conjunctiva
after parenteral administration [43]. Injection or oral administration of med-
ications is required for most diseases that affect the posterior segment of the
eye, which not be well treated with topical drugs. Parenteral and oral drugs
may have value in treating inflamed eyes with anterior segment involvement.
Antimicrobial, anti-inflammatory, and some antiglaucoma medications (eg,
oral carbonic anhydrase inhibitors) can be formulated in feed and adminis-
tered with minimal stress to the animal. The potential benefits of parenteral
administration must be weighed against the risk from any potential systemic
side effects of the drugs.

Surgical treatment of ocular disease in exotic species

‘‘A chance to cut is a chance to cure’’ has particular significance for exotic
species, particularly for animals in the wild or for those in which frequent
handling in captivity is difficult. Regardless of whether surgery is used for
 N.J. Millichamp / Vet Clin Exot Anim 5 (2002) 223–241 237

therapy, it is important to use medical therapy before surgery in species that

can be handled without pharmacologic restraint—this allows assessment of
how difficult it may be to medicate the eyes after surgery and gives the ani-
mal time to get used to regular handling.
There are situations in which surgery is absolutely necessary (eg, eyelid or
corneal lacerations or cases of traumatic proptosis). Less obvious are the
ocular conditions in which surgery may be preferable to medical manage-
ment to avoid frequent animal contact and the need to topically apply med-
ications. Keratoconjunctivitis sicca, which does not seem to occur often in
exotic species, could be extremely difficult to manage. Parotid duct transpo-
sition, used commonly in dogs, has been used in other species. Although
technically more demanding in some species, it might be a suitable approach
to treating this difficult disease. Other surgical options for keratoconjuncti-
vitis sicca include occlusion of the nasolacrimal duct and permanent partial
tarsorraphy to reduce evaporation and tear loss. In an animal with severe
unilateral keratoconjunctivitis sicca, enucleation may be the only effective
option to render the eye pain free.
Deep corneal ulcers or descemetoceles are conditions in exotic species that
should be treated surgically whenever possible. Although severe ulcers can
heal with (and occasionally without) medical therapy, they are best treated
surgically to minimize animal contact and restraint. Pedicle or bridge
conjunctival grafts or flaps are an ideal way to bring a blood supply to the
area of the lesion quickly while preserving vision; however, these techniques
do not provide much support for a thin cornea, which may rupture if pres-
sure is applied to the globe. Corneal reinforcement using partial- or full-
thickness grafts of cornea is an ideal treatment of severe and deep corneal
lesions. Because donor tissue from the same species can be difficult to obtain
for most exotic species, advancement grafts of cornea and conjunctiva or
sclera (corneoconjunctival and corneoscleral transpositions) are useful sur-
gical techniques [44]. The main limitation to these techniques is the size of
the globe, because they are technically more difficult in a small eye with a
thin cornea. Even for an animal with a large globe, involvement of an
ophthalmologist in the surgical therapy is recommended.
There is tendency for practitioners to prefer third-eyelid flaps (TELs) or
tarsorraphies to conjunctival grafting procedures or corneal surgery; how-
ever, for various reasons, TELs have little place in veterinary ophthalmol-
ogy. TELs prevent examination of the cornea and can limit the access of
drugs to the corneal surface. If incorrectly placed, a TEL can exert pressure
on the cornea and potentate corneal rupture. These considerations notwith-
standing, TEL may be indicated for superficial corneal lesions in which
application of medications is impractical. In this situation, the flap protects
the cornea and may allow an ulcer to heal with otherwise minimal attention.
This potential advantage has to be weighed carefully against the risk of
injury—ocular or otherwise—because of temporary blindness on the side
of the flap.
238 N.J. Millichamp / Vet Clin Exot Anim 5 (2002) 223–241

Surgical paracentesis of the anterior chamber is occasionally indicated in

aiding the diagnosis of intraocular disease. In the case of some intraocular
tumors and infections paracentesis or aspirates of intraocular masses may
be performed on an eye with uveitis while the animal is anesthetized as part
of the ocular examination.
Cataract surgery has been performed in various mammalian and avian
species with both success and failure [7,45]. Because the overall number of
cases tends to be small, the success rate in exotics species is difficult to assess,
and a single report of a surgical failure in cataract surgery may reflect only
the variation expected for the surgery, regardless of species. Treating intra-
ocular inflammation associated with surgery is inevitably empirical and may
involve medical approaches (subconjunctival injections rather than repeated
topical therapy) that are less than ideal. Some situations involve failure that
is caused by the present technology (eg, in galactosemic cataracts in marsu-
pials [see article by Stanley]). As practitioners become more experienced
with these procedures in different exotic species, the success rate may
improve (see article by Gionfriddo elsewhere in this issue).
Eyes with glaucoma are good candidates for surgical therapy. The overall
prognosis with glaucoma in most species is so poor that aggressive surgical
therapy usually is justified. Long-term medical therapy of glaucoma in most
exotic species is difficult to achieve practically.
There are two glaucoma presentations in which surgery may be beneficial.
In eyes with elevated pressures that cannot be medicated in the long term but
still have vision or visual potential, cyclocryotherapy or cyclophotoablation
with a continuous wave yttrium-aluminum-garnet (YAG) or diode laser can
be an effective therapy. In domestic animals, there seem to be interspecies
variations in the effectiveness of these treatments (possibly relating to the
physiology of aqueous production and underlying pathogenesis of the glau-
coma). A lack of knowledge about the absolute anatomic relationships in the
eye can reduce the effectiveness of these procedures (the exact location of the
ciliary epithelium that secretes aqueous humor relative to the overlying sclera
may not be known in most species). Invariably, practicioners have to rely on
experience with these techniques in domestic species when applying them to
exotic species.
In eyes that are blind and painful from trauma, uveitis, or glaucoma, the
best surgical options are enucleation or evisceration of the globe and place-
ment of an intraocular silicone prosthesis. In enucleation, the tissue is
obtained that may aid the diagnosis of systemic disease with ocular involve-
ment and that also may be useful in advancing knowledge about the pathol-
ogy of ocular disease in exotic animals.
Evisceration of the globe with implantation of a silicone prosthesis
is ideal for animals with blind eyes that are on exhibit and that need to
maintain their cosmetic appearance. Silicone prostheses are available in
sizes from 10- to 35-mm diameters to fit the globe sizes of a wide range of
species. This surgery can be used in animals with ocular trauma (severe
 N.J. Millichamp / Vet Clin Exot Anim 5 (2002) 223–241 239

lacerations of the cornea) with no visual potential but should not be per-
formed in eyes with intraocular infection or neoplasia.

Analgesia
Most eye diseases result in a significant level of patient discomfort.
Besides for humanitarian considerations, discomfort should be minimized
as much as possible to avoid further self-induced damage to the eye. In
domestic species, the value of keeping animals in familiar surroundings to
minimize stress and management of pain are important in treating disease.
Although these considerations may seem obvious, pain management only
recently has become a significant issue in veterinary medicine [46]. The
reader is referred to reviews of analgesia in exotic species [47,48].
There are limited studies in domestic species that address which analgesic
agents reduce pain associated with ocular inflammation. Some studies in
dogs, cats, and horses have shown that particular anti-inflammatory media-
tors are involved in ocular inflammation, hence determining which anti-
inflammatory groups of drugs might reduce inflammation and pain [49–
52]. Because prostaglandins and leukotrienes may be involved in ocular
inflammation, it seems that use of nonsteroidal anti-inflammatory drugs
to reduce ocular inflammation can provide some degree of analgesia in
many species. These drugs can be administered systemically in feed to avoid
contact with the animals. Opioids also may be indicated for treatment of
ocular-derived pain after ocular surgery. Use of parasympatholytic agents
such as atropine reduce spasm of intraocular muscles, which contributes
to the pain associated with ocular inflammation.

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