A detailed history, careful slit lamp examination, and close monitoring of the clinical course will assist the clinician in determining the correct diagnosis and treatment for these challenging patients. Authentic HSV epithelial disease typically presents as a unilateral, branching lesion with little end bulbs, which stain very brightly with fluorescein. The pathophysiologic hallmark of EBMD is an abnormality in the formation and maintenance of the epithelial basement membrane adhesion complex of the corneal epithelium, a phenomenon that accounts for the recurrent erosions that are associated with this disorder.
Initially, there may be few clinical signs associated with EBMD; however, a history of recurrent erosions should suggest this diagnosis, especially if they are bilateral and occur in multiple sites.
Successful treatment of EBMD is predicated upon optimizing conditions necessary for the formation of stable epithelial basement membrane adhesion complexes throughout the entire cornea, preferably before the development of vision-compromising morphological abnormalities in the visual axis. In the event that substantial epithelial erosions develop (Figure 4), more aggressive intervention is indicated. In the present study, we reviewed the outcome of treating symptomatic EBMD with manual SK at University of Iowa Hospitals and Clinics (UIHC). The medical records of every patient with EBMD who had been treated with manual SK by a member of the Cornea Service at UIHC from January 1, 1998, to December 31, 2007, were retrospectively reviewed.
The surgical procedures were performed with topical anesthesia by members of the cornea faculty (KMG, JES, MDW) in the minor outpatient procedure room. Postoperatively, all patients were treated with topical antibiotics and steroid drops 4 times daily for 1 week. All 15 (100.0%) eyes with recurrent erosions had complete resolution of symptoms during the first 6 postoperative months. Our study strongly suggests that manual SK is a safe and effective treatment for visual disturbances and recurrent epithelial erosions associated with EBMD. Obtaining a lasting and satisfactory result with manual SK requires meticulous attention to the surgical technique, especially the thorough removal of all abnormal subepithelial pathology in the visual axis and the use of anterior stromal puncture, prolonged postoperative bandage SCL therapy, and appropriate pharmacological support. Excimer laser PTK may be offered in combination with photorefractive keratectomy (PRK) in primary therapy of EBMD if the therapeutic objective is to attain an improvement in uncorrected visual acuity. 59-year-old male with history of schizophrenia and long-term chlorpromazine (thorazine) treatment. These findings are characteristic of long-term thorazine use and are suspected to be related to dose and duration of treatment. The opinions set forth in this report are those of the committee members and do not represent the Food and Drug Administration in any way.
A standard classification system for rosacea was published in the April 2002 issue of the Journal of the American Academy of Dermatology.1 Developed by the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea and reviewed by rosacea experts worldwide, it describes primary and secondary features of rosacea and recognizes 4 patterns of signs and symptoms, designated as subtypes.
For optimal utility, the grading system is designed to be reproducible and easily performed based on observation in clinical practice, while forming a consistent framework for more comprehensive measurements that may be developed for specific research studies. Rosacea is a chronic cutaneous disorder affecting primarily the convexities of the central face (cheek, nose, chin, and central forehead). The committee first identified primary and secondary features of rosacea, and then delineated subtypes based on the most common patterns or groupings of these features. For clinicians assessing patients, primary signs and symptoms may be graded as absent, mild, moderate, or severe (0-3), and most secondary features may be graded simply as absent or present (Table I). Flushing (transient erythema) Clinically, physicians should determine the presence or absence of flushing through patient history, and may ask about frequency, duration, extent, and severity. A modified version of the descriptive grading system established for acne vulgaris is recommended and shown in Table II.
Burning or stinging In the clinical setting, burning or stinging may be reported by the patient and, if present, may be weighed into the overall assessment of severity.
In clinical practice, edema may be identified by location (eg, periorbital, glabellar, malar) through patient history and examination. Clinicians and researchers may determine the presence of any extrafacial signs and symptoms, and note the anatomic sites. In the clinical setting, severity may be rated from 0 to 3, with 1 being patulous follicles but no contour changes, 2 being a change in contour without a nodular component, and 3 indicating a change in contour with a nodular component. Because the potential manifestations of rosacea are so numerous and varied, the committee concluded that global assessment can be most easily and meaningfully performed by subtype. Subtype 2 (Fig 2) includes persistent central facial erythema with transient papules, pustules, or both in a central facial distribution. This subtype (Fig 3) may include thickening skin, irregular surface nodularities, and enlargement.
Ocular rosacea (Fig 4) may include watery or bloodshot appearance (interpalpebral conjunctival hyperemia), foreign-body sensation, burning or stinging, dryness, itching, light sensitivity, blurred vision, telangiectasia of the conjunctiva and lid margin, or lid and periocular erythema. For clinicians, global assessment for each subtype should be performed with a standard rating of 0 to 3, based on a composite of the severity of the signs and symptoms. Patients might be informed of potential primary and secondary features of rosacea before their global assessments to aid them in evaluating their individual conditions more thoroughly.
In developing a standard grading system for rosacea, the committee attempted to design a basic examination process that is practical, useful, and similar to the usual examinations currently performed in clinical practice.
As with the standard classification system, this grading system is considered provisional and is subject to modification as the pathogenesis and subtypes of rosacea become clearer, and as its relevance and applicability are tested by investigators and clinicians.
The National Rosacea Society is a 501(c)(3) nonprofit organization whose mission is to support rosacea research, including the awarding of research grants, and to provide educational information on rosacea to physicians, patients, and the public. The National Rosacea Society is a 501(c)(3) nonprofit organization whose mission is to improve the lives of people with rosacea by raising awareness, providing public health information and supporting medical research on this widespread but little-known disorder. Reproduction, re-transmission or reprinting of the contents of this website, in part or in its entirety, is expressly prohibited without prior written permission from the National Rosacea Society. Although there is really no need to treat this condition as it will eventually go away on its own, many prefer treatment for cosmetic reasons. A biopsy can be performed if there is any concern existing for the lesions to be a basal cell carcinoma.
Because the condition is quite similar to acne, numerous individuals have had very good success when using simple acne treatments to keep the condition in check.
This website is for informational purposes only and Is not a substitute for medical advice, diagnosis or treatment. My dog's eyelids are swollen, his eye waters (the left is worse than the right), he scratches at it, will scratch the skin off and get scabs, and he squints.
Hello Susan,As a holistic veterinarian, it will be difficult for me to treat your dogs' eyes from the description and history you submitted. PART 2- OF DOG WITH SWOLLEN EYELIDSTo really clean out the eye, you may have to put the saline into a plastic bottle with a spout, and actually squirt a 'stream' of saline into the inner corner of his eye or pull down the lower lid area to squirt it there.After 48 hours, you will only need to rinse or flush his eyes every 8 hours, or 3 times daily. August 5, 2013 Hi Jakkii, From your description without a photo, it is difficult to tell you exactly what the problem might be. Disclaimers: The information contained in this web site is provided for general informational purposes only. Those patients will have associated findings of mental retardation and hyperkeratosis of the hands and feet.
Originally described by Hansen[3] over a century ago, and further characterized by Thygeson[4] a half century later, recurrent erosions are acute disruptions of the corneal epithelium, which classically occur upon awakening and are associated with severe, sharp pain that may be transient or last for several hours or days, depending upon the surface area of epithelial sloughing.
In most cases of EBMD, recurrent epithelial erosions can be prevented by the bedtime application of a lubricating or hyperosmotic ointment.


Successful management can be accomplished with manual superficial keratectomy (SK), followed by the reestablishment of an intact corneal epithelium that is firmly adherent and remains optically clear. For more than a century, the treatment of choice for recurrent erosions was the simple debridement of devitalized and poorly adherent epithelium and the use of pressure patching until reepithelialization was complete. Simple epithelial debridement may not be effective in removing all the abnormal basement membrane and may be associated with the recurrence of epithelial erosions even after the discontinuation of extended bandage SCL therapy.[6] As early as 1906, Franke[7] reported a reduced rate of recurrent epithelial erosions when epithelial debridement was followed by the application of chlorinated water. Brown and Bron[6] suggested that some disruption of Bowman's layer may be necessary to maximize the opportunity for permanent resolution of recalcitrant epithelial erosions.
The diagnosis was established by a member of the cornea faculty on the basis of the characteristic clinical findings. Early in the study period, the bandage SCL therapy was discontinued in most cases after 1 week, the topical antibiotics and steroids were rapidly tapered and discontinued, and bedtime lubricating ointment was continued for at least 3 months. Between 6 and 60 months after initial treatment, 3 (20.0%) eyes experienced recurrent erosions. This technique is effective in providing a sustained improvement in the spectacle acuity of virtually every patient and relief from recurrent erosions in the vast majority of patients. If this approach is adopted, the treating ophthalmologist must be cognizant of the potential that some of the measured refractive error may be factitiously induced by the epithelial and subepithelial morphological abnormalities associated with EBMD and that the refractive accuracy of PRK cannot be predicted with certainty.
Superficial keratectomy in the treatment of epithelial basement membrane dystrophy: a preliminary report.
Superficial epithelial keratectomy in the treatment of epithelial basement membrane dystrophy. Treatment of recalcitrant recurrent corneal erosions with inhibitors of matrix metalloproteinase-9, doxycycline and corticosteroids. His ocular exam is notable for fine pigment deposition in the posterior corneal stroma and endothelium.
It is recommended that persons undergoing long-term treatment with thorazine have regular eye examinations.
To enhance the utility of the system for both clinicians and researchers, the committee has devised a standard method for assessing gradations of the severity of rosacea.
Moreover, as with the standard classification system, this grading system is an investigative instrument that can be readily modified based on clinical experience or updated and expanded as new discoveries are made.
The primary signs of rosacea include flushing (transient erythema), nontransient erythema, papules and pustules, and telangiectasia. Although inflammation (papules, pustules, plaques) or dry appearance may obscure the level of erythema, underlying redness should be evaluated disregarding this effect.
If erythema is intense, it may be difficult to definitively score telangiectasia, because erythema may mask some telangiectases, which become more visible if redness fades. Researchers should seek out this information, record the locations of both symptoms if present, and use a systematic method of assessing both symptoms. Plaques may be defined as confluent areas of inflammation, often seen as larger red areas among papules and pustules without epidermal changes in the surrounding skin. In research, this may also be stratified based on such criteria as distribution and severity.
If present, it may be noted as acute, chronic recurrent, or chronic persistent and, if chronic, as pitting or nonpitting.
The standard classification system established the following subtypes of rosacea, which are described in depth in the standard classification system.1 The following descriptions include the minimum signs and symptoms required to diagnose each subtype, and patients may have characteristics of more than one rosacea subtype at the same time.
Subtype 1, erythematotelangiectatic rosacea, is characterized by flushing and persistent central facial erythema. Subtype 2, papulopustular rosacea, includes persistent central facial erythema with transient papules, pustules, or both in central facial distribution.
Phymatous rosacea occurs most commonly as rhinophyma but may appear elsewhere, including the chin, forehead, cheeks, and ears.
Subtype 3, phymatous rosacea, may include thickening skin, irregular surface nodularities, and enlargement.
Subtype 4, ocular rosacea, may include watery or bloodshot appearance, telangiectasia of conjunctiva and lid margin, or lid and periocular erythema.
The evaluation may also take into consideration the duration of signs and symptoms through patient history, and their extent at time of examination. Of particular concern is ocular rosacea, which patients may not associate with cutaneous rosacea and that may require further evaluation.
To aid clinicians in evaluating their patients, the committee has developed a standard diagnostic flow chart (Table I). The National Rosacea Society Expert Committee welcomes comments on the usefulness and limitations of these criteria. The final document does not necessarily reflect the views of any single individual, and not all comments were incorporated.
The Society does not evaluate, endorse or recommend any particular medications, products, equipment or treatments. I'm happy to help, but we only accept new questions from subscribers (the original question above was from a subscriber). I'm happy to help, but we only accept new questions from subscribers (the original question above was from a subscriber). But from the description of your problem, and no photo, I am VERY suspicious that your dog has an insect bite or sting that has caused the swelling. I suspect she may have been stung on the eyelid by a bee or wasp. Please take her to an Emergency clinic ASAP to have her checked. In severe cases, the erosion syndrome may be associated with considerable morbidity and occupational disability.
If mild erosions frequently occur despite bedtime lubrication, the prolonged use of a bandage soft contact lens (SCL) may eliminate or greatly reduce the frequency of symptomatic erosions. Although the prolonged subsequent use of bedtime lubricating ointments subsequently resulted in permanent resolution in many cases, recurrent disease remained quite common. Kenyon and Wagoner[2,8] further emphasized the importance of meticulously cleaning the subepithelial debris as an integral part of the management of this disorder. Later in the study period, the bandage SCL therapy was continued for 6 to 12 weeks in most cases, along with the administration of prophylactic topical antibiotics. Among these, 2 eyes were successfully treated with a course of bandage SCL therapy, and 1 eye was successfully treated with excimer laser PTK.
It is preferred over broad area ablation with the excimer laser because it is much less expensive, is not associated with a hyperopic shift in the baseline refractive error, and is less likely to induce visually significant haze in the visual axis (Table 2).12,13 Nonetheless, it will occasionally be necessary to offer excimer laser PTK to the small percentage of patients in which manual SK is not completely successful in providing sustained relief from recurrent erosions, as was the case with 1 patient in the present series. In such cases, a more conservative approach would be to perform a 2-stage procedure consisting of manual SK followed by PRK (after the refractive error has stabilized and can be measured accurately). In addition, there is pigmentation in a stellate pattern on the anterior lens and lens capsule.
In addition to the classification system, a standard grading system is often essential to perform research, analyze results, and compare data from different sources, and in turn provides a common reference for diagnosis, treatment, and assessment of results in clinical practice. In most cases, some rather than all of these features appear in any given patient, and they are often characterized by remissions and exacerbations. The presence of one or more of these features with a central face distribution is indicative of rosacea. In some situations, more detailed or finer distinctions, perhaps supplemented by advanced technology, might be possible.


Perimenopausal flushing should not be considered significant unless it is accompanied by other characteristics of rosacea.
Inflammation or dry appearance may be noted, but perilesional erythema should not be included in this assessment. This phenomenon has been described as posterythema-revealed telangiectasia.5 On the other hand, the presence of one or two isolated telangiectases in the absence of any other primary signs of rosacea may be insufficient for a diagnosis.
In research studies, they may be further differentiated by severity, location, or other criteria.
The diagnosis of rosacea in locations other than the face may be problematic in the absence of diagnostic clinical or histologic features.
Patulous, expressive follicles may appear in the phymatous area, and telangiectases may be present. Patulous, expressive follicles may appear in phymatous area, and telangiectases may be present.
Meibomian gland dysfunction presenting as chalazion, or chronic infection as manifested by hordeolum (stye), are common. For researchers, additional detail and assessment technology may be added beyond the basic rating system to provide further data and precision.
Superimposed on this basic standard system, researchers are encouraged to study and explore features beyond the minimum, using more sensitive and reproducible systems and applying new technology and methodologies that may further advance the scientific knowledge of rosacea. Standard classification of rosacea: report of the National Rosacea Society expert committee on the classification and staging of rosacea.
Rosacea may vary substantially from one patient to another, and treatment must be tailored by a physician for each individual case. Holistic veterinarians need to know more about the patient than just the 'problem' at hand. And I'm happy to help, but we only accept new questions from subscribers (the original question above was from a subscriber). Please take your dog to an emergency clinic ASAP! Please click here to sign up and submit your question and photos. She may have scratched her cornea while she was rubbing her eye, causing even more problems.
It is important for clinicians to realize that a dendrite (referring to the shape) is not always the infectious epithelial lesion of HSV. Although erosions may occur in association with prior corneal trauma, EBMD is the most common cause of this disorder.
In 1983, Buxton and Fox[5] reported a success rate of 85% with epithelial debridement followed by the extended use of bandage SCL therapy, which facilitated the uninterrupted development of a stable epithelial basement membrane adhesion complex. In the latter half of the study, most patients were concomitantly treated with systemic doxycycline and topical corticosteroids until the bandage SCL therapy was completed. 5 and 6 The committee based the standard classification system on current scientific knowledge and morphologic characteristics to avoid assumptions on pathogenesis and progression, which are at present incompletely understood.
Secondary features, which often appear with one or more of the primary features but can occur independently, include burning or stinging, plaques, dry appearance, edema, ocular manifestations, peripheral locations, and phymatous changes. Certain clinicians also may wish to use some of these other more comprehensive analytic methods, especially when based on visual observation. In clinical studies, researchers may use instruments or other measurements to score erythema beyond a score of 0 to 3.
Some patients may experience loss of vision as a result of corneal complications (punctate keratitis, corneal infiltrates, ulcers, or marginal keratitis). The committee noted that the ultimate goal of diagnosis and treatment of rosacea is both to control the disorder and to minimize the discomfort of the patient.
This investigational instrument is intended to help provide a foundation for better understanding of rosacea among practitioners and researchers by establishing a common language for communication and facilitating the development of a research-based approach to diagnosis and treatment. Simply click here to return to Ask a Vet Online via My Online Vet (SUBSCRIPTION REQUIRED FOR NEW QUESTIONS).
The standard grading system rates the primary and secondary features of rosacea established by the standard classification system, and provides a global assessment of subtypes by both the physician and the patient. As knowledge increases, the definition of rosacea may ultimately be based on causality rather than on morphology alone.
In addition, duration of flushing may be noted, because some episodes are very transient (eg, from embarrassment) and some are not (eg, from ingestion of alcohol). Nasal and malar telangiectases should be identified independently, and be qualitatively described as fine and threadlike to coarse. The scorecard (Table I) is included for those who wish to have a more detailed investigative record of the patient's disorder.
These patients are often placed on topical antivirals, which leads to delayed epithelial healing and persistence of this pseudodendrite. Beyond clinical manifestations, additional factors are important in determining the severity of rosacea from the patient's viewpoint. The patient may provide a 0 to 3 global assessment of the severity of their condition in general terms that encompasses both the physical manifestations of rosacea and its impact on quality of life, which may include psychological, social, and occupational effects.
57 Beaver blade was also used to remove the basement membrane and subepithelial fibrosis with gentle scraping.
These may include the psychological, social, or occupational effects of the disorder,4 and other potential factors such as responsiveness to treatment. Special precautions were taken to minimize the disturbance of the underlying Bowman's layer. A classic clinical observation is a scalloped-shaped boarder, not to be confused with healing abrasions and epithelial defects from neurotrophic keratopathy, which have smooth borders.
In some cases early in the study period, a diamond burr was gently applied to the anterior surface of Bowman's layer. Later in the study period, stromal puncture was directly applied to Bowman's layer outside the visual axis where the epithelium had been debrided and through the epithelium in areas where it remained in place. One surgeon (MDW) applied light treatment in the visual axis in cases where erosions had been documented to occur in this zone or where substantial subepithelial fibrosis had been detected prior to the operative procedure. I have tried homeopathic eye drops, allergy eye drops, changed his dog food, tried Arnica cream on the outside of his eye, antibiotic cream on the outside. See our page on Raw Natural Dog Food for more information.You did not mention if the problem started after a vaccination, which may have been given to him at the same time you moved.
It seems to get better and then gets worse again.I am on disability for cancer and do not have the money to take him to the vet. Do this VERY frequently, every 2-3 hours (let him sleep during the night), for the first 1-2 days.
We opened his eye and it looked like something might have gotten into his eye and then worked its way into his skin.
This will help remove any debris, discharge, and help to 'cool' off or decrease the inflammation in the conjunctiva.



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