Dr. Alex Sigmund joins Dr. Andy Roark to tackle a common but tricky case, a 9-year-old shih tzu with persistent red eyes. In this “How Do You Treat That?” episode, Dr. Sigmund walks through his diagnostic approach to chronic canine eye redness, including Schirmer tear tests, fluorescein staining, tonometry, and the critical red flags for glaucoma, dry eye, and autoimmune conditions. They also cover practical tips for intraocular pressure measurements, antibiotic stewardship, and how to guide pet owners through managing long-term eye care. If you want to sharpen your skills diagnosing and treating red-eye cases in dogs, especially in brachycephalic breeds, this episode is a must-listen!
You can also listen to this episode on Apple Podcasts, Amazon Music, Spotify, YouTube or wherever you get your podcasts!
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ABOUT OUR GUEST
Alex is a dedicated veterinary ophthalmologist with a passion for educating pet owners and veterinarians about animal eye health. With a background from UGA and the University of Tennessee, Alex shares insights from a diverse career treating various species, including dogs, cats, and exotic animals. Based in Atlanta, Alex offers teleconsultations and engages with a growing community of animal lovers.
EPISODE TRANSCRIPT
Dr. Andy Roark: Welcome everybody to the Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I gotta, how do you treat that episode today? For those who don’t know, these are medical episodes. These are episodes where I bring a case to a specialist or expert that I admire, and I asked them, how do you treat these cases? Like what do you look for? How can I raise my game? And the one and only vet eye guy, Dr. Alex Sigmund delivers guys, we’re looking at the classic red eye dog today. That’s right. You my red eye dog. This is a 9-year-old shihtzu that’s coming in for a two month history of bilateral redness in the eyes.
And I go straight to one of the masters and say, Hey, how do you treat this? And we find an interesting case. And so we knock out your easy stuff and we wade into your more challenging stuff. And it’s a really, really good episode that I think everybody who sees pets that have eyes should take a listen to.
So I’m glad you’re here. Guys, let’s get into it.
Kelsey Beth Carpenter: This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.
Dr. Andy Roark: Welcome to the podcast, Dr. Alex Sigmund. Thank you for being here, my friend.
Dr. Alex Sigmund: Yeah. Thank you for having me again.
Dr. Andy Roark: I love having you on the podcast. I don’t think that eyes get enough love
Dr. Alex Sigmund: Thank you.
Dr. Andy Roark: From me specifically. Probably. Like, I, it’s, it’s, it’s just eyes are something, I don’t think I’m alone when I say that.
Eyes are scary. I think for a lot of practitioners, they’re I think it’s a thing that we had not minimal training, but we had, we did not a huge amount of training in school. And eyes are something that think I know the basics and I’ve got the basics down to work out, but feel like I’m outta my depth fairly quickly with in depth eye cases.
And so I wanna be better. I wanna be better, Alex. And so I have a case…
Dr. Alex Sigmund: oh,
Dr. Andy Roark: that I would like to run by you, and I think this is a pretty common ish sort of case that people see but I would like…
Dr. Alex Sigmund: Okay.
Dr. Andy Roark: you to help me just walk me through how you’d work this case up and where your head would be at. Can we do that?
Dr. Alex Sigmund: Absolutely. Let’s do it.
Dr. Andy Roark: Great. So I have a 9-year-old male neutered shihtzu named…
Dr. Alex Sigmund: Mmm – hmm.
Dr. Andy Roark: Tucker, and Tucker is here because he’s got red eyes. It’s both eyes. The owner said it started with one and, and then became both. He’s got just sort of some redness, he’s got a little bit of goopiness. He’s got some like matted fur, you know, around his eyes.
So you can tell..
Dr. Alex Sigmund: Mm-hmm.
Dr. Andy Roark: he’s been having this sort of discharge and, and sometimes according to the owner, he squints, but I’m not seeing, you know, hardcore squinting right now. This apparently started just about two months ago.
That’s the history that I’m looking at. And so I’m looking at this little dog. Let’s just start at the beginning. Two months ago, the owner thinks she might have poked him and she said she thought she poked him in the eye. At first she also says they have a swimming pool and he gets into the swimming pool, and so she thinks maybe the swimming pool has something to do with it.
So all of those things are going on.
Dr. Alex Sigmund: Wow.
Dr. Andy Roark: Yeah, I know it’s a lot
Dr. Alex Sigmund: Gotta filter through.
Dr. Andy Roark: help, yeah, help help me sort this out and get down to what really matters here so I can get some kind of understanding of what the underlying process probably is.
Dr. Alex Sigmund: I mean that this is a great case. I feel like this is something that is at least common for me to see, which I hope means it’s common for general practitioners to see too, which are these red kind of nondescript eye symptoms. So the good thing is that most people have everything they need to rule out those kind of quote unquote scary stuff in their own practice.
And so I will start with your basic eye exam, Schermer Stain and IOP. And I feel like I have heard that a lot of owners may not approve all of those diagnostics being done. So frankly, to get around that, at my previous practice, we lumped them all together. It was, this is the eye exam fee.
Dr. Andy Roark: You’re like this is the workup, right?
Dr. Alex Sigmund: This is the workup, this is what we need to do.
And then we’re trying to rule out these important things so that we are ruling out the scary stuff. So a scharmer tear test that’s gonna look at our tear production. Shitzu are definitely a breed any brachiocephalic breed, pretty much, but they’re definitely a breed that can get an autoimmune dry eye.
And that is gonna be the probably the one of the easiest things that you could find, because we have great treatment options for that, that are, over 80% effective at controlling their clinical signs. Biggest thing about that is that is lifelong therapy for dry eye.
Dr. Andy Roark: Are there certain
Dr. Alex Sigmund: Uh, so,
Dr. Andy Roark: breeds that you’re just immediately looking for that in?
Dr. Alex Sigmund: Pretty much any brachiocephalic or small breed dog when, if I’m looking at large breed dogs.
Dr. Andy Roark: yeah. Okay. A pretty, wide swath here.
Dr. Alex Sigmund: Wide swath ’cause all of ’em, all of ’em can potentially do it. But I would be less likely to think of dry eye as my number one differential for a lab that comes in unless they have a history of TMS, like sulfa drug use type of thing.
But so if we’ve done our Schirmer and guess what our Schirmer is on this case. Both say 16, so still pretty normal. And you’re like, okay, so now we go to our next one. And so we’re gonna do a fluorescein stain to look, to make sure there’s not a particular ulcer. Now, it would be a little interesting to have ulcers in both eyes, but that is a hundred percent something that I see.
A lot of times with these bugeye dogs. They just stick their whole face into a bush. I had a shihtzu growing up myself, and he would just whole face right into a bush. So it’s very possible that they can get poked in both eyes at the same time. So definitely both. And you can, you know, obviously we’re looking for any type of stain uptake.
And then the last thing that we’ll do for diagnostically is our tonometry and so that’s gonna look at our intraocular pressure. And really that’s probably the, one of the more urgent things to rule out is we’re trying to rule out glaucoma. Because glaucoma is one thing that can blind an animal within 24 to 48 hours in some cases, depending on how high the pressure gets.
So that is an emergent thing. So if you don’t have a tonometer in your practice. I highly urge you to get that because it is the difference between saving vision for a while in an eye versus them being blind.
Dr. Andy Roark: Talk, talk to me a little bit about acute onset of glaucoma. So 24, 48 hours. don’t know that glaucoma pops into my mind as an emergency necessarily. Like, like that type of rapid onset deterioration. How common is that and then in the sort of, what are the underlying mechanisms that make glaucoma?
Oh, my dog got glaucoma yesterday
Dr. Alex Sigmund: Mm-hmm.
Dr. Andy Roark: and today we have blindness.
Dr. Alex Sigmund: Glaucoma is one of those conditions that I think is probably the most hated condition in ophthalmology because we don’t really know enough about it. There are a lot of different factors that predispose dogs to going blind sooner and then other dogs it may they may have some protective mechanism that they can tolerate higher pressures for a longer period of time.
It’s very patient dependent when it comes to predicting how well these dogs will do. The other important thing for people to remember is that glaucoma and dogs is not the same as it is in humans. Humans you can get diagnosed with glaucoma, go on treatment and stay visual for decades. And in dogs it is not like that whatsoever.
Usually when they do present to us. Acutely, they have a red eye. There’s vision changes. There’s a blueness, like a blue discoloration to their eye, which is swelling or corneal edema. And, a lot of times, frankly, that kind of gets blown off as a just normal red eye here will put you on empiric therapy for some type of inflammation.
But a pressure was never taken because people don’t think about it. And then they get sent to me because the eye, red eye is still red. And then I diagnose glaucoma and then I have to have the conversation with them about why this wasn’t caught earlier. And a lot of times it’s just because people aren’t aware of it.
And also there are many general practitioners that don’t have the means to measure intraocular pressure. And so a lot of times that first eye we’re at an end stage by the time it gets to me where it’s blind and we’re just going for comfort. And then we actually will then focus more on the right eye because a lot of these dogs that present with glaucoma have a primary glaucoma, which means that they can get it in both eyes.
So there’s a lot of other things that can cause glaucoma too. But that’s the more common thing that we see. So it’s it can look, it can be fairly subtle in some cases where it is just a, a little bit of redness. And so that’s why I think that checking endometry for any red eye. Makes sense because the downside of not checking is if you miss a glaucoma diagnosis, that patient’s gonna lose vision.
Dr. Andy Roark: So if you start to see redness in the eyes, that glaucoma is on your list and you’re gonna check a pressure.
Dr. Alex Sigmund: Yes. Yes. I, and I will say some of that is for peace of mind. The other part of that is, I guess that would maybe say. You don’t have to do it every time. Not to be confusing is this particular case is that we’re talking about is a shihtzu who’s had a red eye for like two months. And so if you had a high pressure for two months, you will be blind pretty much unless you’re a cat.
Just cats do weird things. But with dogs, they, I mean, they would be blind and so if you were prioritizing, maybe tomometry goes lower since it doesn’t necessarily fit the signal meant.
Dr. Andy Roark: What’s your best little pearls and tips for getting good intraocular pressure readings? Because I know that people sort of struggle with that a little bit. There’s definitely a little bit of, art to the capturing
Dr. Alex Sigmund: Hmm.
Dr. Andy Roark: of, of this values, Yeah. Are are there certain things that you see as best practices or little pearls that you think people find helpful?
Dr. Alex Sigmund: Yes. So the biggest thing is less is more. So if I can have a dog just sitting there on the counter and I can just come up and do pressures without having to touch much of anything that would be ideal. Now of course our patients move around and they don’t wanna sit still. So usually I wanna make sure that there’s no pressure on the neck and there’s no pressure on the chest.
And so that is really important. If you have an owner that is restraining, sometimes they’re like really holding onto them. And we’ve seen in reports with cats that even just. Opening the eyelids and putting pressure on the orbital bones can significantly increase the pressure like by a watch.
Dr. Andy Roark: Oh
Dr. Alex Sigmund: And so we, it’s a, like I will just barely open those eyelids. I literally just need a small opening. I like the tone of vet partic in particular ’cause it has such a smaller footprint. You can kind of shoot it in smaller openings. sometimes you do have to wrap ’em up, but it’s always with the idea of less pressure, less pressure, and one of the, pearls is if you have a Brachycephalic dog or you have a dog that is moving around a lot more and you’re getting a marginally high pressure, that’s probably one I would recheck.
You know, I wouldn’t necessarily just jump onto the glaucoma diagnosis and start therapy and doom and gloom. They’re gonna go blind sometime. But I would say let’s just recheck. So if you have that pug that’s screaming and you get a 27 I’m gonna say, okay, maybe we’ll just give some sedatives next time so you can get Gabapentin and Trazodone and maybe recheck ’cause those are not gonna affect the IOP.
Dr. Andy Roark: Yeah, that, that’s, that, that’s a slick little move as well. Just if you know you’re gonna do it, go ahead and, try to reduce that anxiety. So this little package. makes sense. The Schirmer tear test, the fluorescein stain and the IOP check.
Dr. Andy Roark: And so with our little guy we said that we decided that the schirmer test was gonna be normal.
You didn’t expect glaucoma because of the two month onset here.
Dr. Alex Sigmund: Mm-hmm.
Dr. Andy Roark: no evidence of a corneal ulcer. I’m kind of stuck here, Alex,
Dr. Alex Sigmund: Yeah. What do you do?
Dr. Andy Roark: our base. I’m glad you did this. This is kind of where I, I start to go, oh boy, my bag of tricks is, is kind of empty here.
Where do we go from here?
Dr. Alex Sigmund: From here we start looking at any structural abnormalities. So do, did we have some type of trichiasis entropion, synechiae or ectopic cilia that could be there? Now the big thing about those that makes them all very unlikely in this case is how old this dog is. So if this dog were one to two years old, I’d be thinking about those a whole lot more since we’re nine.
We should be good to go since that’s not been a problem for the last nine years, we’ve rolled all that stuff out, we’re really left with things that respond to steroids uh, is pretty much what we’re left with. And I say it that way because there are immune autoimmune conditions.
There’s something called episcleritis. There is nodular granulomatous, episcleral keratitis. So that’s NGEK. And those are all just descriptor words. They’re not really a diagnosis per se, it’s just like what’s happening in the tissue. And those are usually autoimmune and typically will respond to steroids.
You also have allergies. So, I mean, I’m in Georgia. You’re in South Carolina. There are allergies everywhere, abounding. And so that is one thing that I will be very honest with the clients and say the good thing is, is that I don’t see anything super scary that’s happening. Uh, But there is something happening.
It is red, there’s some inflammation. And what we’re gonna do is we’re gonna have to use our therapies as our diagnostics to see what path we’re gonna have to go down. So if I’m starting a topical steroid for two weeks. Like on taper dose and then the redness stays away, then it’s probably something like allergy related.
If it is like twice a day steroid doesn’t touch it. Then I’m like, Ooh, allergies usually respond to that. So maybe we’re dealing more with an episcleritis, other autoimmune disease, and we need to ramp up our steroid therapy, and then we try and taper that. Once everything’s con, hopefully we can get things controlled and then we’ll use that to say, oh, well now they’re flaring back up.
So there’s this cycle, this process that’s happening and over and over again. And so we will need to do long-term anti-inflammatory therapy. Usually not with steroids long-term, but we can switch ’em over to immunomodulators like Optune, cyclosporine, and tacrolimus. We will use their response and how they respond as we wean things down to guide us.
So we may not get like the diagnosis, but we will hopefully get a better idea of we’re dealing with something probably autoimmune, or allergy.
Dr. Andy Roark: Is there any value in, routine, blood work in this case? Are you gonna see anything in the CBC that’s gonna give you an indication of, autoimmune or, or anything like that?
Dr. Alex Sigmund: Things like ehrlichia. So ehrlichia has been associated with episcleritis and a redness to the eye. So if you most, I feel like most of my patients are on preventatives already. And they have been forever. So it is unlikely for those things to happen, but there are definitely
cases where, things are not getting better and I’m gonna try a trial of doxycycline just to see if that makes a significant difference. I don’t, I do like a 40 x test in those cases. But I don’t do like really extended tick panels just because they’re expensive for one, and most animals tolerate doxycycline.
Okay. And so if we’re doing a trial, I don’t like to use antibiotics, obviously indiscriminately, but if it’s the choice between doing a $400 test versus here’s your, you know, $10 of doxycycline. A lot of owners, I give ’em the option, but they’re gonna pick so.
Dr. Andy Roark: What would you say to this lady about her swimming pool?
Dr. Alex Sigmund: So it’s funny ’cause that’s not an uncommon thing. Well, they’ll fall into the pool and then BA or something. Just in general. Something happens and now they’re paying attention.
Dr. Andy Roark: Yeah.
Dr. Alex Sigmund: now so they’re like, oh, this has just happened. And I’ll say the corneal blood vessels that are present indicate that this has been going on for a very long time.
And it, I think you just something drew your attention to it and then you started noticing, especially with Shihtzu or any long haired dog their eyes are hidden a lot of the time and dark, and so they can’t see some of those changes right when they happen.
Dr. Andy Roark: Okay. I feel like we’ve got a pretty good path now to start to sort these things out to go long to run my baseline diagnostics and start to separate out and even get into some therapies. And I do like the therapy as diagnostics, and that’s a, a nice way to sort of approach these things. Is there anything I need to be looking out for where this is gonna go off the rails? Is there any chance that I’ve done a good job? I do not find corneal ulcers in this dog, things like that. We’re gonna go ahead and we’re gonna start steroid treatments to sort of see if this is allergies or stuff like that. Are there any big things I should put into their mind? Red flags they should look out for, or reasons that they should call me right away. Anything like that I should make sure to call attention to.
Dr. Alex Sigmund: Yeah, I think anytime I start a steroid, I’m always. Honestly, I guess any therapy, anytime I start a therapy, I give them what they should expect. We’re starting a steroid. If it’s not getting better in some way in the next, seven to 14 days, so one to two weeks, then we may need to reevaluate if you think it’s getting worse on this therapy, then please don’t wait and please come in earlier so we can get to the bottom of it. And so it’s setting out that plan, which I feel like some referrals that I get, the owners don’t know what the plan is and where things should, when they should have checked in and changed some, and some things should have changed therapeutically, and they’re lost.
And so I try to just lay all that out. We’re gonna check in here. If that doesn’t work, we’re gonna do this. And if that doesn’t work, we’re gonna try this and just lay out A, B, C, and D for our plans just to provide some direction. And also I write all that down for myself so that I can remember it.
Dr. Andy Roark: Yeah.
Dr. Alex Sigmund: what I’m talking about and what my plan will be.
Or if I case see somebody else next time. You know that they know the direction that, and that we are trying to go.
Dr. Andy Roark: What is your general sort of recheck schedule for things like this? Alex, do you let ’em go for two weeks? Eyes always make me nervous and I feel like,
Dr. Alex Sigmund: Yeah,
Dr. Andy Roark: I always say the great thing about eyes is they can get better really fast, but they can also get bad really fast. And so we’re gonna keep a close eye on them.
Yeah. How do you, how do you think about that?
Dr. Alex Sigmund: It definitely depends on the condition. Think of this particular case of redness where we’ve ruled out everything else. Then I will leave it to the owner and say, Hey, I’m gonna, I need you to monitor for these specific changes. I need there to be less redness, less goofiness. No squinting. If you’re seeing any of that getting worse, you’re gonna come in earlier, but I’m gonna give you about two weeks before we recheck.
Dr. Andy Roark: Alright.
Dr. Alex Sigmund: To see, and then that’s how I do most of my autoimmune therapies, whether it’s oral or topical steroids is about a two week interval in between the rechecks.
Dr. Andy Roark: That makes sense. Great. Good. Is there any any other last words or advice that you have for me before I head off to talk to our shih tzu owner?
Dr. Alex Sigmund: One thing you did not hear me say when it came to this red eye was treating with Neo Poly.
Dr. Andy Roark: Okay.
Dr. Alex Sigmund: Bacterial conjunctivitis is uncommon in dogs it is more common in cats ’cause they can get chlamydia and mycoplasma. But dogs don’t really get bacterial conjunctivitis. They can have bacteria present
Dr. Andy Roark: Uh That is like an opportunistic thing from dry eye, let’s say.
Dr. Alex Sigmund: But if you treat, I’m very big on, less is more when it comes to therapies. So I’m gonna treat. The foundation of the issue. So if I have a dry eye case, I’m gonna treat them for dry eye. I’m gonna not risk using a steroid if I don’t have to because if once that dry eye is under control, all of that will be washed away and we don’t actually have to address that.
So I just see a lot of cases that come in on, well, we tried neo polybac and it didn’t do anything. And you’re like, yes, because the issue is dry eye, you know, or glaucoma. Again, if we’re going back to antibiotic stewardship then I try to minimize the use of that. And I will only use really a topical antibiotic, I feel like, for a corneal ulcer.
Dr. Andy Roark: That dude, that’s great. That’s really good to hear. I, I love that you, every time we talk you bring up bacterial stewardship and I, I just think that that’s such an important message and it’s a good reminder for me. You know, these are things we always try to know more and do better year after year in medicine, and there’s the old saying about like.
Only half of what we know in medicine is right. We just don’t know which half. And
Dr. Alex Sigmund: Yeah.
Dr. Andy Roark: these are anyway, I, I love this perspective and it’s, it’s definitely something that I, I wanna incorporate into how I’m practicing. So Alex, thank you so much for being here. You have a phenomenal online presence where can people find you?
Dr. Alex Sigmund: You can find me on Instagram. I am the Vet Eye Guy, and I’ll have little snippet videos about various conditions and some fun stuff on there too.
Dr. Andy Roark: Excellent. Thanks so much for being here, Alex. Guys, thanks for tuning everybody and, and listening. Take care of yourselves, gang.
Dr. Alex Sigmund: Thank y’all.
Dr. Andy Roark: And that’s what we got. Guys, thanks so much for being here. Thanks to Dr. Alex Sigmund for being here. I am going to go and sing you my red eye dog to my dog and to my wife until she makes me stop. And so that’s what I’m gonna go and do, take care of yourselves, everybody. I’ll talk to you later.
Bye.
