Question Details
Retinal Detachment In A Dog
by tracyb - May 16, 2023    View Case Report
I apologize for this long history.
Neville is a 3 YO MC Pit Bull
Presenting complaint: detached retinas
Late March presented to GP vet who found:
scleral injection, blepharospasm, and third eyelid protrusion he was started on antibiotic eye drops.

He became blind and represented with:
absent menace and direct/indirect PLRs OU. scleral injection and blepharospasm OU. Fundic examination revealed retinal hemorrhage OS.
Blood pressure ranged from: systolic 170-190 mmHg

Several days later he was referred to an ophthalmologist who found:
systemic hypertension and retinal detachment of both eyes. Increased IOP (I don’t have numbers on IOP)
He was started on dorzolamide, latanoprost, amlodipine, prednisone, and doxycycline.

During this time a workup ruled out:
Abdominal ultrasound ruled out adrenal tumor, found some punctate urolithiasis
Thoracic and abdominal radiographs were normal except for BB gunshot
CBC: unremarkable?Superchem: unremarkable?Total T4: wnl?Fungal Serology: histoplasma antibody negative, blastomyces antibody negative, aspergillus antibody negative Coccidioidomycosis: IgM negative, IgG negative, titer not indicated?Ehrlichia Canis: negative?Rocky Mountain Spotted Fever: negative?Cryptococcal Antigen: negative?Toxoplasmosis IgG/IgM: negative
Uveitis PCR negative
UA has +1 protein but normal UPC
Several days later another ophthalmologist found:
OU: absent menace response, conjunctival hyperemia, mild aqueous flare, miosis, fundus partially visible: vessels enlarged/poorly defined; optic nerve hazy/dark. IOP 5 mm Hg OD, 4 mm Hg OS. suggestive of vasculitis OU, hypertensive retinopathy can not be excluded, uveitis OU: likely secondary to systemic disease Recommend: STOP XALANTAN, cosopt BID OU, predacetate BID OU

At this time he also had:
Tbili= 7.3 (0-0.3)
And hepatocellular hepatopathy
Alkphos=3285 (5-160)
ALT 5678 (18-121)
AST 1219 (16-55)
Cholesterol 465 (131-345)

This was worked up and assumed to be a reaction to doxycycline; indeed it started resolving upon discontinuing doxy and is almost normal now.

This is when I met Neville
I diagnosed him with Blood/Yin deficiency and started him on tian ma gou teng yin based on:

Pale tongue
Thin pulse
History of chronic mild ear infections, skin that turned pink at night which resolved with change to hydrolyzed food
Heat intolerance
Some anxiety related to fear of certain types of people and rustling bags
This illness began several weeks after a young (healthy) female basset hound was adopted, I also interpreted this as an anxiety response.

I did not really buy the autoimmune uveitis idea- because I couldn’t really find evidence for autoimmune disease at this point.
I thought he had essential hypertension leading to retinal detachment and uveitis.

The client is reluctant to cook for him 100% but has agreed to start adding some cooked pork to his hydrolyzed kibble since pork is cooling and a novel protein for him to tonify Blood.

2 weeks later:
He was much improved, his retinas were partially reattached and he regained some sight

So he was tapered from prednisone.

Shortly after tapering prednisone the uveitis returned despite his blood pressure remaining regulated at around systolic 140.
So clearly I was wrong and he must have an autoimmune disease.

He has just been restarted on prednisone and his internist is planning on changing to cyclosporine once he is stable again.

I am thinking I should change him to Xiao chai hu tang since he has autoimmune uveitis?

But I could not find any physical exam evidence for it like a wiry pulse that responds to GB34.

I also find it confusing that he has hypertension with no glomerulonephritis, I don’t know how an autoimmune disease could produce these signs?

He does have a long medical history for a 3 year old dog who was adopted as an adult:
Several months previous to the retinal detachment he developed some temporal muscle atrophy. His masseter muscles seem normal, and it has not progressed much. He has not been tested for masseter muscle myositis.
When he was adopted :
heartworm positive (treated with melarsomine 3/22) which caused a facial droop which resolved, and a shock reaction which also resolved.

So after that long history my questions are:
Should I change him from Tian Ma Gou teng yin to Xiao chai hu tang?

or something else?

Thank you in advance for any guidance!
by naturevet
May 18, 2023
Wow, this is a tough case! All over the map! Well, you certainly were right to use the TMGTY, which means your read of the dog as having an underlying Blood deficiency likely has merit. The question is, how could he have retinal detachment from it?

The elevated liver enzymes have some bearing. I know they went away, but when a dog has that kind of reaction to doxycycline, it says something about the dog, not the drug. So he is capable of severe liver inflammation as well as acute eye inflammation, and possibly hypertension. I say 'possibly' because you can't rule out stress or operator error if it's just one reading that was high.

Given the above, I can see why you're circling around XCHT, but a lack of response to GB points is meaningful, as is the pulse. My thinking is that you should try Long Dan Xie Gan Tang.

LDXGT as made by NPHC and Kan Essentials has a strong Blood tonifying ability, addresses intraocular inflammation, can lower blood pressure and of course addresses Liver Yang rising. So it would mesh well with the TMGTY. It also addresses the underlying propensity to severe liver inflammation.

How did the retina detach? Hypertension isn't the only way to get fluid back there. In humans, chronic retinal inflammation is a direct cause, and is why 'wet forms' of macular degeneration are so problematic. I see no reason why the exudate from inflammation of the uvea in a dog would not produce the same problem. If that's the case, an anti-inflammatory Blood tonifying herb like Long Dan Xie Gan Tang might be perfect for getting control of the case so the dog can come off immune suppressive drugs.

There may be more than one way to do this. Minor Bupleurum is still a consideration, or Chai Hu Jia Long Gu Mu Li Tang. You'd want to pair these with a Blood tonic. Si Wu Tang goes well with XCHT and Yi Guan Jian goes well with either formula. If you didn't get a response from GB points on the pulse, though, I'm inclined to go the Liver route.

Let us know how things go! Hopefully this advice helps!

by tracyb
June 13, 2023
Dear Steve,
Thanks so much for the advice. I did change him to LDXGT.
He had been doing better:
He was re-started on immunesuppressive dose of pred. Cyclosporine was started as well, in the hopes that once the cyclosporine took effect it could be used long term and the pred tapered/discontinued.
He remained on amlodipine and his blood pressures remained acceptable.
his retinas had partially reattached per the ophthalmologist and continued pred acetate opthalmic.

during this time his labs were good except his tbili remained mildly elevated at 0.5 (0-0.3)

I saw him last on Wednesday 6/7. His pulse still felt empty and his tongue was lavender though less than previously, with tiny white cracks on the surface.

I discontinued the Tian Ma Gou Teng Yin and he started him on Long Dan Xie Gan Tang (around 6/1/23)which really did make more sense considering the severity of his signs.

Friday 6/9/23 he went to Emergency with vomiting, anorexia diarrhea.
here were his labs:
Neutrophils 0.98 (2.95-11.64)
ALT 526 (10-125)
ALKP 412 (23-212)
GGT 13 (0-11)
Tbili 2.5 (0-0.9)
CL- 102 (109-122)
Tp 5.1 (5.2-8.2)
ALB 2.1 (2.3-4.0)

and he was you guessed it parvo+.
My interpretation is that he picked up Parvo (yes he was vaccinated) due to immunosuppression from pred/cyclosporine. (he looks mostly pit bull and we are having a surge here in nyc.)

I haven't treated parvo in a while but I don't remember parvo infected dogs having these liver enzyme elevations.
so I guess that goes along with his liver yang rising exacerbated now by the virus and the v/d?

He won't be having acupuncture or herbs anytime soon but I just wanted to update, and ask: can anything additional be learned from this latest?
Thanks! Tracy
by naturevet
June 16, 2023
Hi Tracy,

I guess the elaboration of GI weakness would now make me think of Si Miao San as what he could graduate to from LDXGT. It offers more Spleen support but would still have the action against extreme liver enzyme elevations. It doesn't have as much effect on the eyes (in theory), but maybe that doesn't matter as much right now. If you did still want to keep a focus on the eyes, I would add in Xian Fang Huo Ming Yin, as it pairs well with SMS, and I've used it successfully in macular degeneration in people. Lastly, it's a good formula to think of for animals that appear dependent upon corticosteroids, if only to allow lower doses to be used, thus resulting in reduced side effects.

Hope this answers your question. Quite the case!

by tracyb
June 19, 2023
Dear Steve,
Thanks so much for this.
Unfortunately Neville developed a coagulopathy and was euthanized. so devastating.

I would never have thought of sms since I didn't see damp signs so that is something for me to think about.
that will be a useful tip re Xian fang huo Ming Yin and steroid reduction!

Neville's owner agreed to a necropsy so if the pathalogist can figure out what the heck was Neville's diagnosis I will report back...
by naturevet
June 27, 2023
Thanks, Tracy. It's actually SMS that lowers steroid requirements. I realized that isn't too clear when I re-read my post
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