Lucky was diagnosed with Severe Dry Eye

Lucky has Horner's Syndrome (with severe dry eye)

I noticed on Friday night that Lucky seemed to be squinting a bit and his left eye had lost it's shine. I knew something wasn't right so took him into the vet first thing Saturday when they opened.

I had to drop him off because the vet was packed with appointments, but the vets will see drop ins in between appointments. They ran all the usual eye tests and Lucky's left eye came back with no tear production at all - 0/25. And his right eye was 13/25 … not as bad, but the vet said 15 is the goal. So now we are doing Optimunne Ointment twice a day and tears whenever I can do them since he can't produce his own.

Lucky is 8.5 … it seems so odd this would happen so suddenly but I just read an article that average onset is 6 - 10 years. He had a corneal ulcer maybe 6 months ago and tear production was absolutely normal when he was tested then. I am sort of in shock.

I know I've been relatively lucky with Lucky (no pun intended). His heart is a grade 3, and he's only had a murmur for 2.5 years, so late onset compared to many Cavaliers but I feel just awful for him about his eye. He does take the drops well though, he seems to like them, I'll bet they feel good.

Really just an update for those of you who have "known" Lucky since he was a little puppy, but I'm curious and interested in any stories you have of your own dogs with severe dry eye and how they are doing.

Lucky's vet is very good - she's also an internal medicine specialist, but I'm curious if you think a specialist is warranted for dry eye or if a regular vet/internal medicine specialist is familiar enough with dry eye that seeing the Ophthalmologist is not required (My sister takes her dog to an ophthalmologist, but her King Charles/English Toy Gemma has a much rarer condition - corneal edema).

Here's a picture of my Lucky

So sorry that Lucky has just been diagnosed with Dry Eye Lani, but trust me on this, it should be manageable.

Holly P is my second Cavalier to have this condition. The first was Miss Hattie whose tear production suddenly took a dip when she was 5 or 6 years old. I applied Optimune twice daily, which was all that was required.

Holly P is a very different story because she has Curly Coat/Dry Eye syndrome, which is a much more serious and troublesome condition, in fact she was still a very young puppy when it was diagnosed and it transpired that she is allergic to Optimune and rejects her own tissue into the bargain! Even with these complications a very experienced opthalmologist was able to prescribe a pair of ointments designed and licensed for human skin conditions, but which work extremely well for her. She also has regular applications of artificial tears, which bring her production up to very healthy average levels of 20/21 in each eye.

Lucky doesn't seem to have a complex condition and Optimune and artificial tears is often all that is required for a lifetime's healthy eyes. I don't think you need to consult an ophthalmologist unless and until Lucky's tear count repeatedly drops below, say, about 15 tears per minute on the Schirmer tape. Your regular vet seems to be doing exactly the right thing so far as I can tell.

Please try not to worry about Lucky. His mvd could really be a lot worse than it actually is and of course with a sensible regime recommended by your vet it may not progress at all. The same goes for the Dry Eye, so stop worrying and enjoy your beautiful boy. I really like that picture; he looks absolutely adorable.

One of our cavaliers has a bad case of dry eye, but not nearly as bad as Lucky's. He is examined by a nearby ophthalmologist every 4 to 6 months. He has been prescribed three different eye drops: (1) a high-percentage cyclosporine solution; (2) a neomycin and polymyxin B sulfates and dexamethasone suspension; and (3) "I-drop" over-the-counter product by Vet Plus. We've had cavaliers go blind before, and it can completely demoralize a dog. We do not think it is worth relying upon a general veterinarian to keep our dogs able to see.

Thanks Flo & Rod for your feedback.

It's interesting - Lucky has had some really odd behavior in the last month that now I am wondering whether it was related to his dry eye. He'd be scratching to go outside at 12:30 at night. I'd take him out and he'd scratch again a couple hours later. I had chronic insomnia for most of last year and was finally able to sleep so it got to the point where I had to crate him so I could sleep. I was planning to see the doctor about that since the behavior was so unusual for him (I forgot to ask this time since it was a drop off), but I am wondering now in retrospect if the cooler air outside felt better on his eyes. He's actually sleeping through the night now that we are treating his dry eyes. I've also made some adjustments to his diet based on recommendations from Monica Segal (K9Kitchen Facebook group) and Dr. Judy Morgan's book "From Needles to Natural" - hopefully those help as well with his tear production.

Lucky had an MRI today. Good news is there were only very mild malformations at the base of his skull - nothing that had the neurologist worrying about SM or Chiari malformations. That said, his left middle ear was definitely filled with something. We are treating it now with a one month trial of antibiotics, and if that seems to be helping, we will do at least another month to ensure it is cleared up. Apparently it takes a very long time for antibiotics to penetrate into the middle ear.

If the antibiotics do not help clear up his facial paresis (dry eye & drooling), then we will take it from there and potentially investigate other options, but hopefully the antibiotics do their job and his facial nerve starts functioning normally again. Right now I have him in a cone a lot of the time because he likes to rub is eye on the carpet and I want to prevent ulcers given his lack of tears.

Writing this just before I'm off on a PAT visit with Holly P, so sorry I haven't time for the usual pleasantries.

What I think must be urgently said is to ask why you aren't using artificial tears to prevent corneal ulcers. In the UK I use Lacrilube or sometimes Visco Tears. Not sure what they call them in the USA. He might stop rubbing his eyes if you put the tears in several times a day.

More later

I would second what Flo says - if he has dry eye, antibiotics will do nothing for it as it isn't an infection. And he does badly need artificial tears such as Visco Tears or Optimmune ointment before the lack of tears can do irreparable damage to his eyes. Dry eye is a serious condition.

I'm puzzled that your neurologist has diagnosed 'very mild malformations at the base of his skull' but then says that there was nothing to have him worrying about SM or Chiari Malformation - because that is precisely what Chiari Malformation is - a malformation at the base of the skull. The majority of all Cavaliers have CM in some degree. If it is mild, it may never cause problems or go one to cause SM, but it does sound as if it is there. There are very many different diseases that neurologists have to treat - is your neurologist actually experienced with CM/SM?

Kate, Oliver and Aled (both with CM/SM)

RE: Lucky's severe dry eye, that is caused by the middle ear issue and pressure it is putting on his 7th cranial nerve. Lucky IS getting Genteel Tear severe drops *hourly* to prevent ulcers, as well as Terramycin and Cyclosporine (aka optimunne) ointments to help produce tears and as an antibiotic. Lucky's dry eye is not ordinary dry eye like many Cavaliers have because the cause is neurological, so I'm not sure the cyclosporine is going to help a lot until his nerve functions normally and he can blink. He also literally cannot close his eye. My concern is that if he rubs his head on the carpet it doesn't matter how often he gets drops, he is still at risk for a carpet fiber to get in his eye and give him an ulcer. He's under the care of an opthamologist as well as the neurologist and my regular vet who has a specialty in Internal medicine. I expect he is not rubbing his head because of his dry eye but because his ear hurts, but his eye is still at risk for ulcers if he's rubbing his face on the carpet.

The MRI for Lucky's middle ear looked EXACTLY like the MRI on CavalierHealth.org for PSOM except unilateral, not bilateral. I think Lucky's issue is really PSOM. He's on a one month trial of antibiotics because it *could* be a middle ear infection. My concern is if it is PSOM, I'm not sure I want to give the antibiotics a month to find out they are not working. I am planning to talk to my vet about it and give her the printouts from CavalierHealth on PSOM. The neurologist said PSOM could be the issue if the antibiotic trial doesn't work. My gut tells me it is most likely PSOM that is causing the issue in his middle ear that is responsible for everything else.

Regarding Lucky's malformation, it is very minor. The neurologist was not concerned with it causing Lucky's facial paralysis as it is super minor compared to most cavaliers he sees. As we know, almost all Cavaliers have some malformation. I was relieved that Lucky's was very minor.

Lani said:

RE: Lucky's severe dry eye, that is caused by the middle ear issue and pressure it is putting on his 7th cranial nerve. Lucky IS getting Genteel Tear severe drops *hourly* to prevent ulcers, as well as Terramycin and Cyclosporine (aka optimunne) ointments to help produce tears and as an antibiotic. Lucky's dry eye is not ordinary dry eye like many Cavaliers have because the cause is neurological, so I'm not sure the cyclosporine is going to help a lot until his nerve functions normally and he can blink. He also literally cannot close his eye. My concern is that if he rubs his head on the carpet it doesn't matter how often he gets drops, he is still at risk for a carpet fiber to get in his eye and give him an ulcer. He's under the care of an opthamologist as well as the neurologist and my regular vet who has a specialty in Internal medicine. I expect he is not rubbing his head because of his dry eye but because his ear hurts, but his eye is still at risk for ulcers if he's rubbing his face on the carpet.

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Wow, another reason for dry eye in our breed! Since you are in New Jersey, I think I can guess your neurologist -- Eric Glass -- and he has seen a lot of cavaliers with CM/SM, that's for sure. So, if he has diagnosed the middle ear issue as the cause of severe dry eye (cannot even close the eye), this may be a clinical case for the journals.

Hi Rod - actually we are seeing Dr. Richard Joseph in Yonkers. I'm a little concerned because I'm not sure of his experience with Cavaliers (although he was MRI'ing a Cavalier puppy after Lucky the same afternoon and he has been practicing since the 80's). That said, my vet highly recommended him based on her experience with other patients.

I hope it does turn out to just be a middle ear infection and we see improvement from the first month trial of antibiotics - but I sort of wish they would have just done a myringotomy when he was under on Tuesday so Lucky would have immediate relief and he won't need to do another procedure if it doesn't clear up. It feels like I've known a lot of Cavaliers with PSOM, but haven't really heard of one with a severe middle ear infection detected via MRI.

The neurologist also suggested a bulla osteotomy surgery if the "infection" does not clear up. This is what is concerning me - wouldn't a myringotomy be less invasive? I want to advocate for what is best for Lucky.

BTW, I actually searched "PSOM Horner's Syndrome" and came across CavalierHealth.org

Specifically, I found an excerpt from this Clinician's Brief referenced on Cavalier Health.

PSOM of Cavalier King Charles spaniels (CKCSs) commonly occurs as head and neck pain that may be difficult to localize. With pressure in the bulla, Horner syndrome or facial nerve palsy may be evident.

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It would be interesting to know how many Cavaliers with PSOM also have dry eye and if that dry eye is really caused by a genetic eye disorder (keratitis sicca or keratoconjunctivitis sicca) or if it is actually Horner's Syndrome masquerading as dry eye (caused by pressure from the middle ear pushing on the nerve that controls the eye and facial muscles).

Lani said:

Hi Rod - actually we are seeing Dr. Richard Joseph in Yonkers. I'm a little concerned because I'm not sure of his experience with Cavaliers (although he was MRI'ing a Cavalier puppy after Lucky the same afternoon and he has been practicing since the 80's). That said, my vet highly recommended him based on her experience with other patients.

I hope it does turn out to just be a middle ear infection and we see improvement from the first month trial of antibiotics - but I sort of wish they would have just done a myringotomy when he was under on Tuesday so Lucky would have immediate relief and he won't need to do another procedure if it doesn't clear up. It feels like I've known a lot of Cavaliers with PSOM, but haven't really heard of one with a severe middle ear infection detected via MRI.

The neurologist also suggested a bulla osteotomy surgery if the "infection" does not clear up. This is what is concerning me - wouldn't a myringotomy be less invasive? I want to advocate for what is best for Lucky.

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Dr. Joseph has a good reputation with cavaliers, as far as I can recall. The infection question does seem a little old fashioned, since PSOM is so common in cavaliers, but I guess he is old school. Also, I missed the fact that he had not performed the myringotomy at the same time as getting the sample. Myringotomy is far less invasive than a ventral bulla osteotomy, and if it was my dog, I would want to know why the vet chooses the latter. There may be some belief that the bulla surgery reduces the chance that the PSOM will recur, but I am not sure.

I gave my vet the info on CavalierHealth.org re PSOM. He believes also that Lucky has PSOM and doesn't think we should wait a month with antibiotics to remove what is in his middle ear (even if it were infected). He also was concerned that a more serious surgery had been recommended, so he is going to send our file to another neurologist who we will go to and consult for a second opinion (we are thinking LIVS, even though it's quite a drive from North Jersey, since they have a lot of experience with Cavaliers).