http://www.thehorse.

com/articles/29856/diagnosing-treating-and-managing-equine-recurrent-
uveitis"

Equine recurrent uveitis has been an interest of mine for as long as I've been an
ophthalmologist," began Brian C. Gilger, DVM, MS, Dipl. ACVO. "Unfortunately, it's still
an interest because we can't seem to get this disease under control."

While a cure for equine recurrent uveitis (ERU) remains elusive, veterinarians have learned
how to best control this devastating disease and are continuously working to unravel new
treatment options. Gilger, professor of ophthalmology at the North Carolina State University
College of Veterinary Medicine, reviewed the current diagnostic, treatment, and management
options for ERU at the 2012 American Association of Equine Practitioners' Focus on
Ophthalmology conference, held Sept. 6-8 in Raleigh, N.C.

Gilger stressed that there is a difference between ERU and "garden variety" uveitis, and he
discussed aspects of both during the presentation.

Types and Signs of ERU

Gilger explained that there are three distinct types of ERU that can affect horses: classic,
insidious, and posterior.

Classic, or anterior, ERU is the most common type, and is characterized by concurrent bouts
of pain and inflammation which last approximately two weeks. This "active" period is
followed by a period of quiet (which lasts for an unknown amount of time), Gilger said,
which is followed by another active spell. This pattern continues indefinitely until the eye
goes blind, he said.

Gilger explained that insidious, or subclinical, uveitis can be challenging for owners and
veterinarians alike. Although affected horses typically don't show signs of pain, low-grade
inflammation remains in the eye after the active phase, damaging the internal structures.
Affected horses often slowly develop signs of chronic ERU (more on that in a moment), but
owners might not recognize disease presence until significant damage is done. "It's sad,"
Gilger said. "You have an owner come in, eager to do something (to help the horse), but the
eye's already blind."

Finally, posterior uveitis is the least common type seen in the United States. With this
syndrome, the majority of the associated inflammation develops behind the lens, Gilger said.
Association vitreal opacities, degeneration, and infiltration are common, as is retinal
detachment, he said.

Gilger noted that classic and insidious ERU are common in Appaloosa horses, insidious ERU
is common in draft horses, and posterior ERU is commonly seen in Warmblood horses.

Clinical signs of active ERU include:

● Photophobia (sensitivity to light);

● Blepharospasm (squinting);
● Corneal edema;
● Aqueous flare (small "floaters" in the front chamber of the eye);
● Hypopyon (pus in the eye);
● Miosis (pupillary constriction);
● Vitreous haze (a haze in the gel that fills the eyeball between the lens and the retina);
and
● Chorioretinitis (inflammation of the choroid and retina).
● Signs of chronic ERU include:
● Corneal edema;
● Iris fibrosis and hyperpigmentation;
● Posterior synechia (adhesion of the iris to the capsule of the lens);
● Corpora nigra degeneration (the irregular body at the edge of the iris that shades the
pupil);
● Miosis;
● Cataract formation;
● Vitreous degeneration and discoloration; and
● Retinal degeneration.
Causes and Diagnosis
"There's a big controversy about what actually sets this off," Gilger said, noting that there are
several different theories about the pathogenesis of both uveitis and ERU.

"It's becoming more and more likely we have a genetic component to this," he noted.
Additionally, environmental factors, ocular injury, certain infections (such as leptospirosis),
and the presence of certain cells (such at T-lymphocytes, or T-cells) are each believed to
contribute to disease development.

"The clinical diagnosis of ERU is based on the presence of characteristic clinical signs and a
history of documented recurrent or persistent episodes of uveitis," Gilger explained. He noted
that in most horses, a normal uveitic spell lasts for two to three weeks before it calms down,
even without therapy. Multiple occurrences points to ERU.

"If it's a first bout of inflammation, this is one you really need to work up (examine)
carefully," he said. If recurrence is observed, the diagnosis is typically ERU.

At that point, treating and managing ERU becomes the priority.

http://www.merckvetmanual.com/eye-and-ear/equine-recurrent-uveitis/overview-of-equine-
recurrent-uveitis

Treatment and Management

Traditional medical treatments for ERU are aimed at reducing inflammation and minimizing
ocular damage, Gilger said; however they will not effectively prevent recurrence. Common
medical treatment includes topical and systemic non-steroidal anti-inflammatory drugs
(NSAIDs, most often flunixin meglumine) and corticosteroids.

"Other medications used to prevent or decrease severity or recurrent episodes, such as aspirin,
phenylbutazone, and various herbal treatments have limited efficacy and potential detrimental
effects on the gastrointestinal and hematologic systems when used chronically in the horse,"
Gilger added.

He recommends slowly weaning horses off these treatments as active episodes subside. Many
horses, he said, respond well to medical treatment if it is implemented early and aggressively.
If medical treatment proves unsuccessful, surgical intervention might be a viable option.
Current surgical options include a vitrectomy (CV) and the implantation of a sustained-
release cyclosporine device (CsA).

Although simply removing the cells and vitreous from inside the eye might "sound
remarkably straight forward," Gilger said, a vitrectomy is a very expensive option and carries
a high complication rate, such as cataract development. Thus, if surgery is required, some
veterinarians are more inclined to recommend a CsA device.

In these cases, a surgeon implants a small disc (about 6 millimeters in diameter and weighing
about 25 milligrams) into the sclera of the affected eye, Gilger said, adding that the entire
procedure takes about 15 minutes, on average. The device will release medication to the eye
at a predetermined dosage for at least four years, he said. Currently, he said, more than 500
procedures have been completed worldwide, and owners have reported a significant decrease
in the number of active episodes affected horses have.

Even with aggressive treatment, affected horses can go blind in a matter of years, Gilger said.

Once acute episodes are under control, Gilger said, there are several relatively simple steps
owners of affected horses can take on a daily basis to help keep their charges healthy. For
instance, changing stable or pasture mates if ocular injury is common or has occurred can
help keep a uveitic horse healthy. Additionally, decreasing their sun exposure can help keep
them comfortable.

Other management practices Gilger recommended include:

● Increase insect and rodent control, and use a quality fly mask with ultraviolet
protection;
● Decrease dust;
● Change bedding;
● Eliminate sharp objects from around the barn and pasture;
● Eliminate low branches;
● Decrease training and show schedule, and minimize trailering;
● Avoid using hay nets;
 ● Maintain proper hoof and dental care, as well as deworming and vaccination
schedules; and
● Ensure a proper diet.
Take-Home Message

Equine recurrent uveitis and uveitis are two different diseases, Gilger stressed. Although
there is no cure for ERU, an immune-mediated disease, treatment is often effective in
controlling clinical signs and active episodes.

Treatment, Prevention, and Control:

The primary goals of therapy are to reduce inflammation, relieve discomfort, and prevent
vision loss. If possible, the specific underlying cause should be diagnosed and addressed as
part of the initial treatment regimen. Regardless of whether the underlying cause is identified,
aggressive treatment with systemic and topical anti-inflammatory medications is initiated
immediately to minimize damage from intraocular inflammation. Flunixin meglumine
administered systemically (especially IV) is critical to the initial management of acute uveitis
in horses. The typical initial IV dosage is 1.1 mg/kg, administered at the time of diagnosis,
followed by a 5- to 7-day course at a dosage of 0.5–1.1 mg/kg, PO, bid. As inflammation
resolves, the dosage can be reduced to 0.25–0.5 mg/kg once daily or every other day
throughout a 1- to 3-mo treatment period. Because of the potential for renal toxicity, serum
creatinine is intermittently monitored if flunixin meglumine is used for >1 mo. Horses treated
with flunixin meglumine should also be observed for signs of GI ulceration, and concurrent
prophylactic administration of omeprazole (2 mg/kg/day, PO) may be indicated. If flunixin
meglumine is not tolerated, phenylbutazone (2–4 mg/kg, PO, once to twice daily) or aspirin
(10–25 mg/kg, PO, once to twice daily) can be used alternatively, but neither is as potent or
effective. Historically, horses with frequent recurrences or chronic, low-grade uveitis were
managed medically with daily (or every other day) doses of oral phenylbutazone or aspirin.
Although most horses tolerate this regimen well, these medications can have adverse GI,
hematologic, or renal effects, and these regimens frequently do not eliminate recurrence.
Systemic steroids, specifically prednisolone (100–300 mg/day) and dexamethasone (5–10
mg/day) have also been successfully used to treat acute uveitis episodes, but their longterm
use has been associated with laminitis. Except in cases when bacterial infection is present,
systemic antibiotics are not indicated.
Topical steroidal medications, including dexamethasone (0.1% suspension or ointment) and
prednisolone acetate (1% suspension), are very effective at decreasing inflammation. Topical
acetate and suspension preparations of steroids are designed to penetrate the cornea and
achieve adequate uveal concentrations and are thus preferred to sodium phosphate
formulations. Topical hydrocortisone should be avoided, because it lacks adequate corneal
penetration and is not sufficiently potent to treat anterior uveitis. A fluorescein stain is
warranted before initiation of topical steroids, because these medications are contraindicated
with corneal ulceration and/or infection. Topical nonsteroidal medications include
flurbiprofen (0.03% solution) and diclofenac (0.1% solution); they are less potent than topical
steroids but offer a wider safety margin in cases of concurrent corneal disease. Frequency of
administration depends on inflammation severity; initially, administration may be 4–6 times
daily. With improvement in clinical signs, frequency of administration of topical steroidal or
nonsteroidal medications can be gradually decreased. However, therapy should continue for 1
mo after complete resolution of active inflammation. Topical atropine (1% solution or
ointment) causes mydriasis (which decreases the likelihood of posterior synechia formation)
and cycloplegia (which decreases pain associated with ciliary body muscle spasm) and
stabilizes the blood-aqueous barrier. Atropine is applied topically 2–3 times daily until the
pupil is widely dilated; the frequency can then be adjusted to maintain mydriasis. Because
atropine decreases GI motility, horses treated with topical atropine should be monitored for
signs of ileus. If frequent topical medication is not possible, subconjunctival injections of
triamcinolone acetamide (1–2 mg) provide adequate intraocular anti-inflammatory
concentrations for 7–10 days and are less likely to cause abscess or granuloma formation than
other steroids, including methylprednisolone acetate (10–40 mg). However, all
subconjunctival steroids should be used with caution, because they cannot be easily removed
once injected and can have devastating consequences if an infectious component is present or
a corneal ulcer develops.
Two surgical procedures are commonly used in longterm management. A suprachoroidal
cyclosporine implant is a sustained-release medication device that provides therapeutic
concentrations of cyclosporineA, an immunosuppressive T-cell inhibitor, for ~3 yr after
implantation. During this procedure, a cyclosporine A disk (~5 mm in diameter) is implanted
under a scleral flap created ~8 mm posterior to the dorsolateral aspect of the limbus. Horses
with implants have markedly fewer uveitic episodes than they did before surgery, and this
device results in effective longterm control of ERU. Core vitrectomy removes virtually all of
the vitreous through an incision posterior to the dorsolateral aspect of the limbus. The
vitreous is then replaced with either balanced salt solution or saline. The theorized benefit of
this procedure is that organisms, especially Leptospira spp, and/or inflammatory cells in the
vitreous significantly contribute to the chronic inflammation of ERU. By removing these
factors, the frequency and severity of uveitic episodes are minimized.
Good husbandry practices to manage ERU ensure proper health maintenance, prevent ocular
trauma, and reduce environmental triggers. Specific management recommendations include
routine deworming and vaccinations, proper nutrition and dental care, a quality fly mask,
minimizing contact with cattle or wildlife, draining stagnant ponds or restricting access to
swampy pastures, effective fly control, and frequent bedding changes. Although such
measures benefit individual horses, the extent to which they impact the clinical course of
ERU has not been evaluated.
https://www.google.ro/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&
ved=0ahUKEwjw8eTViL_YAhVKIlAKHRZuBiIQjRwIBw&url=https%3A%2F%2Fwww.p
interest.com%2Fpin%2F45458277464969373%2F&psig=AOvVaw26IM1GyDZSypMtHdby
Lah1&ust=1515181365481988

https://practicalhors
emanmag.com/healt
h-archive/first-
equine-vaccine-leptospirosis-31716

ZOETIS
INTRODU
CES
FIRST
LICENSE
D EQUINE
LEPTOSP
IROSIS
VACCINE
New LEPTO EQ INNOVATOR® helps protect horses from leptospirosis caused by L. pomona.

FLORHAM PARK, N.J., Nov. 10, 2015 — Today Zoetis announced the introduction of LEPTO EQ
INNOVATOR®, the first and only vaccine licensed for use in horses, six months of age or older, to aid
in the prevention of leptospirosis caused by Leptospira interrogans serovar Pomona, known as L.
pomona. A recent study supported by Zoetis showed 75% of healthy horses have been exposed to at
least one leptospiral serovar.1 As clinical signs associated with leptospirosis are non-specific, disease
in horses likely occurs more frequently than is diagnosed, and exposure to Leptospira may be more
prevalent than was previously understood. “Until this vaccine, preventive options against leptospirosis
have been limited in horses,” said Jacquelin Boggs, DVM, MS, ACVIM, senior veterinarian, Equine
Technical Services at Zoetis. “Leptospirosis is a disease that can cause devastating health risks to
horses and can require costly treatment. In response to the equine industry’s requests for a vaccine,
Zoetis developed LEPTO EQ INNOVATOR to better equip veterinarians with the tools they need to
help ensure the health and well-being of their horses.”

The addition of LEPTO EQ INNOVATOR enriches the broad portfolio of core and risk-based equine
vaccines from Zoetis. LEPTO EQ INNOVATOR was shown to be clinically safe for use in foals three
months of age or older and healthy pregnant mares in the second trimester.2,3 The vaccine has been
field tested in more than 1,800 horses.2,3 In field safety studies with the administration of 1,808
vaccine doses, 99.8% of the horses remained reaction-free.2,3 A reaction rate of 0.002%
demonstrates the vaccine’s safety.2,3
https://www.zoetisus.com/misc/files/imgs/image002.jpg

Horses can become infected with leptospires from standing or slow-moving water contaminated by
Leptospira-infected urine, contaminated soil, bedding, feed and drinking water as well as urine from
infected cattle or dogs.4,5 Common maintenance hosts — including skunks, raccoons, white-tailed
deer and opossums — can become infected with L. pomona, which can be shed into shared
environments and infect horses. After penetrating through mucous membranes or skin abrasions,
leptospires can concentrate in the kidneys and can cause devastating clinical disease.

LEPTO EQ INNOVATOR is currently available and as with any Zoetis product, is supported by
credible research and superior support. For more information please contact your Zoetis
representative or visit www.LEPTOEQUINNOVATOR.COM to access a free, online Leptospirosis
Risk Assessment.
Rata incidenței anuale a leptospirozei în anul 2015 a fost 0,2%000, în scădere cu 56,6% față de anul
2014 (0,46%000).