Peer Reviewed DIAGNOSING ACUTE BLINDNESS IN DOGS

Diagnosing Acute Blindness in Dogs

Caryn E. Plummer, DVM, Diplomate ACVO
University of Florida

Vision loss can occur gradually or manifest quite different depending upon the onset and
acutely in dogs, but acute and complete blindness duration of the deficits.
can be particularly devastating. The abrupt The history should determine:
nature of this blindness is very disconcerting • Whether vision loss is partial or complete.
for all involved and pet owners may make hasty • Whether vision loss is acute or has been
conclusions and decisions. developing gradually: Did the dog have
The diagnostic approach to these patients functional vision yesterday, but blindness today
should include: or has it been gradually losing vision and now is
An Eye 1. Ophthalmic history identifying the onset and completely blind?
Toward duration of blindness, degree of blindness (as • When signs of vision loss developed: Did signs of
perceived by the owner), other signs of disease, vision loss manifest yesterday or 2 months ago?
Anxiety and medication regimen • Whether the appearance of the eye has changed.
2. Vision assessments, including menace If so, when was this change noted? This
When a dog is
response, visual placing, and “maze” tests, that information is important because, in many
presented for acute
confirm whether the patient is blind instances, the physical appearance of the eye may
blindness, or what
is perceived as 3. Causative lesion localization by pupillary change over time.
acute blindness, light reflex examination of the eye, potentially • Systemic signs of disease are present, or
it is important with ocular ultrasound, blood pressure whether a systemic problem has been
to proceed with measurement, electrophysiologic testing, previously diagnosed. Note that many systemic
patience and specifically electroretinogram. diseases (eg, infectious disease, lymphoma,
care because the hypertension) may initially be recognized by
patient is likely HISTORY their ophthalmic manifestations.1,2
anxious and upset, A thorough general and ophthalmic history • What medications the patient receives/has
while its owner is is crucially important to the investigation of received, both chronically and more recently,
often distraught. blindness because differential diagnoses can be including inadvertent administration/ingestion.
Slow movements, For example, has the dog recently received or
accompanied ingested ivermectin?
by a calm voice,
facilitate the VISION ASSESSMENT
examination, may As the history is being gathered, confirmation
soothe or allay of vision—or the lack thereof—should be
some anxiety, and performed. Note that some patients—those
make the clinician’s
with neurologic disease and aged animals with
presence known to
cognitive dysfunction—may behave as if they
the dog at all times.
are visually impaired even though their visual
systems are functional.

Menace Response
Vision requires functioning central and
FIGURE 1. Complete resting mydriasis in a peripheral ophthalmic systems, and may be
young Chihuahua with bilateral optic neuritis.
roughly assessed with a menace response. The
Both direct and consensual PLRs were absent.
menace response test is performed by making

18 TODAY’S VETERINARY PRACTICE | An Official Journal of the NAVC | November/December 2016 | tvpjournal.com
 DIAGNOSING ACUTE BLINDNESS IN DOGS Peer Reviewed

a menacing gesture with the hand toward the LESION LOCALIZATION

patient’s eye. Take care not to touch the vibrissae The next step in the evaluation of the blind patient
Eye
or cause excessive air currents, both of which is to determine where the causative lesion is located.
stimulate the sensation of touch rather than Is the patient blind because something is obscuring Evaluation
sight, potentially inducing a false-positive result.2 the visual axis, such as pigmentary keratitis, corneal
For the menace
If the animal can see, it should blink or move its edema, or a cataract? Or is the patient blind because
response, cotton
head away from the stimulus. the retina or central nervous system is at fault?
ball test, and visual
placing reaction,
Cotton Ball Test Pupillary Light Reflex each eye should
The patient’s vision can be further evaluated by The size of the pupils and the direct and consensual be evaluated
noting its response to cotton balls (or some such (response in the fellow, non-stimulated eye) separately by
noiseless, scentless object) tossed into the visual field pupillary light reflexes (PLRs) are very important covering each in
or observing the visual placing reaction. for lesion localization (Figure 1).2 These turn and testing the
assessments should be performed with a bright light exposed eye.
Visual Placing Reaction in a dimly lit room.
Visual placing is assessed most easily in small The PLR evaluates:
patients that are able to be held. For this test, the • Rapidity of pupillary light response
patient is held in the examiner’s arms so that the • Extent of miosis Dark
forelimbs dangle freely. The dog is moved slowly • Ability to maintain miosis to constant light
toward a table or other elevated flat surface. stimulation.
adaption
As the limbs approach the edge of the table/ The consensual pupillary reflex is normally equal to is the adjustment
flat surface, if visual and able to respond, the
the direct. of the eye to low
dog will raise its limbs in order to step onto the
The PLRs require integrity of retinal neural light intensities,
table.2 If the dog does not see the table, it will
cells, optic nerves, optic chiasm, optic tracts, involving reflex
not raise its limbs, allowing them to bump into dilation of the pupil
midbrain (Edinger-Westphal nucleus), and
the edge. and activation of
parasympathetic fibers via the oculomotor
nerve, ciliary ganglia, and the iridal sphincter the rod cells in
Maze Test preference to the
musculature, but integrity of the cerebral
In patients with suspected blindness, an obstacle cone cells.
cortex is not required (Figure 2). The reflex is,
course or “maze test” may be used to
determine whether vision is present.
Traffic cones, foam cylinders, or even
examination room furniture, such as
chairs and waste cans, suffice, although
elaborate mazes may be constructed for
standardized testing. The dog should be
placed at the opposite end of the maze
from its human companion, who is asked
to call the dog’s name only once, which
keeps the dog from following voice cues
in order to maneuver.
Vision should be evaluated in normal
light and then dim light (after dark
adaption) and obstacles should be adjusted
between tests to avoid memorization and
mapping. To assess night vision, dim the
ambient illumination until you can barely
distinguish the room furniture and maze
course obstacles. Normally sighted dogs
have better developed night vision than
humans; therefore, the patient should be
able to see the maze obstacles better than
FIGURE 2. The pathway of the pupillary light reflex.
the examiner.3

tvpjournal.com | November/December 2016 | An Official Journal of the NAVC | TODAY’S VETERINARY PRACTICE 19
 Peer Reviewed DIAGNOSING ACUTE BLINDNESS IN DOGS

in a focused (non-scattered) manner

TABLE 1.
• Lack of response by the retina to light stimulation
Acute Blindness & Pupillary Light Reflexes
• Inability of the optic nerve and tracts to transmit
VISION PLR LESION LOCALIZATION the electrical response of the retina
RESULTS
• Inability of the occipital cortex to process the
Visual Normal No lesion
information supplied by the eyes and optic pathways.
Visual Abnormal Lesion in efferent pathway Lesions obscuring the visual axis are often
dictating pupillary
constriction (iris sphincter
relatively easy to diagnose and may develop slowly
muscle atrophy, lesion in or rapidly. Table 3, page 22, provides a list of ocular
oculomotor cranial nerve III) lesions that may present as an acute onset of vision
Avisual Normal Lesion obscuring visual axis loss.
(corneal pigment or edema, Because vision can potentially be restored with
cataract) or interfering with
cortical processing of visual appropriate management, rapidly developing
information (brain or central cataracts, corneal ulcers, severe uveitis, intraocular
nervous system disease) hemorrhage, and anterior lens luxation should
Avisual Abnormal Lesion in retina or optic be considered urgent or emergent depending
nerve of affected eye
on severity. Acute glaucoma should always be
considered an emergency.
therefore, subcortical and should be considered
A thorough fundic examination is the next step
an evaluation of the integrity of the retina and optic
if the:
tracts, not of vision.2
• Anterior segment (ie, cornea, anterior chamber,
In general, in dogs with vision impairment, when
and lens) appears normal
PLRs are (Table 1):
• Anterior segment abnormalities found are not
• Absent or diminished: The lesion is likely located
severe enough to account for the degree of vision
in the retina or optic nerve.
loss noted.
• Intact: The lesion often obscures the visual axis
Often, if the retina or optic nerve is affected,
or interferes with the cortical processing of
the pupil is dilated, making pharmacologic
visual information.
mydriasis unnecessary.

Examination of the Eye

Optic Nerve
Because the eye can often be visualized to the level
The optic nerve should be thoroughly examined for
of the posterior segment (in its normal state), a
evidence of disease or inflammation.
complete ophthalmic examination can provide a rapid
and accurate diagnosis for many ophthalmic diseases
(Table 2).
During the ophthalmic examination, keep in mind
the general causes of vision loss:
• Lesions that prevent light from reaching the retina

Keep in Mind Remember, PLRs are affected by the

psychological state of the animal, room
During PLR illumination, age, many topical and systemic
drugs, and the intensity of the light stimulus.
If an animal is highly nervous or frightened,
the pupils may be dilated and respond poorly to
low-intensity light. However, with acclimation or a
strong light source, this effect is minimized.
Older animals may exhibit slow and incomplete FIGURE 3. Iris atrophy in a Yorkshire terrier has
PLRs resulting from atrophy of the iris sphincter resulted in mydriasis and an incomplete pupillary
muscle. This response is common in small dogs, light reflex. Note the scalloping of the pupil
especially poodles. The pupil margin may have an margin and the holes in the temporal iris stroma.
irregular or scalloped appearance or an irregular This aged individual also has an immature
pupil shape, referred to as dyscoria (Figure 3). cataract.

20 TODAY’S VETERINARY PRACTICE | An Official Journal of the NAVC | November/December 2016 | tvpjournal.com
 DIAGNOSING ACUTE BLINDNESS IN DOGS Peer Reviewed

TABLE 2.
Acute Blindness: Diagnostic Approach
DIAGNOSIS VISION LOSS PLR VISUAL AXIS FUNDUS OTHER DIAGNOSTICS

Anterior lens Acute or Impaired, depending on Obscured Visualization of fundus Measure IOP; consider ocular
luxation chronic position of lens and IOP may be limited ultrasound

Chorioretinal Acute or Normal or abnormal, Variably affected, Tapetal hyporeflectivity Pursue systemic inflammatory/
inflammation chronic depending on degree anterior uveitis neoplastic disease workup
of involvement and may be present
severity concurrently

Cortical Acute or Normal Normal Normal Pursue electrophysiologic testing, MRI/

disease chronic CT, CSF analysis, systemic inflammato-
ry/neoplastic disease workup

Corneal Acute Normal or abnormal, Obscured Visualization of fundus Consider corneal culture and cytology;
ulcers/ depending on position may be limited evaluate for concurrent anterior uveitis
perforation of iris and degree of
anterior uveitis present

Diabetic Acute or Normal Obscured Visualization of fundus Measure IOP; evaluate for lens-induced
cataracts chronic may be limited anterior uveitis

Glaucoma Acute Abnormal (mydriatic) Obscured Visualization of fundus Evaluate for concurrent ocular conditions
(acute) may be limited (eg, uveitis, lens luxation) that would
indicate that glaucoma is secondary

Glaucoma Acute or Abnormal (mydriatic) Variably affected Optic nerve recessed or Evaluate for concurrent ocular conditions
(chronic) chronic atrophic (eg, uveitis, lens luxation) that would
indicate that glaucoma is secondary

Intraocular Acute or Normal or abnormal, Obscured Visualization of fundus Consider systemic blood pressure and
hemorrhage chronic depending on etiology may be limited ocular ultrasound

Ocular Acute or Normal or abnormal Variably affected Visualization of fundus Consider ocular ultrasound and
neoplasia chronic may be limited measure IOP

Optic neuritis Acute Abnormal Usually normal, Optic nerve raised, swol- Pursue MRI/CT, CSF analysis, systemic
(acute) unless there len, or hemorrhagic (optic inflammatory/neoplastic disease
is concurrent disc); may be unremark- workup + neurologic examination
anterior uveitis able if retrobulbar optic
nerve is solely affected

Optic neuritis Acute or Abnormal Usually normal Optic nerve recessed or Pursue electrophysiologic testing, MRI/
(chronic) chronic atrophic CT, CSF analysis, systemic inflammato-
ry/neoplastic disease workup

Progressive Gradual onset Normal or abnormal Usually normal; Tapetal hyperreflectivity Consider genetic testing in purebred
retinal cataracts often dogs
atrophy develop over time

Retinal Gradual onset Abnormal Usually normal Tapetal hyperreflectivity, Complete ophthalmic examination and
degeneration (usually) retinal vascular history (Toxins? Antibiotics? Medica-
attenuation tions? Historical ophthalmic disease?)

Retinal Acute Abnormal Usually normal, Retina edematous, Consider ocular ultrasound; measure
detachment unless there is displaced anteriorly; systemic blood pressure; consider
hemorrhage or hemorrhage may be systemic/vascular/inflammatory/
anterior segment present; visualization of neoplastic disease workup
involvement fundus may be limited

Retinitis Acute Abnormal Usually normal Normal Pursue electrophysiologic testing

SARDS Acute Normal or abnormal Normal Initially normal; tapetal Pursue electrophysiologic testing
hyperreflectivity and
vascular attenuation
develop over time

Uveitis Acute Abnormal (miotic) Obscured Visualization of fundus Evaluate for presence of concurrent
(severe) may be limited ophthalmic disease (cataract); measure
IOP; consider systemic inflammatory/
neoplastic disease workup
CSF = cerebrospinal fluid; CT = computed tomography; IOP = intraocular pressure; MRI = magnetic resonance imaging; PLR = pupillary light reflex;
SARDS = sudden acquired retinal degeneration syndrome

tvpjournal.com | November/December 2016 | An Official Journal of the NAVC | TODAY’S VETERINARY PRACTICE 21
 Peer Reviewed DIAGNOSING ACUTE BLINDNESS IN DOGS

first, followed by decreasing day vision and then

TABLE 3.
complete blindness. In both advanced PRA and
Lesions Obscuring the Visual Axis &
SARDS, vascular attenuation and diffuse tapetal
Resulting in Acute Blindness
hypereflectivity develop; a dog with SARDS, though,
Anterior lens luxation
Corneal ulcers or perforation has a normal fundus initially and becomes acutely
Diabetic cataracts blind. Physical evidence of retinal degeneration
Glaucomaa (tapetal hyperreflectivity and vascular attenuation)
Intraocular hemorrhage
Severe uveitisb develops over time in SARDS patients.
a. Generally manifests with episcleral injection, corneal
Tapetal hyporeflectivity (dull tapetal appearance) is
edema, and mydriasis seen with chorioretinal inflammation. Since much of
b. Recognized by presence of episcleral injection, corneal
edema, aqueous flare, fibrin, and miosis the retina must be inflamed for obvious vision loss to
be present, diagnosis is often easily made by fundus
If the optic nerve is raised, swollen, or examination.
hemorrhagic, optic neuritis is a likely diagnosis. A
variety of infectious or inflammatory diseases and Ocular Ultrasound
neoplastic processes may result in optic neuritis, If the fundus cannot be visualized due to vitreal
which usually manifests with an acute onset of hemorrhage or inflammation, an ocular ultrasound
marked vision loss. Once diagnosed, neurologic should be performed to assess for conditions that
evaluation should be pursued as other neurologic result in ocular hemorrhage: retinal detachment and
deficits often are present concurrently. ocular neoplasia.
Conversely, if the optic nerve is recessed or
atrophic, the changes present are chronic. This Blood Pressure Measurement
condition can occur due to damage from chronic If retinal detachment is identified—either by fundus
glaucoma, retinal degeneration, or chronic optic examination or by ultrasound—or if posterior
neuritis. Optic nerve disease carries a guarded to poor segment hemorrhage is present, systemic blood
prognosis for vision return. pressure should be measured. As a result of increased
hydrostatic pressure in the vasculature, systemic
Retina hypertension can cause fluid accumulation in the
Examination of the retina should include both subretinal space, which displaces the retina into the
the tapetal and non-tapetal regions and the retinal vitreal chamber, resulting in retinal detachment.1,4
vasculature. The appearance of the tapetal fundus Retinal detachments can also occur:
should be carefully evaluated, particularly its • With congenital or developmental disorders (eg,
reflectivity. collie eye anomaly)
Generalized tapetal hyperreflectivity (excessively • Secondary to inflammatory disease (eg,
shiny tapetal appearance) indicates retinal thinning chorioretinal inflammation), vitreal degeneration,
and degeneration, which can be associated with: cataracts, or lens luxation
• Gradual onset of vision loss, as found with • As a complication of intraocular surgery (eg,
progressive retinal atrophy (PRA) following cataract surgery).
• Acute onset of vision loss, as found with sudden
acquired retinal degeneration syndrome (SARDS). Electrophysiologic Testing
Dogs with PRA generally lose night vision If the fundus appears normal and the animal is
avisual, especially if vision loss was acute, consider
CARYN E. PLUMMER the following retinal conditions:
Caryn E. Plummer, DVM, Diplomate ACVO, is an associate professor • SARDS (as hyperreflectivity occurs over time)
in comparative ophthalmology at University of Florida College of
• Retinitis (typically immune-mediated)
Veterinary Medicine, where she also serves as chief of the compar-
ative ophthalmology service. Her research interests include corneal • Cortical disease
wound healing and glaucoma, and she has lectured extensively— • Retrobulbar optic neuritis (optic disc appears
both nationally and internationally—on many topics associated with
normal but retrobulbar optic nerve is affected).
clinical veterinary ophthalmology and animal models of ophthalmic
disease, especially glaucoma. Dr. Plummer received her DVM from These conditions can usually be differentiated with
University of Florida; then she completed an internship in small an- PLRs and electrophysiologic testing. Abnormal PLRs
imal medicine and surgery at Michigan State University and a resi-
are typically associated with retinal or optic nerve
dency in comparative ophthalmology at University of Florida.
disease and normal PLRs with cerebral cortical disease.

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 DIAGNOSING ACUTE BLINDNESS IN DOGS

Electroretinogram
Sometimes a normal PLR is present with retina
and optic nerve disease, even if the animal is
avisual. An electroretinogram (ERG) can be used
to differentiate vision loss due to retinal disease
(abnormal ERG result) from vision loss due
to disease of the optic nerve or cerebral cortex
(normal ERG result).3

Further Diagnostic Testing

Animals with cortical or optic nerve blindness
should be evaluated with:
• Magnetic resonance imaging or computed
tomography
• Cerebrospinal fluid analysis
• Generalized workup for systemic inflammatory
or neoplastic diseases.
In addition, a normal ophthalmic examination
should prompt consideration of the central
nervous system as the primary site of disease,
especially when the PLRs are normal.

IN SUMMARY
Acute vision loss in the dog is generally
considered an emergency and warrants prompt
evaluation by a veterinarian to confirm vision
loss, localize the causative lesion, and institute
therapy. In some cases, prompt medical treatment
will result in return of vision. Delayed care
carries a poor prognosis for sight and may delay
diagnosis of a significant systemic condition.

ERG = electroretinogram; PLR = pupillary

light reflex; PRA = progressive retinal atrophy;
SARDS = sudden acquired retinal degeneration
syndrome

References
1. Webb AA, Cullen CL. Neuro-ophthalmology. In
Gelatt KN (ed): Veterinary Ophthalmology, 5th ed.
Ames, IA: Wiley-Blackwell, 2013, pp 1820-1896.
2. Webb AA, Cullen CL. Ocular manifestations of
systemic disease: The dog. In Gelatt KN (ed):
Veterinary Ophthalmology, 5th ed. Ames, IA: Wiley-
Blackwell, 2013, pp 1897-1977.
3. Ekesten B. Ophthalmic examination and
diagnostics: Electrodiagnostic evaluation of vision.
In Gelatt KN (ed): Veterinary Ophthalmology, 5th
ed. Ames, IA: Wiley-Blackwell, 2013, pp 684-702.
4. Ofri R. Retina. In Maggs DJ, Miller PE, Ofri
R (eds): Slatter’s Fundamentals of Veterinary
Ophthalmology, 4th ed. St. Louis: Saunders, 2008,
pp 285-317.

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