Coping With Dry Eyes or a KCS Diagnosis in Dogs
Puppy Girl Before the Advent of KCS
To Continue Our Story . . .
This is my personal experience with discovering that my beloved miniature schnauzer had developed a condition called Keratoconjunctivitis Sicca, or "dry eye." It has been a long journey, with many visits to the veterinarian and some difficult decisions about medical care. Along the way, I learned volumes about this condition, available treatments, and how to help keep a dog comfortable when they have it.
I divided my story into two separate articles: (1) what happened leading up to my dog's diagnosis, and (2) this one—how we learn to live with the disease. I used the word "we" in that last phrase because both Puppy Girl and I were required to make adjustments.
If you have to contend with KCS, I hope you'll find some support by reading both of these articles. Even if your dog does not have the disease, it's helpful to learn about canine disorders that may affect many breeds.
The Aftermath of a KCS Diagnosis
When I next took Puppy Girl to the vet clinic (sooner than her scheduled appointment because her eyes still looked very bad), treatment with the cyclosporine drops was not stimulating her lacrimal glands to produce sufficient tears, and the secondary infection was lingering. Sometimes she could barely open both eyes; at other times, only one.
The examining vet, Dr. Thrash, agreed there was no real improvement and said she considered this case "one of the worst I’ve seen . . .”. She felt justified continuing the PNB ophthalmic antibiotic ointment to alleviate the persistent secondary infection, while changing from cyclosporine drops to tacrolimus, a drug with the same mechanism but 100 times more potent. This newer canine medication had shown success when used for dogs that didn't respond to cyclosporine. Because my dog's eyes were so very dry, Dr. Thrash didn't want to wait a few weeks to discover whether or not the cyclosporine would begin working.
In addition, she asked if I'd like for her to refer Puppy Girl to a veterinary ophthalmologist. She said that when dogs don't respond to treatment, there's a surgical procedure that re-routes the salivary gland to the eye. Saliva isn't a perfect "fix" to lubricate and clean the eye, and the procedure has its drawbacks, but should be kept in mind "just in case." I agreed, and she made the appointment for us.
Puppy Girl and I went home with the two meds, and she went straight to her soft floor pillow to recover from vet clinic-induced "trauma." I put her special CD of soothing slow-tempo music on to play. It was developed to calm nervous dogs, and I play it for her a lot these days. Meanwhile, I headed for the computer.
Whenever a new diagnosis or prescription drug is introduced into my family—and when I use the word “family” I include myself, my immediate and extended family, close friends, and, yes, my dog—I spend time researching reputable medical sites for as much information as possible about the medical issue, potential complications, long-term prognosis, drugs prescribed and their possible side effects, and other available options. I’m teased about my research proclivities, but I feel more secure when I'm armed with the knowledge to make sound decisions during what may be an emotional time.
I’d already researched KCS and cyclosporine. I wasn’t pleased about using the cyclosporine, because it’s a canine ophthalmic version of the drug used for humans to prevent rejection of organ transplants. Its mechanism for doing so suppresses the immune system—specifically inhibiting T-cell proliferation and preventing the release of pro-inflammatory cytokines. T-cells are like policemen that patrol the body to stop invading bacteria, other pathogens, and abnormal body cells. The latter may later develop into cancer without the intervention of T-cells.
In other words, this drug that stimulates tear production to some extent in 80% of dogs treated may also suppress the dog’s natural ability to fight off dangerous infections. Although most of the sites recommending use of either cyclosporine or tacrolimus state that very little is absorbed into the bloodstream, excuse me if I’m skeptical about that claim. I’ve witnessed the recall of too many drugs by the FDA because of serious side effects (including death, which I consider very “serious” indeed). Often these dangerous drugs were allowed to remain "approved" far too long before the recall.
One prominent veterinarian with a Ph.D. wrote on his website that there is no reason to believe the use of cyclosporine and tacrolimus will not cause health issues with dogs in the long term just as they occur in humans, i.e., cancer (particularly lymphoma and skin cancer), kidney disease, liver disease, infections such as bacterial pneumonia, and the virus that causes warts.
The reason I paid close attention to his article was because, within a week of cyclosporine administration to Puppy Girl’s eyes, she developed a lesion just above one eye that looks like a wart. It wasn’t visible through her long schnauzer eyebrows (the “awning”, as I often refer to them), but those eyebrows had to go.
Puppy Girl Gets a New Look
Those Schnauzer hallmarks—the eyebrows, long eyelashes, and the hair on her face—were all obscuring the treatment area and making it difficult not to spill medication into the hair and on her skin (not good). I made the decision to have her face completely shaved to facilitate administering meds to her eyes.
In fact, Puppy Girl got a complete body shave. She no longer looks like a mini schnauzer, but instead appears to be a “new” breed of short-haired terrier with a distinctive facial coloration. This type of haircut is going to be high-maintenance—just another in the series of “things to do” on a regular basis from now on. Her hair grows very quickly. In the interest of saving money on grooming visits (and I certainly need to save it somewhere with all the vet bills), I should learn to do it myself. (That’s one more “thing to do,” but I’m going to sleep on the thought for a while.)
I must admit, I got a bit teary when her hair was first cut, so drastically changing her gorgeous schnauzer “look,” but I soon grew accustomed to her new appearance. The shaved hair definitely makes it easier to apply medications, so it serves its purpose. I never realized how well-shaped her face is under all that hair. She's still beautiful to me!
I used the tacrolimus ophthalmic drops for about a week, and they seemed to be helping some—not much, but my dog's eyes looked better for about an hour after application, so I assumed the medication was stimulating some tear production. I still had to put frequently, day and night. Between 11:30 or midnight, when she was "doctored" for the last time before I went to sleep, and her normal wake-up time of 7:00 a.m., her eyes were "glued" shut and had to be gently cleaned with warm water and a soft cloth first thing in the morning. Even after one drop of tacrolimus in each eye, it was several hours (and more GenTeal ointment) before she opened her eyes fully and faced the light. GenTeal lubricant in her eyes
I continued to read about cyclosporine and tacrolimus. I thought about possible long-term side effects. I thought about the much greater potency of tacrolimus versus cyclosporine. I worried. (Did I mention I'm a world-class worrier?)
Then something happened that "stirred the pot" and made the whole situation worse.
Pet Insurance Debacle
I'm old enough to remember the old black-and-white TV sitcom from the mid-century (the twentieth, that is), "The Life of Riley", starring the late William Bendix. One of the character's favorite sayings when faced with problematic issues—of which there were many in every episode—was, "What a revolting development this is!"
I knew just what Riley meant the day I opened an envelope from the pet insurance company that took my $51.88 premium each month. They had already denied other claims after arbitrarily attaching a "secondary diagnosis" of "allergy," even though the vet sent statements to the contrary and I appealed . . . simply because my dog once had dermatitis due to one flea bite! She's never had another flea on her since, or experienced insect bite dermatitis, and the problem in question had nothing to do with an insect bite of any kind. I was already not happy with this insurance carrier, but I thought, "At least, they can't call KCS a pre-existing condition since she was only recently diagnosed, and she'll have coverage from here on out."
They didn't. They just paid me a very small amount of one claim (after the $50 deductible for each incident) and informed me I'd reached the maximum payout. Since I thought the annual maximum (minus deductibles) was $14,000, I called and asked a customer service agent what the explanation of benefits meant. That's when I learned for the first time—as there was no information about it in the policy I was sent—that this company establishes maximum annual amounts payable for a long list of dog illnesses. With KCS, this limit was $120—less than one visit to the vet clinic!
Since it was obvious this policy was worthless, and KCS would now be considered a pre-existing condition if I tried to change carriers to get a better one, I cancelled the policy. I decided to put the amount of the monthly premium toward her vet and medication expenses, as well as save some extra each month for Puppy Girl's future "health expenses fund."
Now that I didn't have any pet health insurance at all (instead of just having worthless pet insurance for which I was paying too much), the appointment with the veterinary ophthalmologist loomed large. I'd already had second thoughts about taking PG to see this specialist, anyway. After the appointment was confirmed, I spent a couple of hours reading an online forum about the topic of KCS and the parotid duct transposition, the surgical procedure PG's vet had mentioned as a "last resort" if the meds didn't work. The forum thread began in 2006 and continued through mid-2012, with pet parents weighing in on meds, treatments and—especially—the effectiveness (or not) of re-routing a dog's salivary glands to serve as substitute tears.
The general consensus (there was only one person on the forum whose dog had a "successful" parotid duct transposition) was "Don't do it unless the dog is in terrible, unceasing pain and losing one or both eyes!" Everyone (with that one exception) whose dog had undergone the surgery required near-constant cleaning of the face. Any time it smelled or ate food, the salivary glands dumped liquid in the eyes, and it poured down the dog's face. Formation of salt crystals over the cornea was anything but rare—they were practically a given. These hardened crystals required more surgery to remove, often multiple times in a dog's life. The clincher was that the dog would still need lubricants or drops all through the day and night because saliva is not as effective as real tears to clean or condition the eyes.
Thus, my mind was already made up against the surgery, especially since there was slight improvement from using the tacrolimus. Many people on the forum said not to give up too quickly on cyclosporine. It sometimes took up to twelve weeks or more to "kick in." One woman wrote that her beautiful collie developed a cancer after taking tacrolimus a few months. That information helped me with my other decision.
Okay, this is what I would do: (1) I'd cancel Puppy Girl's appointment with the specialist. (2) I'd stop using tacrolimus immediately and switch back to the cyclosporine (not as strong as the former, so perhaps more safe for longer-term use). It seemed logical to me that, with the start Puppy Girl's tear production had experienced from the week of tacrolimus treatment, use of the cyclosporine might keep the tear duct stimulation going.
And that's exactly what happened. I switched that day, and within two days could be sure there was no difference at all. My dog's eyes still didn't have a normal amount of tears, and the cornea still looked somewhat cloudy, but they were better than before treatment began. That level of improvement was stationary at that time.
I gathered up my courage and e-mailed the vet who referred PG to the specialist, telling her of both my decisions, as well as the fact that I no longer have pet insurance and why. She was very understanding. The vets who normally care for Puppy Girl, Dr. Thrash and Dr. Camp, are terrific veterinary professionals who truly care for their patients—and their patients' humans.
Puppy Girl will be returning to the vet clinic soon for a checkup. She may be placed on a regular schedule of visits to ensure her corneas don't scar or any other major problem threaten her eyesight.
She rarely acts as though she's in pain—only sometimes right after awakening in the morning. I can tell when she's in discomfort because she will whimper ever so slightly when preparing for the cyclosporine treatment. I have to strain to hear it, but after the initial sting of the drops (the medication is compounded in a base of olive oil), she begins to open her eyes wider within the next half hour and acts as though she's more comfortable. I'm trying to get accustomed to routinely waking at 3:00 a.m. to put more GenTeal ointment in her eyes. You see, her eyes don't close tightly when she sleeps, and the ointment obviously evaporates before morning.
Just like me. You see, I can understand what she's going through because I have blepharospasm, and a surgical procedure I had for that condition 20 years ago keeps my eyes from closing tightly when I sleep also. Every night before I turn out my bedside light, I use an ophthalmic ointment. Just like Puppy Girl. I switched from the brand GenTeal for my personal use to Refresh P.M. to avoid the possibility of getting our respective tubes mixed up and causing cross-contamination.
They say that dogs and owners who live together a long time often grow to look alike. With my hair graying, I already share that characteristic with Puppy Girl. Now we have similar eye conditions. This is a true story. You couldn't make up something so bizarre!
I know from personal experience what it is like to live with an incurable, though treatable, medical disorder. The paramount lesson I learned is that something which seems devastating and insurmountable in the early stages eventually begins to seem like just another part of your life. The adjustments that feel so difficult at first become much easier as time goes by.
I expect Puppy Girl's KCS to follow the same path—for me, at least. I'm already adjusting to the changes her eye disorder made in our lives, and observation leads me to believe she's accepting the changes, too. She seems more resigned to her treatments, and she's stopped hiding from me. When she "asked" for a tummy rub, that was icing on the cake. It would be great if I could end this story with a totally happy ending that included a cure. Since that isn't possible, I want readers to realize that it still ends on a positive note. My girl is closer now to her pre-KCS behavior, and I'm feeling more confident about caring for her chronic disorder. We're going to be okay!
A Cool Compress Apparently Feels Good in the Morning
Relaxed Too Soon . . .
So much for my optimism! After three months, Puppy Girl's regular vet determined that her lacrimal glands were not being stimulated by the drops that were supposed to make tears. She was referred to an ophthalmology veterinarian, and I told him on our first visit that I would not consider the surgical procedure. Although tests showed she still had no tears, he prescribed a combination of cyclosporine and tacrolimus to be put in her eyes daily (one drop each eye) to prevent inflammation. Her KCS is not "curable," but he reassured me that he uses these drops with many dogs suffering from the condition and has seen no ill effects from the medication's use. The "jury is still out" with me, but I'm using it for now.
At the specialist's instruction, I continue to place GenTeal nighttime lubricant in her eyes periodically throughout the day and evening until after midnight. It is obvious that the thick ointment blurs her vision, but it protects her cornea and prevents painful corneal abrasions. Therefore, our schedule (Puppy Girl's and mine) remains established for life, with routine veterinary checkups of her eyes. I searched online to find the best price (with free shipping and no tax) for the ointment because the tubes are very small and are emptied in two or three days.
She's worth it.
Puppy Girl Loses Her Vision
In the summer of 2013, after a year of chronic KCS, Puppy Girl lost her eyesight. In spite of a strict regimen of frequently cleaning mucous from her eyes and applying Genteal P.M. eye ointment to both eyes no less than every two hours day and night, she was diagnosed with scar tissue on her corneas and rapidly progressing blindness. This was heartbreaking for me, but I determined to do everything possible to help her adjust. You can read my account of how Puppy Girl reacted to going blind and her ongoing adjustment.
Her regular vet discussed potential bilateral enucleation (removal of both eyes) to ensure that she doesn't have any pain. This is a very difficult decision for a pet parent to make. The very thought of having her eyes removed is traumatic to me, but not as much as if she weren't already blind. I've read accounts of the benefits of enucleation (which is used for a variety of diagnoses) on a support website for people with blind dogs, and they're encouraging.
Thanks to my readers for your kind comments and for caring about dear Puppy Girl!
This article is accurate and true to the best of the author’s knowledge. It is not meant to substitute for diagnosis, prognosis, treatment, prescription, or formal and individualized advice from a veterinary medical professional. Animals exhibiting signs and symptoms of distress should be seen by a veterinarian immediately.
© 2012 Jaye Denman