Vet Clin Equine 20 (2004) 285–299

Equine ocular anatomy and

ophthalmic examination
Susan M. Carastro, DVM, MS
Animal Eye Specialty Clinic, 3421 Forest Hill Boulevard,
West Palm Beach, FL 33406, USA

This article is intended to provide the practitioner with a succinct but

complete source regarding equine orbital and ocular anatomy, instrumen-
tation available for ophthalmic examination, a methodical examination
technique, sedation and regional nerve blocks, and diagnostic procedures
involving the eye. Such knowledge of orbital and ocular anatomy is essential
to allow recognition of normal, normal variations, or an abnormality of the
equine eye and orbit.

Anatomy
Equine orbit
The equine orbit is closed laterally and completely encircles the globe,
with a bony rim. The bones that comprise the orbit are the frontal, lacrimal,
zygomatic, temporal, palatine, and sphenoid. The orbital rim consists of the
frontal bone superiorly/nasally containing the supraorbital foramen, lacri-
mal bone nasally, zygomatic bone inferiorly, and zygomatic process of the
temporal bone completing the orbit temporally. The palatine and sphenoid
bones form the medial wall of the orbit. The orbital floor is soft tissue
consisting mostly of fat and resting on the pterygoid muscles. Approximate
dimensions of the orbit are 62 mm wide  59 mm high  98 mm deep [1] but
may vary depending on the breed and size of the horse. Approximate globe
dimensions are 42 to 44 mm from the anterior to posterior axis, 45 to 50 mm
vertically, and 50 to 54 mm horizontally [2]. The orbital space contains the
globe, third eyelid, extraocular muscles, nerves, vessels, lacrimal gland, and
fat. Foramina within the orbital bones allow vessels and nerves to traverse
from the cranial cavity to the orbit. The alar or rostral foramen contains the

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286 S.M. Carastro / Vet Clin Equine 20 (2004) 285–299

maxillary artery and nerve. The ethmoidal foramen permits passage of the
ethmoidal vessels and nerve. The oculomotor (cranial nerve III), trochlear
nerve (cranial nerve IV), ophthalmic branch of the trigeminal nerve (cranial
nerve V), and abducens (cranial nerve VI) travel through the orbital
foramen to reach the orbit. The optic nerve (cranial nerve II) and internal
ophthalmic artery enter the orbit through the optic foramen.
The extraocular muscles facilitate movement of the globe. The rectus
muscles include the superior, inferior, medial, and lateral recti, which tether
the globe within the orbit and are capable of moving the globe in their
respective directions. The superior oblique attaches to the superior/lateral
aspect of the globe, rotating the superior portion of the globe inferiorly and
nasally. The inferior oblique muscle attaches to the inferior/lateral aspect of
the globe, moving the globe superiorly and nasally. The retractor bulbi
muscle consists of four muscle bellies withdrawing the globe posteriorly. The
retractor bulbi muscle is one of the largest extraocular muscles, or at least it
seems so when evaluating a horse with a painful eye. Origination of the
muscle is from the posterior orbital wall, and insertion is to the posterior
sclera. Innervation of the superior, inferior, medial rectus, and inferior
oblique muscles is via the oculomotor nerve. The superior oblique is
innervated by the trochlear nerve and the lateral rectus, and retractor bulbi
are innervated by the abducens nerve.

Eyelids
The eyelids comprise haired skin, subcutaneous tissue, the tarsal plate,
the orbicularis oculi muscle, the levator palpebrae superioris muscle,
Mueller’s muscle, and the palpebral conjunctiva from exterior to interior.
Specialized structures in the lid margin are the meibomian glands and glands
of Zeiss. The tarsal plate is an area of dense connective tissue lending rigidity
to the eyelid margins. The meibomian glands are oriented perpendicular to
the superior and inferior eyelid margin. The lipid layer of the tear film is
a product of the meibomian glands. There are approximately 40 to 50 glands
in the superior and inferior lids, with a few more glands located in the
superior lid. The gray line or openings of the glands are visible along the lid
margin. The glands of Zeiss are sebaceous glands associated with periocular
cutaneous hair follicles. Numerous stiff hairs or vibrissae are located
beneath the lower lid, and a few vibrissae are noted in the eyebrow
superiorly. The facial nerve innervates the orbicularis oculi muscle, which is
responsible for eyelid closure. Elevation of the superior lid is accomplished
by the levator palpebrae superioris muscle, which is innervated by the
oculomotor nerve. The corrugator supercilii muscle, innervated by the facial
nerve, assists in elevation of the nasal aspect of the superior lid (brow
muscle). Evaluation of the lids should include the cutaneous, marginal, and
conjunctival surfaces. Examination of the lids should begin by studying the
symmetry, palpebral fissure size, position, blink response (frequency and
 S.M. Carastro / Vet Clin Equine 20 (2004) 285–299 287

excursion), and eyelid defects. Magnification using a loupe or otoscope

head may be useful in detailed evaluation for distichia, masses, or foreign
bodies.

Nasolacrimal/lacrimal
The nasolacrimal duct comprises the superior and inferior puncta located
adjacent to the medial-most meibomian gland. Punctal openings may be
identified as small slits in the palpebral conjunctiva, often adjacent to the
pigment boundary. The superior and inferior canaliculi extend from their
respective puncta, joining at the lacrimal sac. The lacrimal sac is located in
a depression in the lacrimal bone. The distal portion of the nasolacrimal
duct originates from the lacrimal sac, traverses through the maxilla, and
exits through the nasal orifice or distal punctum. The nasal orifice may be
identified adjacent to the mucocutaneous junction on the nasal aspect of the
vestibulum floor 5 to 7 cm from the nares. In mules, however, the distal
punctum may be on the nasal septum or even behind the alar cartilage.
The tear film is a trilaminar substance responsible for cleansing the ocular
surface, lubrication, supplying nutrition to the avascular cornea, and
providing secretory/local immunity. Components of the tear film include
mucin produced by goblet cells, the serous secretion from the lacrimal gland
and the gland of the nictitans, and the lipid layer from meibomian glands.
Dry eye in the horse has been described as a tear-deficient state and an
evaporative disease [3]. Keratoconjunctivitis sicca (KCS) is an uncommon
finding in the horse, but should be suspected when a dull corneal surface,
mucoid to mucopurulent discharge adherent to the corneal surface or to the
periocular hair, blepharospasm, and persistent corneal ulceration are
present. The Schirmer tear test may be performed to diagnose KCS
definitively. Tear testing should be performed before application of any
fluid or ointment substances because this interferes with test results. The
Schirmer tear test is performed by placing a Schirmer tear test strip into the
inferior conjunctival fornix for 1 minute. The tear strip should be placed in
the lateral one third of the inferior fornix, and the notch of the tear strip
should be at the eyelid margin. Test results are a measurement of the reflex
tearing caused by irritation of the tear strip to the ocular surface and of
basal tear secretion. Tear production of 11 to 30 mm/min is considered
normal in the horse [4]. Considering the wide range published for normal
tear values in the horse, most normal horses have a Schirmer tear test result
greater than 20 mm/min. The most common cause for dry eye in the horse is
neurogenic [5]. It is surprising that dry eye is not diagnosed more commonly
in the horse, with removal of the nictitans being performed frequently.
Fortunately, the gland of the nictitans in the horse seems to be responsible
for a lower percentage of tear production than documented in other
domestic animals. The evaporative form of dry eye may occur in hot dry
climates or may be associated with eyelid defects or facial nerve palsy. A
288 S.M. Carastro / Vet Clin Equine 20 (2004) 285–299

high index of suspicion is generally stimulated by recurrent ulceration,

epiphora, and increased blinking or blepharospasm. Evaporation or poor
spreading of the tears results in corneal desiccation. Corneal lesions may be
identified by close scrutiny for dry spots or using rose bengal staining.
Further details of the tear film are presented elsewhere in this issue.

Conjunctiva/third eyelid
The conjunctiva is a simple continuous folded surface consisting of the
palpebral conjunctiva, bulbar conjunctiva, and conjunctiva of the nictitans.
Palpebral conjunctiva lines the posterior surface of the eyelids, reflecting at
the conjunctival fornices and continuing loosely over the globe as bulbar
conjunctiva. Conjunctiva of the nictitans covers the cartilage of the third
eyelid. The conjunctiva consists of nonkeratinized surface epithelium, goblet
cells, Tenon’s capsule, and spongy connective tissue. A high concentration
of goblet cells occurs in the inferior conjunctival fornices. The conjunctiva is
a resilient and highly regenerative structure used frequently to treat globe
and vision-threatening corneal diseases. Conjunctival flaps are transposed
and sutured to the corneal surface for support and vascular perfusion of
lesions.
Evaluation of the conjunctiva should reveal a smooth glistening surface.
Irregularities, imperfections, thickening, and hyperemia of the conjunctiva
are noteworthy. Conjunctivitis is a common diagnosis but should always
stimulate further investigation as to the initiating cause of the inflammation.
Primary diseases of the conjunctiva include foreign bodies, parasites, dry
eye, viral disease, neoplasia, trauma, or allergic conditions. Secondary
conjunctivitis may occur with keratitis, uveitis, and glaucoma; in such cases,
therapy for the conjunctivitis is less critical than identification and treatment
of the underlying cause.
The third eyelid or nictitans is composed of a T-shaped cartilage covered
by conjunctiva. Lymphoid follicles are located on the posterior surface of
the nictitans, and the gland of the nictitans is positioned at the base of the T-
shaped cartilage. The function of the third eyelid is protection of the globe,
spreading of the tears, and removal of foreign material from the corneal
surface. The leading edge of the nictitans may have variable amounts of
pigmentation. Horses with a paucity of pigmentation are at increased risk
for solar-induced pathologic conditions. The position of the nictitans as well
as its texture and color should be scrutinized for any irregularity or a
cobblestone appearance. Evaluation of the space between the posterior
surface of the nictitans and cornea should be visually conducted if persistent
discharge, conjunctival hyperemia, or blepharospasm is a presenting clinical
sign. Examination may be performed with the aid of topical anesthesia and
thumb forceps to grasp the leading edge of the nictitans to prolapse it fully
from the globe.
 S.M. Carastro / Vet Clin Equine 20 (2004) 285–299 289

Cornea
The cornea has the highest refractive power of the eye because of its
location between the intraocular fluid interface and air on the anterior
surface. Corneal durability is constantly being challenged by bombardment
of toxins, allergens, foreign bodies, bacteria, fungi, and viruses. Corneal
clarity relies on a regular arrangement of the corneal lamellae. The cornea is
approximately 1 mm thick, and its lamellar structure has been likened to the
layers of an onion. If the corneal lamellae have equal width and travel in
the same direction, light rays pass through the cornea without scattering. If
the layers of the cornea are disorganized, the resultant scatter of light causes
a corneal opacity. The lipophilic corneal epithelium, 10 to 15 cell layers thick
in the horse, is the outermost layer of the cornea. The basement membrane
of the corneal epithelium attaches epithelial cells to the underlying stroma.
The hydrophilic corneal stroma is responsible for approximately 90% of the
corneal thickness. Descemet’s membrane is the basement membrane for the
innermost layer of the cornea, the endothelium. Descemet’s membrane
thickens as new layers of basement membrane formation occur with age.
The lipophilic endothelium has an active sodium/potassium pump creating
deturgescence or relative dehydration of the corneal stroma. The circum-
corneal gray line noted at the limbus is the attachment of pectinate
ligaments to the endothelium, representing the opening into the drainage
angle, which may be better appreciated with magnification.
Evaluation of the cornea should be performed in a dark room with a bright
light source from several angles. Magnification is helpful to identify smaller
lesions. The cornea should be evaluated for clarity, luster, and defects. Stains
commonly used to evaluate the integrity of the corneal epithelium and health
of the corneal surface include fluorescein and rose bengal. Fluorescein
staining is an essential diagnostic aid and should be performed on any painful
red eye. Fluorescein’s water-soluble properties result in absorption of the
stain by exposed corneal stroma, and fluorescein staining can indicate a full-
thickness corneal epithelial defect. Peak excitement or fluorescence is
facilitated with a cobalt blue filter. Thus, the use of cobalt blue lighting is
optimal when evaluating the cornea for fluorescein retention. Rose bengal
stain may be used as a secondary stain but should not be used routinely on all
eyes, because irritation may occur for up to 24 hours after instillation.
Identification of partial-thickness epithelial lesions or tear film deficiencies is
facilitated with rose bengal staining. In particular, viral keratitis and early
fungal keratomycosis may be more easily recognized as rose bengal–positive
lesions. Evaluation for rose bengal dye retention should be performed with
a bright white light in dim lighting. Lissamine green is a similar stain,
originally used to evaluate dry eye in people. It is uncommonly used at this
time in veterinary medicine and may also be toxic to the corneal epithelium.
Indications would include identification of partial-thickness or subtle corneal
disease, and staining should be evaluated with a bright white light.
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Anterior uveal tract (iris and ciliary body)

The anterior uveal tract consists of the iris and ciliary body. The iris is
divided by the collarette into a pupillary zone and peripheral ciliary zone.
Components of the iris include a sphincter muscle, dilator muscle, vascula-
ture, posterior pigmented epithelium, stroma, and varying numbers of
melanocytes. Innervation of the sphincter muscle for pupillary constriction
is via the parasympathetic portion of the oculomotor nerve. Sympathetic
nerves innervate the dilator muscle, controlling pupillary dilation. The iris
vasculature is supplied by long posterior ciliary arteries entering the iris at the
9- and 3-o’clock positions and traveling circumferentially around the iris
periphery, creating the major arterial circle. Closer to the pupillary margin lies
the minor arterial circle, which is more easily identified in blue irides.
Prominence of the posterior pigmented iris epithelium or corpora nigra is
noted superiorly on the anterior rim of the pupil, but smaller excrescences may
be noted inferiorly. Corpora nigra or granula iridica should be evaluated for
hyperplasia and cyst formation, which may obstruct vision by compromising
the pupillary aperture, especially when the pupil is constricted. Absence of the
corpora nigra may be congenital or traumatic or may imply atrophy from past
uveitis. The pupil is oblong and longer in the horizontal meridian than in the
vertical meridian, with a wider opening nasally. A circular pupil is generally
noted in the foal. Iris color may vary but is generally a caramel brown. Blue
irides may occur in color-dilute animals, and a combination of colors in the
same eye, known as heterochromia iridium, is considered a normal variation.
The ciliary body located directly behind the iris is divided into the pars
plicata anteriorly and pars plana posteriorly. Approximately 100 ciliary
processes extend into the posterior chamber to make up a portion of the
pars plicata. The processes consist of a core pigmented epithelium covered
by nonpigmented epithelium exteriorly. Ciliary body epithelial cells produce
aqueous humor for nourishment of the avascular lens and cornea. The
zonules attach at the lens equator and insert between the ciliary processes to
stabilize lens position. Smooth muscle of the ciliary body is located beneath
the ciliary processes in the pars plicata. Innervation of this circumferential
muscle is via parasympathetic nerve fibers from the oculomotor nerve and
sympathetic nerve fibers. Accommodative ability is weak in the horse but is
performed by the ciliary musculature. The pars plana is a flat region of the
ciliary body transitioning to the retina. The innermost layer of the pars
plana, the nonpigmented epithelium, is continuous with the neurosensory
retina. The pigmented epithelium of the ciliary body is contiguous with the
retinal pigmented epithelium posteriorly.

Vitreous
The vitreous gel is the largest component of the eye. The gel is composed
of 99% water and 1% hyaluronic acid, hyalocytes, and collagen fibrils. The
 S.M. Carastro / Vet Clin Equine 20 (2004) 285–299 291

vitreous is a transparent gel that aids in retinal and lenticular support.

Condensations of the vitreous appearing as white filamentous fibers or
floaters are a common aging change. During gestation, the hyaloid artery or
primary vitreous extends from the optic nerve to the posterior lens capsule.
The vessel should completely regress by 6 to 9 months of age. Cloquet’s
canal is a residual sinusoid channel from the hyaloid artery visible in the
adult vitreous. An axial gray to white opacity on the posterior lens capsule,
Middendorf’s dot, marks the previous attachment of the hyaloid artery to
the posterior lens capsule. The secondary vitreous is the major portion of the
adult vitreous secreted by the retinal glial cells and ciliary body epithelium.
The tertiary vitreous or zonules attach to the equator of the lens capsule and
insert between the ciliary processes.

Fundus
Evaluation of the fundus should include the retina, optic nerve, and
choroid. The retina is 10 layers thick and firmly attached at the ora serrata
and the optic nerve head. Inner to outer retinal layers consist of the internal
limiting membrane, nerve fiber layer, ganglion cells, inner plexiform layer,
inner nuclear layer, outer plexiform layer, outer nuclear layer, external
limiting membrane, photoreceptor (including the rods and cones), and
retinal pigmented epithelium. Retinal pigmented epithelial cells do not
contain pigment where they overlie the tapetum. The retinal pigmented cells
inferiorly usually contain melanin, lending the homogeneous brown
coloration to the nontapetal fundus. The equine retina is paurangiotic,
indicating that retinal blood vessels only occur around the optic nerve.
Approximately 30 retinal arterioles and 30 retinal venules radiate 1.5 to 2
disk diameters from the optic nerve head, traveling in the nerve fiber layer.
The retina proper cannot be identified on ophthalmic examination, but
changes, including edema, cellular infiltrate, size of retinal vasculature, and
reflectivity of the tapetum, result in characteristic recognizable changes
indicative of retinal disease.
The choroid is the posterior extension of the vascular coat of the eye
joining the ciliary body at the ora serrata. Choroidal blood vessels are
responsible for nourishment of the retina. Choroidal vasculature consists of
larger vessels exteriorly adjacent to a medium-sized vessel layer interiorly.
The tapetum fibrosum is a specialized reflective layer of the choroid located
in the superior fundus. The tapetum is visible because the retinal pigmented
epithelial cells overlying the tapetum do not contain melanin. Tapetal color
may vary between yellow, green, and blue. The choriocapillaris is the
innermost layer of the choroid and is composed of a thin capillary network.
Choroidal vessels seen end-on are known as the stars of Winslow and may
be identified as dark spots visible in the tapetal fundus. The extent of
choroidal vasculature visible with fundic evaluation is dependent on coat
color. Color-dilute animals have less melanin in the retinal pigmented
292 S.M. Carastro / Vet Clin Equine 20 (2004) 285–299

epithelium and choroid and may have tapetal hypoplasia exposing variably
sized choroidal vessels. Choroidal vessels lend a red-striped or tigroid
appearance to the fundus that should not be mistaken for retinal
hemorrhage.
The optic nerve head is a salmon-colored oval structure in the inferior/
lateral portion of the nontapetal fundus. The optic nerve fibers enter the
globe posteriorly through the lamina cribrosa, a sieve-like structure in the
sclera. If myelination of the optic nerve head is limited, the lamina cribrosa
may be visible as a disorganized grid-like structure. Optic nerve fibers are
contiguous with the nerve fiber layer in the retina. Myelination of the optic
nerve fibers may extend into the retinal nerve fiber layer, imparting a white
feathering around the optic nerve head.

Instrumentation
A complement of instruments and supplies should be available at the time
of the ophthalmic examination. A bright halogen-based focused light
source, such as a Finoff transilluminator, is critical. The use of a loupe or
otoscope head for magnification is helpful to identify smaller lesions. These
two instruments are capable of allowing adequate evaluation of the eyelids
and anterior segment. Pupillary dilation with tropicamide 1% is necessary
to evaluate the lens and fundus completely. Slit-lamp biomicroscopy is
a more technical technique used to evaluate the anterior segment. Portable
slit lamps include the SL-14 and SL-15 (Kowa Optimed, Torrance, CA), the
HSO-10 (Carl Zeiss, Dublin, CA), and the less-expensive pocket lamp by
Heine (Heine USA, Dover, NH). The slit beam of a direct ophthalmoscope
may also fulfill some of the criteria. Use of these instruments permits higher
magnification and the ability to discern the depth of lesions.
Cursory examination of the posterior segment (vitreous and retina) is
best performed in dim lighting. A comprehensive examination is best
achieved with dilation of the pupil. Posterior segment evaluation may be
performed via direct ophthalmoscopy, resulting in the most magnified view
of the fundus. The direct ophthalmoscope is an excellent instrument for
detailed evaluation of fundic lesions. Routine screening for fundic lesions is
lengthy and arduous because of the small field of view. Indirect ophthal-
moscopy with a 20-diopter lens held 5 to 7 cm from the globe and a bright
light source close to the observer’s eye is the easiest and most rapid screening
method for fundic examination. Once mastered, this technique allows the
veterinarian a superior method for funduscopy. Binocular indirect ophthal-
moscopy is accomplished by using a head piece and lenses, allowing the
observer to use both eyes to evaluate the fundus. This technique permits the
observer to perceive raised or depressed lesions in the fundus. The PanOptic
ophthalmoscope (Welch Allyn, Skaneateles Falls, NY) combines several of
the benefits of each instrument; a monocular technique is used, but a wide
 S.M. Carastro / Vet Clin Equine 20 (2004) 285–299 293

field is visible. A halogen light source is necessary for sufficient light intensity
for useful operation of the PanOptic.

Ophthalmic examination
The examination should commence and proceed in a methodical manner
such that a routine is instilled, thus limiting the chance for overlooking or
missing a critical component of the clinical picture. Additional diagnostics
and testing are then added to delineate the individual patient’s condition
further. The examination should ideally take place in a darkened stall or
examination room to limit scatter of external light sources, which may
conceal or mimic lesions.

History
The examination never begins with evaluation of the patient. A thorough
history and signalment permit the veterinarian to establish a broad
differential diagnosis list even before the examination. The individual
observing the abnormality should be questioned because he or she may be
better able to define the problem noted. Inquiries should evaluate the
primary complaint, such as color change to the eye, squinting, discharge
(which should be further qualified), diminished vision, and whether the
condition is affecting one or both eyes. If the primary complaint is
diminished vision, further investigation as to differences in dim lighting
versus lighted conditions, near versus distant vision, and motion vision is
warranted.
The duration of the clinical signs, the nature of the onset (hours, days,
weeks, or months), and the use of any previous or present medications,
including ophthalmic and systemic preparations, should be recorded. If
possible, ask the client to present the medication for your evaluation to
confirm the ingredients, because many drugs have similar constituents but
may be confused by the client. A history of previous ocular problems would
be of importance as well as whether there are any other animals in the
vicinity that are ill or have ocular problems. Once the history is completed,
the veterinarian will have a grasp of the clinical situation and what
instruments and testing may be necessary to evaluate the complaint.

Observation
Before any manipulation, the patient should be studied to perceive any
visual deficits and to determine comfort level. If there is a complaint of poor
vision, vision testing should be performed before sedation. Horses are
frequently uncooperative with vision testing, but maze testing with barrels,
buckets, or hay bales, for example, may be constructed. The visual ability in
a particular eye may be evaluated by blindfolding the other eye. It is also
294 S.M. Carastro / Vet Clin Equine 20 (2004) 285–299

important to recreate the illumination if the owner notes that the visual
problem is present in particular lighting.

Reflexes associated with the eye

Menace response
The menace response is a cortical reflex generated by an unexpected or
threatening gesture in the near visual field. Closure of the eyelid and possible
withdrawal of the head are the anticipated responses. A menace response is
acquired in the foal at approximately 2 weeks of age. Four quadrants of the
visual field should be evaluated individually, because partial visual field
deficits may occur. Care must be taken not to stimulate the vibrissae or hairs
around the eye or to generate an air current that would stimulate the
trigeminal nerve. The afferent portion of the reflex is initiated by the retina/
optic nerve and observation of the gesture. The efferent portion of the reflex
is completed by the facial nerve with closure of the eyelid.

Dazzle reflex
A dazzle response is a subcortical reflex initiated by suddenly shining an
intense bright light into the eye. Partial eyelid closure or globe retraction is
the expected reaction. The afferent portion of the reflex is generated by the
optic nerve. The efferent pathway is via the facial nerve. A positive dazzle
response does not necessarily indicate the presence of vision.

Pupillary light response/swinging flashlight test

Pupil size and symmetry should be evaluated at this time (before
pupillary dilation). Use of the direct ophthalmoscope on a dioptric setting
of zero, with the observer approximately 3 to 5 ft in front of the horse,
allows simultaneous evaluation of the fundic reflex from both eyes, outlining
pupil size. Anisocoria is always noteworthy. Potential causes for anisocoria
include glaucoma, uveitis, synechia, iris atrophy, pharmacologic agents like
atropine (the effects of which may last up to 2 weeks in the horse), retinal or
optic nerve disease, central neurologic disease, and oculomotor nerve palsy.
The pupillary light response (PLR) is generated by the use of a strong light
source, preferably a Finoff transilluminator with a halogen light source. The
PLR in the horse is not as complete or as swift as noted in the dog and cat.
Aiming the light toward the temporal fundus stimulates the best reaction.
Constriction of the pupil in the eye being directly stimulated is the
anticipated response. The consensual PLR is evaluated in the eye not being
directly stimulated by swinging the light swiftly from the stimulated eye to
the other eye. There should be partial constriction of the opposite pupil
because of the initial stimulation of the first eye, but the opposite pupil
 S.M. Carastro / Vet Clin Equine 20 (2004) 285–299 295

should constrict further by direct stimulation of the light source. The

swinging light test is considered positive if shifting the light from the eye first
stimulated to the other eye results in dilation of the pupil of the subsequent
eye. Dilation of the pupil while being illuminated is indicative of an
ipsilateral retinal or prechiasmal optic nerve lesion.

Blink reflex
The blink reflex is initiated by touching the periocular skin, which should
result in eyelid closure. The afferent portion of this reflex is the maxillary
branch of the trigeminal nerve, which is sensory to the face. The efferent
portion of the reflex is initiated by the facial nerve, generating eyelid closure.
If the menace response is negative, it important to determine whether the
lack of response is a result of the horse’s inability to perceive the gesture
visually or an inadequate response caused by facial nerve palsy.

Corneal reflex
The corneal reflex occurs with a tactile stimulus or any object touching
the unanesthetized cornea. The expected response is closure of the lids. The
afferent pathway is the ophthalmic branch of the trigeminal nerve. The
efferent or motor pathway is the facial nerve.

Sedation
To perform a thorough ophthalmic examination, uncooperative horses
may require sedation. The level of sedation necessary depends on the
excitability of the animal, the level of discomfort exhibited by the patient,
whether a mare is in foal, and whether any diagnostics or procedures are
being considered after examination. The drug of choice when expecting
a short examination is xylazine at a dose of 0.25 to 0.5 mg/kg administered
intravenously. This dose generally gives 15 to 30 minutes of sedation. If
diagnostics or minor procedures are anticipated, butorphanol at a dose of
0.15 to 0.25 mg/kg may be added as an analgesic but may cause minor head
bobbing or shivering in some horses. If a prolonged examination or
procedure is anticipated, detomidine at a dose of 0.005 to 0.01 mg/kg is
an excellent option, allowing approximately 30 to 45 minutes of sedation.

Regional nerve blocks and akinesia

Nerve blocks are imperative to permit evaluation of a painful equine eye.
The horse has a powerful orbicularis oculi muscle that cannot be counter-
acted without pharmacologic aid. Paralysis of the lids limits possible
iatrogenic rupture of the globe with infected deep corneal ulcers or deep
296 S.M. Carastro / Vet Clin Equine 20 (2004) 285–299

corneal lacerations. Drugs commonly used to perform regional nerve blocks

include lidocaine 1% or 2%, bupivacaine, and mepivacaine. The difference
between these drugs is duration of action. Lidocaine is the shortest acting
and generally lasts for 45 minutes to 1 hour. Bupivacaine has the advantage
of a longer duration of effect, typically 6 to 8 hours. Mepivacaine is
considered less potent than lidocaine or bupivacaine. The burning sensation
of injectable anesthetics is related to the low pH. Addition of a small
quantity of sodium bicarbonate limits the stinging sensation. Addition of
epinephrine may prolong the effects. Only 1 to 5 mL of the anesthetic agent
is necessary to complete the nerve block. The agent should be fanned out
around the area of the nerve to ensure complete paralysis.

Auriculopalpebral nerve
The auriculopalpebral nerve is responsible for motor control to the
superior lid. The nerve is the terminal branch of the facial nerve controlling
the orbicularis oculi muscle. Injection is performed at the caudal border of
the ramus of the mandible and zygomatic arch. A depression can be felt, and
the nerve can sometimes be strummed as it passes over the bone.

Supraorbital nerve
The supraorbital nerve supplies sensation to 60% to 80% of the central
superior eyelid. The nerve is the terminal branch of the ophthalmic branch
of the trigeminal nerve (cranial nerve V). The supraorbital nerve can be
blocked as it exits the supraorbital foramen in the frontal bone. Identifica-
tion of the foramen is possible as the superior rim of the orbit widens
nasally. A 5/8 inch 25-gauge needle is inserted into the foramen, and the
anesthetic drug is injected. A small amount of drug should be injected while
removing the needle from the foramen. The frontal nerve is block
simultaneously. This nerve block is advantageous when placing a subpalpe-
bral lavage or performing minor surgery on the superior lid.

Zygomatic nerve
The zygomatic nerve is sensory to the temporal aspect of the inferior lid.
The nerve may be blocked by injecting along the inferior orbital rim
adjacent to the lateral canthus.

Infratrochlear nerve
The infratrochlear nerve is sensory to the medial canthal area. The nerve
is located in the notch along the superior rim of the orbit near the medial
canthus.
 S.M. Carastro / Vet Clin Equine 20 (2004) 285–299 297

Lacrimal nerve
The lacrimal nerve is sensory to the lateral canthus and the lateral 25% of
the superior lid. The nerve may be blocked by injecting along the superior
rim of the orbit just medial to the lateral canthus.

Local anesthesia or line block

Periocular injection subdermally with a 22- to 25-gauge needle provides
excellent analgesia to the eyelid.

Retrobulbar anesthesia
A retrobulbar nerve block is generally performed in an anesthetized horse
before enucleation to block the oculocardiac reflex, to maintain the plane of
general anesthesia with less gas inhalation, and to proptose the globe
partially. Anesthesia of the eyelids and the globe, pupillary dilation,
transient loss of vision, and decrease in intraocular pressure (IOP) are
noted. The block may be performed by using a 22- to 25-gauge spinal needle
inserted either through the lids or in the conjunctival fornix between the lid
and the globe. Two to four quadrants may be injected with a total dose of
anesthetic agent of 10 to 15 mL. A pop is generally palpable when
penetrating the orbital muscle cone. The Peterson block is the alternative
method, injecting 15 to 20 mL through a curvilinear 18-gauge needle
approximately 1 cm lateral to the lateral canthus directed ventromedially.
Addition of 1% epinephrine to the injection prolongs the anesthetic effect
and aids in control of hemorrhage if enucleating the globe.

Topical anesthesia
The most commonly used topical anesthetic agents are 0.5% tetracaine or
proparacaine. These agents are considered interchangeable. Surface anes-
thesia is attained within 30 seconds of application, which allows for
tonometry. Serial applications may be necessary if the patient is experienc-
ing excessive lacrimation, which will dilute the anesthetic. Corneal cytology,
debridement, and grid keratotomy may be performed after deep anesthesia
is obtained by serial applications and waiting 3 to 5 minutes. Direct
application of topical anesthetic agents with a cotton-tipped applicator or
Weck cell sponge to the location of the procedure (ie, biopsy, subconjunc-
tival injection) facilitates anesthesia.
Topical anesthetic agents should never be used as a therapeutic agent
because of corneal epithelial toxicity, inhibition of the blink reflex, and
delayed corneal wound healing. Corneal and conjunctival sampling for
culture should ideally be performed before application of topical anesthesia,
although minimal effects on culture results after application of topical
anesthesia have been cited [6]. The concern is that the preservative in the
298 S.M. Carastro / Vet Clin Equine 20 (2004) 285–299

topical anesthetic agents may inhibit growth of microorganisms, viruses,

and fungi. In eyes that are painful or in reluctant animals, topical anesthesia
may be necessary to attain a valid sample, because accidentally touching
other areas of the eye renders the sample worthless.

Diagnostics
Tonometry
Portable instrumentation to measure the IOP has become readily avail-
able with the introduction of the Tonopen (Medtronics, Jacksonville, FL).
Applanation tonometers, such as the Tonopen, estimate the IOP by
calculating the force necessary to applanate or flatten a constant area of
the cornea. Normal IOP in the horse is 16 to 30 mm Hg, with a less than
5–mm Hg variation between the two eyes in an individual animal. Topical
anesthesia should be used before testing the IOP. Performing an auriculo-
palpebral nerve block was shown not to have an effect on the IOP but may
be necessary in an uncooperative patient, because forceful blinking raises
IOP instantaneously for the duration of muscle contraction. Sedatives, such
as xylazine, may decrease IOP by approximately 25% [7].

Nasolacrimal flush
Nasolacrimal flushing should be performed when a cause for epiphora
cannot be identified after the ocular examination. Epiphora caused by
uveitis, keratitis, or glaucoma does not require nasolacrimal duct flushing,
because the excess tearing is related to pain and blepharospasm. Fluorescein
staining should be performed on any eye with tearing. Patency of the
nasolacrimal duct may be established if fluorescein passage is noted out the
nares within 5 to 10 minutes of placing solution on the ocular surface. If no
fluorescein is noted, the nasolacrimal duct may be flushed retrograde with
a tomcat catheter or polyethylene tubing passed up the nasal orifice. Saline
at a rate of approximately 5 to 10 mL may be injected up the tube while
monitoring for fluid from the medial canthus. Alternatively, the inferior
puncta may be cannulated with a nasolacrimal cannula and flushed
antegrade with saline while monitoring for passage of fluid from the nares.

Culture and cytology

Cultures of the ocular tissues should ideally be performed without topical
anesthesia, because this may have an effect on microbial growth as a result
of preservatives in the topical anesthesia. A recent study has indicated this
may not be a valid concern, however. Cytologic examination of ocular
tissues may be performed with a Kimura spatula, microbrush technique, or
the back of a no. 10 or no. 15 blade to gather a valid sampling. The edges of
 S.M. Carastro / Vet Clin Equine 20 (2004) 285–299 299

a lesion are typically the most fruitful location for providing valuable
cellular information. All nonhealing corneal lesions should be sampled for
culture and cytology.

Ocular ultrasound/CT/MRI
Ocular ultrasound is helpful in evaluating intraocular structures when
examination inside the globe may be limited by corneal disease, hemorrhage,
uveitis, or cataract. Identification of large periocular or retrobulbar masses,
cysts, or metallic foreign bodies is possible with ultrasound.
Advanced imaging of the periocular structures and the globe is available
with CT and MRI; however, the availability of these modalities is limited.
These techniques allow for superior imaging of the equine orbit and
intraocular structures. The main issues with obtaining a scan are weight
limitations and size of the gantry.

Summary
Before ophthalmic evaluation, history and signalment can supply the
veterinarian with a differential list. When preparing to evaluate a horse with
ocular disease, have all the supplies possibly required readily available,
together with a charged and bright halogen light source. Perform all
examinations in exactly the same sequence, and use ancillary diagnostics,
nerve blocks, and sedation as needed to obtain a definitive diagnosis. If
a definitive diagnosis cannot be obtained, consider referral to a veterinary
ophthalmologist.

References
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domestic animals. Springfield, IL: Charles C Thomas; 1960. p. 128–53.
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Ophthalmol 2000;3(2/3):87–92.
[4] Marts BS, Bryan GM, Prieur DJ. Schirmer tear test measurement and lysozyme
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Veterinary Ophthalmology. 1995. p. 144.
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