Seeing Red

The sunlight is fading on a world-class California summer day as I arrive for the first time at a small emergency veterinary hospital nestled in a residential section of Palo Alto, California. As I stretch out the kinks in my legs and back from my two-hour commute, the still air and encroaching dusk make me think back to chasing a baseball on a darkening diamond as a youngster, convinced I could will the day to continue so I wouldn’t have to get back to real life.

                                                                   Illustration by Amanda Lauri, all rights reserved by DerekTheVet.com

But real life insists, so I enter the hospital, introduce myself to the staff, and learn about my first patient - she’s already roomed and waiting for me.

Lemon Drop is a stunning, if shy, 8-year-old female spayed tabby cat. Her coat is a vibrant cacophony of fine gold, brown, and black fur. Her soft coat makes me want to lift her from the exam table and hug her close, but her skeptical gaze and tense, hunched posture tell me she isn’t onboard with that plan. She looks like she’s trying to disappear into the surface of the table.

I need to put her at ease, so I fight the urge to stare directly into her alarmingly abnormal right eye. Instead, I direct my eyes and body across the table toward her owners and gently spin her around so we face the same direction, making sure she can see and feel an escape route. I place my elbows on either side of her, cradling the length of her body in my forearms. I cup my left hand around the front of her chest and pet her her above the shoulders with medium pressure and a calm tempo. Her purring, an effort to self-sooth, reverberates through my hands, arms, and chest. I can feel her relax ever so slightly.  

                        Illustration by Amanda Lauri, all rights reserved by DerekTheVet.com

When I address her owners, I maintain a quiet, even voice. “Tell me about what brought you in today with Lemon Drop.”

Lemon Drop’s owners are a clean-cut couple in their early or mid-twenties. Their faces are taut with apprehension, lines etched at the corners of their eyes and mouths. They glance at one another and silently agree that the boyfriend will talk first. “Well, we just came home from out of town. We were gone for three days. She had something like this before, but it wasn’t as bad. We were giving medication. Her eye, I mean.”

When taking a medical history, I try to keep it open ended at first because most of my rote questions get answered more thoroughly through the owner’s own words. When I get a jumbled narrative, however, I suggest a structure. “Tell me more about that first episode - when it was, what you noticed, how you addressed it, how it went.”

He nods and pauses to gather his thoughts. “There was a much smaller amount of blood in her eye a few months ago.”

“The same eye, same place?” I clarify.

“Yeah. The doctor that time gave use some drops.” He holds the container out to me, I take it and glance at the label - steroid drops. I put it aside. He continues, “It went away, so we stopped the drops, but it’s much worse now.”

“Any other eye problems or other non-eye problems between then and now?” I ask.

“No.”

“Okay, tell me about this episode.”

“Well, we came home and it looked like this. We just got home an hour ago. We put in one of the drops.”

“Did anyone have a chance to see Lemon Drop during your trip? A pet sitter, anything like that? I’m just trying to figure out when’s the earliest it might’ve started this time.”

“No, no pet sitter. She was alone for three days.” The couple exchange a sheepish look.

“Oh, it’s no problem, don’t beat yourself up. Building a timeline is just helpful for me to figure out what might be causing it.” They don’t look convinced. “Really, please, take a breath.” I smile big. “We’re gonna figure this out.” The owners relax. Slightly.

Lemon Drop feels more relaxed in my arms, but tenses when I shift to stand up. I catch her forward movement in my hand around her chest. The nonthreatening restraint is enough to keep her in place and she settles back into a looser hunch.

“I’m going to examine everything else before I mess with her eye,” I tell her owners. “I want to keep her as happy as possible for as long as possible.”

I examine Lemon Drop from back to front and find no problems to the rear of her neck. The opportunity to satisfy my curiosity has finally arrived. I rotate her 90 degrees with her head pointing to my right, which gives me a good view of her face without putting us nose to nose. Her right eye is squinting slightly. Her irises are a vivid mustard color - normal - and her left is significantly more dilated than her right - abnormal.

Sitting inside Lemon Drop’s eye, obscuring the bottom half of her right iris, is a deep crimson blood clot. It’s big enough that I saw it from the doorway when I first walked in, and it’s rare enough that I’ve never seen one like it in 6 years of practice. I tilt her head at various angles and the clot stays put. Looking from the side, I can see where it’s attached to the iris and is tethered in place, preventing dilation.

                 Illustration by Amanda Lauri, all rights reserved by DerekTheVet.com

I explain to the owners what I’ve seen and narrate what I do next. I tap the corners of Lemon Drop’s eyes and she blinks. “This is called the palpebral reflex and means her nerves can sense the touch and operate her eyelids.”

When I shine a light in her eyes, the pupils expand and contract as expected, but do so much less on the right side because of the tethered iris. “This is called the pupillary light reflex and means that her retinas can sense light and operate her irises. It’s limited in the right eye because of that clot.”

When I cover one eye and act like I’m about to tap the other, Lemon Drop flinches and shuts the open eye to protect it. “This is called the menace response and means that she can see in both eyes. That’s really good news because bleeding in the eye often damages the retina and can cause blindness.” I look directly at the owners and reiterate, “So no matter what else is or isn’t happening, we know she can see.” They both look relieved and settle into their chairs.

I use a lens to look at the retina in the back of Lemon Drop’s eyes and confirm that they both look normal. I let go of Lemon Drop and say, “Okay, she can relax and do what she likes while we talk.”

Inside, I’m simultaneously geeking out and worrying. “Any access to toxins? Do you use rat bait or other poisons? Does she have access to blood thinners in the household?”

The couple look at each other, alarmed. “No,” they reply in unison.

“Ok, good. I want to rule out a bleeding disorder, but based on the history, it’s unlikely. Usually, this kind of thing happens in cats with high blood pressure, which is very treatable.”

“High blood pressure?” The girlfriend cocks her head and half closes one eye suspiciously, “But, they didn’t mention that as a possibility before.”

I’m always cautious when questions or comparisons about another veterinarian come up during a case - there are so many traps on that path. Am I being asked to cast judgement? Am I being distrusted? Am I getting an accurate picture of what actually happened before? I’ve been burned on every side of these conversations. With limited information, it’s best not to get in the middle.

“I’m not sure why that would be. Having come into this situation for the first time tonight, without the record from the previous episode, I can only let you know what I’m seeing and what I think we should do about it.” This seems satisfactory, so I continue. “Head trauma can also do it. Is she a poor climber, have a tendency to fall over, any known head trauma?”

“No.”

“Okay. Infection, foreign material, or inflammation can also contribute. I don’t see a thorn or a splinter or anything, but they can be tiny. Beyond what caused the bleed, I’m concerned about what the clot can do. Nothing typically lives in the anterior chamber, where the clot is, except fluid. Movement of the iris is important for emptying fluid from the eye, so when it gets stuck in position, fluid can build up. When that fluid pressure gets high, that’s glaucoma, which is also dangerous to vision, but treatable. And remember, we know that she can see.”

Lemon Drop’s owners approve diagnostics to work our way through the list of possible causes. First, we measure her blood pressure - it’s sky high, even for a nervous cat. Next, we apply a stain to the surface of each eye that glows bright green under blacklight - no evidence of corneal injury. Next, we apply a topical anesthetic to numb the eyes and tap the surface gently with an instrument to measure pressure within the eye - no glaucoma. A blood test rules out a bleeding disorder.

I inform the owners of the results and prescribe blood pressure medication. Cats are stoic and even squinting can indicate pain, so we err on the side of caution and I send home some pain medication as well. At the end of the visit, we talk long-term plans, “There’s no way to remove or disrupt the clot without surgery or something invasive, so we’re just gonna to have to watch it and monitor for those complications I mentioned. Check in with your regular vet tomorrow and see how Lemon Drop’s blood pressure is doing. She’s probably going to need that blood pressure medication forever. Hold off on the steroid drops that you got before.”

We wrap up and Lemon Drop’s owners put the travel crate on the exam table. Lemon Drop darts in like she’s sliding into second base and the girlfriend laughs and says, “Geez! It was so difficult to get her in there on the way in!”

I smile and say, “That’s typical. Cats cling to the most familiar thing within reach. At home, the crate is foreign. At the hospital, it’s familiar.” I let them know that for planned vet visits, leaving the crate out the day before can give Lemon Drop time to settle down before forcing her into it.

                Illustration by Amanda Lauri, all rights reserved by DerekTheVet.com

We shake hands and the owner’s check out. They carry Lemon Drop outside, where darkness has fully fallen without adding a chill to the air.

A voice from behind me says, “Dr. Calhoon, your next patient is ready for you,” and I get back to work.