Visiting Veterinarian : The ninth life of Peep
Peep is a beloved 20-year-old cat who had been showing signs of advancing age. She was going deaf. Her vision appeared to be less acute. Her owners accepted her limitations and gave the best care they could, but recently they noticed a marked change. Peep seemed befuddled. She fell off the bed, wandered aimlessly around the house, yowling in distress. Her owners concluded her quality of life was declining. Maybe it was time to consider euthanasia, hard as that was.
When her owners brought Peep to see me, they were both on the verge of tears. When a family has gone through the emotional process to come to the decision to request euthanasia, it can be a delicate line for a veterinarian to walk. If there is appropriate medical intervention available, which the owners are not aware of, it is our responsibility to educate them and offer treatment. In some cases, if people have come to the acceptance stage of letting go, proposing diagnostics and treatment can be awkward. Some owners are delighted to receive hope of a reprieve, no matter how temporary. Others may want to decline treatment, but feel guilty if they say no, even if the prognosis is poor. Some people don't want to prolong the anguish of the process. So I began my evaluation with the expectation of confirming their assessment and probably proceeding with euthanasia. After all, they lived with Peep, not me. They were best able to say if her days were filled with contentment or discomfort.
Peep was in good physical condition, considering her age. Twenty is the feline equivalent of a centenarian. She had a touch of arthritis, and during past visits we had documented mild cardiac disease and slight kidney dysfunction but this recent decline seemed primarily associated with vision loss. I did a "menace response test." In other words, while being careful not to give other sensory clues such as touching a whisker, moving air, or making noise, I poked my finger abruptly toward her eye. If she could see my hand, she should blink. Right eye, no blink. Left eye, no blink. I tried again. No blink. I aimed my exam light right at her face. Her widely dilated pupils barely changed. In a normally functioning eye, the pupil should have constricted to a very small opening.
"I can see why Peep has been acting confused," I commented, pulling my ophthalmoscope from its case, "You're right about her vision. She's essentially blind."
Getting nose to nose, I examined the inside of her eyes. Yup, there it was. A hazy film in the back of her eye, like a curtain of grey velvet draped in folds. Retinal detachment. The retina is the organ that receives light and passes images onto the optic nerve. Detachment causes blindness. Retinal detachment can occur from trauma, lens luxation, cataracts, surgery, infectious disease, and cancer, but the most common cause in old cats is hypertension - high blood pressure. Feline hypertension may be secondary to hyperthyroidism or to chronic kidney failure, or may be primary, in other words with no obvious underlying cause. Peep's blindness was probably a byproduct of her kidney problems. Huh? How do her kidneys affect her eyes? Well, here's how it goes. Besides their well-known function filtering the blood and producing urine, the kidneys help regulate blood pressure through the renin-angiotensisn-aldosterone system. As the kidneys fail, so can the regulation of blood pressure, leading to hypertension. In some individuals, high blood pressure affects the delicate fluid balance in the eye, causing damage to the retina.
"Peep's retina's are detaching," I said, scanning her owners' faces for reaction. "I suspect the kidney failure has progressed, causing high blood pressure, causing retinal detachment." I took a breath. "I know you have noticed the visual loss for a while but since it has suddenly worsened in just the last few weeks, maybe the retinal detachment is recent. And yowling can be associated with hypertension." Peep's parents were following me intently. Their interest encouraged me. I didn't want to give false hope about a 20-year-old blind cat in kidney failure, but there was a chance I could help. "If you want to pursue this, we should check Peep's blood pressure, and run blood work. It's been two years since we checked her kidney function. Let's see how much her renal failure has progressed. If it's really bad, we can go ahead with the euthanasia. If she has hyperthyroidism or hypertension, there are a few treatments worth trying, and there's a small chance she might regain her vision."
Peep's owners were optimistic but realistic, agreeing we should get specific data before making any decisions. We measured Peep's blood pressure. Sure enough, it was high. I drew a blood sample and wrote a prescription for medication to lower her blood pressure. "Start these pills immediately," I said gently escorting them to the door. They had come expecting to say good-bye to their ancient buddy. I hoped I was doing the right thing by holding out this bit of hope, not just prolonging their emotional turmoil. "Call tomorrow for lab results."
Peep's renal failure had progressed, but only slightly. She was mildly anemic, another common sequella to chronic kidney disease, and her thyroid was functioning normally. "Nothing here is too dramatic," I said cautiously, when her owners called. "As long as you are comfortable with this, let's give her the medication for a week and see if she regains any vision, and if her behavior improves. If so, then I'll teach you how to give subcutaneous fluids at home to support her kidneys, and we'll talk about special diet and supplements." I put Peep's record in the reception desk file and tucked my thoughts about her case to the back of my mind.
Arriving a week later for her recheck, her owner said tentatively " She's doing a bit better. I think she may be seeing. She was able to find her food." I grabbed my ophthalmoscope. "She could just be using her sense of smell as she acclimates to being blind," I replied, shining the light at her. Wait. Her pupils constricted more definitively in the light..., but she still did not respond to my jabbing finger. But look at that! Her retinas appeared more normal. " Wow," I exhaled. "I think her retinas are reattaching. Still, that doesn't guarantee restoration of normal vision. Let's see how her blood pressure is," I continued, trying not to get too excited. Her blood pressure was perfect. I taught her owners how to give fluids, gave them prescription diet, and set up her next recheck. "Continue to keep her confined," I advised. "We don't want her falling down the stairs or anything like that."
The following week Peep was carried in the arms of her beaming parents. "You won't believe what she did," they kvelled. "We were trying to keep her confined, but last night she jumped over the gate!" I pointed my finger at Peep's face. I poked. Peep blinked. Her owner shook his head and repeated in amazement, "She jumped over the gate." I poked. Peep blinked.
Who knows how many lives Peep has left, but if this is her ninth and final one, at least we have lowered her blood pressure, made her more comfortable, and restored her vision for the remainder.