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Reptiles/Bearded Dragon Eye Swelling

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QUESTION: Greetings Mick,

I have a pogona vitticeps (bearded dragon). She was purchased back in the first week of  Sept. 2013. Judging from her size she couldn't have been more than a few weeks old. She is either an " American smoothie" or  "leatherback" morph. I believe she was captive bred.

She was temporarily housed in an aquarium "holding" tank until her permanent house was completed. She resided there for about 4 weeks. Her current home is 36" x 18" x24" h. It is made of lumber with glass doors. Substrate in both enclosures consisted of tiling (very easy to clean daily). She has a prefab hide and plastic perching branch.

Her lighting set was/is the same in both enclosures, a 24 inch Repitsun 10 (tube) and a 50 watt basking light (spot).  The UVB light is approximately 9 inches from where she basks. Basking spot temps range from 98-102F. Cooler areas of the enclosure are generally between 80-85F. Humidity levels are relatively low   (usually between 14-17%).

Since we have had her, her protein diet consists of black soldier fly larva (phoenix worms/reptiworms) and Dubia roaches. For greens she gets collards and some bits of mango. She is first fed at 6:30am with proteins and fresh greens and again between 4-5pm for more proteins. Shallow water dish is changed daily. She receives two drops of Fluker's "Liquid Vitamin" per week.

No other animals live in her enclosure.
She last shed about a week ago.
She had three bowel movements today and last ate yesterday around 5 pm.
She does get a misting when in shed.
She weighs around 60 grams and has been going to the vet for the past several weeks.

The Problem(s):

A few weeks ago she began excessive rubbing to the left side of her face which I thought was due to shedding. Typically she will get an extra bath duing shed in which I try and help the process by swabbing her with a q-tip in the bath. The rubbing, however, continued beyond the shed.

The eye began to swell behind the lower exterior eyelid. Within several days the swelling continued to the point where pink flesh began protruding from beneath the lower lid. It looks like 'cherry eye' in dogs.

At this point we had taken her to the vet to have this examined. She was prescribed with NeoPolyDexOpth Suspension. Directions are 1-2 drops every 8-12 hours for two weeks.

During the eye exam we had her stool tested and it returned with high coccidia levels. At a subsequent visit we were given Ponazuril oral suspension (0.1 ml) in 4 doses. Instructions for this was one dose and then another 48 hours later, wait two weeks and then repeat.

In the interim the swelling in the eye has not subsided. The redness of the exposed flesh was reduced but she still remains with this large amount of flesh obscuring her sight ( I can see about 25% of her eyeball when she opens it).

At the follow up today, the vet suggested that  a Vitamin A shot may help the situation. The shot was administered to her left rear leg. The leg now is just swollen and lifeless. She cannot move from ground to her basking spot unassisted and it literally just drags behind her.

She has had no appetite since the visit. Since the visit, she has defecated twice more, both small amounts but runnier than normal. She now seems lethargic and uninterested in food.

I am at my wits end. While normally I would exhaust every option to try and help my pet, I feel as though I am hurting her more than helping. She is so small and I am not sure if all of these symptoms are normal and correctable. I am not sure if she would survive yet another trip to the vet for a biopsy.

I feel like we're playing 'pin the tail on the donkey' for an answer.

Thank you for your time and please accept my apology for my poor formatting.

Joe

ANSWER: Your formatting is fine. It's the best I've seen in a long time. I will get back to this with a revised answer as I have the time later in the day, but for now I need to know what type of wood the enclosure was made of? And follow up with a photo of her as well.

Your vet is a dumbass...frankly. As soon as I hear they've picked up the syringe full of vitamin A, I know they have no idea what they're doing, and they're about to hurt the animal. Iatrogenesis is a leading cause of death of reptiles that are taken to vets. Vitamin A injections have a HUGE potential to cause harm, permanent disability, and death. Just do a websearch on it. It has an extremely low safe dose margin. Death from hypervitaminosis A is a horrible thing to see. It's like a severe burn, and skin can begin to slough off, and renal or liver failure is usually the result. Vitamin A should NEVER be used this way unless there was a serum retinol test to establish hypovitaminosis A FIRST. If it is needed, unless blood labs and symptoms show severe deficiency, then I recommend oral form/beta carotene. You've got to be about the thousandth person I've heard from whose vet screwed up their animal with a vitamin A shot, and I'm really sick of how ignorant veterinarians are about this issue.

I'm going to need to know exactly how much Vitamin A he injected, and at what concentration. You will have to DEMAND that information from them. It's not likely that unless they made an actual paper record of it at the time though, that you will now get the real administrated dose that was used. There is a IU/kg dose above which it becomes very dangerous, and the typical bottle of injectable vitamin A seen in vet offices are highly concentrated and meant for much larger animals. In a small reptile, it doesn't take but a tiny drop too much to cause severe and life threatening conditions. I also need to know an exact weight on her. An "about" does not suffice when dealing with pharmaceuticals and small animals.

If you have any calcium powder (without D3) then give her orally about as much as will stand on the tip of a toothpick. Do not give more than this without direction.

If you have any vitamin E liquid or liquid capsules in the house, then let me know the concentration of them in IU. If you don't have any, then you need to go to the store and get some TODAY. Oral vitamin E liquid would be better, or whichever has the least IU per serving/recommended dose. DO NOT administer this without my direction.

Obtain an accurate gram weight on your dragon TODAY before you get back to me with this follow up. Right now, the plan is to try to save her life and her leg after an iatrogenic hypervitaminosis A caused by the vet...and then after the life threatening issue that was caused is taken care of, we can get back to worrying about the relatively insignificant eye issue that was the original concern...

Read my article on veterinarians here:

https://www.facebook.com/notes/wichita-falls-reptile-rescue/selecting-a-reptile-veterinarian/371766756228186






---------- FOLLOW-UP ----------

Habitat
Habitat  
Left Eye open
Left Eye open  
QUESTION: Mick,

The only reference to the Vitamin A administered yesterday is, " Vitamin A 2,000/ml (oil) injection". This was on my invoice. I have left a message for the vet inquiring about the concentration but I doubt I will get a response today.

I was able to find liquid softgels for the Vitamin E. They have 400 U.I.

I already have the calcium w/o D3. Getting her to eat that may be a chore in itself.

Peyton, the dragon, weighed 59 grams (digital scale) as of this morning.  For reference, she weighed 70 grams(via analog scale at vet's) prior to having bowel movements.

I was able to feed her a few worms by hand.

She does seem more alert this morning but the leg appears them same (still no movement).

The enclosure is all untreated pine. Prior to moving her in, I did let it set for several days so whatever moisture it retained should have dissipated. I used  no adhesives in making it. The only exposed wood she would have access to are the sides, however, she is usually content staying on her branch and isn't very adventurous (with the exception of eating and poo).

I did put in a small container of moist sphagnum moss several days ago at the vet's suggestion as she inferred the original eye problem may be due to lack of (or low) humidity.

Attached are photos of the initial eye problem and habitat setup.

Thanks,

Joe

ANSWER: OK the concentration is on the invoice then. It's 2000IU per ml. What I need to know now then is how much he actually administered. They don't tend to put the specifics of how much they gave of anything on the invoice. That's going to be in the notes in the chart folder and they are probably going to be resistant to giving that info out to you, but you paid for the service and have a right to it.

The standard accepted max safe dose is 2000IU/Kg, which for a 60 gram animal would mean that he should have given no more than .06ml (6 units on a syringe graduated in 100ths of ml) in vitamin A. Unless he had something else in the syringe to dilute the vitamin A for ease of injection, then there shouldn't have been more than .06ml in the syringe. Some references allow for up to 5000IU/Kg, but in my opinion this is too much, and the use of vitamin A here in this case to begin with was not wise. #1. considering the animal had plant matter as part of her diet and was getting vitamin supplementation, and #2. the presentation was not bi-lateral. Meaning he should have looked first to debris in the eyes or some other environmental cause and treated accordingly before assuming without good evidence that there was a hypovitaminosis A condition, not supported by the history of the diet and supplementation, not supported by serum retinol tests, and not supported by a bi-lateral presentation.

I always urge reptile keepers to avoid vets who aren't reptile keepers, and this is one of the reasons. Reptile medicine is not the same as dog and cat medicine. It's not the same as large animal medicine. The closest thing to a reptile vet would be a bird vet. I'd urge you to see a bird vet before you saw a vet who mostly saw dogs, cats, and horses. A lot of these vets want to give injections and things in order to justify the billing, but as we see it can do more harm than good. She had a little eye issue, and now she has a swollen and lifeless leg and her life may be in danger from an iatrogenic vitamin A overdose because the vet didn't know enough to look to other causes before assuming she needed a potentially dangerous intervention of drugs.

I need you to attach a picture of the affected leg.

In the meantime for the eye, get a bottle of contact lens grade saline (sterile saline only, not multi solution) and a helper, and give the eye a flush several times a day or as needed. You may also take a cotton swab and to the outside of the eyelid, use a rolling motion and roll the eyelid down to see if there is any debris in there. Have the helper ready to flush the eye. She could have been rubbing her face against the side of the terrarium and gotten a splinter or something in there. This is far more likely than assuming she had a vitamin A deficiency.

For some relief in between saline irrigations, I would suggest getting some lubricant drops that contain carboxymethyl cellulose. And an antihistamine containing drop may help with inflammation of the blepharitis. Look for something containing ketotifen fumarate preferably as the only active ingredient. Administer that for now only once per day, after a saline irrigation, and do not use a standard drop as you would place in your eye. Use a drop about the size of a pinhead.

Helping the eye may help her mood and appetite, but for right now my main worry is this vitamin A injection. You may have trouble getting her to take something orally, but you may have to get a helper. Or dust a couple of feeders with the calcium powder I advised previously. I don't care if you have to get a helper and pull her dewlap down and drop a pinch in, but get a small pinch of calcium into her. This will help mitigate any vitamin A overdose. The vitamin E will as well, but that's going to be a much smaller amount, and you should give it a couple or more hours after giving the calcium. Don't give them together. I can't know exactly the concentration of the vitamin E per ml unless I know the volume of the gelcap though. Unless you can tell me that, then I will have to wing it, but it's preferable to letting a potential vitamin A overdose go untreated today.  

Take the vitamin A gelcap and pierce it so that you can squeeze a drop out, and give her orally a tiny drop of this. The actual prescribed dose for her (normally for a simple hypovitaminosis E) would be 1IU/Kg, or .06IU, but without knowing the volume of the gelcap, only that the gelcap contains 400IU, I can't make a specific calculation. I'm disclosing this, and telling you to give her ONLY about a pinhead size drop of vitamin E. It's shoot from the hip, but vitamin E is a bit safer than vitamin A if it were overdosed, and specifically when given orally it's a lot safer than injected. In cases of hypervitaminosis A (overdose), more vitamin E than normal dose would be used as well.

Sources:

http://ps.fass.org/content/49/4/1050
http://jn.nutrition.org/content/105/12/1600.full.pdf

Don't be mistaken about references to vitamin E non-toxicity. If it's overdosed, it can be toxic as well. It seems that a lack of vitamin E toxicity was noted in cases of already existing overdose of vitamin A in these specific studies. This is why I stress use only the amounts I am telling you, and don't assume that more is better. Everything I am telling you to do, I have done in the past here at the rescue.

PS - I do want to ask a couple of questions about the UVB lighting. How old is this tube, and when she normally sits and basks on the branch, is the affected eye the one that is normally facing the UVB source?




---------- FOLLOW-UP ----------

Left Leg
Left Leg  

Vitamin E Capsule
Vitamin E Capsule  
QUESTION: Mick,

I was able to give her the Calcium (with no D3) earlier this morning after reading your reply.

I attached a  photo of the Vitamin E caps that were available for size reference. I tried to weigh it but it did not register on the scale in gram increments.

She has licked about drop off of the punctured capsule.

The leg swelling was a bit more pronounced yesterday but as you can see it is more "fired up" in color than the normal leg.

The UVB light was purchased in September when we got her. It is the light above in the ballast. The basking light does face the affected side though. I do have an equal wattage bulb in red and a CHE available should I need to change the white light out.

I will have to wait an hour or so for help to arrive for irrigating the eye.

Thank you so very much for your time and patience,

Joe

Answer
Unfortunately, I can't determine volume of the gelcap from the photo. I can only guess that maybe it's a .5ml cap, but that's not accurate. I would have to know the volume of the cap. Not the weight. In this case though, I don't want her to lick a "drop" off the cap, unless that drop is about the size of a pinhead. I want to stress that. This is medicine. Unless otherwise stated, this needs to be very specific, which means that if you tell me "about a drop", I need to know about how big, because a "drop" is not a specific measure.

Monitor the leg and keep me posted on inflammation and her use of it, as well as the color. She may recover from it, but then again, vitamin A is one of those things that can drag on and you don't even know until weeks and weeks later when their skin sloughs off in the injection site and they begin shedding little pieces here and there like crazy, indicating they are going into organ failure. Vitamin A overdoses can kill MONTHS after the fact.

As to the light, new UVB lights have a burn in time and until they are burned in they may output more strongly. This normally isn't the case in a tube lamp (I am not a fan, especially for arid dwellers like beardies and I would recommend a Zoomed Powersun, because while linear tubes are better and safer than compacts, they aren't that great for high UV demand species like beardies), but in this case, the affected eye mostly facing the UVB source (her head is more than likely tilted upward on that side to some degree), I would consider this a likely cause. It would then be known as photo-kerato-conjunctivitis (or UV keratitis).

I will recommend that you back the UVB source up to 12" for now. I will also recommend that you place the basking heat source overhead, and not to the side. The basking lamp isn't likely to be the cause (the UVB source is), but the basking lamp should not be shining in from the side directly in her eyes, and so this could lead to dry eye and it won't help matters, but new UVB sources being too close to the animal, and substrate or other foreign debris in the eye, are the leading causes of an issue such as this (not vitamin A deficiency). A skilled herp vet should have known this. She has limited choice of orientation for basking here, whereas in the wild the choices would be nearly unlimited as to how she wanted to face the sun on a pile of big rocks. Get a lamp stand if you have to, but get the light out of her eyes and put it overhead.

Adjust height accordingly to maintain proper basking site temp. Both of these can be eliminated with purchase of a PowerSun though, and take note that I am making a specific recommendation. I did not say an Exo Terra, for example, because those are crap.

Also, be advised to look over my previous answers again because I included additional revised answer under PS and PPS...

===============================
Any updates on her condition?  

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Mick

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YOU WILL GET A REJECTION OF YOUR QUESTION IF YOU FAIL TO FOLLOW THE INSTRUCTIONS TO QUESTIONER IN FULL!. I am primarily here to assist with health concerns. I am here for the more difficult questions. Not for questions that you could research & easily find the answer yourself. My standards are that you provide DETAILED and RELEVANT background history on your pet before you ask me any question about it other than GENDER or ID. The requested information is in the instructions to questioner. Failure to answer each of those questions to provide that background, will result in your question being rejected. I can answer questions related reptile husbandry, identification (esp. in Texas and the SW), legal aspects, and advanced level medical care. I am the director of Wichita Falls Reptile Rescue (TX), a wildlife rehabilitator specializing in reptiles, a founding member of The Society for Horned Lizard Preservation, a subscriber to the International Veterinary Information Service, wikivet.net, educational content contributor to lafebervet.com, and a Dept of State Health Services accredited animal control instructor (CE) for reptile handling. I do most of my own veterinary care in-house, including minor surgery and necropsy. I am most experienced in Chelonia with box turtles and common smaller tortoises; and in Squamata with everything from Anoles, Geckos, Beardies, and Monitors, to venomous snakes. I am most known for my expertise with horned lizards (Phrynosoma). With snakes, my primary expertise is in Crotalids (rattlesnakes), but I can answer a broad range of questions about various species. I am not aware of any reptile related question that I would not be able to provide some reasonable answer for. I have a direct style and may tell you something you did not want to hear; but the welfare of the animal comes FIRST with me, and I will always reflect that position in my answer, despite how it might make you feel.

Experience



I am a non-academic herpetologist with 25+ years reptile experience, and I am an accredited Texas Dept of State Health Services Animal Control Instructor for Reptiles (CE). I am a reptile rescuer, reptile wildlife rehabilitator, and subscriber to the International Veterinary Information Service, wikivet, and article/journal content contributor to Lafebervet. I have medical and scientific resources available, and I perform in house reptile veterinary care for my rescues. I am not a vet, but I read from the same materials and have had to correct quite a few in the past. The average vet is not well versed with reptile physiology and medical treatments.

Animals that I am currently caring for, or have significant rehabilitation and husbandry experience with: Horned Lizards (5 species); Eastern and Western Box Turtles; Painted, RES, YBS, Soft-Shell, and Cooter aquatic turtles; Russian Tortoises; Fire Bellied Toads; Fire Bellied Newts; Ornate Horned Frogs; Green Iguanas; Desert Iguanas; Spiny Lizards; Long Nosed Leopard Lizards; Anoles; Racerunners; Collared Lizards; Bullsnakes; Eastern Ratsnakes; Great Plains Ratsnakes; Kingsnakes; Gartersnakes; Cornsnakes; Boas; Pythons; Bearded Dragons; Water Dragons; Massasauga Rattlesnakes; Western Diamondback Rattlesnakes; Leopard, Mediterranean, Golden, Indo-Pacific, African White-Spotted Geckos; Savannah Monitors; Jeweled Curly-Tailed Lizards; Long-Tailed Grass Lizards; Fox Squirrels; Deer Mice; Hispid Cotton Rats; Merriam's Pocket Mice; Eastern Cotton-Tails; Blue Bar racing pigeon; Budgies; Asian Forest Scorpions.

Organizations


Co-Founder & Director: Wichita Falls Reptile Rescue http://wichitafallsreptilerescue.webs.com http://facebook.com/reptilerescue

Founder: The Society for Horned Lizard Preservationhttp://facebook.com/hornedlizards



Publications
LafeberVet.com contributor. The Horned Lizard Husbandry Manual - self published 75 pages of care information on genus Phrynosoma.

Wikipedia entry "Horned Lizards" - contributed to a majority of the content.

allexperts.com, and various reptile related forums and email lists under the handles "fireside3" and PhrynosomaTexas".

Education/Credentials
My hands-on field, rehabilitation, and captive husbandry experience beats a PhD any day of the week. I am also a state accredited animal control instructor for reptile handling.

Past/Present Clients


I was requested to provide my care manual on the Desert Horned Lizard (Phrynosoma platyrhinos), for the Montreal zoo. My manual is also used by several other zoological institutions in N. America. I also teach reptile education to summer camps, and instruct wildlife rehabilitators on live saving and rehab techniques with reptiles.


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