Vet AI Scribe for Ophthalmology

Munchkin

Monday, August 3, 2026 at 10:57 PM

Subjective

Chief Complaint

Munchkin, a 9-month-old male Weimaraner, presented for evaluation of an abnormal protrusion of the third eyelid in the left eye.

History

• The issue started a week ago.
• Slightly clear discharge from the left eye.
• No squinting, redness, or rubbing of the left eye.
• No issues with the right eye (no squinting, discharge, redness, or rubbing).
• No significant medical history.
• Not on any medications.
• Bright, alert, and responsive.
• Eating and drinking normally.

Objective

Left Eye

• OS Direct PLR: normal on exam
• OS Menace response: normal on exam
• OS Dazzle reflex: normal on exam
• OS Schirmer tear test value: 22 mm/min
• OS Intraocular pressure: 17 mmHg
• OS Fluorescein stain retention: negative
• OS Eyelid: normal on exam
• OS Cornea: normal on exam
• OS Palpebral response: normal on exam
• OS Conjunctiva: normal on exam
• OS Anterior Chamber: normal on exam
• OS Iris: normal on exam
• OS Lens: normal on exam
• OS Vitreous: normal on exam
• OS Retina: normal on exam
• OS Optic nerve: normal on exam
• OS Globe: normal on exam

Right Eye

• OD Direct PLR: normal on exam
• OD Menace response: normal on exam
• OD Dazzle reflex: normal on exam
• OD Schirmer tear test value: 21 mm/min
• OD Intraocular pressure: 16 mmHg
• OD Fluorescein stain retention: negative
• OD Eyelid: normal on exam
• OD Cornea: normal on exam
• OD Palpebral response: normal on exam
• OD Conjunctiva: normal on exam
• OD Anterior Chamber: normal on exam
• OD Iris: normal on exam
• OD Lens: normal on exam
• OD Vitreous: normal on exam
• OD Retina: normal on exam
• OD Optic nerve: normal on exam
• OD Globe: normal on exam

Other

• OD Indirect PLR: normal on exam
• OS Indirect PLR: normal on exam
• OS Third eyelid: leading edge everted (scrolled outward); conjunctiva of the third eyelid mildly hyperemic

Assessment

Munchkin has a scrolled cartilage of the third eyelid in the left eye, causing the edge of the third eyelid to protrude slightly outward.

Plan

• Surgery under general anesthesia to remove the abnormal scrolled cartilage and reposition the edge of the third eyelid to its normal position.
• Surgery recommended in three days.
• Owner advised to monitor for clinical signs such as swelling, inability to open the eye, squinting, color changes, thickening, discharge, bleeding, lumps, third eyelid protrusion, lethargy, or changes in eating and drinking behavior, and to make an emergency appointment if any of these signs occur.

Client Discharge Note

Thank you for bringing Munchkin in today. It was a pleasure to assist you.

Summary

Munchkin was evaluated for a protruding third eyelid on the left eye, which has been present for about a week. Upon examination, the right eye was completely normal. The left eye showed a condition called scrolled cartilage of the third eyelid, where the edge of the cartilage is scrolling slightly outward. All other eye structures and functions were normal.

Key Topics We Discussed

• Surgical Recommendation:

  • Surgery is recommended to correct the scrolled cartilage of the third eyelid. This will involve a small incision under general anesthesia to remove the abnormal cartilage and reposition the third eyelid to its normal position.
  • Please book an appointment for surgery in three days' time.

• Monitoring at Home:

  • Watch for any of the following signs and make an emergency appointment if they occur:
    • Swelling of the eye.
    • Inability to open the eye.
    • Squinting.
    • Change in eye color.
    • Thickened appearance of the eye.
    • Discharge or bleeding from the eye.
    • Lump on or near the eye.
    • Third eyelid protrusion.
    • Lethargy, or if Munchkin stops eating or drinking.

• Prognosis:

  • The prognosis for this condition is generally good following surgery.

Thank you for entrusting us with Munchkin's care! Please do not hesitate to contact us if you have any questions or concerns.

— Dr Kamiko Honda