Hello and thank you for that introduction and thank you to ANO for their sponsorship of the Pit Boydell Memorial seminar series. So, today I'll be talking really about Simplifying an approach so that you can approach emergencies in ophthalmology calmly, systematically and give the best care to your patients and the best service to your clients. So, it's going to be, we're gonna try to make this as approachable as it possibly can be.
So we're going to first think about what's actually going on, because until we know what's going on, we're not really sure what to tell the owners, because I, I work in real practise. I know that animals don't come in with their diagnosis, written on their forehead. We've got to first answer the question, what's actually happening, so that we can Then talk to the owners about what needs to happen next, and help them to decide for themselves and for their own individual pet, you know, how they want to go forward.
What, what tests do they want to do? How much is it going to cost? What are, what is the prognosis depending on what we, determine as the problem.
So, let's get the answer first, then we want to be able to confidently tell the owners, well, what's going to happen? And then we need you to know, what am I actually going to do? You know, what, what, what medication am I actually going to use?
Which one, how frequently, you know, the details, the, the, the things you actually want to know, when an animal walks in to an emergency clinic. So, I'm really a fan of trying to take a systematic approach. So I, I, I believe that with the right approach, every case can be managed with the same steps.
And that's helpful because it gets you a bit of breathing space so that rather than trying to give all of the answers and explain everything to the owners all at once, I really think we're better off taking a big breath, taking a step back, and being systematic. So I'm gonna walk you through what I think that systematic approach could look like. Specifically, we're then going to talk about the most common problems, the, the, the, the usual reasons why these cases come into a general practise during the day, you know, these are the cases that the owner calls and you want, you want the people answering the phone to know that these are the cases that really can't wait.
So the, the, the, the real, the real problems, so corneal ulcers. Complicated and uncomplicated, and I'll explain to you what I mean by that and why that's important. We'll talk about corneal lacerations and foreign bodies.
Lauchia? Blunt trauma, which often goes along with high femur or blood inside the eye, proctosis or the eyeball popping out, and eyelid lacerations. OK.
But The 4 steps. I'm, I'm not gonna save them to the end. There's no, no surprise here.
I really wanna, reinforce this as we go. But that the first part of approaching an ophthalmic emergency or I, I, I, I hazard that I guess that it's probably the case for any type of emergency case, but that it's beginning with you. So, taking a deep breath.
And just starting from the beginning, not being in a rush, so I've given some examples, so taking a deep breath and saying, OK, look, there's a, the eyeballs sitting on the cheek, but I'm still going to follow my process. So check your own pulse, and I've written sculpt the chest, and that is a little bit, I'm being a little bit funny, but actually, I'm not a person who uses the stethoscope very often at all, and in fact, you know, people would probably laugh at me if they saw me with, using a stethoscope as an ophthalmologist. However, in addition to being able to listen to heart and lung sounds, it also gives you some time.
So, putting a stethoscope in your ears, is a great way to get clients to stop talking. So if you just need a moment to calm yourself, Well, you're calming the patient and trying to figure out what's going on, then listening to the chest is a good place to start. Signalment.
So the patient's age and breed can also really help you to try to figure out what's going on with the case. Then be systematic and do a complete ophthalmic examination. And I can't stress that enough because I speak to a lot of people on the phone, you know, that's, that's, that's one of the most important things that I do in my job is trying to support vets, And, you know, it's pretty rare that when I speak to someone on the phone, they've actually done a complete exam.
And that's, you know, that's, that's fine. Then they can go back and check things, but, you know, just if you go through and be systematic, then it will really help. And the other thing that I I do with my clients is I tell them that that's what I'm going to do.
So when the, when the pet comes into the room, I, I set people up. I tell them what to expect. I, I, I talk to them, I get a history, and then I say, now I'm going to look at your, I'm going to do a complete exam.
When I'm finished, I'll speak to you about what I'm seeing and what the options are. And that way they can, they, it seems to, I think it probably reassures people a little bit that they're going to get what they came in for, which is that they'd like an answer, they'd like to know what's going to happen. They're worried, they're scared, they're upset, they're thinking about money, they're thinking about, you know, their poor animal, and, so walking through and telling them what's going to happen next, I think is, is really helpful.
And then the fourth is use resources, so you don't have to know all the answers all at once, and just having a problem list, you know, is enough to then go to a resource in order to, to answer the rest of the, to, to figure out what exactly is happening and what should I do. So the, veterinary ophthalmology, slightest fundamentals of veterinary ophthalmology is the textbook I would really recommend is a great investment for, general practise vets and emergency vets, our ophthalmology specific interns and even, you know, past residents, they've really gotten a lot out of this book too. It's pitched at a really, really good level.
So it into enough detail that it will give you the answers, but it's not so dense as to be overwhelming as some, some of the ophthalmology textbooks are. Anyway, I'm going to put this slide up a few times so we can talk a little bit more about about that as we go. So using resources, not trying to keep all the information in your head, because that's going to be a little bit too hard.
So, a systematic approach, so this is the approach you take to every case, and so it means that you see an ophthalmology case, whether it's an emergency or not an emergency, this is the process that you follow. And I've, I've prepared a handout that, that goes through this. So, you know, maybe you even want to make up a little, a little checklist, so that you make sure that you go through all of this.
So with the history, the things I'm most interested in is, well, when did all of this start? What has been used in the past and what are you using now? And that's going to be relevant both for your ophthalmic medications, but also for the systemic medications that you might want to use.
For example, you know, is this an animal that has allergies and therefore is on chronic steroids, that's something that you would want to know about before you started a non-steroidal, oral non-steroidal, for example. Has this animal had other eye problems in the past? And that can sometimes give you a little bit of a clue, because sometimes the problem that presents itself to you is not actually the patient's most significant issue.
And, and I guess I encounter that quite regularly, where, for example, an animal might come in with a corneal ulcer, but once I examine them, I notice that their eye is extremely enlarged, and that actually, The patient has glaucoma, and that the corneal ulcer is a secondary effect of poor corneal health, and so just, just making sure that we know, you know, what's what's been going on with this animal, in the longer term. It, it is relevant to know about current or past systemic disease or comorbidities. And again, just to kind of make sure that we don't send our patients away in poorer health than they come in.
So if they have heart disease, I will, for example, avoid using timolol, which is a beta blocker. And we'll, we'll talk a little bit more about that. As we go.
Then, Performing a general physical examination, and stabilisation. So there is no situation that I can think of where pain relief would be a serious impediment to your looking after the eye of the patient. So, if an animal comes in and they're really painful.
The need to do an eye exam, I think comes secondary to the need to make sure that that animal is given some pain relief. So there's, there's, there's, it's always a good idea to do that if you think it might help. And sometimes people are worried, oh, you know, it might affect my tear test.
Or things like that. The, the, the truth is, is that it really doesn't affect it very much. If, if you, have a real problem with tear production, you're going to be able to diagnose that, even if the using an opioid, for example, lowers the tear reading slightly.
You're still going to be able to figure out what's going on. And also stabilising them. So particularly cases that present with something, you know, really significant trauma like a high femur, or proctosis, and proctosis is the main one.
So proctosis meaning that the eye has come out of the orbit and the eyelids are behind the eye and we're going to talk about it in much more detail. But if there has been a trauma sufficient to cause that level of injury, then you really want to be making sure that there isn't something else going on with that patient. And owners will be very concerned about a proctoed eye, but even as an ophthalmologist, I'm concerned about that patient's breathing, about It's, you know, the possibility of head trauma, about whether it might have rib fractures that could affect, you know, it's ventilation.
So, I, I, I do think it's really important to take a step back from what's going on that's obvious and concerning, and make sure that we, remember that there's a patient attached to those eyeballs. So, having, having a good listen to the chest. And checking your capillary refill time, placing a catheter and you know, maybe giving some IV fluids or pain relief.
So when it comes, so once we've done that, then, then, then we turn our attention to the eye. And I guess my suggestion is that we first go, look, is the eye about to rupture? Because if there is, if the eye is about to rupture, then I might perform a bit more of a cursory or a careful assessment, rather than saying, OK, well, I'm going to begin with retropulsion.
Work my way through, you know, this is my process and it's, and I don't change it for anything. Well, I think we first need to determine, well, is, is the cornea about to rupture? Because if it is, then we might not do a tier test, for example.
So, answering that question. If it doesn't look like the eye is about to rupture, it hasn't already ruptured, then I would go ahead and perform your Sherman tier test and perform your tonometry. So there are, it's important to be consistent when it comes to the Shermatier test.
So record either how long it takes to get to 15 millimetres of wetting. Or how much wetting total occurs in 60 seconds. So one or the other.
So I would encourage you not to record, for example, 20 millimetres in 40 seconds, because that's a really arbitrary reading. So either the time it takes to get to 15, and that's just For me, because it's often quicker than a minute, you know, a normal, a normal dog will wet to 15 millimetres really quite quickly. So that way you don't have to wait a whole minute.
But if you want to record how much wetting takes place in 60 seconds, that's fine too. So you can, even if it's 30 millimetres in 60 seconds, then that's what you record. Now, more than 15 millimetres per minute is normal in a dog, but it can be can be a bit lower in a normal cat.
And I think it's good to also think about the difference between the two eyes. Same with tonometry, so comparing between the two eyes with tonometry, and I hope that most of you do have access to a toometer, but I understand that you, you might not, but they are, you know, really a very good investment, either the tono pen or the tono bet, so, different types of toometers, and they are quite expensive, but, you know, again, I, I think they probably are a worthwhile tool to keep, to keep in the hospital. But go ahead if you've got access to a tonometer, then go ahead and do that right at the beginning.
Now, this is sometimes what you're presented with. Now, this is a, a big dog with its eyes completely closed. And I know, I work in, I work in practise.
You sometimes have a patient who walks in and they, you can't see their eyes at all. Mm. The, I, I'd make the comment at this point that there's no contraindication to using a topical anaesthetic.
Now, particularly if you've already done your Shermat test, you can go ahead and pop the, pop some anaesthetic in. I use oxybupreine, but Lca is fine also. So a topical anaesthetic.
Now, even in a ruptured eye, it's OK to use a topical anaesthetic. Despite what you might have been told as well, it's not a problem to use a topical anaesthetic and then take a sample of an ulcer for cytology or the culture. In fact, I would strongly encourage you to do so.
So if you're having, if you're presented with this. A dog with it, you know, one or both of the eyes completely closed, you can't see anything. You can give systemic pain relief, but the other thing you can do is use a topical anaesthetic.
I use the little individual vials that are called minims. We keep them in the fridge, you know, you charge, charge it out. We charge about $8 for one of those, use it, for that patient and that patient only.
And that's quite nice because it means you don't have one of those big multi-dose vials of Ean, or other anaesthetic that you, you, you might use really infrequently. So the little individual vials are a really good way to go. So you can feel free to go ahead and, put in your topical anaesthetic.
And then you might be better able to do the next steps of your exam. So, I, in every patient would suggest looking at menace, looking at dazzle, helppebril, then pupil symmetry. Now, pupil symmetry, I include this as an important point, because, unless you specifically compare pupil size.
It's really easy not to notice if the pupils are different sizes. And that's important because it can give you a clue. So that first step, trying to make a diagnosis, whether the pupil is big or small is going to help you to do that more easily.
So there's both the direct PLR, so when you shine the light into, into the eye, and that pupil constricts. But there's also the pupil in the other eye, and that's called the consensual. And this is something that I talked to vets about a lot, where an animal will present, and say they have a ruptured eye.
And it may be very hard to see the pupil in the affected eye. So, If the cornea is very opaque, you know, say it's malaysia or, it's, it's, it's got a lot of cellular infiltrate, which is making it very cloudy, you might not be able to see through. The other thing is that you might not be able to see the pupil because the eye is full of blood.
So looking at the consensual, so when you shine the light into the affected eye, what does the other people do? Because both of them should constrict. So if you shine a light in the eye, both people should constrict.
And if they don't, then, then that tells you that there's a more significant problem deeper within the eye. So then going ahead and doing a sequential examination. So I like to typically start from the outside and work my way in.
And again, this is something where a checklist either in your head or actually on a piece of paper, might be really a good idea just to make sure that you're not missing something. Because if you're presented with Corneal ulcer, you might diagnose the corneal ulcer, but if you don't do a sequential exam, you might not notice that the dog doesn't blink. So unless you actually check their palpal reflex, so touching the inner corner of the eye and seeing that the eyelids close, you might not notice the dog doesn't blink.
And that's the problem, you know, so that's, that's the the underlying issue that if we don't address that, then we're probably not going to get the outcome that we want. So examining each step in the dark with help. I, I think that those things are, are really essential.
And I would argue that owners are poor animal holders. So if there is any way to get someone else who is not the animal's owner to hold the dog or the cat, Then I really think that that helps a lot. And using a light is really important too.
So, having a light in your veterinary hospital, I think is, is just something that, is, is hugely important in ophthalmology. So going through and following all of these steps. And again, like I said, no contraindication to using anaesthetic to help you to examine the patient.
However, don't ever send it home with the owners. anaesthetics are toxic to the corneal epithelium, so it's fine to use them from time to time. It's fine to use them, you know, for example, if you use a toner pen to do genometry, then you'll always apply anaesthetic, and it's, that's absolutely fine, it's not a problem.
But if you're using them over and over again, then that isn't very good for the cornea. And actually, anaesthetics are one of the most abused medications by human medicine. Doctors, for their own corneal ulcers because they have access to them and they keep putting them in, and that can really, there's definitely lots of case reports of, physicians who have ended up with melting corneal ulcers from repeated use of topical anaesthetics.
So, you know, obviously don't send them home. This is the other critter who you may be presented with, and this is the dog that wants to bite you. And so certainly using, some analgesia, using topical anaesthetics, having good health, and, you know, certainly using a muzzle.
I, I use a muzzle if I have any question whatsoever. And I just sort of, I use I use momentum. I say to the owners, with confidence, I'm going to put a muzzle on now, because I, I, I, I would feel more comfortable doing that.
So I, I, if I find that people respond well, if we don't approach it with a lot of hesitancy or ask them if they mind, just telling them, look this This is what I'm going to do in order to keep myself safe. And I'm sort of just, it's just an unspoken, it's a condition of me looking at their pet. And actually, people really don't seem to respond badly to it at all.
But we can't help anybody if we need to go to hospital ourselves, so looking after our own safety. Now, I've put this point as a separate checkpoint, and that is to identify where the lens is. Again, it's a little bit like looking at pupil symmetry where I think unless we actually ask ourselves the question, we leave open the possibility of, of, of, of, of creating a problem.
So, it, it can be actually quite hard to see a luxated lens if it doesn't have a cataract. So, particularly in this little creature, the the chihuahua, you know, or any of the terriers, if you cannot, See, you know, where the lens is, then you need to be thinking about even doing an ultrasound of the eye. And even if you're not great at doing ocular ultrasounds, you can compare to the other side.
And actually it's pretty easy to see, to compare between the two eyes. And, and that my, my, I've, I've done a little bit of, trial and error, and I found the testicle setting actually works very well. So if you've got any presets and you don't have an eye preset, then try the testicle setting, in order to check the position of the lens.
If you can't see it. And the reason that I include this is because you can make things worse. There are medications that will make the situation worse, if you don't know where the lens is.
So if the lens is actually luxated into the front of the eye. So this is a nice image showing the lens in the front part of the eye. And it's quite easy to see because there's cataract.
So you can see the lens equator or the edge of the lens in front of the iris. And this lens is quite opaque, and we can see this afaic crescent or no lens crescent in the top or dorsal part of this dog's left eye. So Probably, you know, I mean, look, a dog that's trying to bite you and, you know, is really painful and has its eyes completely closed.
Even, even this might be difficult to see, but, you know, it's, it's at least, cloudy, as opposed to this image, and this comes from Willows, where the, if it weren't for the arrows, it might be quite hard to see. This lens is luxated. So I like this image because it shows that it's really important to specifically check.
It would be lovely if our patients that had lens luxations came in with these arrows as well. So maybe we should ask Lis if they, have a way of getting these arrows to, come up in their clinical patients, but anyway, These are a few other images, and I guess I include these because again, I think these would be hard to see. The image on the left has quite a lot of corneal edoema, and that I I would be, you know, concerned, probably has glaucoma.
So that patient might be quite difficult to examine. So I think, you know, again, just making sure that you check where they are. So two examples of lenses that are not so easy to see.
I always apply fluoresce to both eyes, and, cats or dogs, particularly in cats, I think it's important, because they, their ulcers are commonly related to herpes virus, there is a pretty good chance that that both eyes can actually be affected. And it is kind of embarrassing to diagnose an ulcer in one eye and then to actually find that they they have ulcers in both eyes and that maybe you didn't notice. So it's good good just to it doesn't take any time at all to put fluoresce in both eyes.
So I would suggest always doing that. And yeah, actually I find that it's not uncommon for me to diagnose an incidental ulcer. In, in the other eye.
So the way I would recommend, applying fluoresce is that you wet the little floret strip. Using, some saline, and then you touch that strip onto the bowlbar conjunctiva. Try not to touch the cornea, because you might actually, you can create either a little, sometimes you get a little paper cut, or other times it will just, create a little bit of an abnormal staining pattern just from the trauma of the paper touching.
Cornea. So touching the bob by conjunctival works quite well. Or you tear off the coloured part of the fluorescene strip and put it in a syringe.
If you're going to do it that way though, it is important not to use more than about 0.5 to 1 mL of saline. You can put too much saline in and And over dilute the fluoresce, and it will then not fluoresce properly.
If you've got a very aggressive dog, then sometimes using, putting a needle on, I use 25 gauge needle, and then I use the needle cap to break off the syringe, the the, you know, the sharp part of the needle at the hub, and make a little squirt. If you're getting some strange uptake, or it's not what you expected, then you can copiously rinse with saline. So you'll never be able to rinse away true fluoresce uptake.
However, if you over dilute the fluoresce to begin with, then you may not get real fluorescence. So feel free to rinse as much as you like. So, moving on, we've talked about the systematic approach, and now we're going to talk about some particular situations that you'll face in when you're dealing with ocular emergencies.
So, corneal ulcers in dogs. Now these are usually painful, the eyes are often red, and they, they can be varying amounts of corneal cloudiness, but there's usually at least a little bit. Most of the time there's fluoresce stain retention, and I've written care with Desmetoceles, because with Desmetoceles, there are very, very deep ulcers, and sometimes the base, if it is a true desmatocele, will not retain fluoroine.
However, the walls of the ulcer, so the edges where the stroma is exposed, they should still, show. Fluoresce retention, as opposed to a facet. So a facet is a heal divot, I suppose.
So like a little valley where there used to be an ulcer, but the ulcer has now epithelialized. And those will not retain fluoroine at all. And those are the ones where rinsing can be really helpful, because you'll be able to see, That the fluoresce will actually rinse out, and, and they should, those eyes should be completely comfortable.
So, if you have an animal and they have a bit of a divot, but you wouldn't, you know, they're here for a vaccination and they don't have any clinical signs associated with an ulcer, then you may be dealing with a facet, or a divot. So here's some examples of corneal ulcers, so we can see that the cornea in each of these images is quite cloudy, on the image on the left of the screen, the, cornea is cloudy because of edoema, whereas the image on the right of the screen, the cornea is more cloudy because of, Cellular infiltrates, so there's that yellow white discoloration, so two different situations, but both of these are corneal pulses, . These eyes look like they're held reasonably open, but probably both of these eyes were quite painful and perhaps an anaesthetic has been applied.
And you can see, at least in the image on the, on the right of the screen, that there, where the conjunctive is exposed that it looks quite red. So pretty good examples of corneal ulcers. So, again, if you're presented with these types of irons, it can be tempting to, you know, feel pretty, pretty worried about that.
But again, just remembering these four steps, so taking a step back, you know, deep breath, considering the patient, so, with corneal ulcers, they, they are more common in brachycephalic breeds, and I would tend to be much more worried about them in brachycephalic breeds. So if I'm presented with a Pekinese or a shih-tzu and it has an ulcer that maybe doesn't even look that bad, I'm much more wary about that, and I'm going to monitor that much more closely, than I might in For example, a Labrador, when the owner tells me that, oh, well, you know, it happened yesterday. I took them for a walk, they ran into the bushes and they came back and they were squinting.
You know, I might be slightly less concerned about that than I would be in, you know, Pekinese, where their ulcers can become very severe very quickly. So thinking about signalling. Comorbidity is particularly Dogs that are on, things like steroids.
So they might have immune-mediated hemolytic anaemia or, they are on, you know, on chronic steroids because they're itchy dogs. Those dogs, are more likely to have ulcers that are more severe. So, just, you know, bearing those things in mind.
Being systematic and using resources. But when it comes to corneal ulcers, the question I would encourage you to ask is, is this a complicated ulcer or an uncomplicated ulcer? So this is the decision-making process, the first question to answer, complicated or uncomplicated.
So an uncomplicated ulcer, these are the ulcers that, look, they can absolutely be urgent to the owner because their dog has painful eye. So they're going to, they're going to bring them into you, and that's good, really, but they're not critical yet, and essentially your goal is to try to keep them that way. So, an ulcer is uncomplicated when it's been there for less than 7 days, and because of that, Acuteness of the ulcer.
There shouldn't be any corneal vessels. The corneal stroma should be normal. So it can have a little bit of edoema, but it shouldn't actually be changed in character.
So no melting or infiltrate or loss. If you can see a divot, then that means it is no longer an uncomplicated ulcer. There should not be any intraocular reactions so There shouldn't be hypoium, there shouldn't be hy femur, and there shouldn't beer.
You can have a bit of meiosis, that's absolutely acceptable. And you may even have a little bit of aqueous flare, but if you're seeing anything more than that, then I would no longer call this an uncomplicated ulcer. So I include these, even though it might not seem like it's an emergency type of case, it is going to be an emergency to owner.
So they, they will bring them into you for this problem. So an uncomplicated ulcer, now we're at the, well, what do I do? So you've made your diagnosis, you've diagnosed an ulcer, you've characterised it as uncomplicated.
Here's what you do. You put on a hard plastic E-collar. There is never a reason in ophthalmology to use a soft E-collar.
Always use hard collars. If you need a collar, you need a hard plastic collar. Use a broad spectrum sort of first line prophylactic antibiotic droproing.
Depending on where you are in the world, those will vary. I do tend to use, what we in Australia called Opticin, which is a combination of chlorumphenacol and polymexin B. If you're in America, then you won't have access to that.
But a triple antibiotic ointment or drop is, is usually fine, . Atropine, if it's an uncomplicated ulcer, a lot of the time, a single treatment will be enough to dilate the pupil and keep it dilated. I always mention to people.
That the pupil will stay dilated for a long time, so it can be a week or even longer, because that's one of the most common reasons you get owners calling you back. And if you're working, you know, this is an emergency case, you squeeze them in or you work in an emergency clinic, then not having people needing to call you back and taking up your time doing that, not having owners need to be worried about something they don't need to be worried about is to tell them that the atropine will last a long time. Again, I use the little individual, bottles that are called minims, so they come in single-use vial.
And that way you don't have to keep a whole bottle of atropine, you know, open, but then, you know, goes out of date and is a waste of the money that your hospital needs to. Spam. So if they are not already on a non-steroidal anti-inflammatory or a steroid, then put them on a, I usually use meloxicam or caprofen, you know, or you can use whatever you like, and then essentially you're checking them to make sure that the ulcer does not become complicated.
So none of the features that we're about to talk about. So again, you know, these four steps, so being systematic, staying calm, and using resources. So a complicated ulcer is an ulcer that has been around for more than 7 days, where there's corneal vascularization, there's a change in the stroma, or there's an intraocular reaction.
So, again, first question when you diagnose an ulcer, is, is it complicated or? So once you diagnose a complicated ulcer, there's then 3 broad categories of complicated ulcers. There are infected ulcers, irritated ulcers, and indolent ulcers.
And the way that you treat them, depends on which of the three categories. So a complicated ulcer due to infection. So you would diagnose this because there's a change in stroma, so it's melting, there's infiltrate, there's a divot.
The image on the right shows a really obvious divot. You can see the fact that it has a cotton bud in the eye, it's a good indicator that we've put some anaesthetic on, which is absolutely fine, that there is an intraocular reaction. So the, I really recommend cytology in these cases.
Now, you do have to be a bit careful because there is, you know, the possibility of, of rupture, so, you know, being careful, and we do also know that cytology together. With culture is beneficial, so, not really, a situation where one or the other, but actually ideally both. So, this is in your notes.
I have written here step two, actually wait a few minutes, and this is sort of, you know, myself included, we put the drops of anaesthetic in, and then we immediately want to go ahead and take the sample. Now, what I would I force myself to actually look up at a clock. So there are clocks in most of the rooms and, the hospital that I practise in, and I'll actually look up and I will force myself to wait for at least a minute.
And that minute feels like a long time, and it reminds me that probably some of the times, if I don't look at a clock, I'm actually not waiting long enough. So, a few drops of anaesthetic, And then, you know, wait a little while and then do that again. So you're trying to get the cornea to be nice and numb.
We know that depending on which anaesthetic you're using, some of them, you know, you don't get complete, anaesthesia of the cornea, and these are pretty sore eyes. Get someone to help you, you're not going to be able to do this by yourself, and then gently contact the edges of the ulcer. If you're worried that you're going to rupture the eye doing this, don't do it.
So you roll the material out and and then you do the same thing using a culture swab. Now there are other ways of doing this, you can use a little spatula to take a sample. You can use the, you know, in horses in particular, I use the blunt end of the scalpel blade, but this is the easiest way is just to use the actual culture swab.
You, if you're going to do the cytology in-house, then you can stain with diff quick. Obviously you can gramme stain as well, so I find that actually gramme stains are not done as frequently in practise, and then you examine it under the high power objective of your microscope. So if you see cockeye, they'll usually be strep or staph, and both of them are usually susceptible to chlorophenacol or cefazolin.
The staphs are usually susceptible to a fluoroquinolone. But I wanted to draw your attention to the fact that streptococcus sensitivity seems to vary by geography, and we'll we'll talk a little bit more about that in a moment. I have in the notes for this presentation given you a recipe for cefazolin.
So cefazolin is a really great antibiotic to use, and you can formulate it from the intravenous cefazolin you probably use for other surgeries. Rods, are usually pseudomonas or E. Coli, and the There is variable resistance, like you said they're usually susceptible to the fluoroquinolone.
So fluoquinolones are things like umofloxacin or ciprofloxacin. There is variable resistance to the aminoglycocytes, so gentamicin or Tobramycin. So I don't really tend to use those very much.
But I, you know, my other talk will, will, will go through the medications I think you should keep on the shelf, and you know, it may be that this is what you've got on hand. So cytology, in this image, we can see a a neutrophil and you can see some what appear to be cockeye-shaped bacteria within the cell. Oftentimes you'll see a lot of streaming nuclear material from degenerate neutrophils.
You'll see some e cells. So, this is a paper that I actually was involved with, the one in Australia, which was, performed and written by, my colleague, Dr. Kate Heinle, and she looked at susceptibility of strep, well, she looked at the susceptibility of various, organisms cultured from infected corneal ulcers in dogs.
And what she found was that in a Australia, all of the samples we looked at were of streptococcus, were resistant to fluoroquinolones, which is really fascinating next to, in a study performed in the USA, where they were all susceptible. You can see that in the same situation was the same in Switzerland, but in Taiwan, resistance, you know, there were significant levels of resistance. As well.
So I mentioned this because there might be a little bit of a tendency to think that a fluoroquinolone is going to cover everything, and that's just not the case. And I'm really happy for, those of you who are in the USA and those of you in Switzerland, where you can probably assume that your strep are susceptible to fluoroquinolones, but in an effort to try to keep it that way, I would encourage you, you know, perhaps to use those drugs judiciously. So, generally, the treatment for a complicated ulcer is going to be aggressive medical therapy or surgery.
So aggressive medical therapy, that can mean, you know, every 1 to 2 hours using antibiotics, using serum. And, assessing and making sure that the cornea, that there's going to be enough healthy cornea left. Now, these really sad images are just a little, request, a little, you know, plea, that if you don't have access to an operating microscope or small calibre suture material, that it's probably not a good idea to be.
Corneal surgery. So these, the image on the left is is some gut, that's been used to suture a cornea. And that's just horrific, you know, that, that poor animal.
And then the image on the right is a graft that was done by someone who was not an ophthalmologist, and that graft, you know, you might not have seen too many of them, but that is incredibly thick, and that is just retracting and pulling. And that is not going to be successful. And I, I just think that that's really sad, putting the animal through, a longer period of discomfort.
Honestly, you know, if, if, if, if, if the option is to do these surgeries like this, or, use medicines only, or even look at eye removal, then probably, you know, to advocate for the patient, it's probably better to, to go with medicines or even other. So, we, you know, these are the cases that we ophthalmologists are here for. So if they're not already on an antibiotic, starting fluoquinolone plus chlorophenol or polymexin B or another broad spectrum, so those are the pretty easy ones, they're probably going to respond quite well, but if they're already on an antibiotic, then, changing to a new antibiotic, ideally based on cytology, and you should choose your antibiotic based on your cytology results.
And again, as I said, using those medications frequently. You can also get complicated ulcers due to ongoing irritation, so hairs, foreign bodies, dry eye, and essentially the treatment is based on identifying and alleviating the underlying cause. So here we have a foxtail, and the image on the right is actually, it's a little bit hard to see, but if you look closely, you'll notice that there is a suture in that eyelid, and the suture from the eyelid surgery has been rubbing on the third eyelid and also on, on the eye itself.
And you can see that little, granulomatous reaction there. So, indolent ulcers, these are the ulcers that probably shouldn't be presenting to you as emergencies, but, you know, they may and you know, the treatment is sort of beyond the scope of, of what you need to be doing, but I guess knowing that that they occur. Signalment is important, so these are really common in boxer dogs.
They're also called boxer ulcers, and the, you know, there's various treatments that probably doesn't need to be done overnight, for example. You can treat them medically as for an uncomplicated ulcer. So again, those 4 steps.
Foreign bodies, they can, be partial or full thickness, and it's pretty important to, to know the difference. Putting fluoroine on and seeing if the fluoroine gets diluted. That's called the Seidel test or a Cal test.
And here we have an image of a little, you can sort of tell that it's raised above the surface of the eye. See these quite often these little sort of, they seem like little seed pods, and they almost suction cut onto the surface of the eye. So you'll be able to diagnose these because you can see them, and there may be some associated opacity of the cornea.
The prognosis depends on where they are, particularly if the lens is involved or not. And you may want, you know, to refer these cases. Those little seed pod ones, they can do really, really well.
And I usually find That attaching a little cannula to break the suction seal, can work really well. Yeah, it's interesting if you rub it with a cotton bud, that will often not do anything. That, you know, if anything, it can make it a little bit worse.
But if you can get a little bit of fluid up underneath it, then that will break the seal. Now, glaucoma, glaucoma is definitely something that you will face in as an emergency. It's diagnosed when the intraocular pressure is more than 30.
And also consider the symmetry between the eyes. Pain can be variable, and vision can also be variable. Depending on how severe and for how long the pressure has been elevated.
And here's a pretty classic image and a dog with glaucoma and see that the pupil is dilated and those little corneal linear opacities that are called HAR stria, and they indicate that the eyeball has stretched, . So, again, that systematic approach, considering signal, particularly when it comes to glaucoma, so primary versus secondary glaucoma, and we'll talk a little bit about the, the reasons to have glaucoma. So primary glaucoma is where there's a problem with the drainage angle.
It usually comes in middle age. So even though we'd say, developmental abnormality, the symptoms often come, you know, middle age, versus secondary glaucoma, where the angle, the draining used to be normal, but has become abnormal, particularly things like lens luxation, but it can be from inflammation or from cancers inside the eye. You can treat these, using your carbonic anhydrase inhibitors, so things like coopt, Trusopp, Azo, and Cosopt has both drizolamide and Timolol.
Azaga is the other one with combination of brinzolamide and Timolol. It's, you can always use those, if you're worried about glaucoma, as opposed to the prostag gland and analogues like Latanoprost or traviprost, where you need to know that the lens is not luxated. So, careful examination and or an ultrasound before you use those.
And if you're not sure, because you can't get a good look, then don't use. The Manitol and glycerin and all of those, look, I'm not too sure about them because they're really only going to give you a short-term effect. So you can use them to give you a prognosis, you know, is the eye going to be able to see again, but they're not going to give you, long-term control.
As soon as the patient's hydrated again, then that pressure's going to go back up. So, When the lens is luxated, usually very painful, and breed is really important, so terriers are the classic. Again, here's an image, you know, a little bit harder to see.
This image comes from the UC Davis website and again it comes with an arrow. So, you know, I think these arrows are really helpful. We need to get, get more dogs to come in with arrows.
In their eyes. So carbonic anhydrose inhibitor, maybe manit and. There's no reason to, you know, if, if, if, if we don't surgically remove the lens, then this lens is going to continue to be a problem for this animal.
Usually, it's a case of either removing the lens or removing the eye. Now, trauma and blood within the eye, I guess it's, it's just a question of, generally we treat these as for just any other kind of inflammation, any other kind of uveitis. But do bear in mind the possibility of a coagulopathy.
So having a doing a good physical exam, which you will have done because you're following the four steps, and, and, you know, not missing something that that's going to be significant for the rest of the dog. If there is severe high femur, we call that 8-ball hy femur where the eye looks completely black, then that indicates something serious is going on, probably involving the back of the eye. This is a time when your dazzle reflex is probably missing, your consensual pupillary light reflex is probably missing, and that is a poor prognostic indicator.
It usually means that either the retina has attached or the eyeball itself has ruptured. You treat as for inflammation, and, you know, that's all been written in your handouts. So proctosis, my colleague, Vicky Little shared this, image with me.
It was actually from a case she saw while we were working together, and I performed the eye removal on this case. So, this is a great example of a proctosis that does not have a good prognosis. So when the eye is literally on the cheek of the dog.
It's, you know, I, I would be really, would not be replacing that eye. Again, remember the rest of the patients, stabilise and perform a complete exam, and provide analgesia. Do a complete, ophthalmic exam, and normally you would be able to, you know, if there is an intact consensual pupillary light reflex, then that's good.
So again, particularly cases like this, this is when you need to take a deep breath, you need to remember the rest of the patient. So, depending on the breed, so signalment again, it keeps coming up, if it came out easily, then that is going to suggest there was less trauma involved and therefore a better prognosis. So you know, that the eye proctosis during ultra, when you're positioning for radiology, then, you know, probably the prognosis is very good, as opposed to a cat where the prognosis is very, very poor.
You know, again, depending on, you know, the breed and what else is going on, you need to talk to the owners about the risks, and I've included them here. So the image on the, these, these two images, in fact, these are eyes that I would be feeling, you know, a bit more positive about, as opposed to the, the one I showed before, here, and, . And this is the image on the right, is the, is is a dog that is not brachycephalic, and so that always worries me.
It's also a really good, picture of the medial rectus muscle having been torn. So I'd be a little bit more worried about that dog, and also be, you know, really wanting to do a complete physical exam. And the image on the left, that is not an eye that should be replaced.
There are some good images, in the textbooks about replacing. I, tend to use the muscle hook. I really like using that technique, and, using, doing a lateral canthotomy, if necessary.
Eyelid lacerations, the main thing about these is addressing them quickly. Well, the eyelid, tissue is still quite healthy. Good prognosis if corrected early, there's a good blood supply, within eyelids.
The figure 8 stitch. So this is a beautiful image from the, slater textbook that I was mentioning to you. Don't debride aggressively, you know, debridement, you know, if, if at all, hopefully you're getting to them soon enough that you won't need to do any, .
And have a look, you know, this image is, here and, certainly readily available in other places about the figure 8. And practically it's a great idea to try to practise this, when you're not, you know, when, when, so that you've got it up your sleeve as a technique to use when you need to. So those 4 steps, staying calm, considering the signalment, being systematic, and using your resources.
So your resources might include the handout from this presentation. As I mentioned, I really like the textbook Fundamentals of Veterinary Ophthalmology. There's some great images on the UC Davis website, and I've included the link here, and then of course you're a friendly neighbourhood veterinary ophthalmologist.
Thank you to AMPRO again for the sponsorship, and I would now invite any questions. So So we've had a couple of questions. The first question is about corneal ulcer cytology.
The sterile swab to sample the cornea, is it dry or is it dampened with saline? I use it dry. I have not wet it before.
I use mine dry. And then, and then I put it in the culture medium. So I, I swab with it while it's dry, and then I put it in the culture medium, and then when I'm so for culture and then for cytology, I tend to use it dry also.
OK, and the second question we have is about odd sound and this what probe is needed for almic odd sound. Oh, gosh, what a great question. And I'm afraid I'm going to need to get back to you on the answer to that question.
I use a linear probe, but I'm actually not sure what the frequency range is for that linear probe. So is that OK? Is there a way that I can post the answer to that question?
Yeah, that's fine. We can put that one up on our blog as I use the one I always use attached to the ultrasound machine, and I don't know the question off the top of my head. So just ask, we access notes.
Notes will all be posted on to the website when recordings go live. The, there's no question, and it's what are the current recommendations to manage the question in cats. Ah, wow.
OK. So corneal sequetri in cats, I am a, I'm probably a little bit biassed because I tend to see the cases that do not go so well with medical treatment. So I am an advocate of surgery.
Now, obviously, you know, that's something that I do as an ophthalmologist, I do a keratectomy and I always do a corneal graft. I never leave them. Open, so I will do a keroectomy, so removing the portion affected by sequetrum, which can be full thickness or near full thickness.
And then I do a corneal conjunctible transposition, so sliding corneal graft to fill in the defect, so that at the end of surgery, I've got intact. Complete epithelium over the area so that there is very little chance for recurrence because there is not much left for healing. Now, that's obviously something that I can do, but if I were not able to do that, I would treat with cyclovir at 90 milligrammes per kilogramme.
2 to 3 times a day, an antibiotic and a lubricant, and I would warn the owner that although the sequester may slough, there's not necessarily any reason to expect that it's going to slough out rather than become deeper. So yeah, again, I do think surgery is the preferred method to address those. OK.
So what we'll do, we'll take a couple minutes break. So what we'll do is start next lecture about 1005.