Thank you all for joining this TVM sponsored webinar. My name is Helen. I'm a veterinary technical advisor at TM UK.

And before Neil gets started, I wanted to do a brief introduction to our Corneal focus range and also flag up some resources that we have for you as part of our national pet Eye Health Awareness Week campaign. Many of you will be familiar with our corneal focus range, which includes diagnostic aids and general use products to help support eye health along with handy resources for use in practise to help manage eye cases effectively. And in case you weren't already aware, we also have an exciting new product called Stromes.

Stromese contains annoylcysteine, also known as NAC, and this molecule is widely used in human and veterinary medicine for its antilagenase, muolytic and antioxidant properties. It's an off the shelf antilagenase eyedrop in a ready-made sterile formulation, and this makes it really convenient to use because you're not having to formulate anything within the clinic. It's easy to store with no need to refrigerate and a long shelf life, and it comes in a 5 mL bottle with an easy applicator nozzle for simple and consistent dosing.

And the dosing is 3 to 4 times daily. We recommend considering strames as an adjunct treatment in any ulcer where there is a concern about paratomalacia. National Eye Health Awareness Week runs during the final week of September every year, and we've been running our own pet version for the last 3 years now.

This year we wanted to focus on brachycephalic breeds and the eye problems that they suffer with. Their popularity is only increasing with pet owners and therefore it's part of our duty as veterinary professionals to educate owners on the conditions that they need to be aware of in these breeds and also what they can do to help. We've created client leaflets for use in practise, which can be distributed to owners of brachycephalic dogs or cats, and also to owners that are thinking of purchasing one.

There's also more in-depth information on our website via a dedicated landing page, and the URL for that is on the leaflets. We also have got waiting room displays and social media packs, and this is to help spread owner awareness of the various symptoms of poor eye health that they need to be looking out for in their pets. Practics can use these during September if they want to promote National Eye Health Awareness Week or even all year round.

And more information on how you can order kits can be found on our website at TBMuk.com/ihealth. Along with our website, you can also get in touch with our technical support team via telephone or email.

And please do follow us on social media to stay up to date with product news, the latest resources and guidelines that we have available, and from time to time we also run competitions on social media as well. Thank you once again for joining this webinar and a massive thank you for Neil to for agreeing to deliver the the webinar on the topic of brachycephalic ocular syndrome and also to the webinar vet for hosting. Good afternoon everyone.

My name is Charlotte and thank you for joining us for today's lunchtime webinar, brachycephalic ocular syndrome, Why Do Pugs Keep Getting Ulcers by Doctor Neil Gs. Today's webinar has been kindly sponsored by TVM, so a big thank you to TVM. Neil qualified from RDSVS in 1987.

He passed his RCVS ophthalmology certificate in 1996 and became an advanced practitioner in 202015. He works in Kirkcaldy, Scotland, and runs full-time ophthalmology service with a busy primary care practise. His interests include corneal and Cashact surgery.

So we're in good hands today to talk about this subject. I wish to let you all know that today's session will be recorded and available on playback, and you will all receive a certificate for the day for today's attendance. Please use the Q&A box for any questions you may have for Doctor Neil throughout the presentation, and at the end of today's session, we will see if we can answer any of these questions you may have.

If we run out of time with the questions submitted, we will email out any responses to you in the next few days. So with no further ado, I'd now like to hand over to Neil to start today's session. Thank you, Neil.

Thanks, Charlotte. OK, so we're gonna try and go through, brachycephalic oculus syndrome today, which is a term that's been coined over the last couple of years. Really trying to just get to the bottom of, why we see so many pugs with ulcers and, why they are so difficult to treat.

So, as you all know, it's the, brachycephalic dogs and cats that are the ones that get the really complicated ulcers. Obviously it's not just the pugs, it's the French bulldogs, it's English bulldogs, it's any dog that's got a flat face, so that's shih-tzus and Mazapsos and, and calier and child spaniels, but it's also cats as well. So we're starting to see increasingly cats with melting ulcers.

So again, it tends to be the bracketophytic cats. So that's the, exotics, the Persians, and the British shorthairs. What we're saying here is that we're talking about, as I say, all of the flat foisted breeds, so a non-dole cephallic breeds, and as I say, that's both dogs and cats, and that we're talking about a syndrome.

So we're coining the term syndrome to mean that it's a concurrence of, of, clinical signs, all of which adds to the issues, and together they, they create a really complicated and, and difficult, condition to treat. So what we're saying is that, brachycephalic dogs and cats, have a number of issues, all of which, or at least a large number of which are anatomical, and that they include, macropalpyal fissure, so that means, an overly long eyelid margin, that's particularly true for dogs, not quite as obvious in cats, but they're la ophthalmic, which means that they have an inability to blink fully. So what tends to happen is that the, The blink doesn't meet in the middle, so the two eyelid margins don't meet in the middle, and as a result of that, the tear film isn't spread properly, which is why, you get drying, especially in the centre of the eye, which that's where you tend to see the majority of the ulcers.

But these dogs have a shallow orbit and therefore their eyeball is further out of their skull and therefore not as well protected. And although the eyeball looks bigger than it is in other dogs, it's still the same size, it's still about 23 to 25 millimetres in, in, diameter. But they may have reduced corneal sensation as well, and that means that they, tend to blink less often, and that's a real issue for us, partly because, as I say, they're not blinking as often, it's not spreading that tear film, but also, they're not aware often of the amount of trauma that's been, that's happening to their corneal surface.

They tend to have medial entropion as well, and that's on the lower lid, and as a result of that, we get trachiasis, so we get hairs, normal hairs from the eyelid margin touching the cornea, and that's often why you see these dogs with, with pigment on their, on their medial limbus and medial cornea. And that they may well have, a poor tier film, and that can be either quantitative or qualitative. So quantitative would be, the English bulldogs that have, true dry eye like KCS, but that we see a number of these dogs with qualitative issues as well.

So, and we'll talk about that in a bit more detail in a minute, but we're talking essentially about, lack of mybomium secretion or, lack of, lipid secretion as well. And there is some evidence, and again, we'll talk about that in a minute, about whether or not these dogs also have some issues with proteolytic enzymes, which are normal in the tear foam and in the cornea, and the fact that they may be up regulated and therefore, you get more digestion of collagen, in these dogs. So this is just a couple of photographs, of a French bulldog.

So obviously we're interested in all breeds that are brachycephallic, but now that we know that, these are the most registered breeds, or most registered breeds, sorry, in the, with the Kennel Club at the moment. So they're the most popular breed at the moment. This is what we're seeing.

So what we're seeing, I don't know if the marker works, but what we're seeing is that this eyelid margin is far too long, so you see far too much exposure of the sclera. And as a result of that, it means that you're getting more exposure, so more drying of the front of the eye. It means that they're like phthalmic too, so the blink doesn't meet in the middle, so the majority of the blink comes from your upper eyelid, but, they just, the two eyelids won't meet in the middle, so the drying of the central cornea is the issue.

And that on the slide on the right here, you can actually see this, this unfolding, this entropion of the lower medial lid, partly down to the fact that they've got a, a nasal fold, but partly down to the fact that they've got too long an eyelid margin. And if you have a long eyelid margin, you're much more likely then to get an entropion, partly because it's too long, but partly because the, the medial canal ligament is probably too tight in these dogs, which means that, that, it tends to pull the eyelid in. And pulls the hairs onto the surface too.

So, so that's what you're seeing there. And And And the same again. This is, another friend she obviously, and again, just showing this idea of a macropo pupil fissure again.

And in this photograph, what I was trying to show was that the pigment is starting already. So you can see the pigment out here on the sclera, and this is, this is corneal pigmentation of the, overlying conjunctiva, and again, that's to do with exposure of the, of the conjunctiva, to do with the fact that, this dog obviously is not protecting that conjunctiva properly. And then if you have a look in a bit more detail, this is showing macroop people fissure just to show the full extent of how far, this, this coordinate is not being protected by this, this eyelid, which is far too long.

You can see third eyelid here, and you can just see again pigment this time immediately starting. And then again just a close up of the medial entropy and just to show that the hairs are actually touching the corneal surface here at the at the medial margin. Then this is a comparison really between a normal eyelid and and a a dog with a macropod pupil fissure.

It's actually not particularly easy to see because this one is taken at an angle, but, but the idea is to try and show you just how much more or conjunctiva and therefore cornea is exposed relative to a, to a normal eye. So we think about normal eyes. What we're saying is that the eyelid margin is particularly important for the spreading of the tear film, and that the, tear film itself is composed of three components.

So what we're saying is that the mybomian glands, which are on the lid margin here and here, produce the, lipid part of the tear film. So that's the exterior part of the tear film, and stop the evaporation of the tear foam. That the lacrimal gland, which is up in the upper eyelid, and the gland of the third eyelid produced the aqueous part of the til, which is the largest part of the tor film in terms of quantity.

And, that the third part of the tear film is produced by the conjunct type of goblet cells, which are these little cells down here. So that's the mucus part of the tear film. And that's the one that basically allows the tear film to slide across the front of the corneal surface.

So they're not three distinct layers, but they are, it tends to be that the lipid is on the outside, that the aqueous is in the middle, and that the, mucus is the one nearest to the corneal surface. And it's just, again, to illustrate the fact, and, and we will probably have time today to talk about it, but the third eyelid gland, which sits down here at the base of the third eyelid, is a really important structure and, it's not uncommon at all to see brachycephalic, especially puppies, with cherry eyes or prolapse of the third eyelid gland. And if at all possible, it is really important that you actually preserve that gland.

And that if you see a puppy that's got a prolapsed or the gland, that that gland is replaced back into the contract type or pocket rather than being removed, so that there is less chance of that dog developing a qualitative or quantitative, sorry, dry eye, in later life because the, the, the, the gland that's in the third eyelid, can produce up to 30% of the tear film. So if it's removed, then you're already predisposing this dog to a dry. This is just a repeat of what we've just said, that there's 3 phases in the in the pre-colonial 2 film, and that the aqueous phase is the largest by volume.

The cornea itself obviously is is the bit that we're really interested today, so we're really going to talk about ulcerative keratitis is what really we're talking about. So you understand that the cornea is avascular, which is why it's transparent. And that's fantastic, but it does mean that it's healing properties are really poor.

It's very, very difficult for the, for the cornea, especially the exposed stroma, to heal. And, it, it, it, it, it, because it doesn't have a direct blood supply and depends on the aqueous and the tear film for its nourishment, it means that everything happens much more slowly. The cornea is only 0.5 to 0.6 m millimetre deep, and that means that, the melting ulcers in particular, can happen very quickly.

They don't have far to go before they reach decimate's membrane, and therefore, rupture of the cornea is a real issue, and it's certainly the case that in the brachycephalixx, we can see rupture, from what was a very superficial ulcer to rupture within a few hours or even a couple of days. You understand that the epithelium, the stroma, testimy's membrane, and the endothelium are the four layers of the cornea, and we'll just take a moment, just in a minute anyway, to have a look at the slides and just, so you can see that in a bit more detail. But the stroma is the one that, is the largest layer by far, and that's essentially made up of collagen fibrils, which are laid parallel to each other, allowing the wavelengths of light to travel between them, which is why they're transparent.

But they're purely cellular. There's very few cells in there. There's kratocytes, obviously, and, some ground substance, but very little in there to actually protect them, and also to allow them to, to heal.

Nerve endings in the cornea tend to be situated superficially, so that means the most superficial ulcers tend to be the, the, the most painful. The epithelial, the, the nerve endings are situated just below the othelial surface. So the idea is that if you get a, an abrasion or, or sic ulcer that your nerve endings are stimulated, that means you produce more tears, you're more likely to shut your eye, which we should protect it.

But it also means that as the ulcer gets deeper. You are, often, faced with the circumstances that the ulcer appears to be getting better, i.e., the dog's eye is more open.

And certainly it's not uncommon for owners to come back to us and say that the, they think that the eye is actually getting better because the dog's got its eye open, but there are fewer nerve endings, the deeper you go into the corneal surface, and, it, it, it sometimes, works in a, in a really, sort of detrimental way. So epithelium and then stroma decimy's membrane, you all know about is the inner limiting membrane of the cornea, that's the last layer really before the, the, the cornea ruptures. And then there's a single cell layer underneath that called the endothelium, and that's where the pump cells are, and they're the ones that keep the cornea dehydrated, which is part of what keeps it transparent.

But really it's the stroma which is the issue because protein digestion of the stroma happens very easily and that's particularly true in brachycephalic. So this is a slide, taken a section of a normal cornea. So just trying to show you the various layers.

There we go, let's go back again. So this is epithelial layer here, so it's only 10 cells thick, usually, and they start out clumner and end up stratified like this, and then they're shed, and they're shed every day. So there's, there's corneal damage every day, but it's repaired routinely without there being any issues.

And then the vast majority of the, of the cornea is made up of the stroma, which is the pink layer here, which you can see with all the fibrils in it, and the carratocytes. And then down here at the bottom is this inner limiting membrane which is decima, and then you can just see the wee nuclei of the endothelium, that single cell layer on the inside of the cornea, and that's all that there is between, between the cornea and the aids. So this is it in more detail.

So again, just showing the, the, the corneal epithelium here, and then on the other side here, just showing the last of the, of the stroma. So right down into the very deep stroma. This is decime's membrane here, so it's just a hyaline membrane, and then these are the nuclei of the of the endothelium.

So as I said, epithelial damage happens every day, that's that's normal, you're gonna get abrasions, you're gonna get dryness, that, that, that's not the issue. The issue is that in bracephalic, the healing response is abnormal. So normal exthelial healing should take place within 7 days, and we know that if any ulcer persists beyond 7 days that there's an underlying issue, and that's true for all dogs, that's not just brachycephalics.

So we know that even dolichocephalic dogs who have ulcers that persist past the seven day mark, often have other things going on, and that means that they're either, they've got, issues with their tear film, or they may have some sort of trachiasis disticiasis or oppocilia or something like that going on, or there's potential that they've got underrunning of the epithelium as you see in the, in the scared ulcers. The problem is that the stromal healing takes much, much longer, and again, we're just going to talk about that in a minute. But the big thing to remember is that stromal healing is a balance between protelytic enzymes.

So there's, there's protelytic enzymes there all the time in digesting the dying cells, and then there's anti-protelytic enzymes that are there to stop excessive digestion, and that is our problem with our brachycephaly. So you understand that a corneal ulcer is a full thickness epithelial defect, and that, most ulcers in dogs are traumatic in origin. So either that's self trauma, so those are atopic dogs who are scratching their faces or, or rubbing on their faces, or it's the dog that, that, that sticks its head into the bush or something like that and scratch itself or the dog that has had a bit of a wrestle with another dog, and And to me that seems remarkably common, especially in brachyphylax so I'm not quite sure why they think it's a great idea, but they seem to do a lot of wrestling where they're, where they're sort of biting and and pulling at each other's faces just as a, as a bit of fun.

In dogs, most of it I say is traumatic, but in cats, feline herpes virus one is the other complicating factor for us. So understand that feline herpes virus one is epitheliotoxic, so it would kill epithelial cells both in the cornea and the conjunctiva. That it, as a result of that predisposes those brachycephalic cats to, to, ulcers and then, subsequently to melting, that the, majority of the cats that have got feeling herpes virus one contracted it as kittens, so that means that they were, they were infected before we had a chance to vaccinate them.

So much as we have a very good herpes vaccine that we use in our kittens, unfortunately, it's the case that the majority of those cats that have herpes have it because they're infected prior to vaccination. And as I said earlier, the, the, the big thing with corneal ulcers is the fact that if we expose the underlying corneal stroma, so, in other words, let these ulcers go from being superficial to being slightly deeper, that's when we get, real issues because you can get excessive pro proteolysis, which is known as melting or caratomalacia, and that once you get that, you get into a much more dangerous situation where you get a deep ulcer, which can deepen very quickly. And lead to perforation.

And, I suppose essentially the thrust of this talk is to talk about the idea that that we see too many, monocular pugs and French bulldogs, because they have, we've not had a chance to treat them in time or that we've not treated them aggressively enough. And the the the kind of thrust of this talk is to try and stop that happening as often. So.

So current ulcer diagnosis, you'll all do on a daily basis. It's important that every red eye, as we say to the students all the time, every red eye that comes into your, your, your, consulting room, should have, fluorocine applied to it to make sure that, in fact, it hasn't got an ulcer. So you understand that fluorocine is your, the orange dye, which you all keep in your, in your fridges and pipettes or else as, as, florets, which are paper strips which you apply to the contrativa.

And that they're green and alkaline environments, that means the tear film, and that the fluoresce is lipophobic and hydrophilic. So it means that the, essentially, they won't stain, fat-rich epithelial cells, but it will stain exposed stroma, which is why it's, it's, it's, it's great for, for staining ulcers. I think the students get a bit, worried about the fact that, You might flush it off accidentally, having put the, the, the dye on, but it's the case that once you put the flourishing on, the ocular surface, on the corneal surface, it will persist for hours.

So, so we always tell them to flush the, the fluorescine back off again, stop the false staining, which you can get with the mucus, because mucus can stain with, fluorescine as well, and that there is, if there's any exposed stroma at all, it will continue to stain for hours afterwards. So there's no chance you're going to miss the ulcer. You also know that the fluorine is excited by blue light, which means it appears brighter if you shine a blue light in it, which is really important, especially if you're looking for subtle ulcerations or feline herpes virus one often produces a very subtle dendritic ulcer to begin with, and, it's a really useful tool to use the blue light on your ophthalmoscope, and have a look for more subtle alteration.

And the, and the big thing, and the thing that you all know is that that fluoresce staining does not happen on decimate's membrane. And for you, that, that's an absolute, red line. So if you see a deep ulcer that is not staining in the centre, then the chances are you have a dematocele, which is an extremely deep ulcer, and that's a surgical emergency.

So, So, we'll have a look at those in a minute, but, hopefully we don't get anywhere near those, but, but if we do, then those are the ones that you really, really do need to admit, treat as medical emergencies with a view to surgery. So we'll talk about that. So here's fluorescine again, just showing this idea that if you use a blue light, and then you can excite the the the the fluorescine more which makes it far easier for you to see.

So it's really deep ulcers. They're the ones that we're really interested in brachycephalics. We know that all dogs get ulcers, we know that ulcers should heal, so official ulcers should heal very quickly within 7 days, but we understand that the brachycephalic breeds of dog and cat get melting ulcers on a, on a, on a much more frequent basis than than other types of dogs, or dog phallic dogs.

We know that the melting or caratomlaia are a result of the imbalance between the proteasus and the antiprotetic activity. And we understand that there are proteases and antiproteases both in the cornea and in the tearful. And the suggestion is that in, brachycephalic dogs, the, anti-protease activity is, is probably not sufficient, and as a result of that, the proteases, hold the sway and therefore get corneal digestion much more quickly.

And so what we're saying is that you get, caratomalacia, so digestion or melting of the cornea, because we're getting excessive endogenous proteolysis. So, lack of antiproteases in the corneal tur film, so they should potentially, be neutralised. They're obviously produced by kratocytes that are dying by, neutrophils and macrophages.

And the enzymes should also be there to counter that, but, to complicate matters and to make our lives much more, disappointing sometimes, you can also get exogenous, protelytic enzymes produced as well, and that's particularly true of certain bacteria, and certain fungi, and the ones that we see, are the pseudomonas serachinosa and the beta hemolytic streptococci. Both of which produce, a number of proteolytic enzymes, and, and end up complicating our ulcers on a, on a regular basis. So if you look at the papers, that have been published recently, the most common bacterial isolate from melting ulcers in the UK is pseudomonasserachinosa.

It's the one that, produces a number of proteolytic enzymes, including PASP. PSP is a particularly nasty, protease, enzyme, which can cleave intact collagen. So the suggestion is that the pseudomonas might even be able to colonise the surface of the, stroma, before there's any real damage done, there may be an epithelial breach, but no more than that.

And then the, pseudomonas can actually get in there and, start to colonise and digest the, the, the, stroma. And that unfortunately, the highest nucleation rate, is associated with the presence of the pseudomys. So, although they all present the same way, and although you see melting, in, in dogs, they all look the same regardless of, of what, whether it's fungi or bacteria or sterile, melting that goes on, they all look the same at the beginning.

There's unfortunately the case that, not only is the pseudomonas the most commonly, Isolated bacteria, but it's also the one that leads to the greatest loss of of globes in itself. So we're thinking about pseudomos, we're now starting to think about, well, how are we going to treat these dogs and cats because we are gonna see them, you know, they're, they're a huge percentage of our population and small animals now. I don't, much as I think the BDA have done a great job in trying to deter people from buying brachycephalic breeds.

Certainly in our practise, anyway, I don't see any fall off at all in numbers coming through the door. So I think there has to be some sort of pragmatism where we're, we're saying that we understand these, these dogs and cats are out there and, what are we going to do and try and help them, to a, not form a melting ulcer, and B, keep their, their eyesight for as long as possible. So if you're thinking about what you're gonna use in the face of melting ulcers, then, you're going to talk about the use of, not probably first line antibiotics.

So unfortunately, phidic acid, is not active against pseudomonas, and now is chlorophenacol. So, we tend to use fluoroquinolone, so we use either ciprofloxacin or ulfloxacin. We also sometimes use gentamicin, although we've slightly gone away from that, on the basis that.

It's not that uncommon to get, mixed infections in your corneal ulcers, which means that you may get streptococci in there as well as pseudomonas, and certainly afloxacin seems to be better at countering both, whereas the gentamicin is very good at killing pseudomonas, but not any gramme positives, . Just to kind of make things just a little bit more complicated as well, it turns out that some of the BT hemolytic streptococci that are also part of the melting issue, can be, resistant to the fluoroquinolones. So, we often use, chlorophenacy at the same time because we know that, the streptococci are sensitive to chlorrophenac.

So there is an argument that if you see a melting ulcer that you should try and swab it, or at least, try and get a very small sample at the very edge of the ulcer nowhere near the deepest part, obviously, in case you rupture it, and just quickly put it under, just, just quick it and have a look under the microscope and see whether you're dealing with, gramme positive cocky or gram-negative rods, but in reality, sometimes we just end up, treating right from the get-go, with the appropriate antibiotic. Difficult, I think, because obviously antibiotic stewardship is a big deal and I, and I, I don't have any doubt that we have to be very careful about what antibiotics we use both technically and systemically. And I think if you're seeing doloocephalic dogs with superficial ulcers, then I think the use of beidic acid or chlorophenacy is perfectly acceptable.

But I do think in brachycephalics, where there's a higher index of suspicion in terms of the potential for melting, that, that you need to think about your antibiotic choice, in a, in a different way. And I think you have to be far more aggressive. Other things to continue, to consider are that, melty ulcers, can be sterile.

We've seen this again and again. So there's some suggestion that there's an immune needed to the inflammatory reaction that takes place even when there are either no bacteria or the bacteria are dead, so that you can get continuing stromal loss even after you've managed to sterilise the ulcer. There's also again that the kind of question mark over whether or not the brachycephalics, have, basically not got enough antiproteolytic activity going on in their cornea and their tear film on, on a daily basis and therefore are more prone to a sterile melt rather than than always being associated with an infection.

And as we said earlier that the BC analytic strap just complicate our picture, whatever, whatever we see. So when we're talking about melting corneal ulcers, you'll all have seen these in practise. They're the classic ulcers that have taken on a very odd kind of grey or yellow, appearance.

They have a very indistinct border as if the, the cornea is becoming a gelatinous, which it is, it's being digested in, in, in, in front of you. And, if you are really unlucky, then what happens is that that the corneal rigidity starts to be affected too, and tectonically, the, the, the cornea is not as rigid, cornea. It's a particularly rigid structure, normally, but when it's, when it's being digested, then that, that becomes a real issue and, and you actually start to see changes in the cornea profile.

The cornea can actually start to bulge towards you, so. So it's you, but the big thing is that, that when you're dealing with brachycephalics, you, you, you have to be super careful. You need to see them regularly.

So even if you see a brachycephalic, for what appears to be a very superficial level, you need to see them again very, you know, quickly afterwards, so within 1 to 2 days, just to make sure that they, they aren't starting to melt. And if there's any suggestion that the Corneal surface is starting to become indistinct. If it's any looks an odd colour, because obviously your cornea should be clear.

It's grey or if it's yellow, or if it's starting to become gelatinous at all, then you, you need to get on with your anti-proteolytic, treatment, and also make sure that you're, that you're treating with the appropriate antibiotic. So these are a couple of slides taken, of, of various melting ulcers and, and what you're looking at obviously is this idea that it's becoming grey in colour, that, that, that this isn't just mucus now that's appearing on this corneal surface. This is actually digested cornea.

So this, this cornea is actually coming off often and comes off in, in strings of, of, of, of digested collagen. And that's what you're seeing there. This one obviously has been going for a bit longer because it's obviously it's quite a, a marked, vascular response.

So, obviously there are no blood vessels on your corneal surface, so they all have to ingress from the limbus. So this one's still, obviously been going for a few days cause your blood vessels, your, your, limbo vessels only grow up to a millimetre a day. So, so it must have been growing for a few days, and then obviously it's still got this, this horrible grey gelatinous centre to it.

And then, same again. The one on the, on the left was a really, really unfortunate pug that we happened to see on a Friday night, and you can see that that tectonically this, this cornea is completely, spent, and as a result of that, it's about to rupture. It's pointing almost like an abscess because this is a, this is a, a cornea that that that's lost all of its corneal rigidity.

And then the one on the right is obviously just a a very sort of profound looking gelatinous cornea, which is, which is again just a sign of ongoing melting in in the corneal surface. So in this case, not the corneal surface but but deep in the stream. And then this is a cat, so this is a cat that had herpes virus, so it's cultured herpes positive.

It's just to complicate pictures. It's also got a bit of hair in it's, and it's, in its, defect which has obviously been rubbing at it with its eyes, obviously been going for a while. You can see the ingressing blood vessels, the, the short ones are the superficial ones, the deeper ones are the are the broader ones, and then you can see this, this area of degenerate cornea that's that's melting away.

So it's very, very common. So what are we saying? We're saying that melting is common, that the greatest risk factor for melting is bra brachycephalic confirmation.

So what we've just talked about the study of a brachycephalic ocular syndrome. We're saying that that, on top of that, the presence of certain pathogenic bacteria and fungi add to that, so that's classically pseudomonas or streptococci, but certainly some of the Aspergillus, some other bacteria fungi, sorry, can, can cause melting as well and produce protelytic enzymes. That that the presence of pre-existing corneal disease is, is also an issue and that obviously ulceration or superficial ulceration would be an issue, but, also tear film issues.

So this idea that, that, in certain breeds like English bulldogs, the, presence of a quantitative dry eye is an issue, but in certain of the other breeds like French bulldogs and pugs, there's a qualitative dry eye as well, and that that predisposes them to melting. We know that recent general anaesthesia is an issue as well. It's remarkable that the, the tear film following sedation or anaesthesia is, does not recover.

It takes often hours or even days for it to recover, so it's really important that your patients are, well lubricated during the procedure, but also after the procedure, so that you're reducing your chances of, of, ulceration and melting. Certainly, we know that that our systemically unwell patients are the ones that, that also seem to, to not do well, so the diabetics are the, are the, are the ones that we see. And interestingly, I think anyway, that, that the presence of or use of topical steroids or previous ocular surgery doesn't seem to be as much of a, of a risk factor for melting.

Having said that, we would always obviously, encourage everybody not to use topical steroids, . Especially on brachycephalax, unless you're absolutely sure that that wasn't an issue because it's, it's certainly, it may not be the case that it that it starts the melting, but it's certainly, causes a lot of issues if they're on steroids when they're presented with a melting. So this is the brachystatic and the Crateom Malaysia just to kind of round that off there.

So a pug with a normal eye and a melting eye, and this is a dog that actually had a GA two days previously. So, no, apparent issues at the time. It wasn't in for, anything to do with its eyes, and, it was lubricated during the operation, went home, and then this is how it presented two days after the anaesthetic.

So treatment of melting ulcers, topical antibiotics, that is absolutely at the top of it, even though we know that up to 50% of them are sterile on culture. It's still the case that you're going to use antibiotics, and that means appropriate antibiotics, which in a perfect world means, taking a swab, but if you're not gonna do that, then at least you're gonna use the appropriate antibiotics, which means that you have to keep some sort of Cipro on your shelf, or some gentamicin, but it needs to be there, and it needs to be there every day. It's not sufficient for you to, To say that you'll order some in in 2 days' time, especially if it's a weekend, that that could be too late.

We're saying that systemic antibiotics are probably appropriate as well, especially doxycycline. There's quite a lot of evidence in humans that, doxycycline can have antiprotease activity. Whether it's quite as obvious in dogs, I think it's a bit debatable, but it's certainly the case that we use them.

And that topical antiproteases are absolutely, at the root of the, of the treatment as well. And that can be obviously serum or plasma or now thankfully stromies because it's a little bit easier cause stromies can stay on your shelf at all times without you having to think about refrigeration or, or getting blood samples or something like that and creating your own serum. And then the final thing obviously is to use analgesics, so appropriate analgesics, to keep the dogs as comfortable as possible, stop themselves traumatising, and possibly some midriatics on the basis that your pain comes partly from your corneal, sensation, but partly from your iris spasm.

And if you get a small pupil a secondary uveitis associated with your ulcer, then, a good way of, of, of getting rid of that pain is to, is to give them a topical, midriatic like. So when we are treating the melting ulcers, we're talking about, potentially hospitalising these patients because we want them to get hourly drops. So that's either, if the idea is that, that, that, anti-protease activity only probably lasts, if you're using drops only about 15 minutes, we're, we're, we're talking about giving them hourly drops to try and, and, and make sure that, that we neutralise all those protetic enzymes as quickly as possible.

As we said earlier, you're gonna try and swab them, but you're gonna be very careful that you swab them at the edge of the defect, nowhere near the middle. That you use the appropriate antibiotics as we said, and the antiprotease both hourly, obviously 5 to 10 minutes apart, but they use them both. They use antibiotic analgesics, and, that you also give them, buster colour to stop them from, self-traumatizing.

And we sometimes sedate them to just, just, it's just a bit easier to, to apply drops, especially if you're having to do it on an hourly basis, . So we often give them just a, just a small dose of sedation, even just to orgesic, just to, just to, keep them, ease their way into the, into the treatment. So we treat for 48 hours usually on an hourly basis.

So that's those dogs that are admitted to be hospitalised. It's really, really important that if you've got a dog with a melting ulcer and you've decided you're going to admit it to treat it, that you do assess it regularly. So that means every 4 hours.

The melting can take place really quickly. And it's really important that you don't just stick the dog or cat in a kennel and, and start the drops and don't actually assess what's going on. And we understand that if the stromal loss is greater than 50%, we're really now talking about surgery.

We're not talking about medical treatment anymore. And certainly it seems to be that about half of the melting ulcers end up, requiring surgery. Some of them, unfortunately are requiring a nucleation, which is, which is extremely sad.

So if we're talking about anti-proteolytics, there are 3 main antiprotelytics that we would use. Classically, we've always talked about serum, so serum can either be autogenous or heterogeneous. So you don't have to use the same dog's blood to produce the serum.

You, you have to use a dog's blood in a dog's eye. You can use a cat's blood, or you can use a horse's blood. You just use whatever you've got to hand.

So it's very good. We like it. It has to remain refrigerated.

You can refrigerate it for up to 7 days, but, it's the case that it needs to be fresh when it's drawn off and spun down and or allowed to stand and clot, and, and then the serum is used that way and it's certainly got a lot of anti-protelytic activity in it, and we like it, . as an effective drug, the downside is that you have to have, access to blood to be able to do that. And certainly, it, it wouldn't be uncommon.

It certainly used to be the case that we would see a lot of melting ulcers on a Friday afternoon, and if they're in, pugs and things who are just not necessarily, what's the word, not, not particularly wanting, to comply, trying to get 10 mLs of blood off them to create the serum drops was, was a real issue, and so we ended up, having to try and think of other alternatives. Thankfully, now we've got two alternatives, which makes our life much easier. Stromme obviously is the new product from TBM, which is an acetylcysteine.

So it's, it basically is acting to bind the calcium. Calcium is involved in protelytic activity, and it binds the calcium, and it's a very effective, anti-protelytic, drug. The great thing about stromy is is that again, you can sit it on your shelf, it lasts or appears to have a long shelf life up to 2 years, I think, .

Which means that it can, you can have it sitting there. So for the bracket that comes in that you've got an issue with and you're just not particularly happy with the eye, then you're going to start it on straw meat and not wait to find out whether it's gonna melt or not. The, it doesn't require refrigeration too, which is great.

And then the third alternative is fresh frozen plasma from the blood bank, which is, which is the other thing that we use. So it's got a lot of anti-protease activity. It comes frozen and then we, we defrost it and put it into, a quarts, 10 mil alaquarts, which we then refreeze, so it then becomes frozen plasma, not fresh frozen plasma.

But again, it's got a lot of anti-protelytic activity, which means that it's a very handy thing for, for us to have. And because obviously we're seeing a kind of skewed population, it makes all the difference just to have it to hand, so we can just literally immediately take it out of the freezer and, and get on with it having to think about actually blood sampling, anything. We know that if we treat, melting ulcers, that, that actually, the ones that are, that do best are the ones that actually responded to the medical treatment.

So this is just a, a series of photographs. This is one of, John Moul's series photographs just showing a medical treatment of a corneal ulcer in a cat, and just showing that the visual outcome following a successful medical treatment is still the way to go. That's the one that produces the best visual outcome.

And, and so you can, if you can get ahead with your anti-fertilitic activity and your, antibiotic activity, then actually, those are the ones that do best. But we also know that, they are melting past 50% that that we need to go to surgery. So if you are assessing your patients to see whether you think your treatment is working, you would hopefully find that the eye is less painful.

As I said earlier, that's slightly complicated by the fact that the nerve endings in the deeper part of your corneal stroma are, are less profuse, which means that sometimes deep deeper ulcers aren't as painful, and that's, that can be a bit confusing. So you're looking at the ulcer edges really to make sure that it's static, or hopefully contracting, that the ulcer edge appears smooth rather than that gelatinous, indistinct, area. And that the hopefully the flu syn uptake is, is the area of fluoro synaptic is contracting.

So as I said, 50% could end up as surgical cases, so it is really important that you keep looking at them to make sure if if that's the case. If you do see the demetocele starting to form in the middle of them, so you're getting that, that beautifully clear bit of cornea in the centre of a very deep defect that is not staining with fluorose. Then those are surgical emergencies.

And, either that's something that you do yourselves in practise, having learned to do, for instance, a pedicle graft, or that's the point at which you're referring those dogs. In theory, you'd like to think you'd refer them before they get to this metocele because a dysmece is only about 22 microns thick, which means that If you have a dog that jumps up or barks at you or turns around quickly, that could be enough for that eye to burst, and that again, once they've burst, it's, it's much more difficult to, to save the eye. So these are just metoceles, you can see them, they're very deep, they've got very deep sides, steep sides, and they're clear in the middle.

So the idea is if you look at this one, it's got fluorocine on the outside, but the centre is clear, there's a tiny bit of fluoroine up to there, but basically it's clear in the middle, and they, they are surgeries, they are not medical treatments. And then if you don't get to them in time, this is what happens, they perforate. So perforation is, is a painful event.

It often you hear the dogs cry when it happens, you can see the aqueous exiting from their corneal perforation, running down their cheek, and if you're really unlucky, the iris starts to bleed behind it, which is what's happening here. And if you ever see anything in the centre of a cornea in a very deep stromal ulcer that is brown, then that is, iris. So that's iris pigment or iris itself that's come forward to block the hole.

So that is a really poor sign. Blood in the centre of a of a defect or, or a brown aacity like that are both really, really poor signs. So we're saying perforation is where you often hear the dogs cry, you see a a change in the corneal profile.

Sometimes there's a lot of res loss, the actual cornea collapses. You see protrusion of brown or black material, which I said earlier, is iris, and you may also see the presence of blood, which has come from the iris and afibrin. So just not what you want to see at all.

Yeah, and this again is one of John Wall's brilliant slides just showing a corneal perforation. So you can see that everything moves forward. So the corneal perforates here, and as a result of that, the iris comes forward, the bloody aqueous barrier breaks down and you get, blood and fibrin forming and the and the whole thing is clogged.

So, but that is a much more difficult situation to rectify than if you get to them before they rupture. So if you are going to treat them surgically, you're gonna do one of the following techniques. You're gonna do a pedicle graft or a, transposition, or you're gonna use some grafting material.

What you're not going to do is a third eyelid flap, that's not appropriate for, for ruptured, coronal ulcers. There are some, anecdotal evidence that, that, that occasionally third eye of flats have worked, but I think, that there's a lot of other evidence that those are the ones that actually, end up being in. So we that that is not a recommendation whatsoever.

So conduct table pedicle graph, this is not a surgical lecture, so I'm just showing you quickly the techniques, is the one where you fashion a contact title strip, and sew it into the defects using, 8 or 9 knot, suture material. So the idea is that you start with your cardinal sutures at the at the 12 o'clock position or 6 o'clock position, and then you put 2 more and then you and then you, . Leave that to to tival graft in place usually for about 6 weeks and then you section it just at the neck of the pedicle.

So just here, just where the where the ulcer is, at the dorsal edge of the ulcer, and then you're, you can remove this and then this will be incorporated into the, into the stroma. CCT is what we tend to do more of now and that's where you're taking cornea and conjunctiva into the defect. And the idea is that, it looks pretty messy to begin with.

So this is the contratival surface and this is the corneal surface. But when it finishes, the idea is that you get a much clearer central cornea. So for central corneal lobsters, this is a, a better technique, but technically a bit more difficult to do.

But the honest truth is that prevention is still what we, should be aiming at and that's, essentially, it's twofold really, isn't it? It's not, it's the, it's identification of, of, the breeds and the, the ulcers that you're suspicious of and the appropriate treatment of them early on, so that means anti-protelyotics. And antibiotics, and, that means on a, on a up to an hourly basis.

So, but also this idea of trying to stop them getting to that stage in the first place, which means that we need to be better at recognising them, but we also need to be better, I think, at educating our clients as well. So our clients need to learn that if they've got a brackphallic puppy or kitten, that they, that they, get used to, cleaning their facial folds and also their, their, their, their eyes on a regular basis. So there are plenty of eye drops around to do that with.

There's an argument that maybe these, all of these dogs should just be on, artificial tier supplementation on a, on a daily basis, and we'll talk a bit about that in a minute. There's also an argument that for the ones that really have macropo pupil fissures, so long, long eyelids with the obvious entropin, they should maybe, be considered for prophylactic surgery, and now we do quite a lot of medial cancerplasties in these dogs, so that they have a narrower palpal fissure, so they've got more coverage of their corneal surface, and that they're, therefore less prone to, to developing not only ulceration, but pigmentation. So pigmentation is a huge problem in these breeds as well, and these dogs can go blind simply from pigmentation without ever truly developing, you know, severe ulceration.

So if we're thinking about medial canopplasty, again, it's not a surgical lecture, but this is a kind of before and after. So the two top photographs are showing, a pug, that's had surgery. So you can see underneath here that this, the, the, the, the idea is that you narrow the pup pupil end, medially, and as a result of that, you have a much better coverage of the coneal surface.

That's 45 minutes. And this is the, what it looks like surgically, but again, as I say, we don't really have time to dwell on that much should we. So prevention is still the way forward.

I think, I think this is what we've got on our shelves. I've just, I just brought this out yesterday just have a look to see what we've got, on our shelves and what we hand out on a regular basis. I think that there's lots of good products now like Anhypro and Visco, who are, hyaluronic acid containing artificial tears, which, which are, are well tolerated, and seem to be.

the kind of thing that we would use on a daily basis, so 2 or 3 times a day. Rem is the other product, that we have used. And then at nights we tend to use, carboer gel.

It's the same one that we use during our surgeries. So Ora gel is the one that we're currently using, but Lirothol I think is the same, and bisco tears would be the human product. And the idea is that that's a longer lasting product, so that's a product that you can use either end of the day, especially overnight.

But we need to get into the habit of, of encouraging our owners to be, to use these, as, as much as possible and also to get our, our dogs used to having it done, because so many of these brackets. Come in, and they're just not used to having their faces touched, don't like having their faces touched. I presume that's partly because of bless and the fact that they're, they're worried that they're, you know, that something's going to happen to their airway and that, that, that people are going to restrict them, but we need to get our puppies better at, allowing and tolerating, that sort of cleaning.

This is just a final slide to show pigmentary keratopathy. This is what happens if you have a dog. This is a dog that, came to us and this cornea is now completely black, just because of, of, of lack of lubrication, the fact it's, had macroloup issues, and currently that dog is blind, so it's gonna be a real issue to see.

So this is a close up of the same dog. So we should thank a couple of people, 3 people, in fact, John Mould, obviously, for his wonderful slides, Jim Carter would also provide some slides and, and that's veterinary Surgery, one of them. So, I'd just like to say thank you very much, and if there are any questions, I'm happy to.

Thank you, Neil. So we have had a few questions submitted, so I will go through as much as I can and obviously, with the time that we have left, and if we don't get through to any of them, then we can, email them across, and get them through. So let's start from the first one.

So I've got. Hi, does pigment appearing in the scallara indicate an eyelid issue, or can that appear in a normal eye if no symptoms? Thanks.

Yeah, that's a very good question. I think if it's a brachycephalic, anything that's got a macropod people fish are long eyelid margin with lots of exposure, then that, that is the issue. I mean, you can get pigment obviously for other reasons.

You can get pigment associated with panus. You can also get pigment associated with the presence of neoplasia, so. So you have to be a bit careful but but in brachycephalic breeds, the majority of the pigment is to do with the fact that their eyelid margins are too long and therefore not protecting that congent type.

Thank you. Second one we've got is which topical, Marikaya, sorry, yeah, which, which systemic analgesic agent would you use please? Yeah, good question.

So we use trimide or electrovimide as a, as a, as a, dilating agent. So, I'm not that keen on atropine. I think I'm I'm always worried especially cats, atropine lasts such a long time, days and days that.

But I'm not sure that I want that. The other thing with atropine is it can dry your tear film up a bit, so, which is not necessarily what I want. So I use trayomide, so it only lasts about somewhere between 3 and 6 hours, but often that's enough just to overcome that initial iris spasm.

In terms of, analgesics, we have them on, non-steroidals, so we put them on, metacam or equivalent, and we also have them on opiates, and I find methadone to be our drug of choice now. I really like methadone. It seems to work very well for them.

It keeps them very comfortable, and allows they seem very compliant on it too, which is, which is great. Thank you. The next one is, hi, doc, what, topical anti-proteas are you commonly using?

Thank you. Yeah, so we're doing, so what we're doing at the moment is we've got stromies and we've got plasma. We really like plasma because it's, because we buy the 100 mL bags of, of plasma from pet blood bank and use them, and they're great.

I think it really depends how many cases you're seeing. I think if you're in general practise, we keep the straw meat on the shelf as well, because that, that I think is, you know, it's just such an easy drug to get. so you can have it there and if you're in any doubt, you can start the strome.

If you don't think the stromeat is enough, then you can, you can certainly add in plasma and that's what we do. Tend to do, but, so we would use both. We don't tend to use serum at all anymore.

We've, we've kind of gone past serum partly because of issues with it and, and partly because the pet blood bank can supply us with, with frozen plasma and the stromies we can have on the shelf. So I think that's that the combination of the two is. Fab.

And that also sort of brings us into the next question. I noticed you used a drop a bottle for the serum drops. How long is the serum viable, viable in those drops in those bottles?

I think that's a really good question actually. I, so we say 7 days, so that's what's written on the, on in the papers that they're, it's, it's sterile for 7 days, and that it has anti-roolytic activity for 7 days. Depending on which paper you read, there, there, there are some that say that that the anti-protelytic activity tails off after 2 or 3 days, so that you would be better to, to go again and, and draw some blood again and, and, get some fresh serum.

The big thing is it has to stay in the fridge. That's the big thing. Once you've got it, you have to keep it in the fridge, and only bring it out to, to use it and then put it straight back in the fridge again, because we know that if we leave it out on the shelf, and it comes up to room temperature and stays there, that the protelytic activity.

Or anti-proselytic activity, sorry, actually, starts to tail off quite quickly. Thank you. Next one is, would you start streamers in all bracket cases?

Would you also be using a lubricant? Is 5 to 10 minutes between the drops long enough? I normally advise 30 minutes.

Yeah, I think that's right. It's interesting. I, you know, I think, I think 30, I mean, better to go longer than shorter, to be fair.

In humans, they say 5. Minutes between your eye drops. But, I think 10 minutes is enough.

I, I'm, I think compliance is a real issue, partly because brackies are difficult to medicate anyway, or some of them are anyway, and partly because I think people just tell me have a limited tolerance for putting eye drops in. So that's why I say 10 minutes because I want them to do it regularly. I don't want them to think it's going to take up the whole day.

So, so, unless obviously they're on hourly drops, so. So, we tend to, we tend to do the, the, the 10 minutes. What was, there was another part to that question, wasn't there?

Sorry. Oh, let me just go back, sorry, where am I? To.

Would you also be using a lubricant? Yeah, I like, I, I mean, I like lubricants, and, and I do, I do tend to use them like I kind of feel if I'm doing hourly drops, then I'm probably doing enough. If I'm not, yes, if I'm, if I'm, if I'm sending a dog home, and I've decided it's, it's, you know, it's going to be a sort of 4 times a day dog to begin with, then, then they, they get lubricants on top.

So they would get a, they would get an antibiotic and a lubricant, preferably something with hyaluronic acid in it, because I think they are, they, they, they seem to be more stable and. and, and I think that that has the, the idea is that it's that kind of mucus phase that, that is the bit that's missing, which is, which, whereas that's why hyaluronic acid works. So, so yes, yes, is the short answer.

In a, in a, as long as it's not one of these dogs that we've admitted for hourly drops, then if they're on 4 to 6 times a day, they're getting a lubricant as well. Next one we've got is if you make a swab sample, I think it's what antibiotics, do you prefer to give for melting eye until you get, the bacteriology results back. Yeah, do you know, I, maybe I, maybe I shouldn't say this, but we don't stand for bacteriology.

We just don't, I don't think there's enough time to do that. It's, you know, the thing is you're, if you're dealing with a brachy you're, you're, I mean these dogs can perforate in a matter of hours or days. So I think, I think all we're doing with ours is, .

He is literally just putting it onto glass slides, staining it with diff quick, and then having a look, and even that we don't sometimes do, which is, which is, you know, depending on what else is going on, but we know that, if they're, if they're, if they're gram-negative rods, so they're likely to be pseudomonas, then, then they're getting either ciprofloxacin or Ofloxacin, so that's saloxin or exosin are the are the trade names. And, if there's any suggestion there's any gramme positives in there as well, then they're also gonna get chlorophenacle. So they're actually gonna, sometimes they get two sets of antibiotic drops and a set of, or one or two sets of antiprotelytic drops, and that's all to be done hourly, in, in the, in the ones that are actively melting.

Cheers. With that, I think we have got quite a lot of questions, but I'll go through what we the ones that have come in now and then we'll be able to get the rest. The next one on the list is for ulcers that haven't responded to stromme and, IFL, followed by serum and Extrain, would you recommend going to surgery, even if they aren't very deep, or would you try something else first?

That is a very good question, I think, I think it depends. I, I, I, I just, I'm always nervous about taking. They're superficial ulcers in a brachycephalic breed, I'm just, I'm just really conscious of the fact, and we've done this ourselves where we've taken these.

Dogs to surgery to, to, to, to bride these ulcers thinking that they're just slightly underrun and that we, you know, if we just remove that, epithelial edge, that it might be enough to allow the epithelium to, to hold on to the underlying basement membrane and move across. But we know that if we're, you know, if even if you're just slightly unlucky, if you're, if you're heavy-handed at all, you can actually start a melting ulcer, even though, you know, that wasn't your, your plan. So, So I'm, I'm, if they're brackies, I'm, I'm, I'm more inclined to treat medically, at the beginning unless obviously they're deep, so if they're greater than 50% of the, of the, stromal depth, and they have to go to surgery because they're they're the ones that are gonna perforate.

If it's a non-bracky dog, then I'm much more inclined to go. Surgery and and either to bride them or so that would mean, you know, either using an algae brush or or potentially doing a a grid or pumpta keratopathy, but I'm just super careful about bracky because we, there's just so many of them that that we've had bad experiences with, so you've just got to be careful. Cheers.

Next one, would you recommend sending all bracky dogs home with TF film replacer drops following a routine, i.e. Non-ocular, like procedures?

Yeah, I do. I think I just, that slide that we showed, I think, I think, I think we don't do it enough and we should do. We try and be really careful about, you know, any brackies that's in for anything, to be fair, it gets, you know, gets lots and lots of okra gel in its eyes through the day while it's with us.

But there is an argument, I think that they should be going home with something, maybe not necessarily something longer lasting, one of the carbon words like Ora gel, but even just some Bsol or something like that, or, or, and Hypro or men, they're all, they're all, similar products. yeah, I think because it is the case that the tier film does not return to normal for often several days afterwards, so. Cheers, next one, I don't know if you might have already answered this, so it's for initial treatment for pain.

Wondering if NSAIDs or atrophine would be appropriate or others. I know you talked about, methadone. Yeah, I think so.

So we give systemic non-steroidals and we give methadone. And as I said, I, I'm not a massive atrophine fan. I know some people really like it, but I tend to use, but if I think that that they've got pain associated with iris spasms, so in other words, they've got really, really small pupil, I tend to use tricumide.

Lovely. And then, what's your thoughts on grid, keratostomy for indolescent, ulcers? Yeah, yeah, I think, I think, I think grids are, are good.

Again, it's just, I'm just super careful about doing them in bracket, but, but, yeah, I think grids are great. My, my issue with grids are that, . It's, they need to be really superficial.

So you need to use a 25 gauge needle, you need to use very light pressure, you're only trying to scratch the surface so that you're, so they're exposing the underlying basement membrane at the anterior surface of the stroma. So you're not, you're not trying to create. You know, sometimes you see them, they come in for a referral and they've had, they look like they've got plough marks or furrows on their corneal surface.

That is, the idea is that you can just see the, the, the, the, the, grid pattern that you've created with the needle and only just. You don't, you don't need to do them too deeply. You need to do is make sure you debride the edges of the ulcer properly first before you do it.

So in other words, you're going to take dry, sterile cotton buds, and make sure that you, you actually remove all of the, loose feeling before you do it, because, because that's that, that in itself is, is part of the issue. Fabulous. So that unfortunately does bring us to the end.

We have got quite a few questions. I think we've got about 26 unanswered at the moment. So we obviously will get back to everyone, with answers for those.

But I just want to say thank you again, Neil, for such an informative session, shows how many questions we've had as well. It's such a good topic to go over and such a common thing in practise. I'd like to again, you know, we thank, TM for sponsoring today's session.

And we hope that everyone's enjoyed today's webinar and thank you for all joining us. Very good. Thank you, Charlotte.

Cheers. Thank you, everyone.