Hello, Anthony Chadwick from the webinar vet. Wanting to welcome you today to the first session in our association's day. Glad to see people listening in from all over the world, and we're off to a cracking start with Doctor Doctor Ron Ofri, who is from the Hebrew University of Jerusalem.

He's going to be speaking about the bulging eye. Ron is well known to members of the webinar, he's given many webinars over the years. Great friend of all of us here, and, obviously the, one of the co-authors of Slatter's ophthalmology textbook.

And of course we were very fortunate last night to have David Mike speaking about feline herpes, but today it's going to be the bulging eye, so over to you, Ron. Thank you very much, Anthony, and good morning, good afternoon, or good night wherever you may be or whenever you may be listening to this, lecture. It really gives me great pleasure to be part of this amazing enterprise, the virtual congress, and I thank my friend Dancing Chadwick for honouring me with an invitation to participate in this event.

Thank you very much, Anthony. As Anthony just said, I should note that I'm just one of two speakers at the virtual Congress Ophthalmology stream. I don't have my camera on, so this is me here on the right and on the left is My friend David Maggs from the University of California Davis.

As Anthony noted, David is my co-author on the 4th, 5th, and 6th editions of Slatter's Fundamentals Veterinary Ephthalmology. But he's also an outstanding ophthalmologist, a world authority on feline herpes and til diseases and superb speakers. So I urge you all to hear the talks that he recorded for this congress.

David and I would like to dedicate our talks to Pip Boydell, another leading ophthalmologist from England. In fact, Pip and I took our ECVO, European College of Veterinary ophthalmologists board examination. Together, so Pip will always have a special place in my heart cause whoever sits for the test with you is someone you've bonded with for life.

Pip said he passed away a few years ago and we all miss him. So, the subject of my talk today, as Anthony said, is the bulging eye. And when we talk about the bulging eye, we are really talking about two clinical entities.

The first one is proctosis. When the eye or the globe comes out of the orbit, the most common reason for that would be traumatic prolapse, which we shall discuss in a few minutes. The other entity for a bulging eye is exopthalamus where the eye moves forward in the orbit, but not out of.

So it's and that would usually be caused by a retrobar. A disease process behind the eye that pushes the eye forward, forward, but not out of the orbit. So it's really a relative distinction, how far is the eye moved forward, .

And to distinguish between the two entities, we have to look at the position of the eyelids compared to the equator of the globe. The globe, the eye has an equator, just like the Earth does, the widest point of the sphere. In Eothalmus, the eye moves forward, but the equator is still behind the eyelids, OK, so you can compare these two, you can see here are the eyelids in this drawing, and they are touching the cornea as they usually do.

Here in the bottom, the eye has moved forward, so now the eyelids are here, but they are still forward of the equator, which means that the eye is still in the orbit. In proptosis, the eye has moved so far forward that in fact the eyelids are now behind the equator. Most of the globe is out as you can see in these two drawings, and here is what the two entities look like.

In a patient, in two patients. So over on the left, we have traumatic prolapse. You can see the equator here, you can see that the eyelid margins are trapped behind the equator.

This eye has come flying out of the orbit due to a trauma. Here on the right, you can see that the dog's left eye is obviously displaced forward. It has moved forward in the orbit, but the eyelids still close over it, so the equator is behind the eyelids and therefore this dog has exothalmus in its left eye.

So we're going to talk about these two entities, proptosis and exopthalamus, and let's begin by talking about proptosis and then move on to exopalus. So, talking about proptosis, I would like to begin with the question. Here are two cases of proptosis.

One is a dog, one is a cat. That's all you know about them and I'm gonna ask Helen to turn all the poll question and you can vote on which of the two has a better prognosis. So, do you think that the dog has a better prognosis or the cat?

Which of the two, please go ahead and vote? I'll shout out the results for this run, when er people have had a chance to vote, so do just press on the button, either the dog or the cat, and we'll we'll see what . What Ron thinks.

Now, we'll see what they think. Well, exactly. That's great.

So we've got 68%, so about 2/3 saying the dog and about a 3rd, 32% saying the cat. OK, and as always in a democracy, the majority got it right. They're correct, the dog has much better prognosis than.

The cat and that's because if you look at the cat, you know that the eye is sunk deep in the orbit. It is well protected by the eyelids. When you look at the cat, you barely see any exposed conjunctiva or sclera simply because the eyelids are closed so very well over the globe.

And because the globe of a cat is so well protected by the deep orbit and by the eyelids, it really takes significant trauma to cause proctosis. In fact, if you look at this patient, you see that he's got a fema. In addition to the trauma, blood in the interior chamber, there may be a fracture or the synthesis here.

So the cat underwent significant trauma and therefore you would assume that it has a worse prognosis. The dog on the other hand, especially in a brachycephalic breed like this French bulldog or like a Pekinese or a pug, where in this bracketcephalic breeds, the eye is half out to begin with, you know, all the dog has to do is sneeze and the globe will come flying out. So it.

It really takes a minimal trauma to get the eye to come out and therefore, the prognosis is much better. In fact, you can see here, yeah, there is prolapse, but what we see of the cornea and the interior chamber look to be in much better shape than this cat and therefore, the majority got it right, the dog has a better prognosis. And in fact, I can back up this statement by numbers.

This is a study from North Carolina State University looking at 84 cases of traumatic proctosis. 18 of those cases were in cats. And as you can see, 12 of the cats had to be nucleated due to the severe trauma to the eye as we saw here.

In 4 cats, in fact, the trauma was so severe that the cat had to be euthanized. Only in 2 of the 18 was the globe salvaged and it was salvaged by blind, but blind. None of the 18 cats actually regained vision, and in fact, only 2 globes were salvaged.

And this is in contrast to 66 dogs evaluated in that same study. You can see that, yes, 18 dogs had to be nucleated. You can see that 4 more dogs had to be euthanized, so altogether, we are talking about 1/3 of the dogs being either euthanized or nucleated, but 2/3 of the globes were salvaged.

26 were salvaged cosmetically, but the eye was blind. But still, as we'll talk later, the owners are very happy if you can salvage the globe, and 18 were actually visual at the end of the study. So definitely much better outcome.

2/3 of the globe's salvaged cosmetically or . Sorry, cos cosmetically or functionally. And therefore really when and, and yeah, this would be the outcomes, the likely outcomes after 10 days, dogs, you'd usually save the globe either functionally or cosmetically.

Many of them will have lateral strabismus, as an outcome which we'll discuss in a few minutes, but this would be the most common outcome in a A dog and a cat, as you can see, the most common outcome would be unfortunately, a nucleation. So really, when an owner presents to me with the patient suffering from, from protosis and asks me, Doctor, doctor, can you save the eye? I really divide this question into two scenarios.

Number one, can you save the eye so that it regains vision or maintains vision? And number 2, if you can't salvage vision, can you at least salvage the globe cosmetically so the dog would have two eyes, even though one of them is blind. So if I'm presented with a cat with proptosis, the answer to both questions is most probably not.

You've seen the numbers before, only 2 of the 18 globes were salvaged and both were blind. So, a very bad prognosis in both regards for salvaging the globe and salvaging vision. In dog on the other hand, the prognosis is much better, as you've seen, a significant number of dogs, we can maintain vision and in many of the dogs where we can't maintain vision, we can still salvage the globe as you're seeing here.

You may have noticed that the study I presented from North Carolina State University was From 1995 or 1996, meaning it's a rather old study. So two years ago, yours truly and my team repeated the study. This is Doctor Oren Per, my resident, and basically, the outcome was very similar to the numbers I have just presented.

So you can see that the first prognostic indicator in cases of proctosis is the species. Are you presented with a dog or a cat? The second prognostic indicator is breed, and I will not ask Helen to launch another poll question as to which.

Has a better prognosis because you can already understand that the brachycephalic breed has a much better prognosis than the Doberman here who really resembles a cat with that deep orbit and very protective eyelids. So yes, breed is your second prognostic indicator. Continuing with prognostic indicators and what you should look for before discussing the prognosis with the indicator.

The third one after species and breed would be the number of extraocular muscles that were torn during the trauma. And the number of extraocular muscles is important for two reasons. Number one, it's an indicator of the extent of trauma.

Obviously, if there is greater trauma, more muscles will be torn and this dog obviously suffered a very severe trauma. It seems like all of the muscles have been torn, so obviously very bad prognosis, cause it underwent massive trauma. The second reason is that the Blood vessels supplying the inner tissues of the eye, like the iris and the choroid, etc.

Insert into the globe at the same point where the extraocular muscles insert into the globe. So every muscle. That gets torn means that one blood vessel that supplies the eye has also been torn.

So the more muscles that are torn, the greater number of blood vessels that are torn and the greater intraocular ischemia. And basically, we say that if there are 3 or more extraocular muscles that have been torn, we're going to have a blind eye and due to ischemia and a very grave prognosis for saving the eye due to the massive trauma that you are seeing here. If there are two torn muscles, then we say the prognosis is guarded and if there is just one torn, then Excuse me, the prognosis is rather fair.

I know that sometimes looking at the globe like this, it may be hard to determine, gosh, am I looking at 4 or 3 or 2 or 1 muscles that have been torn. But actually, one muscle being torn is fairly easy to recognise cause it would most often. The medial rectus cause the medial rectus muscle is the shortest and weakest of them all and therefore, as I indicated later earlier, sorry, when the medial rectus is torn, then the likely outcome is lateral strabismus cause the lateral rectus has no opposing force from the medial rectus.

I'm going to digress for one slide from the topic of prognosis to discuss this lateral strabismus cause owners are very, very upset by the presentation, even though in fact, they should be thankful that the dog suffered such minor trauma, but still, as you know, cosmetics is a very important consideration for owners, and they will be asking you, gosh, doctor, what can you do about this? Well, Theoretically, we could go in and repair it, right, find the two stumps of the medial rectus muscle and tie them together and repair. However, this is a very challenging surgery cause you have to find stumps, two stumps of the muscle that it actually is actually very small and minute.

The dog just underwent trauma, so there is lots of edoema and haemorrhage, etc. In this area. We practically never ever tried to repair it immediately.

What we can do later when everything is healed is to actually do a permanent medial canthopplasty, suture the upper eyelid to the lower eyelid in this area, 4 or 5 millimetres. Obviously, This would not resolve the strabismus, but if you cover this exposed conjunctiva, then it makes it less noticeable and the owners are happy. It also this procedure always has the added advantage of reducing the risk of repeated prolapse because you are reducing the size of the palpibral fissure, you.

Making the eyelid opening smaller and therefore, it will be harder for the eye to come flying out next time the dog undergoes trauma. And another alternative if the owner doesn't want to go into another surgery is I tell them, you know what, let's wait a few months and see what happens. And what happens is that this exposed conjunctiva gets pigmented with time.

Again, it means that the strabismus wasn't resolved, but it will become less noticeable if the conjunctiva gets covered with pigment, OK? So, as I said, the first prognostic indicator is species, the second one is breed, the 3rd 1 is the number of extraocular muscles. A 4th, oops sorry, a very important indicator is obviously the additional trauma we just discussed earlier how it is moderating in a dog and more severe in a cat, but yes, there may Trauma to the body, trauma to the skull, so you definitely wanna perform a comprehensive physical examination, good palpation of the skull, and maybe considered neurological exam based on your findings.

Consider radiography if you suspect suspect fractures. So if there is Pain or facial asymmetry or through bismu, then you may wanna take the patient into the radiography and here you see the fractures in the orbital bone. The facial asymmetry and the strabismus I note here are because some of the exocular muscles can get incarcerated by these bone fragments.

Still on the subject of additional trauma, a very important consideration is the duration of a prolapse. Obviously, if the owners came within 1 hour of the accident, then the prognosis is better. Sometimes, you know, if a dog disappears for 3 days and comes back home, with a proctosed eye, it means that the prognosis is worse cause the cornea has become desiccated, it's dry.

I didn't have lubrication of the tears and that's what it would look like. So, a useful tip here is if owners call you and over the phone describe something that sounds like a poptosis, is you instruct them over the phone to keep the globe moist with the wet gauze or va Vaseline all over the eye, do something to maintain corneal health while they make their way to the clinic. So, as I said, there may be trauma to the body, to the head, to the skull, to the orbit, dryness and dissiccation of the cornea, and of course, there may be additional trauma to the eye, maybe the cornea or the sclera perforated, causing rupture of the globe due to The trauma and here actually you can see in in CT that there is a rupture of the posterior aspect of the globe and you can see intraocular contents leaking here.

You'll notice that the cornea may look intact and this is only something you'd notice upon. Imaging. We could have a high femur as we saw in that cat, haemorrhaging the posterior segment lensation, retinal detachment, or maybe in that picture I showed earlier, even a version of the optic nerve if the trauma was severe enough.

So when presented with this patient, you should perform a comprehensive examination of the eye, looking for signs of trauma. You must check the pupillary light reflex to get an indication of retinal function, which is a very important element in prognosis. .

For the direct PLR and if you cannot visualise the pupil, for example, due to severe hyema or if the case I showed you earlier of the dog with the desiccated cornea, then look for the indirect PLR stimulated stimulate the pupil of the proposed eye and check for constriction in the other eye. The reaction of the pupil, the response of the pupil is important. We used to say that the resting pupil size is indicative.

We used to say that If the pupil is dilated, if a patient presents with dilated pupil, then it's bad prognosis. If it presents with a meiotic pupil, it's better prognosis, but actually now we're moving away from the size of the pupil and look more at the pupillary light reflex. And if you can't see what's happening inside the eye due to high femur, for example, then you should definitely ultrasound the eye to rule out retinal detachment or lens laxation such as you are seeing here in the posterior segment of this .

Dog here. So to summarise the prognostic indicators and the things you should look for when presented with a patient is consider the species, the breed, the number of torn muscles, the extent of trauma to the body, to the skull, to the eye, how long has The I been proposed, you should definitely do the PLR maybe you did an ultrasound, pile them up all together and you can give the owners a very good indication of the prognosis of this case. So now that we've established prognosis, how do we actually treat these cases?

My philosophy is summed up in this very important line here. You can always ocleate later, OK? What does that mean and why do I say that?

As I said, owners attach great importance to cosmetic salvage of the globe, even if it's going to be a non-visual eye, they really, really want that. Dog or the cat to have two eyes, OK. Many of them just can't stand the thought of a one-eyed cat and they will do anything, in order to preserve cosmetically the proposed globe.

And therefore, Unless I am 100% sure that the dog needs a nucleation, for example, because of perforation of the globe, then I tell them, you know what, we can. And let's, you know what, let's try and replace the globe. I can't promise you we'll end up with the cosmetically salvaged globe because there may be late onset complications that will force us to a nucleate.

But if you are willing to Undertake the risk of another surgery later on down the road in order to nucleate. If you're under, if you're willing to undertake the extra expense involved in a second surgery down the road, if we need to nucleate, then I'm willing to play ball with you and replace. The globe and let's see what happens.

And as long as you present it that way, telling the owners, you know what, let's try saving the globe, but beware that we may have to perform another surgery later and take it out, then most owners will go along with this proposal. So once the owners agree to let you replace the globe and try and salvage it cosmetically at least, then we have to anaesthetize the patient, clean the globe thoroughly, especially if it's been proposed for a long time. And then comes the most challenging stage, where you have to pull out the eyelids from Behind the globe and return them to their natural position in front of the equator.

This may be done using sutures, such as you're seeing here, place sutures in the lids and use them to pull the eyelids out or maybe a muscle hook. Sometimes it's very tough to get it back into the orbit. Because there is substantial haemorrhage and edoema behind the globe in the orbit, making it challenging to put it, pull it back in, push it back in, and therefore you may choose to do a lateral consultomy to enlarge a palpibral fissure, thus facilitating the globe replacement.

And once you have placed the globe inside the orbit, then you suture it with simply interrupted or horizontal mattres sutures to 20 to 40 nylon using tension relieving stents as shown here. And the most important part of the In this procedure is to carefully place the eyelids on the margin. This is shown here in the next two slides.

So we have a case of proptosis. The eyelids are behind, the equator, this is what it looks like, and then we use the sutures. To pull the eyelids out.

Not that we've already pre pre-placed the tension relieving stents here. Another one, and once both sutures are in place, use a tongue depressor or the handle of your scalpel blade to push the globe in and pull the eyelids up. And once the globe is back in, then you can suture them together and finish your temporarysoy.

Take a close look here and I'll show it again at the next slide, how the sutures come out of the eyelid margins. This is exactly what you want them to do. You want the sutures.

Excuse me, going into the skin, through the eyelid margin, through the eyelid stroma, coming out of the eyelid margin, through the eyelid margin, the my boing gland opening as you can see in fact here of the upper lid and outer skin again, and then tie them together. Obviously, you don't want these sutures to go full thickness. Cause then they will be rubbing on the cornea, but you don't want the suture to be too superficial and come out here at the skin level cause that would cause sort of a secondary entropion.

So this is exactly how you want to place them going again as shown here. Through the stent, through the skin, out the eyelid margin, into the opposite eyelid margin, and out the skin, and the stent shown here as well. And then you can suture everything together.

As I said, you want to avoid this scenario of having the eyelids go, and the sutures, sorry, going for thickness through the eyelids. . Some people, when suturing may also place an underlying third eyelid flap.

It's not mandatory, but it may help by giving extra lubrication and an extra layer of protection. Some people tend to leave a medial opening in, for the owners to administer topical drugs. I usually don't do that cause, you know, the doctor just under one.

Severe trauma, the, it is very painful. I don't want the owners trying to hit this small opening with drops. It's usually they won't make it.

The drop will not get to the cornea and it's just a useless struggle with a very painful dog. So, the treatment as you'll see in a minute, is usually systemic. And if you did a natural consultomy to enlarge the palpable fissure and And to facilitate the replacement of the globe, please don't forget to close it with a figure of 8 suture for perfect alignment.

Post-operative care, yeah, always put it, and it is a bit in colour, always use cold compresses and people sometimes ask me, well, how can I put a cold compress on a, a globe? Easiest thing to do is send the owners to a supermarket to buy a bag of frozen peas or frozen corn kennels or whatever. And then when you put that bag of frozen peas.

Over the globe, it really shapes itself or moulds itself in the shape of the skull and you get very effective application of cold compressors. Topical or systemic therapy, as I said, I usually go for systemic therapy, antibiotics or, and steroids, maybe a. Drop of atropine before you close the torsoy for analgesia and to prevent possible posterior sinicia and another very, very important point is to remove the suture sequentially.

We don't remove all of the sutures at once after 1012, 13 days. Excuse me, cause the muscles may be stretched. There may still be significant edoema in the haemorrhage and you risk the possibility of the eye coming out again if you remove all the sutures at once after 12 or 14 days.

And therefore, what I prefer to do is to remove them sequentially as it says here. So after 12 days or so, I'll open the first suture just to take a Look inside the eye, look at the cornea, try to get an assessment of how we are doing and in which direction are we heading, adjust medications according to what you're seeing. Now that one has been removed, maybe you can start applying topical medications, steroids, antibiotics, artificial tears as the case may be.

Come back in 2 weeks, we've removed the second suture, come back in another 2 weeks, so 6 weeks in total for the removal of the final suture. So to summarise my talk of proptosis, you have to determine the prognosis by considering the species and the breed, the number of extraocular muscles that have been torn, the duration of the prolapse, and assessing the extent of trauma to the body, the skull and the eye. Check the direct or indirect PLR ultrasound the eye, and that will give you the prognosis.

Remember that you can always nucleate later and remember to remove sutures sequentially and not altogether. So that concludes my talk of the proposed eye, and we want to move on to the second entity I want to discuss, and that is the exopthalmic eye. But before I talk about exopthalmus, which, as I said, is an eye that is pushed forward in the globe due to a retrobular disease, I want to first talk.

About whether the case you're seeing here is exophthalmus or boothalus, cause you see that there is something that is obviously wrong with the left eye of this cat, but is it exothalus, which, as I said, is a normal eye pushed forward in The orbit due to a retrobar disease, or is it poofalmus, which is an enlarged eye in a normal position due to elevated pressure. And yes, as I said, there is something wrong with this eye, but I'm not sure whether it's exothalus or exothalus, so I'm going to let you help me and ask Helen to launch our second question. So, what's your diagnosis for the left eye of this cat?

Does it have exothalus or does it have both thalamus? Again, Ron, I'll let you know as people vote, so OK, I'll wait patiently, let's give them time to think. It's a tricky question.

And we've got 40% think it's exothalmus and 60% think it's thalamus, right, OK, so I'm afraid, this time the minority got it right. I'll. As I'll explain in a few, in the next several slides, I'll tell you how I know, but a couple of things we can see in this picture is that there are no signs of glaucoma.

There is no corneal edoema or blue eye that we associate with a buoalmus or glaucoma. The pupil, pupils look to be of equal size. So this is actually a case of exothalus, but let's see how I can determine that.

So the first question that you need to ask yourself when presented with such a patient is whether this is a unilateral presentation or a bilateral presentation. And that's because glaucoma may be either unilateral or bilateral, while ophthalm. Is nearly always unilateral.

So if it's a unilateral presentation, you didn't make much progress on the question of whether it's exothalmus or boothalus, but if it's bilateral, then it is usually glaucoma. The second question you could ask, you should ask yourself when looking at the patient is what is the position of the third eyelid? You've all seen your share of glaucoma cases and you know the, the 3rd eyelid is unaffected by the disease and it is resting.

Peacefully, in the ventromedial aspect of the orbit and it is elevated in exopthalmus cause whatever retro bulbar process is pushing the globe forward, it is also pushing the third eyelid up. However, I'm sure you're all experienced enough to know that for every rule there is an exception. So here is an exception.

You notice that this German shepherd obviously has a bilateral process. Which I said is usually glaucoma, but you see that in both eyes, we have elevation of the third eyelid, which, as I said, suggests exothalamus and retro bulbar disease. So definitely a Contradiction in what you are seeing here and actually this is a very rare case of bilateral retrobular hemangiosarcoma.

So yes, for every rule there is an exception and here is one of them, bilateral exopthalus. Additional indications and hints as to whether we are looking at exopthalmus or both thalamus is to look at the patient laterally. This is a case of exothalus, the eye is pushed forward and therefore you are seeing an excess amount of conjunctiva and sclera here.

If it was an enlarged eye, then it would expand, but it wouldn't be pushed forward. You wouldn't see this excess. Likewise, you can examine the dog from above in order to detect displacement.

Once again, if it's enlarged eye, then it will be enlarged, but it will not be moving forward. You'll not be able to detect this enlargement by looking at the dog from the top. As it says here sounds strange, but you can tell by estimating the corneal curvature in unilateral cases.

A bufalmus is expansion of the globe, which means it has a greater radius, and actually in unilateral cases, you would be able to detect a 2 or 3. Millimetre difference in the radius of the cornea. So in a unilateral case, compare the curvature, the radius of both corneas, obviously this cornea has a greater radius and that means this dog is suffering from glaucoma.

Another Strange but very sensitive indicator is what we call the retropulsion test shown here, where we press on both globes. Now what we're doing in this picture is not measuring intraocular pressure. You cannot measure intraocular pressure with your fingers.

You can do many other things with your fingers, but measure. IOP is not one of them. You need a tornometer for that.

What we're doing here in this picture is pressing on the globe, trying to push it into the orbit and determine whether there is something behind the globe resisting this pushing, OK? Now I know that's Sounds like you're walking a very fine line. Are you pressing on both globes to try and detect whether one is firmer or tougher than the other, or is it a globe with normal pressure that resists being pushed inwards, but try it a few times and you can definitely tell the difference.

So, these are several hints to tell you whether you're looking at the globe with exothalus or boothalmos, but of course, there are the golden standard tests to differentiate between the two, to diagnose buthalmus and glaucoma, you measure IOP as I said, this must be done with some kind of eonometer. I was once showing this picture in a human ophthalmology meeting and one guy raised their hand and said, yeah. I can see that this line with the shields is going to the NHS.

This one with the tonal pen went to a private practitioner. But one way or another, measure intraocular pressure to see whether it is normal or not. And the golden standard to determine if there is retrovular disease is obviously imaging, whether by ultrasound, demonstrating this mass here or CT or MRI showing this mass behind the globe.

And of course behind, besides or in addition to all the signs I've just described till now, there are numerous clinical signs that differentiate between the two. Glaucoma, there are numerous clinical signs of glaucoma. If you go to the webinar vet archives, you'll find my talk about glaucoma and clinical signs associated with the disease.

And if it's a patient with any exothalus, then the signs of exothalmus will depend on the Cause of vexopthalmus? Is it a retrobulbar tumour or is it a retrobulbar abscess? And now that we know how to differentiate between exothalamus and boothalmus, we can move forward to actually talk about exothalamus and the two causes of retro bulbar disease.

So, the signs that unite both To get causes of retrobular diseases, signs that are common to both retrobulbar abscess and a retrobulbar tumour include obviously subthalmus. I mean, that's what we're talking about right now. As I said, it's usually a unilateral disease.

It involves protrusion of the third eyelid cause the mass behind. The eye is pushing against the third eyelid. You'll have lots of swelling around the eye because the venous circulation is disrupted.

You'll have the resistance to to retropulsion that I described, and you may have signs of systemic disease both in Abscess in cases of an abscess with systemic involvement or in a tumour if it's spread in the body, and in both cases, the patient may present with blindness if the optic nerve is involved. So as you can see, there are many signs that are common to both retro bulbar tumours and retro bulbar, . Abscesses and once again we have to rely on the golden standard and the golden standard here in this case is fine needle aspiration, using ultrasound guidance, you.

Aspirate the mass and you send it to cytology, and you can very easily determine whether it is an abscess or a tumour. So we'll discuss both entities starting with The retro bulbar abscess, which is usually a bacterial infection due to dental disease or to a foreign body. It may also be due to hematogeneous infection or spread from a nasal sinus.

While it is usually a bacterial infection, however, I should note that frequently there may be no growth or anaerobic growth or maybe a fungal isolation, so keep it in the back of your mind. You won't always find the cause. How does a patient present?

It's an abscess, so usually it's very acute onset. A very, very telling sign is pain on opening the mouth cause there is an abscess behind the eye. And when the patient opens its mouth, the epicondyle of the mandibula goes up and presses against the abscess and it is very, very painful.

The dog will present with anorexia and will absolutely not let you open the mouth. I mean, even if It's a small chihuahua or a miniature pinscher, it will fight you to death. It will scream, it will bite.

You will not be able to open the mouth. Again, that's a very telling indicator, and you probably have to sedate it in order to successfully open the mouth, and once you do, you may often see a swelling or a fistula of your mucosa behind the last upper molar tooth. Once you've determined that it is an abscess, well, the patient is already sedated or maybe anaesthetized.

If not, you have to proceed to full anaesthesia. You must intubate. This cannot be intravenous anaesthesia.

You must intubate because when we drain the abscess is shown here, then the oral cavity is gonna fill up with lots of Infected and inflamed secretions. You can see that we're also packing lots of gauze around the endotracheal tube to minimise the risk of aspiration and then if it's a fistula, then you know where it's located. If there is no fistula, but you see the swelling as you've shown here, you make an incision of the oral, mucosa and you create a, draining tract using a closed hemostat.

. Mm, and I emphasise the word closed, you wanna go with a closed hemostat in the track you've created, open it once, and withdraw it open. Close it again in the oral cavity, insert it closed, open ones, withdraw it open, close, etc. Etc.

Which one don't want to do is insert the closed Simostat and then start opening, closing, opening, closing while it's still behind the eye, while it's still in the track cause if you do that often enough, I promise that you will clump on the optic nerve. And you will wake, the dog will wake up with a blind eye, OK? So just insert it close, open one, withdrew it open so that you're not clumping on the optic nerve.

You may need to use ultrasound guidance to actually hit the pocket or the abscess. Sometimes, and once you do, there is great satisfaction. You're seeing all that pus or whatever it is coming gushing out.

Even if there isn't This gushing out of fluid, then just creating a tract for cellulitis will often be enough. You can collect this for cultural insensitivity for cytology, but frankly, it's a waste of time and money because this is going to heal very, very fast. It is one of the most satisfying procedures for veteran ophthalmologist.

You flush it with saline, flush it with antibiotics, place the dog on systemic antibiotics, feed it just soft food because, the mouth is painful. And as I said, the recovery is very, very fast, often before you get the results of any lab tests you have submitted. Oops, sorry, here.

On the other hand, when presented with a retro bulbar tumour, the presentation will be different. We are obviously talking about slowly progressive, presentation. It is non-painful cause there is no abscess, for the mandibula to press on.

Obviously, there are older patients and Due to local extent, there may be signs of local extensions. You can see how the globe is deviated in this picture here. There may be nasal discharge if the tumour is extended into the nasal sinuses, if it extended into the brain, there may be central nervous system signs, or if you look almoscopically, sometimes you may see.

The tumour in pressing on the globe, causing this indentation in this picture that you are seeing here. Unfortunately, most tumours are malignant, so you need to examine the patient for metastasis and depending on the staging, well, maybe you can refer to orbitoomy or accenteration and in order to remove the tumour, if you go down that route, then obviously surgery should be combined with chemotherapy, with radiation, or some other modality. And yes, surgery is possible.

Here, a large tumour was taken out and the orbit is reconstructed using these wires and this mesh that you're seeing here and the eye could be salvaged as you're seeing here. However, this is definitely a referral surgery and as I said, cause the tumours are usually malignant. Which you can see here in this study evaluating 112 cases, then you are seeing lots of adenocarcinomas and you're seeing osteosarcomas and meningiomas and lymphomas.

These are these all carry a very bad prognosis and that is the prognosis for the red bulbar tumour. So take home messages for the The Second part of my talk is that periocular swelling, forward displacement of the globe, 3rd eyelid elevation, normal corneal diameter and resistance of retropulsion. All these indicate ensothalus, which can be confirmed with ultrasound and fine needle aspiration, which will tell you whether you're dealing with a tumour or an abscess behind the globe.

If it's an abscess, this is further confirmed by the acute and painful presentation and the abscess should be drained through the mouth after incubation. If it's a progressive non-painful presentation, it is probably a retrovular tumour and the prognosis is not so great. So, this really concludes the two parts of my talk.

I can't really hear you and see you, so I have brought my own applause. I thank you very much for being with me, and I will be glad to take any questions that you may have. Hello, everyone.

Welcome to this webinar and thank you for joining me. This webinar is about young calf rearing and not in its classical sense addressing diseases and therapy, but addressing calf rearing as a management approach. The objectives of this webinar are first to clarify this process approach of Juncker overhearing.

Then address the different risk periods in this process. Present management measures for different risk periods, and finally discuss the analysis and evaluation of calf rearing. The asterisk, the star or orange colour it at the right side, means that there are some slides where I make a sidestep to practical issues from the field which may clarify even more what this process approach means.

The following procedure of the webinar is that I have 7 chapters, so to say. First of all, the layout of the rearing process. The focus on lossum periods, the milk milk reraisal periods.

I addressed general management measures, then the weaning of the calf. Analysis and evaluation of calf rearing performance, and I will end up with some conclusions. First, the basis of young calf management.

It starts with the selection of y and them for artificial insemination. It continues with the pregnant dam during the dry period, transition period, and then I have distinguished some critical periods in calf rearing. That's the birth.

And colostum period. The second is the milkation period, 2nd weaning, and 3 puberty. An artificial insemination in this webinar will address specifically.

The period 1 and critical 2, because this is where it's all happening for the future, so to say. Why do we focus on these 1st 8 weeks of life? The reasons are the following.

The optimal age at risk calving is between 22 and 24 months. In the graph, it's shown with the orange coloured area. After 24 months of age at first calving, life expectancy drops.

Secondly, there is a programming by them and by the farmer in the 1st 6 weeks of life. By the dam through the colostrum quality by the farmer, depending on its level and the quality of farm management. Proper programming may extend the life expectancy of the heifer with 1 or 2 years.

So any investment that the farmer does in the 1st 6 weeks of life pays off. So let us first set the major operational goals for the calf management process. Draw 10.

Starting again with them. Which should stay healthy until at least after giving birth to the calf. The dam should pass an adequate dry period, and the transition management of the dam should be optimal.

The calving birth process should go on without complications for both. And then a healthy female calf should be born in a normal way without dystopia. The navel should be disinfected twice and the animals should be housed properly.

Cluster management should result in high IgG levels in the calf. The calf should stay healthy until at least after weaning. And the calf should show a steady growth until after weaning without any variability, for example, due to diseases.

The calf should be weaned at an age of 8 to 10 weeks without disturbances. Again, diseases. The calves should develop further after this period of 8 to 10 weeks without complications, and at the end, the calf should become a heifer, which calves normally at a proper age 22 to 24 months and a proper weight.

The overall farm process. Is defined by 3 economic pillars. The milking cow hurt.

Nutrition and posturing. And the 3 youngster rearing and as a specific part, the young calves burst to weaning period. And of course we know support the farm domains like that take place in the milking parlour, house farm.

Fi Just the machinery, and of course the consultants as a veterinarian, nutritionists, and potentially other advisors. So we focus on the young calves birth to weaning period, which is a part of the future of the farm. When we consider the timeline of the car management process, starting with the selection of the designer and them, and then go down to the winning moment.

This timeline includes several critical time points, events, and risk periods. We will address that in this webinar. For example, Just the period between birth and colostrum, what we call a process flow diagram, at point A at the left upper side.

We prepared them for carving. So they already management interferes with quality of the birth colostrum period. Then the birth of the calf, the first colostrum, and the last colostrum.

Then this period ends and at point B, the calf shifts on to the next. Periods in the, in the calfaring process. With regard to the birth of the calf and the first colostrum.

We can distinguish several monitoring issues. Hygiene around carving, hygiene and milking the colostrum. The proper own house of the dam.

The naval disinfection, quality of the colostrum. The blood level of IgG in the calf, the housing. And the climate in the barn of the neonatal calf stock of colostrum health status and behaviour.

Left and right of this. Text block You find at the left side monitoring protocols and records. To deliver a kind of mythological structure.

Not to forget things of monitoring and at the right side, the targets associated with the parameters. For example, what should be the optimal IgG blood level in the calf or how should I assess the housing and the barn climate for the neonatal calf. This is a structural approach.

Purely methodological, but based on routine monitoring of certain periods in the kind of life. This is the blueprint for our car rearing methodology. For example, process that preparing the dam.

Body condition? Optimal health, no milk fever, and checking of the other health to make sure that the losum quality will be adequate. Checking off the claw health, feed intake, and to avoid negative energy balance NEB.

The carving pen is the next part of it. Should be cleaned and disaffected before calving. Thick, dry straw layer, spacious.

Preferably a single pan, fresh air, high quality fresh water, and in view or hear of herd mates. Carving hygiene, the third one. Prepare warm water and towels.

Disinfect the animal, prepare lubricants, and make sure that the personal hygiene is optimal. And finally, the 4th carving tools are only to be used if truly needed. And of course you are aware of the fact that there are carving surveillance devices like here the mu at the.

Down right side of this slide. The process that the birth of the calf. Three sectors, the dam again, clean, disinfect every part of the dam prior to carving.

Make sure that the carving pen is clean, dry, and it has a res chick, straw layer, the carve itself. Never force a cow to calf. Be patient.

Eliminated the placenta from the calf's nose and ripped the calf thoroughly to dry it quickly. After birth, this affected navel twice. Check that the placenta comes off.

Milk, the 1st 2 litres of Colostrum ascetically put calf in a single hutch for 5 to 10 days. Provide fresh air and make the cows separate from other cattle, and if needed in cold areas, provide a heating lamp. I conclude this slide by mentioning that you have to mind the thermal neutrality of the cows, which is not at all comparable to the thermal neutrality of cows.

We come to that later on. The Clouston period Second chapter, Clostrom has already been considered for its IgG level. Including also IGA IGM.

However, Recent research shows many other critical issues of colostrum. Colostrum provides the nutritional programming by the dam associated with long-term health and productivity of the newborn. This programming takes place by the leukocytes, cytokines, hormones, and vitamin A in the colostrum.

For example, the leukocytes have already a memory function. They enhance the maturation of calf immune cells and co-protect the calf for the 1st 14 days of life. The hormones in the lostrum enhance the vis development and absorption.

So indeed, the 1st 6 weeks of life impact on the lifespan of the animal. Calves is the first light where the orange star appears. For example, carves worn from he dressed cows.

Show a poor absorption of losing components. A poor immune function. Less immune cell proliferation, a high risk of disease.

Poor growth rate up to weaning, a poor feed intake, and the first calving will be at an older rate than 24 months. These animals show a lower male yield later on and are prone for culling prematurely. This dam's programming has completely gone wrong.

The lustre Management Protocol comprises the issues listed on this slide. First colostrum, 2 to 4 litres within 2 hours after carving. Check the colostrum quality.

For example, by a cholotrometer. Indicating 2000 milligrammes per litre, beware of the fact that the colossal metre is calibrated at 18 to 20 °C. That means that if the temperature is lower, for example, uphill, there is an underestimation, and if the temperature is higher, for example, in the valley, there is an overestimation.

Be careful with that issue. Use the 1st colost also for the 2nd feeding. Feed Colostrum anyway under strict hygienic conditions.

Gloves, clean, disinfected bucket or a bottle. You may stock the surplus glossum in the freezer in packs of 2 litre or in cubes. And check that the lostrum intake is 4 to 6 litres per day.

Record those events. Feed colostrum for 3 to 5 consecutive days, to be sure that all the positive components of the colostrum are indeed beneficial for the calf, and if needed, use the colostrum feeder. The glostrum feeder should be handled correctly.

You have to first clean and disinfect the bag or the bottle and tube and dry it afterwards. And in the middle. Photograph, you have to measure distance between the the cow's mouth.

And the presumed entrance in the gastrointestinal tract in order to be sure that you will not insert the tube. Too much. At the right side photograph, you see that the calf is restrained.

And that the head is somewhat over high. Afterwards, check the calf IgG level by refractometer with the standard reference of 15 to 80 grammes per litre. Record all events around Croton Frieden in Colostrum rock, so you'll be able to follow up this calf, depending on how much it has consumed, if there is any problem with regards to the feeding with the colossum feeder or not, you'll always be able to follow up.

An example of the the refractometer is in the picture down right side. Recent experience, 2019, it dealt with the volume of car number feeding and its energetic effects. The comparison between whole colostom, frozen colostrum, and cell 3 colostom on the occurrence of diarrhoea, respiratory disease, and immune responsiveness.

Every time the fresh old Carlosum came out as the best. What about pasteurisation of cholester? And what about cow's whole milk?

Anyway, pasteurisation kills off some of the components that we have addressed earlier with regards to the programming. So, pasteurisation might not be the best way to feed the calf. Never use antibiotic milk for calves.

It will disturb the microbes in the gastrointestinal tract. The third chapter period. From individual hutches, the calf is transported to group housing.

For milk reraisal, there is also also a protocol. Check the quality of water beforehand. Check the daily mixing temperature for water and powder combinations.

Standard is between 40 and 65 °C. Check the milk power concentration. Standard is 125 gramme per litre.

Check the drinking temperature daily. 38 to 40 °C. Use a fixed feeding schedule throughout the day.

Bovine species is a species which likes routine. So feeding schedule means fixed hours of feeding. Check the quantity of milk powder fed per calf for consistency.

Often errors are made there, that's the asterisks. Give at first feeding 1.5 to 2 litres, for example, by a teeth bracket.

The best is to use an automatic calf heater or so-called calf bar. Apply the highest hygiene levels for equipment, personnel in the barn, and again, keep a cow feeding lock, so we can do the follow-up and evaluate the milk reprisal period. The most common error in Giving milk replacer is that the normal mixing protocol for affected group is, for example, suppose we need 246 litres of the mix.

Fill the mix with 131 litre of water, at 8 38.5 kg of milk powder, lend the mix at 40 to 65 degrees. Add more water to reach the necessary 246 litre.

What is the error in the field? First of all, the farmer puts 246 litre water in the tap and then adds the 35, 38.5 kilogrammes of milk powder.

If you do so, the consequence is that the concentration is too low and there will be a growth problem. So again, back. To the standard protocol, fill the mixer with not the full volume of water, but a large part of it.

What about the automatic car feeder? There are different brands on the market. They all need to be to be programmed.

Are very labour efficient. That's the reason that it's automatic. Advantage is that the milk is always prepared freshly.

Volume, concentration, and temperature are guaranteed. The girls enter in the group housing at the age between 3 and 7 days. More cows consumes an average 10 litres per day.

The weaning weaning date can be preset, and if it's preset, there is a gradual reduction of the feed volume. Machine data and monitoring data are used for evaluation and analysis. One parameter is, for example, the ringing speed pattern.

A feature with automatic calibration, of course, is to be preferred. When you talk about group housing on the right side, the picture and the bar, prefer a maximum group size of 6 for socialisation. So to say, young cows need a friend, so no uneven numbers because there will at least be one or several without any friends.

7 or 11, he is not to be preferred. About general management. We address group housing, climate, and general health.

For group housing, be sure that the age difference between the cops is less than 2 weeks. Provide unlimited fresh water available the whole day. Gift pellets concentrates twice per day.

Provide high quality fever. Available all day. 5 calves.

It is optimal. I had to replace that by 6 scarf is optimal, given the search for friends for socialisation. With regard to the climate.

Make sure there are sufficient air inlets. If there is an open bond. Make sure you have installed windbreak curtains to get rid of draughts.

In cold periods, you might install heaters. Some people have floor heating. Expensive.

Check the ventilation frequently. One rule of thumb with regard to ventilation is that when you enter the curve bar, You should not be able to smell that there are cars. The distribution in the bar.

Can be checked easily with smoke powder. You see the pattern of the air distribution, and you can see whether there are stagnant corners present in the bar or not. Check the air, relative humidity, which would be less than 60%, and check the ammonia in the air.

It would be good to record those monitoring issues on air distribution, relative humidity, and ammonia. With regard to general health, older calves should not have a disease like diarrhoea or respiratory. The features at 5 weeks of age should be brown and solid.

Hair coat at 5 and 10 weeks should be shiny. Record these events in the kind of events log for evaluation. All this Logs served to evaluate whether we were able to programme.

The period of 6 weeks of age in the most optimal situation. On the upper right corner. I have stated minded specific measures for cold stress and heat stress, because those events, cold stress, heat stress may disturb largely what we want to do.

A special note on. Ventilation It's trendy to talk about positive pressure ventilation for cars. At the left side, you'll see two examples.

The tubes on the ceiling. Have holes where the air comes out. Not the direction of the air openings.

It right Down picture. You can see that the simulation. Shows where the air comes down on the calf.

The great advantage is in the upper left photograph, there's a large volume, a thick straw layer. The cars have sufficient space to move around. And the tunnel ventilation, positive pressure ventilation means that the air is completely distributed throughout the barn.

There are no dead airports with droughts, it's a very good situation. An example of calf housing in individual hedges. They are well separated.

They cannot touch each other. No transfer of . Microbes in a direct sense if the farmer Takes away the separation.

They have in fact already a group housing. So the calves know each other from hearing and afterwards from seeing and meeting. Another example, a calf pen individual.

There's a very nice, thick, dry, clean straw layer as it should be. However, there is a very unfriendly design. There is no easy access to feed or water due to the fact that the distance between the poles is too small.

The calves like this one will not easily. Access the bucket for eating or drinking. Meaning that the cow will be afraid to start eating and drinking.

The consequences that feed intake will be reduced and the growth will be reduced. The point is to monitor routinely and what's going on in the Jost and provide with the most optimal situations. Here If the farmer has calves in iglos or hatches outside, it should be protected against the direct sun radiation on all sides.

An exercise area should be provided in front of the igloo or the hutch. To increase ventilation within the hutch or the igloo, you could elevate the backsides with a brick 20 to 30 centimetres high, and that means that there is movement of air. To install wind brake curtains horizontally at 4 metres above floor.

You could install ventilators, 190 centimetres in diameter, which blow in front of the igors or hutches at the speed of 7 to 15 kilometres per hour. This creates air movement sufficient to refresh the air under the windbreak curtain every hour. Don't speed up the the ventilators, the fans above the 15 kilometres per hour.

It's not necessary and it can be a disadvantage for the calf health. Never install misters or focus outside. The wind is blowing the mist away.

If calves are housed inside during hot periods. M.s and foggers could be, could be used.

It's not compulsory but could be used to go to. Cool down the air in the barn. A mister or father have nothing to do with cooling animals.

Keep the straw bedding clean, dry, and thick each day outside and inside and make fresh drinking water available all day long. At the down right corner, you find the thermal neutral zones for young cows and cows a little bit older. For example, between 2 or 3 weeks of age.

The thermal neutral zone is between 15 and 23. If calves are older than 45 or 6 weeks, that zone is between 6 and 22. What is a thermal neutral zone?

That is the range of Ambient temperature where the animal. Does not need to spend energy to get rid of body heat. For cows, it's different.

In the cold dress, there are two options. Acute cold stress and gradual cold stress. Acute coat stress is, for example, when the calf has a wet hair coat.

Or is found in the cold or in the snow. It usually occurs at birth. And or after dystopia.

The gradual exposure of cold stress. Is when they are out with a poor hair coat. And draughts are in the barn or outside.

And when there is no weather protection at all. Gradually, the cow's body temperature will drop. When does it occur?

For young Castle, less than 3 weeks old, it's threshold at 15 °C for cars a little bit older, 4 to 6 weeks, 6 degrees. So especially the very young calves. Are highly susceptible for cold stress issues.

Protocol elements for cold stress cases then. Issues. First of all, be sure that the farmer provides a good start the 1st 48 hours.

Dry the cough. Give 4 litre colostrum within 12 hours. Appropriate navel dipping twice.

A thick straw layer and provide a blanket or a heater. Feed the colostom for 3 to 5 days minimum. Keep the bedding each day clean.

Dry, thick straw layer. Has to be cleaned out often. Provide full adequate ventilation without any draughts.

If there is a real cold stress. Make the farmer give an extra meal for more energy, for example, increasing the percentage of fat in the ration. Or give 3/4 or 1 kilogramme more milk powder to get that energy.

Increase the number of meals per day from 2 to 3 meals. Give the milk at 38 °C temperature. And a hot warm water to drink 30 minutes later.

In very extreme cold situations. The farmer could 100 to 150 grammes of 60% fat in milk for the 1st 14 days of life. And again, be constantly strict in the feeding hours.

High quality starter pellets with 18 to 22% protein can be given from day 3 onwards. Still, Provide ample water. Cars from dystopia dams will make a poor start in life.

They will not stand up properly. Rather late They will show high blood CO2 and low blood pH levels, acidosis. They will not drink colostom by themselves easily.

These calves are prone for early killing as a heifer. And even if they start prediction. The lifespan will be shortened and they will not have had the programme, the proper programming.

For dehorning calves. A 10 point protocol. Dehauling is always painful.

The horned the cops under an age of 6 weeks. Restrain the cf properly. Clip hair around the butt.

Saka. Inject the lidoca locally. The horn properly.

And not too long. This in fact give an IED as follow up against the pain. And don't forget to check the status the next day or next days.

If you take this protocol to the fields and you observe how a farmer or farm worker is doing the dehorning. You will be astonished to see that one or several of these points are not. Applied.

Weaning of the cars. Just a reminder. Reading is probably the most stressful event in the whole bovine life.

Even more stressful than coughing. Winning leads to a sharp rise in rumen pH, which, after winning, declines during the next 6 weeks. It's often done too early.

Leading to stress, diseases, disorders. So it's a very I would say sophisticated manner to properly wean a calf. Should nothing be done abruptly.

Never be done too early or too late, between 8 and 10 weeks. The dietary volume. Should be reduced gradually from 14 days before to the wining date because it stimulates better feed intake, better growth, and better life performance.

This is the clue, the key of proper weaning. And do not combine various stresses at the same time, for example, chasing houses. Do the weaning Changing feats.

Transport the calves. And treat them for several. Events, so to say, including disease.

So The last points and the preceding one. Are the basis of proper weaning. Gros is.

A parameter Which can be used at different critical periods in life, or critical age moments, birth waning, 3 months of age, 6 months of age, and even later on, at puberty. And it's coughing. Target body weights.

Which can be measured, so to say, by using This device. Where the centimetres are impressed on one side and the converted kilogrammes at the other side. So in the table 45 kilogrammes.

Is 75 centimetres of girth measurement. One should always aim for a stable, steady growth, so checking, monitoring growth is a very important. Tool to assess the Rearing period.

You could always look for simple issues like the photograph, the right, downside. Where the farmer is using just a rope. Because he has a rope, for example, of 97 centimetres of 108 centimetres, or even 128 centimetres.

In that way, he can check easily with just a rope. Whether their target values are achieved or not. It's up to the farmer as long as the farmer or a coworker.

Who is assigned to do the monitoring of carve growth. Do the monitoring and record the event in a calf growth performance lock. About evaluation analysis.

In order to be able to conduct an evaluation or analysis, one needs calf rearing data. It's obvious. Therefore, attention is given to the event locks, the corostrum lock, the milk replacer lock, the event lock, and the growth performing lock.

There are not big books. Just sheets. And every time that a sheet is filled, the veterinarian can already check whether there are deviations or not, just using the different colours.

The red ones for truly deviant animals, and maybe the yellow one for the first alarm that something wrong is going on. The second requirement is to have a list of performance standards. To be compared to the data that have been collected.

And the third requirement is that the veterinarian should invest time. In the case of infectious diseases, laboratory results on virus, bacteria, protozoa, parasites. Should be available to complete the analysis.

And finally, investigations, findings, data, conclusions are set in a written evaluation report or analysis report. These are the basic requirements. Maybe an investment of time from the side of the veterinarian, but it pays off.

Not in the least for the farmer, but also for the veterinarian, because the farmer sees that the veterinarian is truly looking to a potential problem in the rearing process. A list of varying performance parameters. Cases of diarrhoea, respiratory disease?

Features colour, consistency, hair coat condition. Mortality, weight gain, body weight, concentrates intake, age ad weaning with the standard reference figures at the right side. Of course, these performance parameters are related to the targets of youngster rearing that we have set in the beginning.

This list is not complete. It gives you a view of what to look for. The 39 may add, of course, several other performance issues.

Like with the miraiser periods and the automatic feeder. The drinking speed pattern. Right or wrong, regular or irregular, can be added to this list.

For analysis of calf disorders. There's a standard comprising 12 points of attention. Addresses different things.

Like the overall health states of the calves, and healthcare measures taken if the veteran does not already know those things. What are the recent management events? Housing, climate, feet, disease?

He said the first probability diagnosis. He does a routine monitoring check on the healthy calves. There is another website, another webinar where routine monitoring checks on healthy animals are addressed.

Calling car signals. They do a clinical checkup on the G scalps. Routine monitoring on calf environments looking for risk factors.

Take samples when indicated. What features urine. The vet narrows down the diagnosis based on the laboratory results.

He does an intervention if indicated drugs, maybe fluids. It gives the farmer instructions about the follow-up. The farmer may be asked to check rectal temperatures in indicated calves.

Look closer to fruit intake and maybe new cases. There always should be a follow-up on the development of the problem. That's why the routine monitoring against comes into the picture.

And again, I point you to the other webinar on cow signals to know where to look for. And constantly the vet should inform the farmer about the steps the vet is taking. He should explain We should discuss with Farmer.

And when there is an action plan, also the action plan should be discussed with the farmer to see whether it's acceptable, compatible to farm management or not. At the conclusion, This presentation was about process approach of calf rearing, methodological, it's very welcomed by the farmer because the farmer sees what you are doing. If explained, he can follow himself X step, each step you are taking, and it gives him clear views on what you're finding.

On what's going on and what should be done. It's truly welcomed by the farmer. The vet needs to invest time for the benefit of the farmer, and of course, of him or herself.

But he needs to explain each step and the action he makes. The routine monitoring, as already said, is highly helpful in these analysis, especially with regard to an action plan. Farm visits are the centre point for evaluation and analysis.

If appropriate, the veterinarian may define working instructions, for example, how to use the colossum feeding, just one page or give hands-on training when he sees that the farm worker or the farmer is not very Handy with applying a lostrom feeding feeder, for example. In that way, the veter becomes the process coach for farmers and farm workers, and that will be beneficial for both parties, because if the farmer farm workers are much more motivated and stimulated, the work of the veterinarian becomes much more pleasant and interesting. Thank you for your attention and I wish you good luck.

Stay safe and stay healthy.