Good evening, everybody, and welcome to our Thursday night members webinar. That is a special one tonight because we've opened it up to everybody. So, that everybody will have a feast on a fantastic presentation that's coming from an amazing speaker.
Little bit of housekeeping for those non-members that have joined us tonight. Very welcome to you all. You have two options to interact with, With us tonight, the what is in the Q&A box.
So just move your mouse over the screen and you will see the little Q&A box pops up. And you can type your questions and your answers and your responses to Ron in there. Or you can use the chat function in the chat box to answer him as well.
All questions that are extras we will try and get to at the end. But Ron likes to ask and answer questions as we go along. Speaking of an amazing presenter, Ron Ofrey was a member of the charter class of Cori School of Veterinary Medicine, Hebrew University in Jerusalem.
After graduation, he spent 4 years at the University of Florida undergoing clinical training in veterinary ophthalmology, and this culminated in him obtaining his PhD. Ron then returned to Israel and joined the faculty of his alma mater, where he is currently a professor in veterinary ophthalmology and winner of numerous Teacher of the Year awards, as well as having published more than 90 refereed papers. Ronnie is also a very popular international speaker, having been invited to talk in more than 30 countries on 6 continents.
Ron is a contributing author to the Gillet's classic textbook, Veterinary Ophthalmology, 3rd, 4th, and 5th editions, as well as co-author of the popular textbook, Slatter's Fundamentals of Veterinary Ophthalmology, 4th, 5th, and 6th editions. Ron is a diplomat of the European College of Veterinary Ophthalmology, as well as a former executive board member and past president of that organisation. Ron, welcome back to the webinar, vet and it's over to you.
Thank you very much, Bruce. It's really a pleasure to be with you tonight. I've been working with the webinar vet for, I believe, 6 years.
Many of, my previous lectures have been recorded, so it's a true pleasure to be with you tonight in live session. As Bruce said, we are having an interactive slide recognition session today. And for those of you who are not familiar with the format, the way it goes is, I will show a picture with 2 to 5 possible answers, and then Bruce would launch a poll and you get to vote on the correct answer.
And just to make sure you are ready to go, here is a first question, which is actually a non-authentic question just to practise, which is the fake one, the owl or the parrot? So take a look at the picture. And please vote, whether you think the owl is fake or whether you think the parrot is fake.
Folks, you simply just click on the answer that you feel is the correct answer. Please remember that this is completely anonymous. Nobody's going to mark your homework.
This is just for you. So don't be shy. Get off the fence.
There's, lots of splinters on the fence, and, make a decision. And then, We will share those results, but it's really important to participate in this because it's also gives Ron some great feedback, what the audience is, feeling, and feeding back to him. Right.
So I hope everyone can see the results of the poll and you see that the vast majority, 87% voted for the owl, and indeed you are correct. The reason I say that the owl is fake is you can see I am holding it with my hand open cause it's a fake. It cannot fly away so my hand is open.
The parrot is real, it's live, it can. Byway, which is why my hand is closed. So all of you who voted for the hour being fake, you were absolutely correct.
I'm very happy that the majority got it got the correct answer. So now that you know how this is gonna work, I should say we're giving you 40, 45 seconds per slide. Here is our first authentic slide.
Bruce, if you want to read the answers. So the question is, this lesion is a neoplastic, B, inflammatory, C, congenital, D, toxic, or last one dietary imbalance? Click on the answer that best suits your opinion, please.
We've got some Quick, quick respondence there, Ron. And we've got a couple of people who are trailing behind, so. There you go.
OK. I am very happy to see that once again, the majority got it correct. Neo congental is the correct answer.
What we're seeing here is a lesion called persistent pupillary membrane or PPM for short. What happens is that, as you know, the lens receives its metabolic support from the aqueous tumour because the lens, just like the cornea is a tissue with no blood vessels. However, during embryonic development, there is no aqueous.
More and therefore during embryonic development, the lens receives its metabolic support from a vascular network that is supposed to regress and resolve around the time of birth. Sometimes we get remains of this. Embryonic vascular supply, and this is what you're seeing here.
It looks like fine spider webs originating in the iris. The base is invariably in the iris, as you can see here. So this will be the base or the proximal end, and the distal end is Either crossing the pupil across to the iris on the opposite side.
Sometimes it can be free floating, sometimes it will touch the lens and cause a, a focal caract. Sometimes it will To the inner cornea and cause a focal edoema or glaucoma. But yes, you are correct, it is congenital, it is non-progressive, .
And basically, we can offer no treatment unless there is a severe cataract, in which case we go into surgery or severe corneal edoema, which would also sometimes require surgery to resolve the edoema. But other than that, A lesion like this, where there is no cataract and there is no edoema, we just leave it the way it is cause it's non-painful, non-progressive, and minimal effect on vision. Does anyone have any questions about PPM?
If so, please type them away. Well, you decide whether to type them away or not. I have another question for you, one for which we don't have a poll questions.
Usually, as I said, it's an incidental finding. It's not painful, it's not progressive, it has no effect on vision, except for one dog breed. In one dog breed, it's inherited as a dominant trait, and if we see PPMs in this dog breed, we recommend that owners do not breed the dog.
Any idea what dog breed is? I didn't even prepare a poll question for it, so just type your answer away in the chat box. Again, I'll not read your name.
Yeah, it's anonymous. But do you know which dog breed? In which dog breed it's a problem.
OK, so I've got 3 breeds so far. I won't read them out, so I don't influence, wow, what a variety. I've got a Labrador.
I've got a boxer, a Basenji. I've got, I don't really know. I've got a Dalmatian, a husky, so 5 different breeds.
OK, the Basenji got a 2nd vote. Ron, we've also got a border collie and golden retriever coming in. OK, I know, right, OK, so Benji is indeed correct.
The Basenji is the one dog breed in which it's dominant, and we recommend not to breed if you see it in Benji. You guys and ladies are doing very well. Next, Bruce.
Would you read the question? Right. So this is a case of 1, pigmentary keratitis, 2, corneal perforation.
3, melanoma, 4, foreign body. And number 5, squamous cell carcinoma. You know how it works, so get on voting, folks.
OK, before I, Answer your question. I, I see a question relating to the previous slide and someone's asking, would you advise against breeding from dogs with PPM of other breeds? And the answer is no.
The only breed which we advise not to breed if you see PPM is the Basenji. All others are clear. Once again, you people are doing very well.
This is indeed a case of corneal perforation. And the reason I wanted to show actually it's a corneal perforation and iris prolapse. The reason I want to show this is that you are seeing something that really doesn't look like an iris.
It's sort of grey, maybe with some vascu blood here. Just a bit of brown. It doesn't look too much like an iris, does it?
Yet it is an iris. And corneal perforation and iris prolapse should be a little differential whenever you see a bulge on the cornea, especially when it's surrounded by corneal edoema, maybe vascularization, maybe signs of corneal abscess, corneal infiltration, but Any lump on the cornea, should be suspected of being an iris, and the reason I want to show this slide is that often it doesn't look like an iris, right? Look at the colour of this lesion compared to the colour of the Irish.
This one is brown, this one is grey, and the reason it's grey is that, is because the iris is easily irritated and once we have a case of iris prolapse, it Immediately gets covered with fibrin, so it looks more like grey. Whitish colour which is what you're seeing here, it is still an iris. It's not pigmentary carotitis.
I'm not seeing any melanin here, nor am I seeing a melanoma or a foreign body. Squamous skull carcinoma would be more infiltrative. This is a case of corneal perforation as a majority, .
Answer correctly. Well, it could be a perforation from a foreign body as someone is suggesting. We have a question with the SEE test, always be positive.
So that's an excellent question and I thank you, Winnie, for the question. Sel test is a test whereby we test for corneal perforation. What we do is we Stain the cornea with fluorescine, but unlike staining for a corneal ulcer, we don't wash it away.
We leave it there. And if there is a hole in the cornea, then aqueous tumour will leak out of the. Interior chamber and wash the fluorine away.
So if you just stain the cornea, don't let the dog blink and you see suddenly the fluorine getting washed away, that's a sign of corneal perforation. In this case, the Seidel may be negative because actually the iris is seeing the hole, so it would be a negative yel. Seel would usually be positive if I had the dematocele which ruptured small hole in the cornea without iris perforation and then we'd see the aqueous wash away the fluorescine.
Thank you, Winnie, for this question. Any more questions? We do have one more question.
OK. Welcome, Winnie. OK.
Take it away, Bruce. Next question. Right, folks, recommended treatment.
1, monitor. 2, in nucleate. 3, anti-glaucoma drugs, 4, anti-inflammatory drugs.
Nice quick voting now, Ron, thank you. Thanks, everybody. Yeah, I was gonna say I'm interested in seeing what you will vote.
. OK, so. Let's speak with the diagnosis. We are seeing a case of Would you like to type away the answer before I actually answer the whole question?
What are we seeing? What's your diagnosis? Type away.
Mhm. What do you think this lesion is? OK, I've got one answer.
After having said everybody is doing so well, they've shy now. Come on, folks. OK, we've got a few answers.
OK. Oh. OK, I've got the majority voting for melanoma or more correctly diffused iris melanoma and in this, indeed this is a correct answer.
All these pigmentary changes on the surface of the iris are a diffused iris melanoma. Not only do we have a case of diffuse iris melanoma, unfortunately, it is causing secondary UVIis and glaucoma. I can see that based on the abnormal shape of the pupil, this is definitely not normal shape pupil for a cat.
We can see here, a red eye, possibly uveitis, but more likely secondary glaucoma cause we are seeing so much of the conjunctiva and underlying sclera. It is probably a boonic eye, so we are having. Diffuse iris melanoma, we are having secondary UVIis as evidenced by the misshaped pupil causing secondary glaucoma.
In such cases, the only recommended treatment is a nucleation. I know we can have a long debate about what to do with pigmentary changes in the feline iris cause sometimes they are just melanocytoma. They start out out as freckles or mild pigmentary changes, in which case we would begin monitoring them.
However, when they do develop. Secondary UVitis, when they do develop secondary glaucoma, when the lesions increase in size, when they increase in area, when they become raised, then it's time to nucleate because in. Did, this can be a very aggressive and in fact a fatal tumour in cats.
So no, we do not treat it with anti-inflammatory drugs. We do not treat it with anti-glaucoma drugs. We don't monitor at this stage, we take the eye out.
Any questions about this picture? If not, I have Another lesion with the same 4 answers, Bruce, please. Right, folks, slide picture has changed, but exactly the same.
What are you going to do to treat this particular condition? Monitor, nucleate, anti-glaucoma drugs, or anti-inflammatory drugs? OK, Before answering this whole question, I see we do have one question in the Q&A about how can we confirm the diagnosis.
I take it that Nicos you're referring to the previous picture. Well, It reminds me, I had a pathology teacher who said the only way to reach a pathological diagnosis is through histopathology. And really the only way to be 100% certain that this is melanoma or in Previous slide, is to have histopathology and indeed some people would recommend an iris biopsy, which is something that the specialist may do, take a snip from the suspected area and send it, submit it to histopathology.
Assuming you are not gonna take a histopathological sample of the iris, as I said, you look at whether, there is secondary UVIT, secondary glaucoma, whether the lesions are increasing in size or in number or in area, whether they are raised. You can do the neoscopy and look at the iridocorneal angle to see if it's being infiltrated. All of these would be indications for nucleating the feline.
This picture, however, indeed, the majority is right, we are going to monitor. Some of you may suspect that it is another case of iris melanoma or melancytic changes in a dog, but in fact, it is an Irish cyst. It is not part of the iris.
It is not a tumour on the iris. It is an Irish cyst. And the way, what it's an Irish cyst is you can see very well defined borders.
It is really very cystic in shape. And if you look closely, it is semi-transparent because you can actually see the iris through this. So it's a cyst full of fluid, it's completely harmless.
We, it has no lying here. It doesn't cause inflammation, it doesn't cause glaucoma, it doesn't interfere with vision. It, if it was huge and if it would obstruct the pupil, then I may have to do something about it cause it does cause visual deficits.
But this one here. Well, we just tell the owners to keep monitoring. There is no need to provide any treatment.
Unless, no need to provide any treatment unless this was a A collie, a German shepherd, a golden retriever, American cocker spaniel, or a beagle. Where would you be concerned if you saw an Irish cyst? Rights.
Answers 1 collie, 2, German Shepherd, 3, golden retriever, 4 American cocker spaniel, and 5, the beagle. Oh, that's a close one. We've got a good spread of the vote and actually the correct answer is C, golden retriever.
In the golden retriever, these cysts may be filled with pigment. They burst. The pigment spreads in the.
Interior chamber, it causes what we call pigmentary uveitis and about half of them get nucleated due to secondary glaucoma cause the pigment in the ruptured cysts, eventually. Clogs the corneal angle and causes secondary glaucoma. So every other breed, it is really a lesion that we just monitor in the golden retriever, we are very concerned because they can and getting UVISs and glaucoma.
Not that we can do much about it. I mean, we can't do anything to prevent them from bursting and popping, but, we would monitor them very, very closely if they are a golden retriever. Right, the powers that be, in the webinar vet asked me to introduce a few exotic slides.
So here is your first one. Bruce, if you would. What systemic disease is affecting this snake?
Pneumonia, gastroenteritis, stomatitis, hepatitis, or renal failure? Mm, I think you've got a couple of people stumped here. Ron, the voting is a little bit slower than it has so, so let's give them more time.
The numbers are starting to creep up, so people are brave. Remember folks, it is anonymous, . Have a guess if you're not sure.
OK. Well, the majority voted for renal failure, and then we've got hepatitis and sto stomatitis for second place and actually see stomatitis is the correct answer. I'll come back to this slide in a second, but a bit of the anatomy of a snake eye.
Snakes have no eyelids. If you look at them, here are two eyes of two snakes, and you see that actually they don't have any eyelids. And if they don't have eyelids, it means that the cornea can easily dry up and to prevent it from drying, what they have is what we call a Spectacle, which is actually a transparent scale, OK?
We've got all the scales on the skin here around the eye and the eye is covered by one transparent scale, which is called a spectacle. And that actually protects the cornea. From drying and you can see it here on ultrasound.
So here is the lens, here is the interior chamber, here is a cornea, and here is a spectacle, completely transparent, which is why we don't really sit in these pictures and here it is in histology again, the cornea here and the spectacle here. And you see that there is a space between the two, which gets the interesting name of subs spectacular space. I wonder who came up with that one, but it's the space.
Beneath the spectacle between the spectacle and the cornea. If I go back here, what we have is really a subs spectacular abscess, and abscess right in this space here between the cornea and the spectacle. And this abscess really is due to stomatitis.
It makes the infection makes its way up through the nasollaal duct from the mouth to the eye. And infect subs spectacular space. The way to treat it is actually to cut, make a wedge incision here, drain it, flush it with antibiotics, and probably give systemic antibiotics.
OK. So this would be a subs spectacular abscess in a snake. Any questions?
If not, Let's move on from snakes to rabbits. Go ahead, Bruce. In rabbits, severe conjunctivitis may be the first and only sign.
Of Rabbit hemorrhagic disease, RHDV or calicivirus, 2, myxomavirus, 03, rabbit fibroma virus or the Shopi virus. Or rotavirus 5 papillomatosis. Wow, OK.
You people do very well. I'm looking at the way I type the answers and maybe it's due to the fact that I actually use capital letters for the correct answer, but Musoma virus is correct. Myxoa virus causes inflammatory and edematous lesions of the leads, the conjunctiva as well as the mouth, the anus, and the gentle area.
Yeah, we've got a vaccination for some strains of the Musoma virus, but in unvaccinated animals, it could be fatal and really a demo exerive lesions around the eyelids may be have pneumonic for the disease and in unvaccinated animals, conjunctivitis may be the only sign of the disease before death. So basically, you look at the clinical signs, you can also look for inclusion bodies in mucosal scrapings or in histopathological samples and please If it's an unvaccinated animal, you should really be very aggressive in your diagnosis and your treatment cause it may be a fatal disease. You people do very well with this slide.
So here is Another rapid question for you. Right, folks, you can read that as well as I can. So get, get clicking.
There we go. So cause cataracts and iris abscesses in rabbits and Pick another species, folks. These ones are coming in thick and fast now, Ron.
OK, but let's see, are they correct or not. Yeah, well, you scared them with a snake, but here you go. OK.
I am sorry to disappoint you. OK, so we are seeing a case of eoniculi infection. Actually, it's a very Interesting parasite cause rabbits transmitted vertically, female rabbits can get infected from urine, etc.
In the bedding, but then, during pregnancy, they transmitted to the embryos through the placenta and the rabbit pups may be born with the encephalosome coniculi in their lens. And it sits there quietly for a year or two until one day it becomes active and it erupts and causes this cataract that you're seeing here and it causes an iris abscess, severeitis, severe cataract. We are all familiar with the disease in rabbits, but a few years ago, it, we have had reports of it being identified in.
Cats. We are also seeing, it is a cause of cataracts, Uveitis and iris abscess in cats. You can do cataract surgery in cats, submit, the sample, the aspirated lens to serology, and actually they come back positive for encephalo con nebula.
So cats is the correct answer. OK, we do have a question here. With the ocular lesions be bilateral as a systemic disease?
No, definitely not cause as I said, it's less of a systemic disease. It's being transmitted vertically, so I'm not sure that both eyes would get infected. In fact, most of the animals I recall seeing had unilateral presentation rather than bilateral.
Thank you, Winnie for the question. So in the previous questions, I told you it's a snake. I told you it's a rabbit.
I'm not telling you what this species is. That's interesting, Ron. Right folks, what species does that eye belong to?
Rabbit, chinchilla, hamster or guinea pig. It's only 1 out of 4 rather than 1 out of 5. OK.
I am impressed. Indeed, the majority voted for guinea pig and guinea pig is the correct answer. I want to check the Q&A.
Going back to the previous, slide, I have a question, what is the treatment for the iris abscess? Well, Usually, it's combined with a cataract, so we take it into cataract surgery. We treat the UVI with anti-inflammatory drugs, and we would treat the animal systemically with fenbendazole, which is the drug of choice for treatment of eunculi.
So thank you for the question. OK, going back to this question here, the majority of you voted for guinea pig and the majority is correct. We are seeing these white lesions in both eyes.
These white lesions are actually in the interior chamber. They're growing from the limbus. Into the interior chamber and actually what we are seeing is bone growing inside the eye.
This is a disease unique to guinea pigs in which high levels of ascorbate in the ciliary body and in the interior chamber actually trigger bone formation. So we are seeing metaplasia, osseous metaplasia in the ciliary body. This bone may be vascularized.
It may even have bone marrow. It may be hematopoieically active. So it could cause secondary glaucoma obviously or secondary uveitis with such tissue growing into the interior chamber, .
As I said, it is caused by high levels of ascorbate, so, it may be, diet may be implicated, renal disease may be implicated, and about 15-20% of the patients may have mineralization in other tissues and organs in the body. So yeah, you can see the vascularization in the animal in the left, none here, but yes, the white tissue growing inside the eye tells me it is bone in the eye of a guinea pig. Any questions about this picture?
OK. You did very well identifying this species. Can you identify this species?
Same 4 answers. Is it a rabbit? Is it a chinchilla?
Is it a hamster, or is it a guinea pig? Oh, that is very, very close. 27 people chose the rabbit, 26 chose the chinchilla, and as often is the case tonight, the majority, the slim majority is correct.
This is a rabbit. The phenomenon we are seeing here is actually growth of the conjunctiva. Which progressively covers the cornea.
It began at the limbus, it's growing, it's growing. Here you're seeing it's covering maybe the peripheral one half of the eye. Here it covered nearly the entire eye.
We have a similar disease in humans whereby you get conjunctiva growing and covering the cornea. In humans, it is called pyridium, and you have to remove it surgically to really do superficial corectomy to remove the pterygium the conjunctiva from the cornea. In rabbits, it is called pseudopterygium, and the reason it's pseudopterygium is that unlike humans in which a conjunctiva is adhered to the cornea, here it's lying over the cornea but it's not adhered.
And in fact, you could take a cannula or IV catheter inserted between the conjunctiva and the cornea and you will see that it is non-adherent, OK? And that's why it is called a pseudopterygium, and adopterygium in humans, . Treatment is surgical.
Basically, we Make incisions in this conjunctiva like pizza slices and then we would take the pizza slices of the conjunctiva and suture them into the forenix underneath the eyelids, sutures coming out through the eyelids and you would retract the conjunctiva that way and restore a clear, transparent cornea. Any questions about this case? OK, one last exotic question before we go back to more common patients.
Oops, we do have a question. Vitamin C deficiency is a cause of conjunctivitis in the same four options again. OK.
Once again, you guys and ladies are doing very well. Before we talk about this question, I had a question about the pseudopterygium and is there a known aetiology? And well, histologically, it is metaplasia of the conjunctiva.
What triggers it? And I'm sorry, we do not know. So, sorry.
OK, yeah, indeed, in guinea pigs, conjunctivitis is an early sign of vitamin C deficiency, just like the sailors in the ocean, back in the old days. the conjunctivitis can range in severity from slight redding of the viva to a very severe conjunctivitis. With thick purulent exudate.
vitamin C deficiency, I should say, can also cause systemic problems including maoclusion, renal disease, and respiratory disease. In fact, it can be fatal, but if you diagnose it correctly, then you can easily treat it with intramuscular injections. Of vitamin C.
In fact, one injection of vitamin C and then 1 or 2 weeks of maintenance doses with oral treatment, OK? But guinea pigs are susceptible to vitamin C deficiency. It causes conjunctivitis, as I said, myocclusion, renal and respiratory diseases.
Any questions? OK, back to dogs. What's your diagnosis?
Entropion, ectropion, diety here, dry eye, or a normal eye. OK, I am truly impressed cause it's always so difficult to say this is normal. You expect me to show abnormalities.
You expect me to show pathologies, yet indeed this is a normal eye. There is no entropion. I can very well see the muccuanous junction, the eyelid margin throughout the lid.
It's in firm contact with the globe, so there is no ectropion either. I'm not seeing any dysychia, even though to make absolutely sure, maybe it would be a good idea to retract the lid slightly if you're watching the camera and look for these hairs against the white background of the conjunctiva. Definitely not a dry eye.
I'm seeing a very nice bright reflection of the camera flash here. This eye is completely normal. Yes, it's very difficult to vote for a normal eye in such a session, yet most of you did.
I am impressed. We are seeing normal like, yeah, well, we do have some criticism of, the quality of the picture. How can we access, OK, maybe.
That is a question for Bruce, yeah, about accessing the archive. Yeah, well, I would say I mean that we have about 35 of my webinars on file and another one coming up in February with a similar session. Bruce can tell you all about it.
OK. Ron, just to let the folks know, sorry to interrupt you. All of our webinars are, in fact, recorded and they are all up on the website within about 36 hours after we have finished with the with the webinar.
So if you have had, if you're a member, you've got free access to everything. If you are a guest and you have had an invite to log in, then you can use that to access the recordings. Right, and again, I should add that we have another interactive session in February as part of VC 2024.
OK. What is your recommended treatment for this patient? Right, folks, #1, constrict the pupil.
2, dilate the pupil. 3, control the inflammation. And 4 is surgery.
OK. The more than half of you want to go into surgery. But actually, in this case, well, I'm not gonna say would you mind typing your presumed diagnosis that made you wish to take, this talking to surgery.
And he's asking to put the Q&A right over the photos. I'm afraid I don't have any control over that. What's your diagnosis for this lesion?
Please be as precise as possible, cause I'm getting a couple of answers that are correct but only partially correct if you are my students. Ron, while people are typing the answers, just to let, folks know when the poll question pops up, you can click it and drag it across to the side so that you can see the picture. Right.
OK. Thank you. OK, so we've got many people voting for lens laxation, and then we've got some people divided as to whether it's interior or posterior lens laxation.
And actually this is a posterior lens laxation. Cause I am seeing part of the lens here, but you know that the lens is completely round, it's suppose I am missing all this part of the lens and I'm missing this part of the lens because it is behind the iris. If this was an interior lens laxation, then.
I would have the lens in front of the iris and I wouldn't be seeing this part of the iris cause the lens would be in front of it. So the fact that I can see the entire iris, the fact that I'm seeing only part of the lens, these two facts tell me that a posterior lens luxation, OK? You're right that if it were an anterior lens taxation, I would take it in surgery cause anterior lens taxation is one very painful.
Whenever the dog moves its head or shakes its head, the lens bangs against the cornea, so it's very Painful and 2, it's a risk factor for glaucoma cause the lens sits in the interior chamber, it disrupts the circulation of the aqueous tumour and it's a risk factor for glaucoma. However, in cases of posterior lens laxation, it's not painful, there is less of a risk of glaucoma and therefore, the treatment of choice is simply to constrict the pupil to give a meiotic agent. The agent of choice nowadays for me would be the tanoprost or the prostaglandin analogue, which A constricts the pupil and B lowers intraocular pressure so it also provides prophylactic treatment against glaucoma.
But really we want to constrict the pupil in order to decrease the risk of the lens moving from the posterior part of the eye where it sits harmlessly into the interior, chamber which, as we said, would require surgery, so constriction of the pupil is. Correct answer. I would even take it one step further.
If the, if you are presented with a dog with anterior lens laxation and the owner cannot afford surgery or maybe the patient is an elderly patient and anaesthetic risk, what we do, what we could consider is what we call transcorneal reduction. A procedure in which we simply push the lens from the or attempt to push the lens from the interior chamber back into the posterior segment of the eye. What we would do in such a case is actually administer manitol to the patient, wait an hour or so in order to shrink the vitreous.
We would temporarily die. The pupil with tropekomide and then simply apply pressure on the cornea. Push against the cornea, push on the lens through the cornea and hopefully it would pop through the pupil into the posterior part of the eye, transcorneal reduction, and then we would apply the latanaro in order to constrict the pupil and hope that the lens stayed there.
Any questions? OK. Is there not a risk of anterior lens access if the owner failed to keep up the eye drops?
Yes, indeed, Paul, you're right. If they don't administer the eye drops, then there is a risk of anterior lensation, which would be a lot more expensive than administering eye drops. But as long they do provide, and I should say that, you know, the fact that they give constricting eye drops doesn't guarantee that the lens would stay there.
Sometimes even with myortic treatment, it may move forward, but it definitely reduces the risk of interior lens laxation or migration from the back to the front. Any more questions about this case? I see another question popping up.
What drop for to constrict the pupil? As I said, I would give latanoprost or prostaglandin analogue. It constricts the pupil and also gives you prophylactic treatment against glaucoma.
OK. First thing to check in this eye. Please, Bruce, take it away.
Right, folks, by now, you know what we're doing. Bowl number 15. Is it 1, fluoresce staining.
2, culture and sensitivity. 3, intraocular pressure, 4, complete blood count, or 5, systemic blood pressure. And again you can drag the answers to the left, so you can see the picture without it being overshadowed by the questions.
OK, very well. So we have about 80% of the people voting for intraocular pressure and that is correct. What we are seeing here is a blue eye and a red eye, OK?
We are seeing corneal edoema and we are seeing a red eye which may be severary injection or epicleral injection. And actually this is a good picture to show you the difference between the two cause I am seeing conjunctival vessel here, but I am seeing an episcleral vessel here and here, not the difference in diameter between the epicleral vessel. Here and here in the conjunct vessels here and here.
But as I said, we are seeing a case of blue eye and red eye. My three differentials for red eye would be injunctivitis, UVitis, and glaucoma. But if there is also blue eye or corneal edoema, then we can scratch conjunctivitis from the list cause in conjunctivitis, we don't get corneal edoema.
We are left with uveitis and glaucoma. And in order to differentiate between the two, the first. The thing we must do is, or the easiest thing we can do is check intraocular pressure, which is obviously elevated in glaucoma and which is decreased in UVI.
We can also look for other signs like aquis flare would indicate, UVI, if the pupil is fixed and dilated, it would indicate glaucoma. Here it doesn't look to be too dilated, so maybe it's UVI, but again, we don't need to guess. We simply measure intraocular pressure.
Yeah, afterwards. I could do fluorescent staining. So those of you who said fluorescent staining, you're not completely wrong, you know, cause, severe corneal edoema could cause bullae in the cornea.
This could rupture and cause ulcers, and yeah, whenever we have severe edoema, it's always a good idea to stain in the cornea. So, yes, that would be maybe the second thing I would do, but as Question says the first thing to do is intraocular pressure, then stay in the cornea. If you get an indication that it's UVITs, then you'd go for complete blood count and systemic workup to find the cause for UVIT.
I don't see any indication here for cultural insensitivity or to measure blood pressure. Let's continue with this picture, and then we'll take some questions. If this was a glaucoma I, what would you recommend as emergency treatment?
So you know how it works, folks, click on the right answer. We'll give you about 45 seconds or so, and then we will reveal those answers for Ron to discuss. Again, you people are doing very well.
All of these are indeed emergency treatment for glaucoma. So when a patient presents with acute glaucoma, and by lut I mean, sometimes, you know, the owners can go to work in the morning, everything will be fine. They come back in the evening and they find a lethargic, painful dog with a red eye and a blue eye.
And a blind eye, acute glaucoma, they come to the clinic, you can administer any of these treatments. What I'd usually do is probably start with latanoprost every 15 or 20 minutes and that can very quickly lower intraocular pressure sometimes, but I'd wait no more than 30 minutes, and if that didn't work, I'd go one of two routes. If I am in a clinic, I would probably tap the interior chamber, what we call aqueousythesis.
I'd go in with the needle right at the limbus. Keep on going with the needle until the tip of the needle is in the centre of the eye over the pupil cause that's the deepest part of the interior chamber. I do not connect the syringe to the needle.
I do not aspirate it with. I just go in with a 25 gauge needle. Let 2 or 3 drops of aqueous come out, bloop, bloop, bloop, loop, and that's it.
Take the needle out. It's actually quite an easy procedure, but if you haven't done before, please practise on one or two cadavers before doing it. .
And if you don't feel safe doing it or if I'm, if it's 2 a.m. In the morning and I'm not coming into the clinic, then I would have the intern administered intravenous manitol, but yes, all of these are correct answers.
I'm being asked, do you check baseline blood gases before and after magnol? Not blood gases. I would maybe check creatinine, and see how the kidneys are functioning.
Steven is asking, are carbonic anitras not useful in emergency situations? I'm afraid not. They are not as potent.
I would send the dog home with carbonica anita inhibitors, but they're not as potent as, the Latanaros and other propagandian analogues. What size needle do you use? I said 25 gauge is what I'd use, and now there is no risk of an eye rupture.
As I said, I would, please practise it if you haven't done it before on a cadaver, but we go in. Right at the limbus. I don't make a hole in the core wall near here, just at the limbus and push the needle until the tip is sitting here in the middle of the interior chamber where it's deepest and no, it's actually a very safe procedure.
. With eosynthesis, what if we insert from the sclera instead of the limbus? Well, number one, you could cause haemorrhage and again, if you insert from the sclera, you would end up here. You wouldn't end up at the deepest part of the interior chamber, which is why we go at the limbus so we can go into the pupil.
OK. We've got 2 minutes and 2 questions left, so let's go quickly. This is a case of.
Alright folks, you can read your options as easy as I can and get voting for us, please. Oh, that's an interesting split of the vote. I'm glad we had time to vote on this question.
Actually, the fifth answer is the correct one. This is an unusual appearance of PAuss or chronic superficial keratitis or Uber writer's syndrome. What we are seeing here, and that's the reason I brought it up, it's called a plasmoma.
Sometimes panuss. An immune mediated disease that we see mainly in German shepherds, a disease in which exposure to ultraviolet radiation is a risk factor. Usually it, Presents as keratiti, which is why it's called chronic superficial keraitis.
It begins as keratiti in the ventromedial part of the cornea cause I don't know if you are seeing the camera, but think of the sun. Shining from the sky and the rays of light really radiate the ventral medial part of the cornea first, and that's why that's usually where the inflammation begins. And you can get a clue that this is actually panels because you do see some, a bit of infiltration here at the cornea, the ventral medial cornea.
Yeah, it could sometimes be squamous cell carcinoma, those squamous. Be more proliferative. Here I see more of the congestion rather than proliferation.
That's why it's not an adenoma. I see that the third eyelid is flushed against the cornea. It's not scrolled.
There is nothing picking behind the third eyelid, so it's not a cherry eye. It is a congested 3rd eyelid, and with this slight infiltration here, it is a panels. We are just on time, but I'm sure Bruce will allow us one last picture.
Yes, here it is. Sorry, oops. The interior chamber of these two dogs contains a lens, fibrine, aquesphere or lipids.
OK, you people do very well. It is not a lens. I'm not seeing something circular and solid, like a lens here.
I understand why some people would be misled by fibrine, even though it's a bit too wide for fibrine, I would say. It's not really, and it's not really a clot. It's something floating in the eye.
So it could be aqueous flare. This one could be more of an a. With flare, this one, gosh, it really fills up the entire interior chamber.
I don't see any thing resembling an iris or a pupil here. This is actually lipids in the interior chamber. This dog is suffering from hyperlipidemia.
2/3 of these dogs are. Diagnosed with diabetes, we'd always think that, gosh, maybe they have pancreatitis or Cushing's or thyroid problems. No, those account for maybe 5%.
Some of them have primary hyperlipidemia, 2/3 of them have diabetes mellitus. So we are now a bit over time, but all for a good cause, . Yeah, for a good cause.
Thank you, Ron. That was absolutely fantastic. And folks, remember that this has been recorded.
It'll be up on the website in the next 3 or 48 hours. And then you can go back and take your time at looking at those pictures again and rewinding and fast forwarding, which unfortunately, we can't do in a live webinar. Ron, it is once again my pleasure to thank you for your time and for a fascinating webinar and really look forward to attending your session at virtual Congress.
To everybody that attended tonight, both our members and our Guests. Thank you so much for your time. Hope you enjoyed it as much as I did.
And as always, a special thank you to my controller, Dawn in the background for making everything happen and run smoothly. From myself, Bruce Stevenson, it's good night. Good night.
Bye-bye.
