Hello, it's Anthony Chadwick from the webinarett welcoming you to another episode of Vet Chat. Today we have our CFO on, on the line, Buddy, who is, just wanting to join us today. And of course we also have Ron Ofre, the very esteemed and very good friend of mine, ophthalmologist based over in Tel Aviv.
Ron, obviously, before we start, I just wanna, say that, you know, our thoughts are with you in these difficult times that you're in and . Let's hope for a better 2024, hey. Indeed, yes, I know this is going on the air in February, but we're recording it, mid December, and yes, let's hope for a peaceful 2024.
We, we go back a long way, Ron, we'll, I'll, I'll, I'll start with my visual aid, which is this beautiful book that you gave me when we met in, I think it was was it Seville or Valencia in SBC the SABC a few years ago and it's much treasured by me, . Obviously we've got all the signatures in as well, and ophthalmology is is closest to my heart, as you know, I did dermatology, but I spent a lot of time working at the Animal Medical Centre in close collaboration with Pit Boydell, and we often talked about eyes and skin being connected. There were certainly issues around eyelids and and things that would mean that both of us could have an opinion on it.
So, this has always been a treasured, part of my bookshelf, so thank you so much again. And thanks for all the contributions you give to Webinar Vet, cos you've done many webinars for us over the years, as we talked recently, some of those possibly need refreshing cos one of my other favourite lecturers apart from yourself is a professor, retired now up at Texas A&M. Mike Willard, who said quite often on lectures, everything I taught you 10 years ago was a lie.
I just didn't realise. So the, the, the, the veterinary medicine is always progressing and some of the things we talked about 56 years ago, we probably want to have a slightly different angle on now, don't we? Yes, let's be diplomatic and call it a mistake rather than a lie.
Yes, I agree, I will let you get away with that one. But yeah, you know, it's, it's really great to have you on the podcast and pleasure to be here. Obviously a, a, a great friend of mine in the veterinary profession.
We've known each other a long time, but perhaps those people who don't know you as well, give us a little history of, your veterinary history as it were. Yeah, well, people always ask me how I became interested in ophthalmology and like many other things in life, it's thanks to a great teacher. My personal story is that actually I am a member or I was a member of the charter class of our school.
Which opened up in 1985. Prior to that, there was no veterinary school in Israel. They opened in 1985 and similar to the American system, you had to have a pre-vet education in order to apply.
I was fortunate enough to just graduate at the right moment with a degree in biology. I applied. And I was accepted, but since it was a new school, they lacked teachers and professors in many areas and many disciplines.
So what they did is invite speakers from overseas to teach specialities for which they had no instructors and Really, they invited some of the biggest names in the time, you know, Bob Hamlin for cardiology and Cornelius taught us, the liver disease, and Kaneo taught us about chemistry. Maybe these names don't mean too much to the younger audience, but in the 1980s, they were really leaders in their field and forthalmology, they brought Kirk Glatt, who was considered by many the grandfather of veterinary ophthalmology. He He has written the Bible of or edited the Bible of veterinary i for many years.
He's first editor of the journal. At the time he was Dean of Florida and he came over to Israel to teach us of emoji for 3 weeks. What they did is those people would come for 3 weeks and they would Teach us everything from A to Z.
So like Kirk came over and taught us the embryology of the eye, the anatomy, the physiology, pharmacology, clinic, surgery and pathology, 3 weeks of pure formology and I fell in love. I kept in touch with him when he went back to Florida. That was back before email was invented, so we'd write letters and stick stamps on the envelope and Write each other, but we kept in touch and when I graduated, I told him I want to come to Florida and he said, come on over.
And I did, and I spent 4 amazing years at the University of Florida training in veterinary phthalmology, getting my PhD at the time, it was really the best place in the world for veterinary othology. They did want me to stay there, when I was done, and I'm still remembered as the only person in the history of Florida who turned them down, but home is home, and after 4 years, I was yearning to go back home, so I packed my bags and I've been here at the University of Jerusalem ever since. What a great story, and I, I don't think I've heard that story before.
Did Kirk go to stay in Florida or did he go to Cornell or who was in Cornell? No, in Cornell, we had, Tom Curran, I guess who's maybe one of the oldest guys, later Gus Guy moved to Cornell for many years. Kirk.
In early stages of his career was in Minnesota and maybe Kansas, I don't remember. Then he migrated to Florida with a colony of beagles, beagles with glaucoma, and I know glaucoma is a subject of great interest to you. A colony of beagles with inherited glaucoma, which he kept for 30 years.
You'd walk into his office and on the wall there'd be a family tree going back as 30 years of Beagles with primary open-angle glaucoma and those beagles generated lots of grants, lots of papers, lots of PhDs, cause they were a model for, for human glaucoma. Mm. I remember I won the Frank BT Travel scholarship in '97.
I went to Cornell to do dermatology and ended up spending time with Danny Scott and Bill Miller, which was fantastic. But I woke up one day with a really painful eye. And didn't know whether it was some sort of allergy or whatever, but it felt like there was something grating on the eye and .
The ophthalmology department was next door to the dermatology department, so I went to see them and there was nobody there and they said, oh come back a bit later, and I came back and there's still nobody there, and my eye was really, really sore. I ended up, the end of the day, I found somebody from the ophthalmology department. They stuck some .
Ligniccaine procaine into my eye, and diverted the, the lower lid and found a nice piece of grit in there that had been rubbing up and down in my cornea, already abrading the cornea a bit, realising how painful that can be, which I've since suffered after a piece of eye surgery, you know, when there was another little abrasion. Corneal abrasions ulcers are painful things. But of course once the piece was taken out, it was it was so much better and.
It was then that I got even more gratitude for ophthalmologists because that was a a a painful, painful eye, and I think you've done webinars for us on that sort of acute painful eye, it's there can be all sorts of things that can get into eyes and cause problems, can't there? Yes, indeed, you know, and you mentioned it was something below your eyelid. Let's not forget that our patients have 3 eyelids.
So there is even more room for foreign objects, foreign bodies to irritate the eye, and you're right, the cornea is one of the most richly and not one of the, the most richly. Innervated tissue in the body, so they can be very painful. Strangely enough, it's the superficial cornea which is richly innervated.
Actually there is, there are fewer sensory nerves in the deeper cornea, so in a bit of a paradox, superficial ulcer. Are more painful than deep ulcers. And sometimes when deep ulcers, and when an ulcer progresses from superficial to deep, the owners think, -huh, things are getting better cause the dog is less painful when in fact, it's less painful because there's less nerves there, but in fact, it's worsening, it's just gotten deeper.
Going back to glaucoma, which I know is one of your favourite, or should we say, say one of those subjects that you battle with the most in, in ophthalmology. I call it my nemesis. Yeah, your nemesis, as you said.
I have a, a family history, it's presents that have been given to me by my grandfather, who I don't remember, he was, I was 2 when he died, he lived with us at home. And he went blind with glaucoma and that was obviously in the late 60s. And then of course my mum and dad both had glaucoma from both sides, so my granddad was my mum's father.
And then my dad developed glaucoma, but they were both in their sort of 60s from what I can remember when they developed it. I have, you know, I had very, very good vision up until my mid-40s. And I went to see my auntie in Australia who unfortunately was dying.
I wanted to see her before she passed. And she said, Antony, your eyes are really, really red, you should go and see an optician when you go back, because I'd never been to an optician, even though in the UK once you reach 40, if you have a history of glaucoma in the family, you can get free consults, but my eyes were so good, I didn't wear glasses, I could see really well. So I never went and then.
Post coming back from seeing my auntie in Australia, I went to the optician. My eyes were possibly starting to just blur a bit, so he said, you might need, you know, a light pair of glasses, but actually the right hand, the right back of the eye, doesn't look in a great shape in the, on the, the retina. So I was referred to the, to the ophthalmologist and obviously the optician, optometrist has also found that I had high pressures in my eye as well, which is obviously a can be a sign of glaucoma.
And then I, I had the diagnosis of pigmentary dispersion syndrome. The only positive, Ron, I was 45, 46 at the time, and, and they called it young person's glaucoma. So there's always a silver cloud to every lining.
I came back feeling good about the fact that people were still classing me as a young person at 46. But otherwise, . One of the things personally it's made me do is appreciate, although my sight isn't as good as it was, I, you know, need to wear glasses for long distance.
You actually appreciate your site a lot more when you realise that maybe it isn't as perfect as. As a young person, you take a lot of these things for granted, don't you? Yes, indeed, and you know, numerous surveys show that that's the one sense that people are most afraid of losing and yes, you're right in so many ways, cause the damage caused to the retina, to the optic nerve, as a result of glaucoma is something that we cannot repair.
We, the retina does not regenerate. The optic nerve does not regenerate. So when you're diagnosed with glaucoma, whether you're a human or a canine or a feline patient, the aim of treatment will be to lower intraocular pressure and to stop further damage, but any damage that has occurred prior to the diagnosis and initiation treatment.
Any vision that has been lost prior to the initiation of treatment, will never recover, which is really a problem because as you know in veterinary medicine, many owners would show up at terminal stage really, when it's too late, when the eye is already. Irreversibly blind, they're not as fortunate as you were to go to an optician and he looks at the retina and says, oh, you should go see an ophthalmologist, they sort of, it creeps up on them and they don't realise it until it's too late and Yeah, often, when presented with a patient with glaucoma, we are really concentrating on the unaffected eyes in cases when it's inherited glaucoma. This one is still seeing, I can fight for it.
I can try and preserve vision. This one, I'm sorry, may be lost. Yeah, and that's a point you mentioned the webinars, I always bring up, you know, when in doubt, treat the unaffected eye.
This affected eye may be lost. The unaffected eye is still visual that should remove, receive a prophylactic treatment. Do you want to become a part of the largest online veterinary community in the world?
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Sometimes, obviously you get a lens luxation that can cause glaucoma, so. Removing lenses quickly can obviously save the eye from going into terminal decline. Do you think, should we as part of clinical exams look more seriously at doing tonometry, because it's something.
You know, I don't think I ever did in veterinary practise. Is that something that we should be doing more routinely perhaps in older animals or in certain breeds that are more prone? I would say in certain breeds, definitely.
It is something that should be done and you can find lists of breeds with the inherited glaucoma. However, if you're and yes, every veterinary clinic really should should have a tonometer, in order to measure intraocular pressure. Maybe not as part of the routine screening, but definitely to manage your, both your glaucoma and your VIS cases, you do need a tonometer.
I'd say that if you want to add and oranic diagnostic technique to your arsenal, always practise ophthalmoscopy on every patient that walks into your clinic cause number one, it's not an easy technique, it does require And number 2, there are lots of variations in the appearance of a normal fundus both especially in our canine patients. So if the first time you're trying homoscopy is when an owner comes in complaining of a blind patient. I'd say it's pretty much a waste of time if you haven't mastered the technique, if you don't know, to recognise normal variations, you'll be lost.
So I would say every patient that comes into your clinic, whether it's for vaccination or a flea problem or diarrhoea, just take a quick look in the eye, 2 seconds. Just to a, familiarise yourself with the technique and be familiarise yourself with the normal appearance of the fundus, and I, I, I find also that clients always appreciate it, you know, it's like they saw in Grey's Anatomy that the doctor always examines, the fundus and wow, my dog, got the same treatment. It always impresses them.
And really with glaucoma, we're looking for atrophy potentially of the blood vessels around, but you also get this sort of Halo or effect around the actual fundus as well, don't you with glaucoma? Yeah, well, there's lots of signs of glaucoma for owners to notice, as you said, red eye would be one of them, blue eye due to corneal edoema. Sometimes if it's really a sensitive owner, they would notice that the pupil is more dilated than normal or doesn't constrict as much as in daytime, and those are really alert owners.
Would come at an early stage. But really, if I could go back to the irreversible damage that is being caused, to the retina, one of the most exciting things in areas in glaucoma research is what we call neuroprotective treatment. And the idea behind that is that When we give drugs to lower intraocular pressure, it is really a losing battle.
Once glaucoma is started, we can try this drug or that drug or drug combination or maybe surgery. Within a year or two, most of our veterinary patients will become blind despite the and humans also become blind despite the fact that we lower their intraocular pressure. So neuroprotection, which actually began in neurology, is a new therapeutic approach whereby you say forget controlling intraocular pressure cause It's something we do not excel in.
Let's concentrate on actually protecting the retina and, protecting the optic nerve from damage. And there are lots of promising drugs, is in rodents, they work very well. Unfortunately, they work less well in humans and dogs, that can protect the retina and the optic nerve from damage despite elevated intraocular pressure and That I think therein lies a big hope for glaucoma patients that we combine hypotensive treatment with treatment to protect the optic nerve and the retina and prevent this damage.
And looking at pressure wise, similar in humans, sort of 20 is where we start to get concerned about pressure numbers in the same in dog and cat. Yeah, well, yeah, actually that's a interesting subject onto itself. There is, there are numerous papers, debating the subject of what is safe IOP.
And you've touched on a very interesting point here cause really glaucoma is one disease that I always tell my students, the more we learn about it, the less we understand it. When you and I were students, glaucoma was an easy disease, pressure goes up, you have glaucoma, pressure comes down, you've cured glaucoma. And With the years we've come to realise that really glaucoma is a multifactorial disease in people and there Many risk factors in play.
Elevated intraocular pressure is probably the most common and most significant one, but the immune system plays a role in it. Blood circulation in the retina plays a role in pathogenesis of glaucoma. .
And lots and lots of other factors that come into play, to the point where in people you actually have what is called normotensive glaucoma, meaning glaucoma with all the hallmarks of glaucoma, with the damage to the optic nerve and the retina, but it's normotensive pressure would Normal and that is about 1/3 of the glaucoma cases in people, which is really scary. So there is really no safe IOP for some people with problems with the immune system or blood circulation in the retina. It may be.
Lower, maybe 1213, 14. For others it may be 20. It's really individual because of all the other factors that are in play.
Yeah, no, it's fascinating and I actually have a pigmentary dispersion syndrome which the doctor has explained will probably get better as I get older, so I'll reach a point in my 60s hopefully where. Actually, the, the pressures would almost drop naturally and then it's the damage that's been done over the last, you know, 1015, 20 years. And of course then your eyes deteriorate as you get older as well, you lose neurons, so it's how you can slow that progress down.
As people are living older, and, you know, potentially dying before you go blind, I suppose is the way that you, you look at it. Is pigmentary dispersion syndrome a problem in dogs or cats? Is that we do have it in a couple of dog breeds, not in cats, but, terriers have a similar disease, pigmentary glaucoma, and .
The retrievers and a few other breeds have a type of glaucoma caused by cysts that are in the eye that burst and they disperse pigment causing secondary uVIis and glaucoma. So uveal cysts are. In many breeds, it's an incidental finding.
It's just a nice balloon floating in the eye, but in, especially in golden retrievers and a few other breeds, if you see it, it's cause for concern because it may pop, disperse pigment and as you say, cause pigmentary UVIT pigmentary glaucoma. And the pigment is interesting because it sort of blocks the angle, doesn't it? Right.
And then you actually need the macrophages to get busy in actually eating up that . That pigment. So I've ended up in the situation where drops weren't working, I've had surgery, which has been an interesting, it's not been a trabeculectomy, this particular surgeon does viscoannulostomies, which is sort of a, it doesn't go right through the membrane because eye surgery with tuberculectomies and so on, there's a danger you can drop the pressure too much, can't you?
Right. Yes, surgery is another interesting aspect of glaucoma. As you say, If in, if you're a general practitioner and you feel that you are unable to control pressure medically, then you should definitely refer the patient to veterin ophthalmologist cause we do have some options, .
For some surgical options including laser and other means of partially destroying the ciliary body and lowering production of aqueous more. We do have shunts and other surgical procedures similar to what you're describing to increase outflow from the eye. So we do have surgical options and they would be a reason to refer your glaucoma cases to Especialist as far as general practitioners go, I regret to say that the most.
Yeah the surgery you will be performed most commonly is, in creation, unfortunately, because often we do end up with an eye that is irre irreversibly blind because I said the blind, the damage is irreversible and painful cause we're unable to control pressure medically, in which case, nucleation may be the best option, and that's another thing I've stressed in my webinar is a very important point. There is A very important difference between cases of acute glaucoma and chronic glaucoma. Cause in, if the dog has become blinded with acute glaucoma, the owners can see that it's painful and they will not argue with you when you recommend a nucleation.
However, in cases of chronic glaucoma, when it's sort of crept up on them very, very gradually, that's come, when you recommending creation, they'll say, what the heck, you know, my dog is not painful, it eats, it drinks, it plays, it goes outdoors. It is Absolutely fine. No, it is not in pain.
And the analogy I always give them in this case is think of glaucoma as a migraine. OK. People with a migraine also wake up, they brush their teeth, they go to work, they come back in the evening, they watch some TV, they go to a pub with a friend.
Yeah, just like a dog, you know, they walk, they eat, they play, but they are suffering constantly because of the migraine and same with those. Canine patients with a chronic glaucoma, they are in constant pain and the proof is that when I win the argument and I convince them to nucleate, they come back two weeks later for removal of sutures, and the first thing they'll say is, the dog is 5 years, yeah. It is so much more active.
It is so much more pain, playful cause we have removed the migraine, so don't give, don't take the owner's word for it. Think of the migraine analogy and insist on. In nucleation and we've got surveys out, a couple of them published in the United Kingdom showing 96% satisfaction rate for owners who agreed to performing nucleation in their pets.
Dogs are resilient, aren't they, and they don't show pain, they don't, you know, it's not always in their interest to show it and they will cope with life. The same analogy is that dog that you diagnose in the waiting room because you can smell the, the rotten teeth. And you take those teeth out and the dog comes back a week, 10 days later with the same thing, you know, my dog is 5 years younger, so it's pain is, is insidious and if it's happening chronically, people don't recognise it because the dog has been like this for months, months, potentially years.
Take that eye away, take those teeth away. You've taken away the source of pain that the dog cat improves immensely. Absolutely though, that reminds me, I was once giving a lecture alongside a dentist in China back in the days before COVID when we could still visit China and we're talking about nucleation, he was talking about teeth extraction.
I told you, gosh, you're so lucky, you know, you've got 30 something, 30 some teeth you can remove 1234. No, I can take out one eye. I take out the other eye, I'm done, you know, that's all I have, yeah, so he's much more fortunate in that, yeah, we ophthalmologists we regard the creation really as euthanasia.
I'm killing my patient. You take out the other eye, that's it. I have nothing to do, but as I said, in the case of glaucoma, it really needs to be done when the eye is irreversibly blind and you can't control pressure.
And actually dogs cope so well with sense of smell and things, you know, even a totally blind dog can get around because he's, he or she is familiar with the house set up. It's amazing how well they will do, isn't it? Absolutely, and you know, .
We as ophthalmologists, or as veterinarians, we have many blind patients, not just because of nucleation, most commonly cause of retinal atrophy or long-term UVIT and they'll be irreversibly blind but like you say, they can cope very well and there are lots of websites out there and help. Guides and books, with lots of tips and you should always refer owners of blind patients to these websites or maybe have them buy one of these books. They are full of wonderful advice and wonderful heartwarming stories about, like you said, how well the animals can cope while being blind.
It is definitely not a death sentence. Ron, I think Buddy is just saying he feels that we've been too dog centric and we can't really call this a podcast, because cats haven't been mentioned enough. How about just the last couple of minutes, where does glaucoma fit in in in cats?
Is it as common? What are the common conditions within that and, and how are we best to deal? With cats who sometimes can be a bit more difficult to dose some things than dogs anyway.
Yeah, thank you for bringing it up. So in dogs, there are studies that show us that about 50% of the case, glaucoma cases are due to UVITs, 50% of them are due to inheritance. And as I've said earlier, it's inherited cases where you should treat the unaffected eye.
In cats, glaucoma is nearly always secondary to, UVIis. There is very, very inherited glaucoma is very rare in cats, so it's nearly always secondary to UVIs and therefore, when you're presented with a cat with glaucoma, you should suspect UVIis, which means you should suspect some primary disease that triggered the uveitis and that cat needs a comprehensive workup, physical exam, blood work, serology. Chest X-rays, whatever, in order to look for the primary reason which the primary disease, the systemic disease which caused UVIis which caused the glaucoma.
Same, I should add for cataracts in cats. In dogs, the two most common reasons for cataracts are diabetes and inheritance. Neither one of them is a common.
Cause of cataracts in cats. Again, in cats, the most common cause for cataract, cataract in cats is UVIT. So again, just like, with glaucoma, whenever you see a cat with cataracts, suspect UVITs, suspect the primary disease, and do the workup, though I should mention in this regard that studies show us that You can do a comprehensive workup and in 40, 50% of the cases, you will come up empty-handed.
You will not find the primary disease, it will be idiopathic UVIT that cause glaucoma or that cause cataract, and this is something you should tell the owner beforehand. You should tell him, hey, I'm going to do all this workup which is going to cost you hundreds of pounds. It's important to do the workup cause maybe your cat.
Toxoplasma, maybe it has fungal disease, maybe it has this, maybe it has that. We need to do the workup, but be prepared, that I'll come up empty-handed. It will be idiopathic UVI and it's always a good idea to warn owners and fans that they're going to spend hundreds of pounds and everything may be normal.
Tell them that the literature shows as it happens in 50% of cases. Buddy, was that OK? Was that a good answer?
He seems, he seems happy, Ron. He seems happy, although he's not paying attention, he's got his back turned to you, which is very rude, so I apologise, Ron. On behalf accepted apology accepted, you know, dogs have owners and .
Cats have stuff, you know, we're all staff to archive. Exactly. I am his butler.
Yeah. So, and, and Chief Petter when er he feels like he needs a he needs a little stroke and a cuddle. He'll let you know.
Ron, it's been fabulous er chatting to you, also learning some about the, the, the ancient history, which I think is fair to say now from the 80s that I, I wasn't aware of, particularly the connection with Kurt Gillat who was obviously, Such a big figure in in ophthalmology, so you've been very fortunate to have that, that link with him. Absolutely, and it was a pleasure just saw him at the ACVO meeting in October 2 months ago in Boston. It was a real pleasure to team up again with all my, former mentors from Florida.
As, as I said at the beginning, good teacher is what it's all about. It makes a big difference, and it's always good. My wife is a teacher, it's.
It's always nice when we tell them how good they were. I remember my professor of animal husbandry, Ron Anderson, we were there for a 100th anniversary of the vet school. And you know, this was a professor and I was, you know, still a relatively young vet, saying how much I'd enjoyed his lectures and how, you know, good he was.
And you could tell he was genuinely touched, so if you, if people are listening, feel free to go out and, show gratitude and thanks to the, the professors and the teachers who've made a difference in your life. They, they, they're never quite sure, but they can have a profound effect on people, can't they? Absolutely.
I'll second that. Ron, thank you so much. I know how busy you are, so giving some time up is, you know, is a gift to us at that chat on the webinar there, and I really appreciate it.
And I've certainly learned a bit more about my glaucoma as well. So thank you so much, Rob. Thank you for having me.
It's a real honour and a real pleasure and wish you a merry holiday season and as we said earlier, a peaceful 2024. Both to the people in the Middle East and people in the Ukraine and wherever throughout the world, all over the world, yeah, absolutely, that this is what the season is all about. Yes, thank you so much, Ron, thanks everyone for listening.
Hopefully see you on a podcast or a webinar very soon. Take care and this has been vet chat, and this is absolutely Chadwick. Thank you very much, bye bye.
Thank you, bye bye.
