Hello, it's Anthony Chadwick from the webinar Vet welcoming you to another one of our lunchtime webinars, really, really pleased to have Doctor Emma Hancocks on today, who's the senior vet veterinary advisor at Dome's Pharma, and she's going to be talking about how to avoid a meltdown, a case-based approach to corneal ulcers and dry eye. Really, great to have you on, Emma, and thank you so much, obviously Dome's Farmer for making this a free webinar for so many people to enjoy and obviously improve their knowledge on. Emma graduated from Bristol Vet School and she worked in first opinion practise for some time before joining Dome's Pharma to pursue her interest in ophthalmology and neurology.
Domes have got a greater collection and selection of products in those particular areas. And she's now the senior technical vet and range advisor for Dos Farmers, ophthalmology and epilepsy and neurology rangers, so really looking forward to it, I don't want to take too much time, Emma, because we all love a little bit of ophthalmology, particularly the stuff that we can easily see on the cornea. So really looking forward to it and it's over to you.
Perfect. Thank you Anthony for the er introduction and yes, I've got a lot to get through today. So thank you for for handing over.
I just wanted to thank you all as well for joining us for today's webinar. So we're going to take a look at a practical case based webinar today. Three hopefully common ophthalmology cases that you might encounter in general practise.
And as Anthony said, I've spent a few years in general practise. So I, I definitely understand the the struggles and and the lack of training unfortunately that's out there with ophthalmology. So we'll be looking at a dog with a deep corneal ulcer, corneal ulcers in cats, and a dog with recurring eye infections.
And really my overall aim today is to improve your confidence in managing these cases, when you're standing in that consult room thinking, OK, what am I looking at? What do I do next? And to hopefully leave you with some practical tips and some take home messages that you can apply from tomorrow in practise.
And as the title of the webinar suggests, I want to help you to avoid a meltdown with your corneal ulcer cases. So a large focus of this webinar will be identifying some of the factors that can cause an ulcer to progress and importantly, what we can do to try and prevent that from happening. Throughout the webinar, we will of course also look at some of the products within the James Farmer Cornell focus range.
Obviously there is quite a few, and don't worry, we won't go through them all. But it's just simply to show you what they're doing, their benefits and where they fit into the management of these cases. And this webinar is particularly exciting for us because it does mark the start of our 6th annual National Eye Health Awareness Week activities.
And this year's campaign called Keep an Eye on Me, really encourages owners to see the world through their pet's eyes. And we all know that pets can be remarkably good at adapting to changes in their vision, using their other senses to compensate, meaning that problems may not always be so obvious to their owners. And that's why we're inviting you to join us to help raise owner awareness.
The week is set for the 21st to the 27th of September, so there's still time to get involved. We have a new waiting room poster, a social media toolkit for owners, as well as a range of interactive ophthalmology, CPD available for vets on the website. You can access all this through the QR code that I have on the screen, but don't worry, I will show it again at the end if you've, if you've missed that.
So without further ado, let's get into the first case. So this is Gizmo. He's a 2 year male neutered Shih Tzu and has a history, or his history is that he initially presented 3 days ago where a superficial epithelial ulcer was diagnosed.
And he's currently receiving a fylic acid, gel, and he should be wearing his buster collar. He also has a history of recurrent eye infections and atopic dermatitis, which may become important later. He's represented today for a recheck because the owner reports that the eye has worsened despite treatment.
And when you see Gizmo and look at his eye, this is what you see. Now when it comes to eyes and ophthalmology, it can be quite easy to be distracted by the obvious, and there's no denying that there's quite a deep ulcer here. However, I find a systematic approach to the eye exam is really useful to help you look for other clues or contributing factors that might otherwise be missed.
So I personally start by looking from the outside in. So firstly, taking a closer look at this picture, is there some mucoid discharge here? It's quite clear that this patient has had fluoresce applied, but it does seem to be collecting or sort of stuck in the fur, so this might be significant.
I can't see that the patient has a medial entropion like other brachycephalics, but this hair might be an issue at this medial campus. There's also simply way too much sclera on show here due to a really wide round eyelid opening, something we call a macro palpebral fissure. And this is an issue because it can cause a leg ophthalmus or an inability to fully blink, leaving that central cornea at risk of exposure and drying out.
The conjunctiva overlying that sclera is also erythematous and inflamed. And then we also have this blue haze to the cornea, and this is indicative of corneal edoema as the stroma takes on water, it has this blue colour to it. But the other issue contributing to corneal opacity is likely an inflammatory cell infiltrate, meaning it's pretty much impossible to evaluate structures behind the cornea.
I can't see the pupil in this case. There's also vascularization here and that demonstrates that this is a chronic issue. And then of course there is a large central stromal ulcer.
So we've now got significant stromal involvement. This superficial ulcer has progressed. And I think this is where it's useful to just take a step back because this case didn't start like this.
This patient initially presented with what sounded like a relatively straightforward, simple ulcer. So how do we decide when that simple ulcer is no longer simple and what should we do differently when that happens? So I've put together this hopefully simple framework for approaching corneal ulcers in practise.
The definition of a simple ulcer is just an epithelial ulcer that heals with appropriate management and within an appropriate time frame, so usually 5 to 7 days. And if it has healed, then great, but it's important that we continue to monitor these patients for recurrence. And my general rule of thumb is that if a patient has more than one eye issue in a year, then that is a red flag to me and warrants deeper investigation of that underlying cause.
If it hasn't healed by 5 to 7 days, or it's progressed beyond that epithelial layer, then this is a a a complicated ulcer, it's now considered complicated. And the first thing we should do is check for an underlying cause. Does the dog have dry eye?
Is there a foreign body we missed? Is there an eyelid or eyelash abnormality, for instance? And also check that the owner is actually applying the medication as you prescribed.
Then we need to assess, well, what's actually happening with the ulcer itself. Is it apparently stuck, as in it doesn't seem to be getting better, but it's not really getting much worse either. And if you ruled out the other causes, then the biggest reason for this in dogs is because it's a scared or an indolent ulcer and requires debriding.
And by the way, that's the only type of ulcer that should ever be debrided. Please don't debride anything that's deep or stramal. Or is the ulcer actually getting worse?
Is it getting deeper or wider? And this is exactly what's happening in our case. And if it is getting worse, well, how bad has it become?
Does it require immediate surgery or referral? But either way, our management will have to change and it probably warrants some intensive medical management. And when it comes to the management of these stramal or deep ulcers, we need to think of these four areas.
Bacterial infection, especially pseudomonas or beta hemolytic streps, are commonly implicated in ulcer progression, and we'll look at antibiotic options on the next slide for that. We also need to stop that ulcer from getting bigger or deeper and arrest that stream or destruction. And this is primarily caused by proteinase and collagease enzymes.
And so we need an anti-collagease for this. And again, we'll look at the options over the coming slides. Ulcers are also acutely painful.
I don't know if anyone's had one who's watching today, but they are really, really sore. So we do need some robust analgesia as appropriate for the patient. And this may also include a cycloplegic or midriatic, as there's often a reflex uveitis present.
And finally with deep ulcers, we also need to limit self trauma and the potential for perforation. A buster collar is useful, of course, for this, but it might also be worth considering antsiolytics or even mild sedatives to facilitate handling and drop administration. And these patients usually need admitting for intensive treatment as drops will need to be applied applied very frequently, at least initially, and also so that you can observe them for any deterioration.
Unless of course you have a committed owner with the time to do so at home and who's willing to come back really daily for checks in these cases. So over the next couple of slides, I want to take a closer look at antibiotic options and our anti-collagegenase options as well. Now I could probably do you a whole separate webinar just on what antibiotic you should use, but instead I'm going to guide you to a reputable source of information.
That's the BSAVA Protect Me scheme. You don't need to be a BSAVA member to access it. It is available, open access from their library, and I've just put the QR code there for you.
But it's really great because it provides general stewardship advice but also separate chapters on different body systems and there's a whole section dedicated to eye infections, so I've just lifted some text from there. With regard to ulcers, for a simple ulcer, they recommend using chloraphenacol, even though it's not currently veterinary licenced in the UK and by the way, this could be your justification for utilising that option on the Cascade. Unfortunately, Fede is is too narrow spectrum for ulcers and not recommended.
It's OK as an option for conjunctivitis where it's licenced and recommended, but not really for ulcers. And then for strainal ulcers or these complicated ulcers, ideally antibiotic choice is based on internal cytology or culture and sensitivity. And but remember these often progress from simple ulcers.
And like gizmo, they might already be receiving topical antibiotics already. So they recommend chloriphenacol for cocci and fluoroquinolones for rods. And if you're unsure how to do corneal cytology, we have put together a practical ophthalmology guide.
It also has step by step instructions on how to videos, including cytology, but other various ophthalmic techniques, and I'll give you the link to that at the end. Next, let's look at these protease enzymes and our collagegenase options. So these protease and collagenase enzymes involved with strainal destruction are called matrix metaloproteinases.
I'm gonna call them MMPs from now on. Now they are meant to be there, normally. They can be found within the healthy tear film where they play a role in corneal homeostasis and turnover.
However, they should be in fine balance with their own inhibitors, the anticollagenases. However, during ulcer situations, the activity of these enzymes is up regulated, and this is any ulcer, so simple ulcers as well. And this makes sense because they're also there to clear debris and make way for healing.
However, we also have MMPs being released from inflammatory cells and exogenous MMPs released by bacteria. So it's not surprising that you can quickly get overwhelmed with these inhibitors, and it's that that results in these ulcers getting bigger or deeper. So in order to stop that MMP activity, restore that balance, and allow these ulcers to heal, we need to supply the eye with their inhibitors.
We need to supply the eye with topical anti-collagegenases. The only currently licenced anticollagenase is Strome, which is licenced for the supportive treatment of coinal ulcers in dogs and cats. It contains the active ingredient Nnacetylcysteine or NAC at 2.5%, which is a potent anticollagenase because it inhibits these MMP enzymes.
It also has additional antioxidant and mucolytic properties and importantly, does not bind to topical antibiotics or interfere with their action. And this is a topic I will come on to in a few slides' time. One of the main benefits of Streamy's is that it's ready made, it's off the shelf.
It's got a reliable and consistent composition, meaning it's basically just super convenient for everybody. You guys prescribing it, owners, and of course the patient themselves has a long unopened shelf life, which means you can keep a bottle or two on the shelf without it going out of date. And that's useful because often when you need an anti-colagenase, you need it now and not necessarily to wait to order in because let's face it, they always present on a Friday night.
And one of the most common questions I get is how does stromies compare to serum? That is generally autologous serum where we bleed a patient, spin down the blood and apply that serum as as eye drops. Now before stramies was available, this was probably most people's go to anticollagenase, so I'm gonna spend the next few slides highlighting some important clinical and practical differences.
Firstly, Streamy's is of course the licenced option, meaning it comes with safety and efficacy data and the backup that it brings you guys as clinicians. Serum would actually be considered an extemporaneous preparation, which is the last step of the prescribing cascade in the UK. And most of what we know about serum is mainly anecdotal, and there's quite a lot of contradictory information published.
We've touched on the practicalities of having an off the shelf anti-collagegena, and I can tell you I definitely never enjoyed bleeding the pug with a deep ulcer, and neither did my nurses. And you also have the sterility risk and the debate on how long to keep it for. But one of the biggest, I want to say myths that I hear about is regarding the role of growth factors within serum, which are thought to aid healing or speed up healing.
Now, trust me, I've done a lot of diving into the literature to find the evidence for this, and that has proved quite challenging. So let me show you. So firstly, what are growth factors?
Well, they're proteins or molecules found within blood and tears. And they help promote and regulate just normal cell turnover and healing. And there are lots of them.
These are just a list of growth factors that are involved in corneal health and turnover, so it is a bit of a minefield. So why do we think that they're important? Well, if we apply blood products like serum to the eye, well, yes, that serum is an anti-collagegenase, but it's more than that, isn't it?
We're also supplying growth factors, and it must speed up healing, right? Not necessarily. Now, as I said, I have tooled the literature on this, and you can trace every reference of growth factors aiding healing back to Fox and his team in the 1980s.
They hypothesise that the beneficial effects of autologous serum probably result from their lubricating ability. That's fine. But that serum proteins may play a significant role, providing nutrients necessary for healing.
And as I say, you can trace everything back to this. Now, more recently than the 80s, another group have studied this. Does the application of serum actually speed up healing of an ulcer?
Does it actually aid re-epithelialization? And their findings suggests that no, it doesn't. So these two studies looked at client owned dogs with scads.
Half had serum or PRP in the bottom study, and half either had saline or artificial tears. And in both studies, there was no difference in time to ulcer healing and nor degree of scarring. Now, don't get me wrong, I'm not saying that serum isn't an anti-collagegenase, but more that it doesn't seem to possess these sort of magical healing properties that so many of us believed it had.
I mentioned, a couple of slides ago that stromies doesn't bind to antibiotics, and one additional and I think very important and clinically relevant point is that recent evidence shows that albumin found in blood products can actually bind to topically applied antibiotics. Now this is very similar to the protein binding capacity of albumin systemically, where we need it really, so that drugs and other products can be transported around the body and get where they're needed. But in the eye, this binding actually just takes the topical antibiotic away from where they're truly needed.
And evidence shows that this potentially reduces how effective the topical antibiotics are and can lead to up to 10 times increases in MIC. So in the worst case scenario, this may lead to treatment failure if your antibiotics are no longer effective and potentially promote antibiotic resistance. So we do have to be really careful about using stramies along er sorry, using serum alongside antibiotics.
So why risk this, I guess is my question. Stramies does not contain albumen. It physically can't bind to antibiotics.
And the author of the paper, er, Lionel Sabag, a well respected ophthalmologist, many of you probably know him, states that in practise clinicians might consider protein free alternatives to blood products, including topical NAC. So I really just wanted to highlight these points as, you know, I too thought of serum as quite an innocuous substance. And I think it's important that we understand that it does have its clinical limitations and its challenges.
So anyway, I digressed there for a moment back to Stromy and now we know what it is. Let's look at how and when we use it. So it's really super simple.
The licenced dose is 2 drops, 3 to 4 times a day until the ulcer's healed and ideally 10 minutes apart from your other drops. In terms of when to use it, well, given its mode of action, it's best used when we have that stromal involvement, so stromal deep or melting ulcers. But I did just say that MMPs are up regulated in any ulcer and that strainal ulcers often progress from simple ulcers.
So how do we know which ones are going to heal and which ones won't? Well, unfortunately I don't have a crystal ball or a magic 8 ball, but I do have a list of risk factors. And this is probably the most important slide in this presentation, understanding the risk factors that make ulcer progression more likely.
The biggest one, as you probably see in practise, is just being a brachycephalic. So up to 65% of melting ulcers are found in brackies. So really, no ulcer in a brachycephalic should ever really be classified as simple.
They really do want treating or managing much more intensively from day one than their non-bracky counterparts. And I'd definitely be treating a Frenchie different to a Labrador, even with a simple ulcer. But other risk factors include dry eye, through that lack of nutrition and healing capacity.
Scares are at risk, especially post debridement. If they have any other ocular surface disease, a recent GA, topical steroids increase the action of MMPs, which is why they're contraindicated for ulcers. And also systemic illnesses, so that includes things like cushing's or hypothyroidism, diabetes, but also skin allergies and atopy.
So really if you have a patient with any of these risk factors to help you avoid a meltdown, it's advised to treat them more intensively, even from day one, and you can use stramies from day one in these patients. So let's go back to Gizmo. Hopefully you can see now that he has a lot of red flags.
For a starter, he is a brachycephalic. I would definitely say that he has some underlying ocular surface disease going on here. Thinking of those other clues and signs that we saw earlier.
I'm also aware that he's had previous eye issues. This is also a red flag, and he has a history of skin issues. Maybe he's also received steroids for these recently as well.
So it's really, it's no wonder that Gizmo's come back today with his eye looking like this. So what are we gonna do for Gizmo? So he was hospitalised for 24 hours for observation and treatment.
He received both liphenacol and ofloxacin based on a mixed cytology. He received stromies as his anticollagenase, as well as various analgesics. And also don't forget the other eye.
How many times have we treated one eye only for them to get an ulcer the next week in the other? So how can we so we can use, sorry, a tear supplement, for example, re me initially in this unaffected eye, and then once we start reducing the application of the other drops, you can then start to apply it to both eyes. And of course we do need to keep a regular eye on him, as the pun was not intended there at regular rechecks once he is discharged.
A common pitfall I think is then thinking great, it's healed, case done. But don't forget a long-term plan. Remember his history and looking closely at that photo, he definitely had some other clues that warrant that further investigation.
I am suspicious of dry eye. He is a Shih Tzu after all. So once his deep ulcer has resolved, we can do a Shermer tear test or do one on the unaffected eye, as it's often bilateral.
It would also be worth sending him for assessment of his brachycephalic ocular syndrome, just like we would his airways. We may well benefit from surgical correction, for example, a medial cancerplasty, for instance, to reduce the eyelid opening and improve his eye health for the future. So don't forget those long-term plans as well.
So just some take home points from case one, a reminder that simple ulcers are just an epithelial ulcer that heals within 5 to 7 days, and anything else is complicated and would warrant a change in management. Importantly, to identify patients that are at risk or have at risk ulcers and to treat those intensively from day one to prevent them worsening. Stromies being your licenced off the shelf anticollagenase, and as we said, don't forget that long term plan, especially for brachycephalics.
Just like we would their airways, there are a lot of things we can do for their ocular syndrome as well. OK, moving on to case 2. There's quite a bit to get through, so bear with me.
Hopefully I can see people putting questions in the the channel, so please do, we can have a look at those at the end. So this is Oreo. He's a 5 year mal neutered European Shorthair, and he's come in to see you with a 5 day history of worsening blepharrospasm, epiphora, and occasional pouring at the left eye.
His owner also reports that he has been quite quieter than normal and he seems to be hiding away. He's recently come back from a stay in the Qatari whilst the owners were on holiday, and he has had previous episodes of conjunctivitis that have cleared up with topical treatment, and he's otherwise up to date with vaccines and appropriate parasiticides. And when you look at his eye, this is what we see.
So just like we did for the previous case, looking or working systematically, looking from the outside in, it's subtle, but I hope you can appreciate that the eyelid margins here seemed thickened and swollen compared to usual. There's also a mild chemosis, and erythema that's most apparent at this medial canthus. There's neovascularization again of the cornea, indicating a chronic keratiis here.
And the fluorescin stain here is stained in this kind of multiple superficial branching pattern, which is really giving us the biggest clue as to what's going on. And finally, this pupil, that is the pupil in the middle, is very severely constricted, indicating a reflex uveitis. So hopefully with the clues from the history and this picture, we can see what's going on.
And these superficial branching or dendritic ulcers are pathonomonic for feline herpes virus. They don't happen with anything else. And we're probably all aware that along with other pathogens like Calici virus, for instance, this is a common cause of cat flu, a highly contagious cause of upper respiratory infections.
But along with its respiratory and systemic signs, herpes virus can have many ocular manifestations as well, including ulcers, but also associated with the development of feline sequester, for instance, chronic non-ulcerative keratitis, and various developmental issues if contracted as a kitten. And it can also be a cause of dry eye in cats, particularly if it's kind of prolonged issues or multiple issues. Obtaining an accurate diagnosis of herpes virus can be difficult, as often multiple pathogens can coexist.
So we mentioned Calici virus, but also mycoplasma or chlamydophilophuss can also be involved as well. And sometimes ulcers can become secondarily infected with opportunistic infections too. Now viral PCR can be used, but unfortunately false positives and negatives can make interpretation challenging.
So more often than not, we're relying on these clinical signs, so looking out for these dendritic patterns, and of course a compatible history. The stay in the cattery might make us suspicious that this was some sort of infectious cause, but it's more likely that this patient was a latent carrier of the virus that has reactivated in response to the stress of being at the cattery. So I just wanted to remind us of the transmission of feline herpes virus.
So as with all viruses, transmission initially occurs when a healthy individual contracts primary disease, during which of course there's active virus shedding, a bit like us having a cold or a flu. We would then assume that the patient would build immunity to the virus, however, in around 80% of individuals, the patient's clinical signs resolve, but FHV1 establishes latency, usually within the trigeminal nerve ganglia. And around 45% of these experience reactivation or recrudescence of the virus with associated clinical signs, either spontaneously or around the time of a stressful event.
And this percentage actually increases to around 70% with glucocorticoid use. So we do have to be careful in these cats. Such individuals are then of course a source of infection for others.
And unfortunately, natural immunity to FHV1 really relies on a cellular immune response rather than humoral and is unfortunately quite short lived. We can of course vaccinate against FHV1, but this kind of merely serves to reduce the clinical signs and hopefully reduce viral shedding and doesn't really completely protect against the disease. And of course, vaccines need to be boosted at fairly regular intervals, which unfortunately in many cats, they are not.
And therefore it's not hard to see why the er prevalence of feline herpes virus is said to be around 97% of the cat population. Looking at the management of feline herpes virus, generally this is symptomatic and supportive, and most cases are eventually self-limiting. Generally, the management can be considered in two categories.
So I've put the ocular therapies and the systemic therapies here, depending on the signs and the need of the patient. For the ocular signs, an appropriate topical antibiotic, again, chlorinephenacol being recommended here due to its activity against mycoplasma and chlamydia species as well as the opportunistic infections. We do encourage the use of stramies in these patients as feline herpes virus is a risk factor for ratomalacia in cats.
And because FHV can affect tear quality, the use of a supplement or tear supplement like Remend is recommended. Of course, anti-inflammatories and pain relief go without saying. Particularly if the patient has respiratory signs, we might also need to include systemic antibiotics to cover secondary infection as well.
An antiviral therapy should really be the mainstay of therapy for active infection, but is often unfortunately overlooked in these cases, and we'll come onto the main options in a minute. And finally, what can't be underestimated is the additional supportive management and certainly just general TLC that goes a long way with these cats. Cleaning up any ocular and nasal secretions, supporting their appetite.
But the problem is we know that stress can in fact worsen the disease and lead to increased viral loads. So actually we might need to balance the management needs with the stress that it causes to the patient. So of course management will be very individual, done on a case by case basis.
And over the next couple of slides, I'm gonna take a look at remand and then we'll look at the antiviral options in a bit more detail. I realise that Remend is probably a name that most of you are familiar with, but I just wanted to spend a moment talking about what it is exactly and how it helps in ulcer cases. So remine contains a cross-linked hyaluronic acid, and hyaluronic acid's a really useful product for ulcers because not only is it a tier supplement in that it's hydrating and lubricating, but it can also act as a physical ligand facilitating cell proliferation and migration.
So it can physically aid with the healing of the epithelium. It's also what we call viscoelastic and mucinomimetic, which basically means that unlike other lubricants, hyaluronic acid is not readily blinked away. And why do we cross link it?
So hyaluronic acids are usually long chain linear molecules, but by cross-linking them, we actually increase the corneal residency time, so we get these beneficial effects for longer. It creates a sort of matrix across the eye, which can act a bit like a a blanket or a bandage over that ulcer. And remand is shown to last on the corneal surface up to 180 minutes versus around or up to 35 minutes for your traditional linear hyaluronic acids.
And what that means for us and for our owners is that they don't have to apply it quite so frequently. Studies demonstrate beneficial effects with just one drop twice a day, which can of course really aid owner compliance. Now Remand has recently had a slight name change and refresh packaging, so I've put the new look here for you, but the formulation remains exactly the same.
The 0.75 in the name refers to the high concentration of cross zinc hyaluronic acid. So for comparison, most other over the counter HAs are around 0.15%.
It's preservative free, and it is the smaller of the two re mends. It is the 3 mL bottle that is designed for acute use to help accelerate that natural healing process. We do have another re mend, Rem.4, and we'll look at that in the next case.
And just a reminder that Remend is not an antibiotic. So we definitely need to apply it alongside an appropriate antibiotic. One of the most common questions I get with re mend is what is the difference between re mend and stromies?
And I'm hoping that this is obvious now we've been through how they both work, but just to kind of summarise or reiterate that, it's really all about the layer of the cornea that you're wishing to target. So this is just a cross section of a cornea. Now remand is all about protecting and facilitating epithelial cell healing, really creating that favourable environment to support epithelial healing.
Whereas stromies, as the name suggests, is all about the corneal stroma, so preventing or arresting that stromal collagen breakdown. So in some situations you might need one or the other or sometimes both. And when it comes to antiviral options, there are topical products available, for example, gancyclovir or cytophobia.
And then there are systemic options, for example, famcyclovir. But it's important to state that none of these are currently veterinary licenced, so they would be prescribed on the prescribing cascade. These all work by inhibiting viral replication, and so they're effective only during active disease, they're not going to get rid of latent infection.
And the main considerations over which one you should choose are really whether the patient requires targeted ocular therapy, for example, in this case for an active ulcer, or whether they need systemic viral medic antiviral medication, for example, if they have respiratory signs. And of course what is gonna be the most er easiest compliance wise and the least stress for the patient. In severe multi-system cases, then they could also be combined as well.
And before we go back to Oreo, I just wanted to quickly mention non-healing ulcers in cats. Annoyingly, ulcers associated with herpes virus can be quite persistent in nature. They can hang around for weeks, and whilst they remain epithelial, if they're not healing within that 5 to 7 days, they are classified as complicated.
And I generally assume herpes virus in these unless proved otherwise, but it is really important to look for other missed causes. For example, entropion is a really common cause of non-healing ulcers in cats, so do look closely for this. Or for example, foreign bodies, like in this picture.
This is actually a piece of plant material, bark, that was stuck in the upper conjunctiva for about 2 months. And you can see the chronic changes that that's caused on the cornea. I also put incomplete blink here just to remind you to double check that the patient can blink and blink fully.
For example, in brachycephalic patients like we saw in case one or patients with Horner syndrome for instance. But it's really important to say that even though cats can get non-healing ulcers, and sometimes they can have loose epithelial edges, they don't get scuds. Scuds are a dog problem with a very unique pathophysiology, and that means that cats don't require debridement in the same way as dogs.
It can be possible to use a cotton bud just very gently to debride the edges of a non-healing ulcer, the aim being to remove all tissue, freshen up that ulcer, and potentially decrease viral load. But it's really important that we don't use things like diamond burrs and definitely don't perform grid or punctate keraotomies in cats. It is contraindicated and potentially leads to an increased risk of sequestrum formation.
So what are we going to do with Oreo? So he received a topical antibiotic and antiviral along with stramies and rem. He received oral NSAIDs and had a a drop, a drop of topical atropine applied in consult with a plan to recheck him after 48 hours.
Don't forget they are a risk factor for melting, so we definitely want to double check that this is progressing in the right, not the wrong direction. And also after 48 hours, whether we need to apply any more midriatic to him. And again, don't forget that long term plan.
He has had eye issues in the past, and that vascularization made me suspicious of chronic changes. So we should think about supporting his eye health long term. We could switch to, for, for example, Remen.4, the dry eye lubricant going forward.
And we want to avoid steroids with him and modify any environmental stressors as much as possible and to reduce future flare-ups. And this can include the use of antiolytics like bonca, for instance, for future vet visits or travel. So Bonca is actually part of our pet anxiety range, but I think a case like Oreos can really highlight how it can help even with our ophthalmology cases.
So if you've not heard of it, Boncat is the licenced feline siolytic for vet visits and travel. And we know that stress is a major barrier to cat owners seeking veterinary care. And if their cat is less anxious, then they're hopefully more likely to seek help and likely earlier too.
Performing an ophthalmic exam in a cat is inherently stressful. Cats don't like direct eye contact, and we do have to come very close. So it might not even be possible in some cats to do this.
So using a pre-vet visit antiolytic can of course aid that physical but also ophthalmic exam. And Boncat contains pregabalin, which is in the class of gabapentinoids, which have been demonstrated to have limited to no effect on the ocular parameters, which of course is beneficial. We also know that stress exacerbates disease, but we are going to want to see them back for rechecks.
So again, Boncat can help here and hopefully if we're seeing them back more regularly, we're going to pick up on any problems quickly. And for the future, the multi-use bottle can be used for future vet visits, so we're more likely to see them for preventative healthcare. It's also licenced for travel, so it can be used for other stressful trips, for instance, to the Qatari.
With the ultimate aim being hopefully improved health and welfare for these cats. So I think it's just a nice kind of showing you where Boncat, even though it's in our anxiety range, can fit into these ophthalmology cases. So just some take home points from case two, remembering that dendritic ulcers are pathonomonic for herpes virus.
That antivirals should be the mainstay of treatment for active infection. Again, they are a risk for ulcer progression, so you can use stramies, think about supporting that tear film, and rechecking them at appropriate intervals. And remember that cats don't get scares.
Non-healing and ulcers, non-healing ulcers in cats really do prompt that closer investigation. OK, moving on to our last case. So this is Lady, she's a six year female neutered cavalier King Charles Spaniel.
Her own has called to request more eye drops for yet another infection, and rightly so, you advise them to come in for a consult instead. The owner reports that she has to clean ladies' eyes twice a day, otherwise they're really mucky. And actually the eyes haven't really improved since we last saw her about 6 weeks ago.
The owner hasn't cleaned the eyes this morning, so we're going to see them in all their glory. And she has a recurrent, a history of recurrent eye issues and occasional corneal ulcers. And when we look at her eyes, they look like this.
So like we did for the others, working our way from the outside in, we have some lovely mucopurulent discharge here. Does she have a bacterial conjunctivitis that is purulent at the end of the day? We also have issues here spreading onto the eyelids.
We've got pigmentation and and alopecia here, signs of chronic blepharitis in this case. The cornea is again vascularized, and we also have pigmentation being laid down, and these are both signs of chronic keratiis. And then we really can't see the pupil at all.
Is this cornea cloudy because of chronic keratiis, previous scarring, or is it just mucopurulent discharge? It's hard to tell, but it's definitely not normal. So I think we probably all agree that we have a strong suspicion of dry eye here.
She is a middle aged female at risk breed, the Cavalier, and we also have compatible clinical signs, we have recurrent issues and signs of chronic inflammation. The question is, does she have an infection? Why does she have a mucopurulent discharge, and why does she usually get better with antibiotic drops?
Well, if you think about the three layered tear film, in dry eye cases and dogs, we most often have a quantitative issue, so we lose this middle aqueous portion, which means the only thing we really have left is mucins and lipids, which they then overproduce to compensate. So of course the tear film is naturally going to look thick and stringy. Yes, we probably do have commensal bacteria overgrowing, but the main reason it probably gets better with antibiotics is simply because we're providing the eye with some liquid, we're actually hydrating it.
And before we delve into the diagnosis and management, I think it can be useful to just go back and understand the term keratoconjunctivitis seeker and what it really means. So, kerato here is referring to keratin or collagen of the cornea. Conjunctiva, of course, is fairly self-explanatory.
Itis being inflammation and sicca being the Latin word for dry. So when we break it down like this, it literally means dry inflammation of the cornea and conjunctiva. And whilst this doesn't offer us any explanation in terms of the cause of the dry eye when it comes to the clinical signs, it's really useful to remember that this is a predominantly inflammatory condition.
They are going to have conjunctivitis with this, but actually, primary bacterial conjunctivitis in dogs is exceedingly rare. So when it comes to dry, I think we're all familiar with the Shermer tear test where we measure the quantity of tears and predominantly this aqueous portion. Normal production is said to be over 15 millimetres per minute.
Anything less than 5 is pretty severe dry eye. And anywhere in the middle, I mean, if you have compatible clinical signs, then you can be pretty confident to make your diagnosis. But you can always repeat it as it is usually progressive.
But sometimes the Schermer tier test can be borderline or even normal, but the patient still keeps coming back and having problems, then what? So there is another test that we can do called the tear film breakup time. This actually measures the stability or the quality of the tears.
So it's predominantly a measure of the mucin and lipid components and a measure of qualitative dry eye. This test actually uses fluoresce and relies on the fact that although the tear film is constantly turning over and it is constantly being replaced, it should be stable for a period of around 20 seconds in dogs. And therefore, if the tear film is unstable, then the tear film breaks up much quicker than that.
So values below 20 seconds can be indicative of dry eye, even in the the presence of a normal Shermer tear test. So I do have a video of this being done, and I hope this plays. Hopefully you can all see this.
So we're gonna apply a drop of fluorescene to the eye, and then we're gonna force blink and then hold the eyes open. And we get this green uniform sheen, and I want you to look in that dorso dorsolateral aspect. That's where we often see it breaking up quickest.
So we can start to see black patches occurring, and it starts to look a bit like the map of the world. Let me just go back and play that again if I can. So again, looking in that dorsolateral area.
This is a stable tear film, so it's usually quicker than this in your dry eye cases. And we start to see this breaking up the tear film breakup time. Just showing that coming down the nasollacrimal duct as well, another test for fluoresce.
So here are our values for lady, and we actually have a problem with both, which is not surprising given the chronic nature of her problem and the associated blepharitis and conjunctivitis. So think about not only the lacrimal gland, but also where the goblet cells and mybomian gland sit and how they can become affected as well. And so from the clinical signs and values here, we can definitely be confident in our diagnosis of dry eye, and luckily she is fluoresce negative at the moment.
When it comes to the management of dry eye, it's generally a four pronged attack, so addressing that underlying cause if possible. And I realise this is hard in a lot of cases, but don't forget there might also be compounding factors at play. Certain medications contributing to disease or even metabolic issues, for instance, hypothyroidism, diabetes, they can affect the quantity and quality of tears.
The mainstay of therapy is a topical immune modulator and we'll look at options on the next slide. And the importance of adjunctive tear replacement alongside that immune modulator cannot be understated, and again we'll come to that too. And then of course addressing any of the other secondary effects.
So let's take a look at immune modulators first. So in terms of in the UK, our licenced and recommended is the 0.2% cyclosporin ointment, which should be applied at least initially twice a day.
And it's important to realise that although we should see effects within around 10 days, maximum effects may not be seen until about six weeks of treatment. So it's really important, but it's also really important we don't just rely on cyclosporins, so again, using that lubricant with a complementary action is really useful. Most dogs will have a good response to cyclosporin, but what about if after 6 to 8 weeks they still haven't had a good response?
Well, then it's time to up the ante with treatment. The options for this include either a higher concentrated cyclosporin or moving to a tacrolimus product, which has a similar action to cyclosporine but is essentially more potent. And again, neither of these are veterinary licenced.
Again, these may need time to work as well, but will pick up the vast majority of non-responders. But if that still doesn't work, then you can either increase the frequency of application even up to 4 times a day, or combine with cyclosporine, or combine the cyclosporine, sorry, and tacrolimus at this point. But honestly, as a GP vet here.
I would be really wanting to consider other causes. Have we missed something? Is this in fact a neurogenic dry eye that might require a completely different medication?
And at this point I would seriously be considering referral or at least speaking to an ophthalmologist if you haven't already, as they will be quite tricky cases to manage. And a word of caution here, topical steroids are really not advised. And yes, they are immune modulators and will probably help to relieve the signs of dry eye, but they're not lachrymo stimulant in the same way as cyclosporine and are very much contraindicated in dogs with ulcers.
We saw they increased the action of MMPs, and dry eye dogs are already at risk, so we don't need to add that in either. Topical non-steroidals can be useful instead to help relieve some of the discomfort and inflammation, and short courses can be used in those first few weeks whilst waiting maximal effect of cyclosporine or during flare-ups, but again I'd probably avoid them in cases of ulcers. And then this brings me to a topic called tear replacements.
So if we think about the consequences of dry eye for a moment, well, regardless of the cause, the consequences are often the same. So the eye is dry, it becomes inflamed and irritated. And this leads to early cell death of the epithelial cells, they dry out and desiccate, which is why they're prone to ulcers.
But also of the mibomian glands and goblet cells, they stop working properly, like we saw in a lady's case. This leads to tear film instability. There's an increased evaporation, so the eye becomes more dry, it becomes more inflamed, and this whole thing is a vicious cycle.
With our cyclosporine, of course, we aim for the eye to be less dry and to help with the inflammation, but an adjunctive tear replacement can help in really all of these places. Now the list of lubricants is ridiculously long, especially if I also include some of the human over the counter products. But as with ulcers, I'm gonna focus on hyaluronic acid because actually for the vast vast majority of your patients, it's a really great all-rounder.
So firstly, of course, it hydrates and it lubricates so the eye is less dry. This in itself is soothing for the eye, but there is some evidence to say that HA can directly reduce inflammatory mediators like inflammatory cytokines. Of course this can prevent the epithelial cells from drying out, but as we mentioned for ulcers, it can facilitate cell migration and proliferation, so it helps those epithelial cells turn over.
We mentioned that HA is a mucinomimetic, which means it mimics the tear film mucins and really anchors the tear film to the eye, which is really stabilising for the tear film. And coming back to those, that word viscoelastic, which means we don't just blink it off, it has that long corneal retention time. So hopefully we get this reduced evaporation as well.
So hopefully you can see how hyaluronic acid can be a really useful, alongside cyclosporine in the management of dry eye. And this brings me to the other rem, so the rem 0.4 dry eye lubricant.
Again, it's had a slight recent name change and packaging update where the 0.4 reflects the 0.4% hyaluronic acid.
And this time it's in the larger 10 mL bottles, this time designed for chronic use. The formulation is preservative free, which is definitely important when we're considering lifelong use of a lubricant. Again, as with the 0.75, the corneal gel, it does contain that same crossing hyaluronic acid.
So we get these beneficial effects of the hyaluronic acid for a long time. And Reman is shown to relieve the signs of dry eye with just twice a day application. And considering most of the lubricants require 34 or more applicants, applications a day, this can really aid compliance.
Again, especially important for a lifelong condition. We just want to make this as easy as possible for our owners. Now don't get me wrong, you can't really over lubricate a dry eye in my opinion.
So if they can apply it more frequently then that's great, but actually if they can't, then at least we are getting prolonged effects from that. And so this brings me to the final topic of addressing secondary effects. Now I'm not gonna spend too long here because I've talked a lot about coinillosis already, so I will just pick out some key points.
As I mentioned, cases of dry eye are often mistaken for bacterial infection. However, antibiotics may not always be required, as most cases will improve on their own with the management of the underlying dry eye and restoration of that tear film. A daily cleaner, however, can be useful to keep the eyes nice and discharge free, soothing and reduce that bacterial load with the use of topical antibiotics on a case by case basis.
And one of the times an antibiotic is definitely indicated is if there is active ulceration present. And remember, dogs with dry eye are a risk factor for ulcer progression due to that impaired tear film. So it's really important that we treat these ulcers promptly and aggressively from day one with the use of an appropriate topical antibiotic and anti-collagease again, to prevent that progression.
And again, the use of an ocular cleanser. And I've just put our product here, Optarime, which is a Trice EDTA based solution. So yes, it cleans, but it also removes biofilms and it facilitates antibacterial action, so it can be really useful in these cases.
So back to Lady, instead of her antibiotic drops, she's going to go home with cyclosporine and Remen.4 alongside regular cleaning. We'll aim to see her back in a couple of weeks, see how they're getting on, but remember we might not see those maximal effects until 6 to 8 weeks later.
The long term plan for lady is obviously, you know, it's pretty obvious, but management of dry eye is of course lifelong. But it's important that we make the owner aware of that and that it's just not one course of treatment and then stop. We might be able to adjust her treatment ongoing depending on how she responds or any flare-ups that she has.
But also don't forget about trying to control contributing or compounding factors. For instance, does the patient always have a flare up in spring or summer months? Do they have underlying atopy or allergies, which are also contributing?
Is the patient actually worse in winter when we put the central heating on, or when they sleep underneath hot duvet covers, for instance? So it's important to really consider the patient as a whole and take a holistic approach to management rather than just relying solely on medication. So just some take home points from case 3, to remember that dry eye is predominantly inflammatory condition and bacterial conjunctivitis in dogs is actually really rare.
Don't forget you can perform a tear film breakup time alongside your Shermer tier test to assess quality as well as quantity. The use of REM.4 as an adjunct to your immune modulators is recommended, and if they do develop ulcers, they are high risk, so do treat them promptly and aggressively and definitely avoiding topical steroids.
And so finally, I'm gonna come back to my original title question and my final take home point. How to avoid a meltdown. Really it's making a conscious effort of completing a full ophthalmic and physical exam.
Try not to be distracted by the obvious and remember to look for other maybe more subtle clues. Identifying those risk factors associated with ulcer progression and really see them as red flags to manage these cases or these patients much more intensively from day one. So I just have to flag you all a regulatory slide.
And just before I close, I'm, I just put in this kind of slide to show you the range of materials that we can support pet owners with, but also veterinary practises with. We have a lot of owner facing resources. I mentioned National Eye Health Awareness Week, but social media kits, waiting room posters, info leaflets, how-to videos, things like how to apply drops and ointments to their pet.
We also have a lot of free CPD available on our website for GP vets, including our new interactive case based CPD and digital lab. So you can practise using the ophthalmic equipment and put what you've learned into another online case. And of course we can offer treatment support, including in-person lunch and learns and various guidelines.
I've shown you the practical ophthalmology guide, but we do have many others available as well. You can find all of these resources at the vet vault area of our website and don't forget to join us for National Eye Health Awareness Week starting on the 21st of September. I'm also more than happy for vets to contact me about cases or whether you're unsure when you should use the product.
Please don't hesitate to give me a call or email us. I'm more than happy for that. And finally, just a massive thank you for joining us today this lunchtime, giving up your time for us and if anyone has any questions, I think we've got a few minutes left.
Thanks Emma, that was really, really good, as someone who is putting drops in his eyes twice a day, even just putting drops in, you know, for glaucoma then. I've just got my Theolos here as, as you say, 0.15%, so, yeah, not as strong as the the the stuff that you're, it, I think just drops going in the eye can be irritating on their own, can't they, so having something to follow up with is really important.
Exactly, exactly, and those hyaluronic acids are really soothing. I mean, I, I know from a dry eye point of view. Putting them in when my eyes feel like sandpaper, can be really, really soothing in itself.
Yeah. Claire said Emma is a very engaging and natural presenter, have really enjoyed this, thank you. Alison, it's a brilliant webinar, really refreshed my knowledge, thank you.
Yolanda, thank you. Thank you very much from Goni, for this good webinar, very useful in practise. We don't hear the tumultuous applause, so I wanted to give you a few positive comments before we.
Thank you everybody. Some questions. So.
Somebody's asked what is scared. Oh, sorry, that is the, new term of spontaneous chronic corneal epithelial defect. That's why I use the term scared.
It's the, the kind of new name I want to say for indolent ulcers, or we used to call them boxer ulcers as well. So they're those ulcers that are epithelial, long standing in nature, and generally have those underrun epithelial edges. So spontaneous chronic corneal epithelial defect, also known as boxer or indolent ulcer.
We also think that that's very much the basement membrane is defective as well, isn't it? So these dogs, you know, exactly brachycephalics are just prone to get exactly. And I, I sort of wish I had time actually to put a scared case in because as you say, there is or there seems to be a problem with the epithelium sticking down onto that basement membrane, that almost seems to be like a, a little fibrous membrane of itself, which is what we remove when we do debridement.
The point I mentioned about cats is that they don't get that same problem. They don't have that same little membrane that needs removing, which is why we don't need to debride them. Always looking for another cause in cats.
Yeah, no, no, really good cats are not small dogs. Exactly, exactly. Suzie is saying I wish I'd known before about TF Butt, so thanks for the awesome summary.
Just, just explain that again cos I must admit I didn't pick that up, so on the video, yeah, what is, that was the normal one wasn't it, where it would be uniform, so what would you see, when it's abnormal, what are you looking for that it disappears quicker? Exactly, exactly, so the tear film breakup time is, Really on the premise that the tear film should be stable. Yes, it's always constantly turning over, but actually you should have a film of tears for around about 20 seconds in docks.
So we can highlight that tear film by using fluoresce, so we apply that drop, and you probably saw that lovely green sheen all across the eye. As the tears start breaking down or breaking up, being replaced by fresh ones, you start to see those black patches start appearing. It starts to almost break up a bit like a map of the world with the islands of green and the black interspersed.
And really you're measuring that time. So that was quite a stable tear film. In an unstable tear film, those black patches are going to appear really quickly.
So within seconds. Hopefully that makes sense. Brilliant, that is fantastic.
Peter has asked, is unilateral conjunctive keratoconjunctivitis seeker always indicative of a neurological case or cause, sorry. . Not necessarily, as much as a dry eye or KCS in dogs is usually bilateral.
Sometimes there is one eye that is like worse than the other, so I wouldn't necessarily say that if you only have symptoms in one eye it's definitely neurogenic. One of the top clues that you can look out for for neurogenic dry eye is a dry nostril or dry nose on the same side. Because it's affecting the, the nerve that goes to both the lacrimal gland and the nose as well.
So that if you're not sure, obviously measure your Shermer tear test, your tear film breakup time in both eyes, but also have a look at the nose as well, because that might give you an indication. And sometimes it was seeing the er dye coming out of the nose that you know that everything was running freely, wasn't it? Exactly, yes.
Georgina is asking, can you use stromies in horses. I have to just say it's off licence. So it's licenced for dogs and cats.
Obviously if you are looking to use an anti-colagenase in horses, it's not specifically contraindicated, but I would definitely have to say it's off licence. So you'd be using it on your prescribing cascade. Exactly.
Tan is asking a question, which I, I've not heard about this before, but maybe you will know. What is your view on administering doxycycline as an anti-collagegenase agent in a corneal ulcer situation, as well as severity of corneal ulcer? Well, yeah, so that was a question.
Have you heard of that? That's, yes, that is a really interesting question. I'm assuming that they are talking about oral doxycycline.
So, contentious is probably the answer to that. The premise behind this is that doxycycline can be and is an anticolagease. It does actually work in quite a similar way to an acetylcysteine.
I do have a couple of issues with it. Firstly, that if we're using an oral antibiotic as an anti-collagegenase, I don't think that's necessarily appropriate, unfortunately, from an antimicrobial stewardship point of view. So definitely take that into account.
And there is some evidence that tear film concentrations after oral administrations are simply too low to have a potent anti-collagegenase effect. So I tend to not use them. I know that they are used by some clinicians, particularly if there's active vascularization of the of the corneal ulcer.
Maybe you do get higher concentrations to your ulcer in that situation. But if there's not vascularization, I would be avoiding it and using something topically instead. Yeah, I mean the tetracycline and doxycycline is known as an anti-inflammatory, isn't it, that's maybe where some of its action comes.
Yeah, potentially. I, I agree with you, we did a webinar in November for rumour, the responsible use of medicines Alliance, and very much we have a responsibility as small animal vets because I think the large animal vets are ahead of us, at reducing our antibiotic use as much as possible, so, yeah, I know, and, and you know I obviously heard, Not to use antibiotics as much with dry eye because the it's a lubricant problem, isn't it? Exactly, and on that point I think it might be wise to just say, corneal ulcers are probably one of the only places left we can use prophylactic antibiotics, in veterinary medicine, and I sometimes get the question of, you know, do we need antibiotics, even in simple ulcers, for instance.
There was actually an RCVS knowledge, kind of hub on this that looked into the, evidence for this. And at the moment, there's not enough evidence to support not using them. So actually topical antibiotics, even in a simple ulcer are still recommended, really because of the risk if you don't, and it gets secondary infected, you know, we could risk vision and the eye.
Exactly, exactly. Yeah, but obviously as you said for the KCS that's very much more just to lubricate. Exactly, if we can get on top of the underlying dry eye, the tear film itself has antibacterial properties, so if we can improve that, do regular hygiene, actually a lot of these cases, they probably don't need antibiotics, but.
No, great point, Emma. Danielle has asked the question, what is the difference between, and by the way, we're now 6 minutes over, so the good thing about webinars is, and I'll see if they have, you, you've had a, we've had a few slink, well they've not slunk off, they've probably got to go back to surgery or whatever. That's fine.
I will let them go back to consult. Got a lot of people wanting to listen, so I'll carry on for another few minutes before we worries, as long as you're, as long as you don't have to rush off anywhere. No, that's fine by me.
Daniella said, what is the difference between a midriatic and a cycloplegic drug? I honestly, I use the term interchangeably. They're essentially there to, open the pupil.
So that constricted pupil that we have, I think it's down to the exact mode of action that it does that. But I tend to use the term interchangeably. Brilliant, OK.
And Somebody's asked how to differentiate eye lesions between pox virus and Calici virus without PCR. Oh. Good good question.
I don't, I don't think you can. I, yeah, I don't think you can. As we said on the slides for herpes virus, they are often mixed infections, and we know that 97% of the cat population carries herpes virus, so you might get a, a positive result, but that might not be the cause of the problem.
There is some studies online that look at the frequency of other signs. I think it was, I think if the cat predominantly shows like sneezing signs, for instance, that's more likely to be herpes virus versus a nasal discharge. I think it was more likely to be Calici virus.
So it might be worth having a look at those, but I don't think there's a definitive. But at the end of the day, all of these viruses are gonna be. Symptomatic supportive treatment, so I, I'm not sure it necessarily matters.
Yeah, no, it's a good point, . Melissa is saying for dendritic ulcers in feline herpes virus staying with the theme, if antiviral is is not available, does treating with the other treatments without the antiviral usually help to heal the ulcer? It does, it does, and I think.
Yes. Yes, the antivirals should always be the mainstay of treatment, but I do think that they are unfortunately underutilised in veterinary practise, and that's probably because like with most viral infections, they do eventually become self limiting. So really the use of the antiviral is to try and get that resolution quicker to help with those clinical signs, but if.
They can't for some reason or you don't have access to an antiviral, then of course doing the other symptomatic treatment, like your antibiotic, like your stramies, Remen for instance, they are going to to help with that ulcer, they're just not necessarily getting to that root cause. Hm. Yeah, brilliant, .
Christopher is asking a very practical question, which is better to use a drop of saline applied to a fluoret paper versus the premade liquid, e.g., minims for a TFBUT test?
I mean, I'm slightly biassed because one of our products in our range is fluid drop. I didn't get to mention it today just because of time, but that is a veterinary drop, so a minim for you. I just, I think it depends on Your personal preference at the end of the day.
I think they made a very good point though, and that the florettes, if you are using those, those are the paper strips. Please don't just put them under the tap and then onto the eye. We definitely want to be using sterile saline or water for injection for those.
And then ideally dropping from the top. So I personally found them very fiddly. And so I preferred a minim, you can just put a quick, quick drop on.
As somebody has said, hasn't said where they're coming from, but do you have distributors outside the, the UK? So I, I, I was gonna say at the beginning, I mean, obviously Dome Farmer is, is very much an international firm, doing great work with us, not only on education but also on sustainability, which I think is really important as well. So, if you are, if you have a question, I, I would suggest anybody around distributors outside the UK.
Just email Emma and pop me an email with that. Yeah, exactly. I apologise.
I spoke mostly of the UK today, but we certainly do. So our our parent company is a French based company. So we have, you know, distributors throughout Europe, into the US now.
So absolutely, . Send us an email and I can always put you in contact with the most appropriate person. Yeah, I think I was at AVMA recently and I think I saw a, a doe's farmer stand probably yeah, brilliant, .
I mean, I think a final question cos so that we can let you go off and have some lunch, Amin is saying how to manage slightly off what we've been talking about, but how to manage allergic conjunctivitis, if not using steroids. Yes, so. Really common.
So I, I've mentioned that primary bacterial conjunctivitis in dogs is really rare. So always look for another cause. Prime cause in this is dry eye, but also things like, allergic conjunctivitis.
Particularly if they've got other kind of skin issues is is quite high on my list of differentials as well. Oftentimes, simply lubricating these, can be enough, systemic, anti anti-allergy type medications can also help reduce a flare up. So if they've got skin allergies.
As well. If you want to avoid steroids, there are antihistamine based eye drops that you can get. Now, they are only human products.
So I would have to kind of send you out to have a have a look at the options there. But I know they are available. And again, that's cascade, isn't it?
Exactly. Just as before we finish, if people want to put up where they are listening from, I think it's always nice to see what parts of the world that we're beaming to, so do stick that in the chat box. But before we do finish properly, you know, really would like to thank you Emma, as, as people said, a marvellous presentation, I've really enjoyed it.
A lot of people on a bit longer for the question as well. But also obviously thanking Dome's Farmer for making this possible. It's a free piece of CPD.
Our mission was to make veterinary education more accessible and more affordable to vets across the world, and I don't think there's anything, that's more affordable than free. So thank you for making this possible, Emma. I know those farmer appreciate it.
Absolutely, and thank you everyone for coming as well. I'm really pleased we're seeing lots of people listening in from America at the beginning of the day, so Switzerland, Alberta and Canada, Albania, Nebraska, Mexico, Kentucky, late late in the day for the Aussies, so thank you for coming on. I thank you, getting up early, staying late.
Yeah, Germany. So people listening in Morocco, so people listening from all over, so really pleased that, hopefully everybody's enjoyed it as much as, I have and, and a lot of other people, and Emma, thank you so much for presenting in such a clear way about conditions that can get us a bit confused. It's lovely that you've got now so many products that really will fit in nicely.
Yeah, yeah, and it's the finesse there sometimes, I remember. When I, when I was teaching dermatology, it was about shampoos, you know, the different types, if you use the wrong one in the wrong place, people then say oh these drops are no good, but no you're using the wrong ones, and I think you've really, clearly shown us what we should be using when, I really appreciate it, yeah. I think that's it, it's seeing the cupboard full of ophthalmic drops and going, oh my goodness, what do they do?
What do we use? Absolutely. I think I'll just go for the one that I've always used, it's a very easy.
Exactly. There is so much more finesse now and thank you domes for giving us such a fine er collection to attack some of these really difficult conditions. Yeah, absolutely.
Thank you Emma, thanks everyone for listening, you know, I appreciate your time as well, late in in the night, early in the morning or just as sitting while you're having lunch, and I hope you have a great rest of the day wherever you are, take care and bye bye. Thank you.
