OK, so my name is Will. I'm a product manager from TVM UK. I spoke to you previously in the previous talk in this series, and today I'm just gonna detail the the rest of the products within our range to you.

So first off, we have chloroli, which is a novel molecule to the UK battery market. It's what's called a heparin sulphate analogue, so that's the active ingredient in it. And if you were to do a bit of reading around about these molecules, then you would often find them, called colloquially regenerating agents or RGTA, and sometimes you would see the action of using them called matrix therapa.

So there's lots of kind of various names for this, so don't get caught out if you do some further research, just be aware of that. Oh, a lot of vets haven't heard of heparin sulphate, so what is it? So basically, heparin sulphate is a gag molecule, that attaches around protein cores within the corneal stroma, and it has two functions within the stroma in the extracellular matrix.

So one, it provides architectural integrity in the 3D space. So it aligns things like collagen, tells cells where they need to be. Also has a protective role as well.

So, heparin sulphate will bind, things like growth factors and cytokines, so these cellular signal molecules that will control where cells travel to, and control things like inflammation as well. When we get a stromal damage, we get influx of enzymes, and then this natural heparin sulphate gets destroyed. So therefore we get disruption in the homeostasis of the environment and therefore corneal regeneration can be delayed or inhibited.

Hyperin sulphate analogues, are analogues, therefore, they're kind of slightly chemically altered, which means they act in the same way, but they are resistant to this enmatic degradation, sovi in amongst this chaos. By replacing them, we can, . Mimic the function of natural heparin sulphate and therefore we get improvement in clinical signs where we have, corneal damage, faster re-epithelialization.

The tissue is of higher quality, so, it helps prevent scar tissue formation. And as you know, in, in a cornea, which needs to remain clear, we don't want scarring, because that can impede vision. And when they've been using the human medical side, the humans reported that, these products had analgesic properties as well, and so helped to reduce kind of pain relief needs.

Because they're based on a natural molecule, they do have excellent ocular safety and tolerance. So if they're used and they weren't needed, they would just get excreted out of the body, because they're localised to the site of injury specifically. There have been studies done on this molecule.

This was a rabbit study done where, they compared two groups where they had corneal ulcers. And as you can see in the, in the group that had heparin sulphur analogues on the left, the cornea, had less scarring, the tissue was of higher quality, there was less swelling, and less inflammation. Whereas in the groups treated with saline, you can see obviously there is a difference there, so certainly it seems to improve clinical outcomes for these patients.

The Claric is a product, so it helps with extracellular matrix restoration and regeneration. The vials are single-use sterile, there's 5 per pack, and the other great thing about Cloroli is that you only have to use one drop on the affected eye every 2-3 days, it's a really low intensity product. It's that you might be using when, when dealing with stromal damage.

It doesn't replace anything, so you use it alongside other treatment options, so it's in addition to what you're already doing. Next product is 12, so this is another hyaluronic acid product and with that same vanishing preservative that I mentioned that Visal has. The difference between 12 is that we have added in vitamin B12, potassium and magnesium.

And this, aids kind of cellular multiplication. So when cells are rapidly dividing, and growing, they want kind of these factors to help with enzymatic processes and survival of DNA and things like that, and they are also antioxidantant as well. Finally, we have fluid drop, which is a fluorocine designed specifically for veterinary use.

The difference being that it has a lower concentration, so most human minims are 1 or 2%, fluid drop is 0 0.5%, and that will help prevent overstaining of the eye and flooding of of the eye with this orange dye. So you're gonna have to flush it less, potentially.

And also flusine does sting as well, so it will help your patients with their comforts. As already. The minims are 10 per pack, and they're non-recapable as well, so it prevents that bad habit of of that's recapping the fluoresin and which can be a good bacterial medium, if, if used again and again.

We have some guidelines on corneal ulcers which are free for download from our website, and we also have a flu fluorescine guide as well. There are other indications for using fluorocin other than staining ulcers, so this just takes you through them. So please go to our website to download those for free.

And these are our contact details, if you had any questions about our products or wanted any supporting literature or information, please email us or give us a call. Good evening everybody. My name is Andy Mee from Veterinary Management Consulting, and tonight we have the 2nd in a series of ophthalmology webinars that are being sponsored by TBM Animal Health.

And again, our speaker is Ron Ori. Ron is, was a member of the charter class of the Coret School of Veterinary Medicine, Hebrew University of Jerusalem, Israel. He's also worked at the University of Florida, where he, underwent clinical training in veterinary ophthalmology and obtained his PhD.

He's since returned to, the Hebrew University of Jerusalem, where he's a professor. He's, spoken widely at various national and international conferences and also published very widely as well. If you have any questions during Ron's talk, please, fill out the Q&A or the chat box at the bottom.

Otherwise, Ron, it's over to you. Thank you very much for this introduction, Andrew. Thank you all for joining us tonight, and I want to thank our sponsors, TDM.

As Andrew mentioned, this is the second of a four-part series of lectures. Today we'll be talking about medical therapy of corneal ulcers, and next week we'll be talking about surgical treatment of Corneal ulcers and both talks are titled Half a millimetre is All You Get cause that's the of the cornea when it's healthy, when you get an ulcer, you have lost part of a 0.5 millimetre, not much of a safety margin there, a point I'll emphasise again and again during my talk.

I've been asked to declare that I've got no financial relationship with any products are mentioned in today's talk, even though, as I mentioned, it is being sponsored by TBM. However, while I have no financial relationship with the product, To disclose, I call it disclosure or Seamus advertising and the fact that many of the pictures I'm showing tonight are from a textbook I've co-authored together with David Maxx, Luy Davis and Paul Miller from University of Madison, Wisconsin. Right.

So this is the only slide I'll be showing of a normal cornea. All the rest will be diseased cornea. And as we all know, the normal cornea is transparent and it is transparent for a number of reasons that can be seen here histologically.

Number one, as you can see and as we all know, it has no blood vessels. Relies on tears for metabolic, metabolic support. We spoke about that last week.

It has no pigment. It has very few cells. The collagen fibres are arranged in very symmetrical and parallel manner, and that allows waves of light to pass between the fibres without being scattered when this Parallel arrangement is disrupted, such as by edoema or scar, then the light is scattered and you'll get an opacity.

And finally, the cornea is being kept in dehydrated state by the innermost layer by the endothelium, and that also contributes to its transparency. During the disease process and during ulceration, this transparency is lost. It is lost due to several paths of physiological responses of the cornea to the ulcers.

I'll discuss some of them very briefly and others I'll talk about in more detail. Very briefly, ulcers are characterised by edoema cause once the epithelial barrier has been breached, then the tears can percolate into the stroma, and therefore, lots of ulcers such as these ones are characterised by a halo of edoema around them. Then during the healing, you may get pigmentation, you may get dystrophy such as you're seeing on the left, or you may get scarring cause the newly generated fibres are not arranged in parallel manner like the original ones.

Some other path of physiological responses I want to talk about in greater detail, first and foremost is vascularization. And while vascularization may be scary to the owners, they don't understand why the eye is turning red all of a sudden. Actually, it's a good sign cause blood vessels allow the ulcers to heal and enable healing.

Here you see. Corneal ulcer, you see the edoema that I mentioned around it. You see the blood vessels coming in, to heal the ulcer, and you can also actually see the reason for the ulcer.

This dog had an entropion, and here are the sutures from the entropion surgery and now hopefully the ulcer would heal. We get two types of blood vessels in the cornea. They differ in their origin and they differ in their presentation and appearance.

Superficial blood vessels are what you see here on the left. They originate in con in conjunct blood vessels. You can Seeing the And every blood vessel here that's invading the cornea originates in the quantum tiva.

These blood vessels are long, individual branching, like branches of a tree or roots of a tree, and as it says here, they characterise superficial ulcers and chronic disease. On the other hand, deep vessels, which is what you are seeing here in red, originate from the inside of the eye. They are ciliary vessels, they are uveal vessels.

They are shorter, they are very dense. You can't even identify the individual vessels here. It's like bristles on toothbrush.

Or something, so these characterise deep ulcers or acute ulcers. So just by looking at the character of the vessels, you can tell where they orig what type of ulcer you're looking at, whether it's acute or chronic, whether it's deep or superficial. Here again, Two more examples and a diagram showing where the vessels are actually located.

So these are the conjunctival vessels characterising the chronic and superficial disease, and here are the deep ciliary vessels that you can see invading this cornea here and as it says, here and as you can see in the picture, sometimes vessels would begin superficially. You can see that these are superficial vessels, but as they get close to the ulcer, they will dive in and they will get the appearance of deep vessels because this is a deep ulcer. Another important path of physiological response is cellular infiltration, and I mentioned it cause you can get two types of cells here, inflammatory cells.

The cells migrate into the cornea, in a chemotactic response from the, they originate in the tears in the limbus or in the uvea. And sometimes, They would be neutrophils in case of an abscess and sometimes you'll be talking about plasma cells and lymphocytes in the case of inflammation. I think the difference here is obvious between the white cellular infiltration that characterises And non-septic inflammation and the yellowish infiltration that characterises an abscess, a septic process.

So again, take a close look to know whether you, the path the pathological process you're dealing with is an abscess is an abscess and septic or whether it's an inflammation. And finally, a very important path of physiological response that people tend to forget, and which I'll come back to again and again is interior UVITs. Every Corneal ulcer triggers interior uveitis.

It triggers reflex uveitis because there is a feedback loop enabled by the trigeminal nerve going back to the ciliary body that cause and whenever the trigeminal nerve. It's irritated in corneal ulcers, you have spasms of the ciliary muscle and you get a secondary uveitis. You can see here an ulcer and the secondary uVitis manifested by hypoion and here another ulcer and the meiosis characteristic of UVitis.

There is always UVI. You must always treat it. Please don't forget it, and we'll come back to it when we talk about treatment.

So now that we know about the anthrophysiological responses of the cornea, let's talk about corneal ulcers themselves. The cornea basically is composed of three layers. There is an epithelial.

Layer is the outermost layer, about 6 or 7 rows thick, basal epithelium here that's constantly renewing itself by mitosis and migrating to the surface and falling off. Most of the cornea is the stromal collagen that I mentioned, the nice parallel fibres, and the innermost layer is the corneal endothelium, the cells I mentioned that are responsible for dehydration, and their basement membrane, desex membrane, which great importance in ulcers as you'd see in a minute. But as you may remember from the title of my talk, all of this is just 0.5 a millimetre thick, not half a centimetre, 0.5 millimetre, 500 microns, so we really don't have much of a safety margin.

And when I say we don't have much of a safety margin that really brings me to the first of two methods by which we classify corneal ulcers. We can classify them by cause and we can classify them by depth, and I will start by talking about depth. Going by depth, you can get superficial epithelial defects that do not involve stroma, then you can have Superficial ulcers involving the superficial stroma, deeper ulcers, deeper, I mean, anything deeper than 1/3, but again I, please remember, I'm talking about 1/3 of 0.5 millimetre.

You may have this maces reaching all the way down to the dema membrane and corneal perforation if that fails, and let's discuss them one by one. So, the most superficial lesion to the cornea is not really an ulcer, which it's an epithelial defect, and I put ulcer in quotation marks here because really the strict definition of an ulcer is when the corn the stroma is exposed. Very superficial defects will involve only the epithelial layer and because there is no stroma exposed, there is, there will be no force in staining.

These ulcers will stain only with rose bengal, which stains down in epithelial cells. Here is a classic case of dendritic ulcers in, and I said ulcers, I should have said different. Dendritic defects in a cat and I should mention that 2 weeks from now we will be talking about feline herpes.

Indeed, these dendritic defects are characteristic of herpes infection in cats. We'll talk about that 2 weeks from now. Epithelial defects are healed by migration of cells.

So here you have the defect. And as I mentioned, we have here basal epithelial cells that multiply, they regenerate magnetosis, they migrate towards the centre and they slowly fill in the defect and promote healing. And this slide here, this diagram explains something I noted last week.

It demonstrates why we don't like treating ulcers with ointment, because if you put a glob of ointment here in the centre of your ulcer or defect, it will just sit there and it will inhibit the healing process. And that's why usually we prefer solutions. And please remember this slide will come back.

So it also later when we talk about healing. Then the next guy, if we go further down following epithelial defects, we have superficial ulcers, this stained by fluorine and here is a fluorine, dye from our sponsor, TDM. Superficial ulcers may be caused by mechanical abrasion such as eyelid or eyelash problems, dry eye, etc.

We'll talk about causes in a minute. Superficial ulcers also tend to heal without blood vessels. You can see the healing process here in this cat.

It involves neutrophils from the tear films, teratocytes that transform fibocytes into new collagen fibres that are laid down. However, as I said earlier, these fibres will not be arranged in a parallel manner and therefore, you will get a scar. Deeper ulcers?

We're going down, are usually infected. They are infected by infectious agents depending on when you, where you are. They may be fungal, they may be bacterial such as Pseudomonas or other bacterial agents and these are the.

Ulcers cause these infectious organisms have proteases, they have collaginases, they have enzymes that degrade the stroma, making them deeper and deeper, and I think you can look at both of these corneas and you can see that indeed. They are infected. Again, we have, oops, sorry, we have the yellowish colour that we don't like seeing the mushy looking cornea because it is being degraded.

These ulcers heal with vascular healing that I mentioned. For this vascular healer blood vessels going from the limbus that will bring cells, they will bring granulation tissue. Maybe pigment that I showed you earlier is part of the healing, but that's a small price to pay if this ulcer would heal.

It's a deeper ulcer and therefore the scar will be denser in these cases. The problem is that as I mentioned, these infectious organisms have their degrading enzymes, the proteases and the colegenases, but you also have degrading enzymes in the tear film. I mentioned that last week.

In the corneal cells. And when you have an ulcer, the activity of these enzymes increases, you have white blood cells coming in fighting the infectious organisms, so they They are dying and they're secreting their enzymes, etc. Etc.

And that's sort of a snowball effect. Enzymes secreted by the tears in response to the ulcer, by the organisms, by the white blood cells that are there as a response to the ulcer, and more and more enzymes digesting. Cornea, which again I remind you is only 500 microns thick, and the result is that we get what is called a melting ulcer.

You literally see the ulcer growing deeper and deeper by the hour or by the day as the stroma is being digested. And if it is digested, while we get down to decimate membrane, the basement membrane of the endothelium, it's called the dematocele. All of the stroma is gone.

The eye is literally hanging by a thread. It is hanging by decimates membrane and one layer of endothelial cells. Because there is no stroma here at the bottom of the ulcer, the centre of a dismantled cell does not stain with fluorescine.

The walls will stain, so the walls of this crater will stain, such as you're seeing here. This will not stain. And that goes back to what I said about healing processes.

Sometimes people will look at this staining pattern and they will say, All right, my cornea is starting to heal. My ulcer is starting to heal because I see decreased staining. Well, it depends on, on where is the decreased staining.

As I said, ulcers would heal by migration of epithelial cells from the periphery. So if you've got healing, you want to see shrinking in the stained area from the periphery towards the centre. That's a sign of healing.

When you have the, the fluorine disappearing from the centre of the ulcer, you are looking intro, you have trouble, you have this mattocele. As I said, there is no stroma here to bind the fluorine, and there is no stroma here to bind, it contains fluid. Therefore, in this metoceles, you'll have edoema in the surrounding cornea here and here, but not in the centre.

The centre will be non-edematous. And here are a few more pictures showing a non-edematous centre of a dematocele and two cases where the walls of the craters staining but not the centre of the dematocele. And obviously this is a very deep ulcer, as I said, we've lost 95%, 99% really of A half a millimetre.

The cornea is really hanging by a monolayer of endothelial cells which can easily rupture. So this is definitely an emergency. And again, you see the non-edematous centre and we put fluorine in it, it will not stain.

So this is an emergency, and if you don't attend to it quickly, you will get corneal perforation, you will get a hole in the cornea and the iris will move forward to plug that hole. So whenever you see an ulcer with a dark centre, you may actually be looking at an iris. So by now, hopefully you can recognise all.

The colours here. We have the red blood vessels. We have the bluish edoema that I mentioned.

We have the cellular infiltration. The blood vessels started out superficial. They're now deep as they near the edge of the crater.

You can see them actually in the walls of the crater, but it was too late, and here we have the iris, . Sometimes, as shown here in this cartoon, it would actually protrude out of the cornea, so it would look like this or more often like that. And that's an intriguing appearance, people take a look at it and say, huh, what's that grey thing, gelatinous thing on the cornea?

Well, that's the iris, the Irish. Becomes easily irritated and is covered in fibrine. So you may not recognise it as an iris cause it doesn't have the characteristic colour, but anything protruding on corneal surface.

In cases of an ulcerated, sick cornea, you are probably looking at an iris and obviously this iris is a bridge between the outer world and the inside of the eye, and it will enable infectious organisms to enter the eye cause endothalmitis such as in this very poor dog. So that's a review of corneal ulcers by depth. However, as I said, you can also classify them by cause.

So let's look at what's causing these ulcers. Well, the causes may be mechanical. I, you already saw this picture earlier of an ulcer caused by entropion.

Again, the sutures used to repair the entropion. So entropion, ectropion. Mechanical irritation by the eyelids, mechanical irritation by eyelashes.

Here you have a case of the stickchia, aberrant eyelashes coming out of my bowing glands that we discussed last week. And yes, you can sometimes see them in poodles or cocker spaniels where they're nice and soft. Probably non-irritating, but in case of dogs, dog breeds like German shepherds or Doberman where they have bristles really, this can definitely cause ulcers and sometimes you will have ulcers caused by an ectopic cilia, which is a single hair.

Walking through the conjunctiva, always of the upper eye for some reason beyond prison that they won't go into. So if you have an ulcer that will not heal and does not respond to treatment, especially in shih-tus, I should mention, slip the upper lid and sometimes you'll find the cause right here. Other foreign bodies, I mean, I mean, can be treated like a foreign body, may hide behind the third eyelid.

Here is a cat claw if you recognise. It's my cat and one cat scratched it and actually tore its claw off cause it Embedded in the cartilage of the third eyelid. So this is a foreign body that would cause an ulcer.

Here's another one in the horse. As I said, don't forget that the 3rd eyelid is a wonderful hiding place for . I, mm, for foreign bodies.

You may have ulcers caused by trauma such as a cat claw, picture on your left, or following prolapse, if the cornea was exposed for a long time, the eyelids couldn't close over it in case of a traumatic prolapse, then you will get a corneal ulcer due to corneal dissiccation. And indeed, dry eye, which we discussed at length last week, is another common cause of all. You can see that this is definitely a dry eye.

You can tell by the dull appearance of the camera flash. So please measure, measure tear production. Sometimes it's scary to measure tear production in cases where the ulcer is very, very deep.

Measure it in the other eye, just to get a baseline indication of what this dog's tear production is like. And as I mentioned earlier, you can get infectious ulcers due to infection of the cornea. You will get a stromal abscess and the infection may be bacterial, fungal, or viral.

And this is a very important sentence that we'll discuss at length two weeks from now when we talk about cats, but Basically, the corneal diseases and corneal ulceration is a classic example of the famous saying that a cat is not a small dog. In cats, you have primary pathogens of the cornea, first and foremost, feline herpes virus, and this is a geographic ulcer caused by feline herpes virus. In dogs, It is usually secondary infection enabled by some of the factors I mentioned earlier, such as eyelid or eyelash irritation, dry eye, etc.

Etc. And that would enable the secondary bacterial infection. So our handling of ulcers in dogs and cats will be completely different.

And finally, we can get ulceration neurogenic ulcers, facial nerve paralysis, so the angle doesn't blink, so it doesn't spread the tears as much, and frequently it is accompanied by reduced tear production because the parasympathetic innervation of the. Gland runs together with the facial nerve, so really the dog is hit with a double whammy, less tears produced and less blinking to spread them or trigeminal paralysis, which you're seeing here, lots of neurotrophic factors in the cornea, and the dog doesn't feel foreign bodies, it doesn't feel the corneal surface drying up, so they don't bleed as much. Right now I have in the hospital 3 such eyes being hospitalised.

So moving on from depth and causes on to treatment, I always quote my friend, my colleague from University of California, Davis, David Man who says any ulcer should heal within 10 days if you diagnose the primary cause and provided appropriate treatment. So we spoke about the diagnosis. Let's talk about the Proper treatment.

And first and foremost, as everyone knows, but they never get tired of mentioning, don't give steroids to ulcerated corneas, and that's because number one, steroids inhibit the healing process, and number 2, they potentiate the proteases and collogenases that I mentioned earlier, . So instead of the ulcer healing, as I showed you earlier, it will deepen and deepen and perforate. At this point, I usually get asked whether it's OK to give systemic corticosteroids in cases of corneal ulcers, and the answer would be, it depends on whether or not the cornea is vascularized.

If it's not vascularized, and you must get. Systemic steroids, you can do so with caution. However, if there are blood vessels in the cornea, they will bring the steroids to the ulcerated region.

Please refrain from using, systemic steroids. So we don't treat with steroids. What do we treat with?

Well, as I said, first and foremost in talk, try to determine. Excuse me. We can get a glass of water here.

Try to determine and treat the primary cause, and we discuss possible causes, measure tear production, look carefully at the eyelid anatomy, is there an entropion, look for apparent eyelashes, flip the eyelids to look for ectopic cilia, flip the third eyelid to look for front, look for the primary cause, and then you can treat, once you found it and treated it, you can treat the infection with topical, systemic or subconjunctable antibiotics. In the dogs, I usually use a mixed wide spectrum against gramme positive and negative. It's my first line of defence, maybe add the floor quinolone as a second line of defence.

As I said, try to avoid ointment because that would killing and people have a tendency to jump in with gentamicin cause they're terrified of Pseudomonas infection, but they forget that gentamicin is cytotoxic and actually may worsen corneal ulcers. Because of the the epithelial toxicity, so don't use gentamicin unless there is indication for that based on cultural insensitivity. So that's for dogs.

In cats, as I said, we have primary pathogens, so you probably need tetracycline for chlamydophila and mycoplasma and antiviral drugs against the herpes virus. However, dealing with the infection is just one aspect of treatment, another very, very important aspect of treatment, especially in these, melting ulcers or contaminated ulcers is to inhibit the proteolytic activity and we can do it with collating agents that co factors necessary for the activity of coagonizes, so we can use EDTA or in or an antibiotic that I use more and more often nowadays is tetracycline. You can use it topically and.

Chemically less for its antibiotic effect in dogs, more number one, because it inhibits protetolytic activity and it's also immunomodulatory and it does help corneal healing. So that can be a second systemic antibiotic you add, but again, not for its antibiotic effect. However, another readily available substance that you can use to inhibit proteolytic activity is a serum.

Or plasma and that's because the serum is very rich in alpha 2 microglobulins that also bind to these proteolytic enzymes and produce great inhibition. They also contain growth factors that promote healing, cynectin, which my teachers in that called the feel-good factor, . And you simply obtain serum or plasma and actually it it says I should remove the word autogenous here.

There is no need to take serum from this from the actual patient. You can. Obtain it from another dog and in fact you can obtain it from other species because the beneficial effects of serum are cross species.

Give it to the owner, tell them that it keeps for 8 days. During these 8 days, they can dispense it. After 8 days, throw it away even if there is some left because there is a risk of contamination.

And really, I don't give serum at each and every case of corneal ulcers cause sometimes they're really superficial ulcers that removed the primary cause. There is no need. But I really never had any occasion to regret giving serum or plasma, .

So you really can't go wrong with it. There are no contraindications. It's safe, it's not toxic, it's impossible to overdose because it's a natural substance.

Sometimes in melting ulcers, we hospitalise the dogs and we have a technician to place a drop of serum every hour, every hour, every half an hour until the melting stop. It is cheap. It is readily available, as I said, to consider using blood from blood donors or from other species.

It will actually make your life easier because half the time these dogs are Pekinese and shih-tzus and good luck trying to find the vein in an irritated and painful shih-tzu. Maybe in the end after lots of struggling, you will get 5 pieces of blood. Your life will be much easier drawing from another species.

Keep it refrigerated and as I said, give it to the owners, tell them to dispense it as much as they want for 8 days. I did mention earlier, and I want to come back to the, I did mention earlier that every ulcer is characterised by secondary UBIs. And if I had a dollar or a pound for every case I see where an ulcer was treated successfully, but the eye was lost because the clinician forgot about the secondary UVITs, I would be a very rich man.

. Cause people often tend to forget it with dramatic consequences. You must treat the secondary UBI tests, again, the cornea is ulcerated, so you will consider non-steroidal drugs which you can give topically, systemically, or subconjunctily, . The route of delivery will depend on the severity of UVIT.

So obviously this dog with this hypoion will need both topical and systemic NSA, . But in more moderate cases, maybe you'll get away just with top ate. It really also depends on the species.

In horses, secondary uveitis is very severe, so every horse I see automatically gets both systemic and topical. Cats, sometimes they get away without giving anything, dog, it depends. So you need to give the NSA, but just as importantly, please give atropine.

And we give atropine to treat the UBI, the secondary uveitis in cases of ulcer for two reasons. Number one, it's analgesic, and I did mention that the reflex uveitis is caused by spasms of the ciliary muscle, very, very painful, . And if you give atropine, you paralyse the muscle and it brings immediate relief.

My patients usually don't talk to me and don't give me feedback about my drugs, but talk to people who've had UVID and they will tell you that atropine really brings immediate relief. The second reason that we give atropine is to achieve maitrisis in order to prevent posterior cytia adhesions of the iris to the lens, and this picture of a horse eye with uveitis explains it wonderfully. You can see a case of uveitis in this horse.

Uveitis is characterised by lots of inflammatory material in the interior chamber. There is platelets and there is fibring and there is white blood cells, etc. Etc.

And you can see them here covering the interior lens capsule of this source except for a very narrow band up here which is unaffected. And all of these inflammatory material, all of these platelets and fibrin are really glue. They're very adhesive molecules.

So if this iris, if this pupil was constricted, there will be lots of iris in contact with the adhesive material and you'll get the serious initia, you'll get glaucoma and you'll likely lose the eye. So you want to dilate the iris. Number one for analgesia, but also to drive it away from the surface of the lens, from the interior lens capsule to minimise the risk of posterior sinicia.

How much aprine do we give? Well, atropinene is a wonderful drug cause the eye, the pupil will tell you exactly how much to give. You want to achieve this picture of my drisis.

So usually I begin twice daily and I adjust according to pupil size. If I get meriasis, I can go down to once daily, once every other day. If twice daily didn't provide adequate marisis, go up to 3 or 4 times daily, you must.

Get the pupil dilated. Please remember when giving atropine, well, if you're a horse practitioner, you may kill your horse with colic, so a definite colic watch. Remember that atropine is parasympathylytic, so it will decrease tear production and I said, checking tear production in the non-affected eye is important.

You may get parasympathholytic toxicity with long-term use. And you will get this picture in parts of intense, intense salivation, which shocks people at first cause they remember that aprine is parasypatolytic supposed to decrease production of tears and of saliva. And here we see a cat salivating.

Due to atropine, it does that as a result of the bitter taste of atropine, making its way down the nasova duct that we discussed last week into the nose, into the mouth. The cat is reacting to the bitter taste. And really, when I want to give atropine to a cat, I would usually put a drop.

While the cat is still on the exam table, the cat would salivate and I'll tell the owner, see, that's OK, that's normal. It's just reacting to taste, cause if I don't do this demonstration, I could get a phone call two hours later, you are killing my cat with whatever drug you gave me. So demonstrate it to people or consider using atropine ointment, which doesn't make its way down the next black duct or trapeomide, which is less bitter but also less potent.

And finally, for each and every corneal ulcer, please don't forget your Elizabethan collar. Again, you had only 0.5 millimetre to begin with.

You lost some of it. You really want to protect this cornea. So you can protect this cornea.

With an Elizabethan colour to prevent self trauma. You can also protect it with soft bandage contact lenses, and these are contact lenses intended for veterinary patients. They come with These 4 black dots which allow the owner to monitor them and see whether the contact lens is still in place, so they can see if it fell out and come back to you.

So you want to protect the cornea. And as I said, if you did everything properly, then these ulcers should heal within 10 days. And if it's not healing, again, I quote my friend David Maggs, if it's not healing, don't change treatment.

Change your diagnosis. In other words, if the holster didn't heal in 10 days, you probably didn't diagnose the primary cause. Go back, take a look at the eye again.

Maybe you missed the entropion, maybe you missed the ectopic cilia, maybe there is a foreign body deep in the forenix. It should heal and if it didn't. Didn't heal, ask yourself why it didn't heal.

If you didn't find a foreign body or the sticky or anything, now it may be time for cytology and cultural insensitivity. If you are going to do cytology and cultural insensitivity, culture should be done first, and that's because cytology requires topical anaesthetic and this contain contain preservatives, so. We start with taking our samples for bacteria fungal and bacterial culture and sensitivity, then we place a drop of topical anaesthetic in the eye and we scrape the corneal surface with the distal end of the scalpel blade, .

I know it sounds scary, but as it says here, you really want to scrape vigorously. If you want your scrape to be diagnostic, you will not get anything if you just brush this blade lightly and gently across the cornea. It's OK if you're with a blunt end of a.

Blade, you are unlikely to cause cause damage, get a diagnostic scrape, and then sometimes you will have your answer, yes, this all cornea is contaminated with bacteria and you can see rods so you can treat accordingly. This one has fungal agents treated accordingly. And finally, if it's not healing, why you may be looking at the case of a boxer ulcer, also known as recurring superficial erosion, indolent ulcers, head, etc.

Etc. We will talk about this entity next week. So this was a very brief review of the medical treatment of corneal ulcers.

Next week, we'll talk about surgery and I'll be glad to take any questions you may have at this stage. And thank you very much for attending and once again thank you to our sponsors PBM. Excellent.

Thank you very much, Ron. We do have several questions pending. All from all from Gordon, he's very keen.

So first question, try to source Rose. Yeah, yeah, try to source Rose Bengals staying in the UK after a previous talk by you but had no success. Do you have any advice in sourcing it?

Oh gosh, since I'm not in England, I'm afraid I cannot help, . No, I'm afraid not. Maybe, maybe someone in the audience knows and can type in an answer.

I'm afraid, I'm not aware of any source in England. OK, yeah, that's a good suggestion. So if anybody out there is aware, then please let us know.

Second question is, some clients told me that they thought that serum irritated the eye. Was it only because it was refrigerated? Maybe refrigerated, really it shouldn't be irritating.

To the contrary, as I said, it contains what we call feel good factors. It really increases their comfort, gives lubrication. So yeah, maybe it was refrigeration.

I can't think why it should be irritating. OK, Gordon's, old school from 1996 in Melbourne, and he was taught, yeah, he's taught about immune complex formation and possible sequelae of immune-mediated uveitis as a long-term possible consequence. He was told to place those on a course of aspirin for 30 days.

Does this still hold true? Oh. Mm, not in dogs, in horses, we do get, a disease called equine recurrent UVITs which, as you say, and, and as the name implies, it's a recurrent UVITs.

Once, you have the initial event be. Some kind of intraocular disease or be corneal ulcer, then yes, you will have migrations of lymphocytes and plasma cells into the uval tissue. You will have antibody antigen formation in the ual tissue and that will bring the immunogenic memory which can trigger recurrent inflammation.

We don't treat these horses with aspirin nowadays, maybe long term NSAIDs, or now we have sacrosporin implants for these horses. In dogs, no, the theory no longer holds true once or also is healed, the UI is mostly resolved. Great, thanks.

So also back in the day, he was told to give atropine hourly until the pupil dilated, then stop. Has that changed? As I said, an hour this sounds dramatic.

In fact, you know, atropine has an onset time of about 2 hours in a normal eye, and also in the UItic eye, probably takes longer. So, you're placing the second drop before you even know whether the first one had an effect. Sounds to me.

Too much of an overdose, you're decreasing tear production, you're drying up the eye. If it's a small dog, and many of these are small dogs that start worrying about the cardiac effect, etc. Etc.

Up to 4 times daily. I don't remember when, when did I go. Higher than 4, and frankly, Gordon, I must say, if it didn't dilate with 4 times daily, I doubt it will dilate at all.

You probably have adhesions, you may want to consider TPA or tissue again activator injection. Great, thanks. Just a quick message from Patrick saying thanks for a terrific talk.

And a question from Jill, topical non-steroidals, which would be your first choice? Oh, thank you for an excellent question. Of course, it's a question of what's available in England.

Volsoreen or diclofenac, would be, not so potent non-steroidal, but it's also cheap. Navina. N E V A N A C Naviac is a more potent one and more expensive drug.

So depending on the severity, you'd go with diclofenac for the moderate cases and navino for the more complicated cases. Another question since we're on the subject, there, you know, obviously we, in patients and dogs, you know, patients, we don't make systemic non-steroidals and steroids, but it is OK to give topical. NSA and systemic steroids, no contradiction there.

So if you're giving NSAIDs, topically, it's still OK to give systemic steroids if the patient requires them. I should add as a side comment that There are some reports that Topical NSAIDs, in certain cases can also be degrading just like steroids. So you do want to invite these patients for frequent rechecks.

Don't give them non-steroidals and send them away for two weeks. OK, great. Another question from Jill and a related one that I'll ask straight away from Elizabeth.

So Jill asked, can you freeze serum and for how long? And Elizabeth has asked, does serum need to be frozen during the eight days or just refrigerated? Oh, OK.

No, OK, so I'll answer both questions. . Once you draw it from an animal and Again, as I said, I, I should go back.

I, I hardly ever draw serum from the actual patient. Number one, as I said, the eye is painful. I don't want to fight the dog and the owner doesn't want to wait 2 or 3 hours until we extract the serum.

And frankly, if we're into marketing, you know, if the owner sees you drawing blood from their dog, and then you want to sell it back to them, they look at you like, heck, you just took blood from my dog. You made me 3, wait 3 hours, now you want me to pay for it, forget it, you know, so it makes much, your life will be so much easier if you don't fight the dog and you And your life, and it would be much easier to convince the owners that, yeah, they should pay for this drug if you say, I have this wonderful drug in my freezer that will help cure your dog's ulcer. So yeah, I keep a freezer full of frozen serum.

If I don't have it from a dog, I'd use a horse serum, and there are studies showing it's equally effective. . Depends how long would it keep?

It depends on which freezer you have. If it's a -80, it will keep for more than a year. If it's a -20, 6 months, and once you dispense it to the owner, no need to freeze it.

You keep it refrigerated and throw it away after 8 days. So it's frozen in your clinic, it's refrigerated in the client's home. Brilliant, thank you.

Gordon says thank you for taking him back into the 21st century, but he, he's also got one last question. Is remed better or worse than EDTA serum? I'm not sure I'm familiar with remed.

I have to confess, oh, re, remand, sorry, he's put as a follow up remand. Does that mean anything? OK, .

And maybe I'd look it up here on another computer because I'm not familiar with that name. I would say, let me try it here. Garden, has it got another name?

Have you got a trade name or anything, or is that the trade name? I'm looking it up. Remain I lubricating drops.

The way I see it here remain is just lubricating drops. I, corneal repair gel. It helps healing according to what I'm seeing here, but no, it doesn't, I don't think that it, the manufacturer is claiming that it would inhibit the proteolytic activity.

So, it can promote healing, but if you have a case of a melting ulcer, you really want to inhibit those enzymes, so you'd want to go with EDTA or serum and actually thank you for mentioning EDTA again, . If you have, don't have serum available and you're asking yourself, jeez, where can I get EDTA, take your CBC tubes. They contain EDTA, put a couple of drops of saline in it, shake it, and you've got a highly concentrated EDTA solution from your purple top tube in which you collect that for CBC.

Great, Jill just says love the answer. Thank you, and God says thanks for the answer. I think we're just about done there.

OK, there's nothing else, I think we have time for more questions or if you think of them later, you can always email the office and I'll be glad to answer. Yeah, presumably if they're on next week, they could ask as well, could they? I assume.

Yeah, and yeah, thank you for reminding me. Yeah, next week we'll be talking about surgical treatment of corneal ulcers. I don't think I'll make you corneal surgeons in an hour, but definitely if you're referring your Patients for surgery, you want to know what their surgical options are, what is the ophthalmologist going to do, what's expected of you in the post-op care, etc.

Etc. And then we'll wrap up the 4th top of the series by talking about corneal and conjunctival diseases in cats. Brilliant.

OK, well, thanks again. I thank CBM for their sponsorship of all these 4 talks. Brilliant.

And thanks again. Excellent talk, Ron and good luck next week. Thank you everybody for attending and hope you can make it for the next one too.

Thanks. Good night.