Good evening, everybody, and welcome to another Thursday night members webinar. My name is Bruce Stevenson, and I have the honour and privilege of chairing tonight's webinar. We are going to have some fun tonight.
This is not going to be like any other webinar you have attended before. Ron has set up the most intriguing, presentation. With questions and polls, literally from one to the next to the next to the next.
It is a very much an interactive session. We want participation. We've got a lot to get through.
So please have your fingers ready on those mice, mouses. And get voting as, as we start to run and to get through. We will not be doing answers at the end with questions and answers.
We are going to do them as they come along with the polls. So if you've got a question about the poll, vote on the poll, pop the question in, and we will take as many in between as we can. Like I said, this is going to be a webinar with a difference.
For you, those of you that have never listened to Ron before, you are really in for a treat. He is one of my favourite speakers. Ron Offrey was a member of the charter class of Coret School of Veterinary Medicine, Hebrew University of Jerusalem in Israel.
Upon his graduation, he travelled to the University of Florida, where he spent the next 4 years undergoing clinical training in veterinary ophthalmology and obtaining his PhD. During that time, Ron developed an interest in the physiology of vision, focusing on retinal electrophysiology and animal models of retinal disease. Upon completion, Ron returned to Israel, and joined the faculty of his alma mater, where he's currently professor in veterinary ophthalmology and winner of numerous Teacher of the Year awards.
Ron is a contributing author to many books, not least of which is Gillet's Textbook of Veterinary Ophthalmology, 3rd, 4th, and 5th editions, as well as co-author of the popular textbook, Slatter's Fundamentals of Veterinary Ophthalmology. Again, 4th, 5th, and 6th editions. Ron is obviously a diplomat of the European College of Veterinary Ophthalmology.
He is a former ECVO executive board member. And he also served as a past president of the European Society of Veterinary Ophthalmology. Ron, welcome back to the webinar vet and let's start the crazy in the evening.
Thank you very much for this introduction, Bruce, and indeed, I, it's great to be back, as you said, Gosh, I've been recording webinars for the past 2, 2.5 years, ever since COVID entered our lives, and I think this is my first live webinar in quite a while. I could almost say I'm glad to see you again, except for the fact that I can't see you, but it's really great to be back on a live webinar with such a large participating audience.
As Bruce was saying, this is an unusual webinar, cause we will, I'll be showing. Of slides of emoji after all, is all about pictures, all about slides. I'll be asking a question about the slide I'm showing and giving you a few possible answers and you'll be asked to vote on the correct answer.
And since none of us are used to this format, I decided to begin with a non-authentic question just to practise our voting system. So here goes, here is your first question, which of the two is fake? Is it the owl or is it the parrot?
Please vote. Fantastic response. This is great, people.
Thank you so much. It really is brilliant to see, see this coming in so quickly. And we are not going to run these polls for very, very long, because of the fact that we've got a lot to get through.
So, there are still a few stragglers, but let's end that poll and share those results for you. OK, so we have a great majority voting for the owl being fake, and the majority is correct, and the hint here is the fact that the owl, I'm holding with an open hand. And that's because it's a fake.
It's a small, doll. It, it cannot fly. Therefore, my hand is open.
The parrot is real. It will fly away if I open my hands. Therefore, this is fake, this is real.
Most of you got it correct. Onto ophthalmology. And here is a puzzling question because we can't see the dog's eye, yet you are asked to determine whether it has blepharitis, conjunctivitis, uveitis, scleratitis, or optic neuritis.
Please vote. So for those of you that didn't play on the first question, let's get involved here. And simply have a look at your options and then just click on the one that you think most represents the correct or closest answer to what You believe is correct.
Remember folks, this is completely and utterly anonymous. Nobody can see what is coming through on the polls or who voted. We only get the percentages and everything at the end.
So let's end that and share those results quickly. Oh wow, what a breakdown. Almost equal.
By the way, I see two people complaining in the chat box that they cannot hear. I wonder if we have a technical problem. I think, if I can just jump in there, you are on the website, and you're having problems with sound, just log out and join through the Zoom.
We do occasionally have, technical problems through the website in with certain connections. So if you're having problems, come in through Zoom and it should sort it all out for you. Sorry, Ron, over to you again.
OK, yeah, I just wanted to draw your attention. OK, so we have, as you can see a very nice split of answers, and I think the winner by 1% is UVI 25% versus 24. So once again, the majority has it right.
This dog is suffering from uveitis. There are two hints here to the fact that it has uveitis. Number one is the breed.
We are looking at an Akita. Number 2 is the skin lesions you are seeing on the nose here, the crusting and The ulceration and the depigmentation of the nose. This dog has what's known as uodermatological syndrome, UDS.
It's an autoimmune disease that is prevalent in all of the so-called northern or Arctic breeds. So we see it in Samoyeds and in Alaskan Malamuds. Excuse me, .
Etc. Etc. But it's definitely most prevalent in the Akita.
A recent study from UC Davis with 50 dogs, more than half of them were Akitas. It's an autoimmune disease whereby the body produces antibodies against melanin and therefore it causes the the pigmentation you're seeing on the nose here. You You may see some pigmentation on the eyelids, but it doesn't cause the ris.
However, as you know, there is lots and lots of pigments in the UVA and therefore it causes very severe uveitis, both interior uveitis, inflammation of the iris and of the posterior uVa inflammation of the choroid. Many of them go blind. I see a question.
Can the poll question pop up after a chance to look at the picture? Yeah, so maybe we can wait a couple of seconds before opening the voting window. Sure, no problem.
And OK. So that is your hint here. The breed and the dermatological lesions suggest it's a UV dermatological syndrome.
Most dogs, I would say about 85% will present first with the ocular signs, first with the uveitis, and only a few months later with the dermatological lesions. On to our next picture. Which organ will you check next?
I'm sorry about spelling mistake here, heart, liver, ear, brain, or the urinary system? And I think you can move the poll question box so it doesn't disturb your pictures. Yeah, if you're on Zoom, you can move it.
I'm not sure about the website. Right, let's give you those results. OK, and I'm glad to see that again, the majority has it right, voting for the ear.
Obviously, the problematic eye is the right eye here. You can see that the third eyelid is elevated. You can see that the pupil is meiotic relative to the left eye, and you can see ptosis of or drooping of the upper eyelid.
These three signs, the ptosis, the 3rd eyelid elevation, and the meiosis are the hallmarks of Horner's syndrome, sympathetic denervation. And that forces you to recall the pathway of the sympathetic trunk going to the eyes, starting in the midbrain, exiting the spinal cord through. 1 through T3 going up the vagual sympathetic trunk through the cranial cervical ganglion next to the ear and eventually innervating these three organs you're seeing here, the pupil, the upper lid, and the third eyelid.
And therefore, if you do have Horner's syndrome, you would, you would do well to check the ear, especially in cats. In dogs, only about 8% of the cases are due to otitiss and about 50 or 60% of the cases are idiopathic. You can do a complete workup and not Find the primary cause of horners in dogs.
In cats, we usually find a primary reason and one of the leading reasons is otitis because the vagal sympathetic tra tract runs so close to the ear to the base of the ear. Let's see if we have any questions here. I'm on Zoom and still have no sound.
OK, there is a question here. Yeah, sorry, go ahead. Yeah, Lindsey, just log out and log back in again.
The zoom sound is working fine. I suspect there may be something with your connection. If we can go up to Charlotte's question there, what would you treat this with?
That came through with your previous one, with the uveitis. OK. The UVR dermatological syndrome, just like any autoimmune disease, should be treated with anti-inflammatory drugs and just like any other autoimmune disease, you try and hit it with everything you can.
Obviously you need systemic drugs because of the skin involvement and because of the involvement of the posterior UVA. So just topical steroids will not do. We try.
With systemic prednisone, but if that doesn't work, we'd work our way up using cyclosporin, using gastro acetate, using mycophenolate, any of the Immunosuppressive drugs in your arsenal. I should say that The condition of the eyes is your guide to increase or decrease treatment. So even though you see such severe lesions in the skin, it's really the severity of the uveitis that tells you, gosh, I should pick up the treatment cause the uveitis is not under control or I can start tapering because I can see that the uveitis is under control.
So that would be treatment for the uVal dermatological syndrome. Thank you for that question and giving me a chance to address it. OK, next, which is your antibiotic of choice for this patient, Doxycycline, gentamicin, chloramphenol, or floxacin, or amoxiccycline clavonic acid?
Right, the pole is open. Oh, and the answers are coming, flooding in. That's fantastic.
Ron, you've got everybody engaged tonight as we knew you would, so that's fantastic. Yeah, but you're getting no rest, Bruce. That's a God I can rest afterwards.
These answers are coming in. Oh wow, that's fantastic. Right, let's share this with you.
OK, and I think we are still at 100% in each and every picture, the majority has it right even though with the uo dermatological syndrome, it was just 1% point. We are looking at the cat, as you can tell by the pupil, the cat is suffering from very severe conjunctivitis and actually I'm not seeing any corneal lesions here in this cat. The cornea looks pretty good.
As we know, in cats, ocular surface diseases, we always have to think of herpes virus, that is our primary suspect. However, herpes would usually also involve the cornea. So there is a possibility here that we are looking at chlamydia or chlamydophila.
Infection or perhaps mycoplasma infection, both of these bacteria are sensitive to doxycycline and therefore that would be the antibiotic of choice. I may add that we would also probably administer it even if it was herpetic infection, we would still probably give an antibiotic just to. Prevent secondary bacterial infection with one of these two bacteria.
So doxycycline would be your antibiotic of choice, both topically and systemically, if you have respiratory tract involvement, we would prefer systemic doxycycline to azithromycin. Is it possible to get just meiosis with this condition? I see, I guess that relates to the previous question.
No, Horner's really. The diagnosis of Horner's is based on all three, changes the meiosis, the elevated third eyelid, and the drooping upperli. If you've got just meiosis, you've got to look for other causes, of meiosis.
I see a couple of more questions here. Some of the drugs I admit I'm not familiar with a systemic chronicone, for example. It is not something I'm familiar with.
It's a systemic doxycycline. Yeah, OK, so I said the systemic doxycycline would be something that I would add if there was respiratory tract infection. If there wasn't, I would just go with topical doxycycline in this cat.
OK, onwards. What is the first thing you check in this patient? Would you take cultural insensitivity?
Would you perform a complete blood count, fluorescent staining, tear measured tear production, or FNA and cytology? Take a good look. Right, we are getting good responses to these questions coming in.
This one is a little bit slower, but that's because it's a more of a tricky question, I think. It is. So we'll we'll give a little bit longer there and .
Right, let's share those with you quickly. OK, we are have a majority voting for complete blood count, 2nd place for fluorescine staining, and we are still at 100% batting average, complete blood count, it is. Let's go through what we are seeing here and the different answers.
So basically we can see that. There is no there are no signs of inflammation or infection of the ocular surface. I don't see any secretions on this eye.
The conjunctiva looks normal, the little that I see of it here and here. So it doesn't look too much like conjunctivitis or anything, . Which leads me to disregard the first and the 4th answers.
Nothing to culture here. Tear production also seems to be normal. Number one, as I said, there is no secretions here.
I also look at the camera flash on the cornea. It looks nice, it looks bright. So no need to check tear production.
And actually, the cornea itself looks very healthy. There is no signs of keratitis or anything. So I don't think I need fluorescent staining.
Instead, what we are seeing here is this lesion, and you can see it's a straight line and we don't get straight. Straight lines in patients. Biology is not about straight lines.
What we have here is a hypopion. There was UVitis in the patient, lots of inflammatory material, in the aqueous tumour, white blood cells and fibrine and the platelets, etc. Etc.
And it settled. Down to the bottom of the interior chamber, which is why we're seeing this straight line. UVIis implies that the patient has a systemic disease and therefore, the first thing you should do upon diagnosing UVitis is a complete blood count in order to determine what causes UVIT.
Answer number 5 here is FNA and cytology, You could argue that yes, if you don't find anything in a comprehensive workup of this patient, meaning do a CBC do biochemistry, do serology, text chest X-rays, urinalysis, etc. Etc. What have you not?
You've tried everything and you didn't come up with a primary cause of the. Diagno of the UVITs, then maybe you could go in with a needle into the interior chamber, aspirate some of it, and submit it to cytology. So that is something you could try, but it definitely won't be the first thing to try.
First thing would be a complete blood count. How soon should this disappear with treatment, with OK, I will divide your question, the answer to your question to 2, Lucy. Treatment of the, if you were lucky enough to diagnose a primary cause, for example, if this was a dog with Ehrlichia, let's say, and you treated the Ehrlique successfully and the anti-inflammatory treatment and it should be gone within a couple of weeks.
However, if you were unable to determine the primary cause of UVITs, And you just give it steroids, this will be symptomatic treatment. Maybe it will recede, maybe it will not, maybe it will recede and recur. So it really depends on whether or not you were able to diagnose the primary cause of UVitis.
What caused this hypopion? In this case, as I said, it is indeed a, a case. Of earlychiosis, what are the main systemic causes of UVIis?
Anything in the textbook. Uveitis, I always tell my students think of UVIis as lymphadenopathy. OK.
It's like asking what would cause enlarged submandibular lymph nodes. Any infectious disease, be it bacterial or protozoal or fungal. Maybe infections in distant organs such as pyometra, etc.
Etc. Any disease that causes lymphadenopathy in the body can cause uveitis. OK.
Good questions coming up in the chat box. I really thank you for those. And as Bruce was saying, feel free to ask them because we'll not be taking questions at the end.
We'll take them one by one per individual slide. So we have an obvious ulcer here and it refuses to heal. Could it be because it has dry eye, corneal dystrophy, so-called Boxer ulcer, maybe there is a bacterial combination or maybe someone treated it with steroids.
Please vote. Another good question. Ron, really good.
And the answers are coming in very, very quickly. That's great. Thanks, folks for playing the game.
It, it really is a different format to what we used to, but, lots of fun and good teaching as we always get from Ron. So that's fantastic. Good thing you don't see me blushing.
Right. I think that's enough time. Let's end that and share those results.
OK. And we have corneal dystrophy in first place. You guys are doing so very well.
We are still batting 100%. OK. So, as I've said, we have got an ulcer here and it is surrounded by this white hallow that you see around it.
And if you take it very Close look, especially at the margins of the hello, you will see that it's made up of grains, or crystals, and this would be corneal dystrophy. It would probably be lipid dystrophy, it's sort of corneal dystrophy. Severe corneal dystrophy that we see in elderly patients frequently with some sort of endocrinological disorder causing maybe hyperlipidemia, maybe not, and they accumulate in the cornea to such an extent that they actually crack and fall off and that's why this This ulcer is not healing.
It doesn't have a dry eye cause again, very little secretion. And again, look at the camera flash, no dry eye. Boxer ulcer will never heal, but it's a very superficial ulcer.
Here, even though it's a two dimensional picture, you can see how deep it is. It's really a pit. This is a dematocele.
It's about to perforate. I don't see any signs of bacterial contamination. There are no blood vessels.
There is no cellular inflammation. When there is bacterial con contamination, you'd really see an abscess in the cornea. You would see yellow cellular infiltration.
I'm not seeing that and I'm not seeing the vascular response. Well, maybe it's so treated. With steroids, but there is nothing in the picture to indicate it.
So again, the majority got it right with corneal dystrophy. Do you recommend Damon bird debridement in this case? Oh, thank you, Edina for that question.
We've been best treated surgically. Can you, OK, all of you, great questions as always. So, When we have let's say that when we have superficial ulcers combined with corneal dystrophy, yes, we can diamond burn them, or better yet, there are recent papers that talk about soaking this eye with EDTA, which is, as you know, a collating agent, and that really can dissolve much of this plaque.
And then you could bury it with a diamond bear whatever is left. This is a rather deep ulcer, so I don't think burying it would be enough. I could try dissolving some of the dystrophy with EDTA and by the way, I don't know if you can get it in England, but now in the United States there is actually commercial.
Of 13.8% EDTA and it works wonders on these ulcers. You can actually, I'm sorry, on those dystrophies, you can actually see them disappearing before your eyes, soak it for five minutes and then if it's superficial, bury it.
If it's this deep, then you'll have to do a carectomy and place a conjunctive flap. Neam is asking, would you see if it had been treated with steroids? No, nothing, to indicate, except that it would go downhill very quickly.
OK, great questions, everyone. What's your diagnosis here? Is this patient suffering from anterior lensation, posterior lens lexation, a corneal ulcer, uveitis or retinal detachment?
Bruce has opened up the voting. Yep, and the votes are coming in very, very nicely. I, I'm so impressed, Ron, that people are so well engaged and on top of the voting.
It's really lovely to see. Yeah, everyone is gay and we're still at 100%. The majority has got it correct each and every time.
Well, I think that's because people are paying attention to what you're saying and . Ophthalmology is one of those fantastic subjects that is very scary. And then you get somebody like you explaining and you think, I can do this.
Oh, Bruce, please. Flattery will get you on your way. Right, let's end this and give you the results and see if you're still happy with 100%.
I am still very Happy and now there is a clear majority going for interior lens taxation and if we add the posterior lens taxation, we can see that actually 80% voted for lens taxation. So, what we are seeing here is this round object. Which, and there are not too many round organs, tissues, objects in the eye.
There is just the lens. So we are definitely seeing the lens here, which has laxated. The question is whether it's anterior or posterior.
Most of you will realise it's interior and it is interior cause you know that. Gosh, I can see the iris quite clearly here, but where the lens has said to the bottom of the eye, I don't see the iris very clearly here, here, here, here. The pupil is also very blurry, and that's because there is a lens sitting in front of the iris, OK?
So it luxated interiorly and here it is, this iris. It is not obscured by the lens. This iris and the pupils are obscured.
Again, no signs of corneal ulcer. There's no vascularization. There is no secretion.
The little conjunctapa that we see here is normal. No signs of interioritis. This is not a hypopion, hypopion we saw earlier, .
You could be confused that maybe it's aqueous flare, but again, it's the round shape that gives it away and it's in front of the iris so it's not a rein detachment. Let's see some of your questions. How often do you use EDTA in case of corneal dystrophy?
Ask Nisha, actually, since the 13.8% solution came out, I use it a lot. Before that, we could only get 5%.
I didn't use it so much. Yes, I did say 13. 8% EDTA and then buried if it's superficial or place a conjunable flap if it was deep as we saw in the previous picture.
What would be the treatment plant in this case? I assume Alexis, you are referring to the interior lensation. Thank you very much.
Treatment of choice would be to take out the lens surgically. However, in some cases maybe the dog is an anaesthetic risk, maybe. The owner can't afford such an expensive surgery.
Maybe you don't have an ophthalmologist within 500 mile radius and then there is a, in such cases, there is an option of what we call couching, which is actually pressing on the cornea, pressing on the lens and trying to physically push it through the pupil. Into the back part of the eye, and if you succeeded, then you give a meiotic agent like latanoprost or something. This is something that we do under sedation in order to relax the exocular muscles, reduce tension in the eye.
I probably give intravenous manitol before that in order to reduce the volume of the. Cause the vitreous is what I'm pushing the lens against. Give tropicaide before that to dilate the pupil, push it physically, and if it went in, then immediately give a meiotic agent.
There was a paper actually a few years ago that said that it has the same success rate as Lens removal, surgical lens removal. I think most ophthalmologists would disagree with it, but it's definitely something you could try instead of referring. Could you, could you use an artificial lens after removing the lens?
OK. . If I remove this lens, there, usually when we do cataract surgery, we, we leave the lens capsule in place and we implant an artificial lens into it.
Here, we've removed the entire lens with a capsule, so yes, it's possible to place an IOL in, but that would mean actually suturing it in place. That's a much more complex surgery. After the rear lens is pushed through, is there a risk of glaucoma?
Well, there is a risk of glaucoma no matter what, but yes, when there is posterior lenssation, or when the lens is in the back of the eye, there is a chance of vitreous leaking. Into the interior chamber and causing glaucoma. That is why I said we'll use meiotic agent that is glauan, so, or a latanoprost, sorry, so you'll both get the hypotensive effect and the meiotic effect to in one.
What's the brand of EDTA eye drops in the USA? I'm sorry, I can't remember the brand name, but it's EDTA 13.8%.
I'll try to get the name for Dawn later next week. On to the next case. Huh, here is a red eye who spoke a bit about red eye in some of my webinars.
Does this dog have conjunctivitis glaucoma, interior uveitis or sub? Contributable haemorrhage. Ron, just while people are busy voting, just to say, folks, if we can't go back on any of the slides or anything else, if there's something that you want to look at again or if you want to see, we are recording this.
It will be up on the webinar vet's website, probably tomorrow, but at least within 48 hours at the latest. You can go back, you can watch the recording, you can stop, you can rewind, you can look at it. So, we can't go back tonight, but please, please, Have a look at the recording.
I know I'm going to look at it quite a few times to look at the pictures a bit more in depth, but that's the best way to do it. Right, let's show you the answers. Excellent.
You guys are doing so very well. So, conjunctivitis, glaucoma, and interior uveitis are the three leading differentials for red eye, and those are the diseases we usually think of. However, once again, I Well, let me backtrack here.
I am seeing an blood vessel here, maybe here, maybe here, but everything else is just a diffuse red flush. I do not see engorged conjunctive blood vessels that would be characteristic of conjunctivitis, and I don't see secretions characteristic of conjunctivitis. I don't see the episcleural blood vessels that are characteristic of glaucoma, and I don't see any blue eye and that's characteristic of glaucoma.
The pupil looks. OK, so glaucoma is unlikely. Interior VI is again, look at how clear and transparent the aqueous tumour is, and again, I'm not seeing individually engorged vessels.
This is a dog that has subcontable haemorrhage. The owner pulled on the leash too tightly and caused this lesion. You guys did very well and since there are no questions, I'll quickly move on to this one.
How would you treat this dog? You, there is a hint. You're treating it with oral drugs?
Would it be steroids, antibiotic, non-steroidals, pylocarine or, gosh, I don't know. It's obviously a very painful eye. What, what are you gonna give it?
Trick question. What's brilliant about these anonymous polls, Ron, is that people feel, free and, and happy to be able to click on answers like I have no idea. which is brilliant because sometimes you just look at it and you think, I really have no idea.
Though I do hope that's gonna be a minority answer. I, it, yeah. Well, it's, it's not the lowest, but it is low.
So, let's show you what it is. OK, we have Pylocarine in 1st place and in 2nd place non-steroidals. OK, you guys are doing so well.
I'm impressed. This is already the 9th slide or the 8th slide and we are still at 100%. So I said that this is obviously a painful eye.
I don't know, just looking at the eye, what it's suffering from this eye is also painful as you can see, but Then I look around and I see this nostril, and you see that the nostril is dry. And if we have a dry nostril and a painful eye, that suggests that this dog is suffering from neurogenic dry eye, and if it has neurogenic dry eye, the drug of choice would be pylocarpine. Let me expand on this just for a bit.
As you know, the most common cause of dry eye in dogs is an autoimmune primary inherited disease where the dog produces autoantibodies against lacrimal gland. In which case we treat it with cyclosporin or with tacrolimus. However, many dogs may be suffering from neurogenic dry eye, neurogenic dry eye would be due to parasympathetic denervation of the tear gland.
And these fibres run along with parasympathetic fibres providing innervation for the sweat glands of the nostril and an ipsilateral dry nostril with a dry eye suggests parasympathetic denervation, which is why the dog is treated with oral pylocarpine. We don't give it topically because it's very painful. We give it on With the food and it's actually quite bitter, so we just treat the dog twice daily.
We put the pylocarpine on a spoon of some tuna, canned tuna or some other tasty treat. The dose is 2 drops of 2% pylocarpine per 10 kg body weight, OK? So 2 drops, 2% 10 kg.
Watch out for signs of parasympathetic toxicity such as vomiting or diarrhoea. If the owner reports any of these symptoms, stop treatment for 2 or 3 days and then just subtract 1 or 2 drops and renew the treatment. Let's see, what is pylocarpine.
Pylocarpine is a parasympathetic agent. You can get it in eye drops cause it's an old drug that we use to treat for glaucoma. What is the alternative to pylocarpine?
There is no medical alternative to pylocarpine. That's the only parasympathetic agent that we can give. The other alternative would be surgical.
That transposition. Can I confirm that you use the topical pylocarpine orally? Yes, Susie, that's exactly what I said.
So be careful when you write a script to the pharmacist because he will be, he or she will think you've gone mad. Yeah, we give a prescription for topical pylocarpine, but we instruct the owner to give it orally, as I said on the spoon of tasty food, 2 drops of 2% topical pilocarbon per 10 kg by weight. Can you use artificial tears here only.
Yeah, you could, but you'd have to apply them every half an hour. No one is going to keep up with that treatment for 2. Long, how long do you use pilocarpen for?
Well, it depends, as long as needed, you know, if the cause of the neurogenic KCS is reversible, then you can stop treatment. If it's irreversed, for example, if it's due to otitiss, then maybe you can stop treatment. If not, it's treatment for life.
OK. Here is a cat that is blind because your neighbour, obviously not you, treated it with gentamicin, sulfa, ivermectin, or and androfloxacin. Right, folks, poll is open.
Let's keep up that fantastic voting record that you have got going so far. Both in the number, the speed of response, as well as let's see if we can keep it at 100%. We're nearly there.
Right, let's share those with you. OK, you guys are doing great. Again, we are still at 100%.
Actually, the answers may be somewhat misleading cause all of the drugs that I'm naming here are toxic. Gentamicin is toxic to every ocular tissue. That is why we inject it, in cases of terminal glaucoma or end stage glaucoma when the owner of flu refuses.
Creation sulfa is a drug that is toxic to the tear gland and may cause acute and irreversible dry eye. Ivermectin toxicity will cause retinal degeneration and blindness in a number of species. Dogs, cats, horses have been reported.
However, animals that are blind due to ivermectin toxicity will show signs of. Retinal edoema, retinal folds, which we are not seeing here. We we're seeing signs of retinal degeneration, we're seeing the hyperreflectivity, we're seeing the attenuation of blood vessels, so it's threatened degeneration caused by Beryl, caused by androfloxacin.
Ophthalmologists would recommend that you never give more than 5 milligrammes per kilo. Of androfloxacin and if it's an elderly cat, you should even divide it into small doses. Do you reckon aofloxacin toxicity has a genetic component?
Yes, it does. It's not me reckoning. For years, we didn't know what causes afloxacin toxicity, but then we've actually found the mutation that causes the disease.
There is a mutation in a protein in the Endothelial, endothelium of the rectum blood vessels, the Eurofloxacin leaks into the rectum stroma and it's phototoxic. So it is a mutation causing this photoreactive drug to leak into the rectum stroma. More informed the use of gentamicin photo.
For glaucoma, please, gosh, I could, OK, if the owner refuses to nucleate the eye, and if it's a primary glaucoma, I'm not talking about cases of glaucoma where you have to take out the eye because there is a primary tumour or cause there is UVI or if it's inherited glaucoma, you could inject 25 milligrammes of Gentamicin into the eye. It's very cytotoxic. It will destroy the ciliary body and reduce aqueous production and in about 60 to 70% of cases, the eye will become hypertensive and will undergo disease.
So that's an alternative for a nucleation. Bruce, if OK with you, I'm going to skip the next question. I don't know if you can skip the poll, show the poll and close it and let's move on to a couple of exotics questions.
No problem. OK. Here is a snake with a funny looking eye.
I'm sure you'll have the occasional snake in your clinic. What are you gonna do with this snake? We have opened that poll for you, Ron.
We just lost your sound there for a second, but I think you're back again. OK. Do you hear me now?
Yes, you're fine. OK, sorry about that. OK.
How would you treat this snake? I'm sure the answers are come more slowly. Oh, you would be surprised.
Oh, OK, good. These people on tonight are wide awake and they're on top of it. OK, great.
Right, let's see if we've kept this 100% going. Here are the answers. Yes, we have, Ruth.
Yes, we have. You guys are doing great. OK, so snakes have no eyelids.
I don't know if you ever took a close look at the eye, and therefore, the eye of a snake, you can see here that it's got no eyelids. The eye of a snake is protected by what we call a spectacle. A spectacle is actually a transparent scale, OK?
You've got all these scales here all around and there is one transparent scale that is covering the cornea and it protects the cornea instead of eyelids. When the snake sheds its skin. Sometimes this spectacle will be retained and that's what we're seeing here, a case of retained spectacle.
The proper treatment for that is increase the humidity in the cage of the snake and come next shedding cycle, it will fall off by itself. It has nothing to do with bedding, diet, surgery, . I sometimes we're forced to operate on them, but I don't envy you doing that surgery.
What do you, you suppose a snake lost their eyelids, I have no idea. Look up a book of evolution. That's a very interesting question.
I have no idea. In fact, I have another exotic picture for you. Here is a rabbit.
Do you think it's a, it's got obvious bilateral exophthalmus. I'll give you that. .
Does it have a retrobar abscess, normal variation, mestinal mass, with a small spelling mistake or stress or glaucoma? Right. So I was just giving a little bit more time to look at that picture quickly.
Oh, our participants tonight are really on the ball. Thanks folks for interacting. It makes it all worthwhile and it's fantastic to see everybody really taking part and, and giving their opinions.
Let's share this with you, Ron. OK. We have fimoma in 1st place.
We've got an abscess in 2nd place. And well, here was a trick question cause actually there are 2 correct answers. Yes, we have bilateral exopthalmus.
It could be caused by a medisal mass, aymoma. So I'm glad this was a vote of the majority. However, it is often caused by stress.
So when you have a rabbit with this presentation, the first thing to ask the owners is, was it like this at home? If it's like that at home, yeah, you have to suspect mea max. If the owners would say, gosh, I don't know, at home, it's normally it's just something that's happening on the car on the way to the clinic, or as I was walking to the clinic, then it's probably due to stress.
A retro boar abscess would cause Exopthalmus, but it would be unilateral exopthalmus. This is definitely not a normal variation, and I said it's exothalmus, it's not bu almus, and therefore glaucoma is incorrect. So there are two correct answers, but you got one of them right, so I'm very happy with that.
I hear tipping the Abita forces. I have no idea of that. Why, that's why husbandry is so important in the clinic.
Absolutely, I agree. Let's go on to this cat. You've just been presented with this cat.
What are you going to do? Stain it with fluorescine, take culture and sensitivity, take a corneal scrape or do a complete blood count. Right, and the answers or the pouring in, it's fantastic to see.
I'm so, so happy that A little experiment or your little experiment, I'm not taking credit for it. It's working so well. I'll make an announcement in a second.
Yeah. OK. We, we'll just deal with that slide and I.
Right, let's show you those answers. OK, we are still at 100%. Excellent.
So we are seeing some sort of an infiltrative process into the cornea. I see blood vessels and I see cellular infiltration, whitish cellular infiltration. You could be suspecting a corneal ulcer, so I forgive you if you said fluorescent staining.
Culture and sensitivity is less of an acceptable answer. Number one, because there are no secretions here. Number 2, as I said earlier in the previous slide, in cats, I always know what are the primary suspects of a ocular surface disease.
It's always herpes, chlamydia, or mycoplasma. So I waste the owner's money if I know on cultural and sensitivity, if I know the answer. This patient doesn't have UVITs.
Look at how clearly I can see the ventral half of the interior chamber, iris of pupils, so complete blood count is not needed. What this patient has actually is usinginophilic keatitis, which is an immune-mediated inflammation of the cornea manifested as this infiltrative process that you are seeing here. However, a very important differential that you must consider is squamous cell carcinoma, another nasty disease that we see, characterised by infiltration into the feline cornea.
So we definitely number one want to distinguish between the two. And we'll do that by taking scrape and cytology. And number 2, the treatment of choice for eosinophilic otitis is steroids.
I always hesitate about giving topical steroids in cats because it may Cause a latent herpetic infection to become active and it will cause a recurring active herpetic disease and therefore I want psychological confirmation that it's aoinophilic otitis. I'll take a scrape if I see just one eosinophi or just one mast cell, that is enough for diagnosis and we can treat this patient. We're winding down.
Just 8 minutes left, I should say we're only halfway through all the number of slides I've prepared. I'm very happy with the participation as Bruce was saying, this is really a first time experiment for us. If you guys are happy, you should write on or the webinar vet or whatever, and then we can schedule a few more of these sessions, maybe, well, later this year or next year cause I've got hundreds and hundreds of slides.
If you guys are interested, we can definitely have more. This is just our first trial in this format. What do you use for corneal scrape?
Thank you. Oh, what an excellent question, Alina. There was actually a paper about it.
There is a special psychological brush you can use. There is a special Kimura spatula you can use, but actually the cheapest instrument you can use is. The distal end of the scalpel blade, not the cutting end, but the base of the blade, just scrape the cornea with it, and there was a paper comparing all of the tools that you could use to sample the cornea and actually the blade gave the greatest cellularity and was most yielded the most diagnostic scrapes.
So I really love that paper that showed that the cheapest of all the options was actually the most diagnostic. Do you find lysine you would supplement for this? No, it's an autoimmune disease and you treat it with steroids.
Hopefully just topical steroids. Sometimes we need bigger guns including systemic therapy, scraping increase in filtration. No, it doesn't.
Yes, we. Do more 1 to 1 more ophthalmology, write the folks in a webinar vet. Please do another session.
This has been excellent. Well, we're not done yet. We've got time for one or two more, but we just write Bruce or Dan or the Office or whoever.
Thank you very much. OK. .
What does this dog have as a systemic disease? Is it hypothyroidism, hyperthyroidism, hyperparathyroidism, or inherited corneal dystrophy? Right, we are about 2/3 of the way through the votes coming in.
I'm just gonna give them a little bit more time. Yeah, it's a tough question. Though it does have British roots, so I'll talk about that in a minute.
Right, let's show you the answers. Oh gosh, we were doing so well till now we should have skipped that question. OK, so this disease is called arcus lipoids, arcus meaning arlipoids from the word lipid and what we are seeing here is lipids in the cornea.
So you could be mistaken for thinking that it's an inherited corneal dystrophy. However, it has a very this dystrophy, and it is a dystrophy, you're right, and you can see the crystals here that I mentioned earlier when we were talking about the ulcer. This dystrophy here has a very distinct shape.
It is crescent shaped like a banana. It's in the periphery, nearly at the limbus, but there is always a couple of millimetres of clear cornea between. With the limbus and with this crescent shaped dystrophy that makes it arcus lipoids and that is pathognomonic for hypothyroidism.
I say that it has British roots cause this disease was investigated in great depth by Sheila Crispin, one of the founders of the ECBO. A highly respected ophthalmologist from the University of Bristol. Later she became, I think, president of the Royal College of Veterinary Surgeons, really a tribute to a great ophthalmologist, and this was the disease that she made a career of studying, hypothyroidism in the German shepherds causing this arc lipid arc.
Your final question coming up as we are running out of time, why is this eye painful? Is it due to entropion, dysthychia, foreign body glaucoma or uveitis? And the last pole is open, folks.
I think it's going to be a pity, Ron, that we had one that was missed out that these people, they were so close to 100%. I think, I think we should give it to them. They've been fantastic.
They are responding well, they are interacting and I think we're all, we're all, yeah, a lot of fun. So, so let's show you these results and then I think we'll give it to them. OK, we are, so we are at 99% because you got it correct again.
There is no entropion here. See how clearly I see the lead margin, so definitely not entropion. I'm not seeing any evidence of foreign body.
I'm not seeing glaucoma because there is no red eye, there is no blue eye. The pupil is normal. Again, for the same reasons, there isn't any indication of uveitis.
What I am seeing is this hair here, here, here, very clearly here and here, we are seeing dysychia, a burnt eyelashes exiting through the my boing gland openings and irritating the eye. Most of our patients have a. Coat and a dark iris.
So sometimes it will be difficult to notice the dystechia, which is why, as you're seeing in this picture, it's easier to see them against the background of a white pink conjunctiva. So you do well to retract the lid, the upper lid or the lower lid a bit and then see these eyelashes against the conjunctiva. You see them clearly against the conjunctiva of the third eyelid here.
It's exactly 9:30. You guys have been fabulous, as Bruce was saying. Both thank you for your participation.
Thank you for the excellent questions. And if you want more of these, let the office know and we shall schedule them. You're absolutely right, Ron.
That was fantastic. And a huge, huge thank you to you for coming up with the idea, for sharing your slides and your knowledge. Thank you so much for your time.
We definitely will do more of these. There's no doubt about that. Thank you very much and goodnight.
And to everybody that attended tonight, thank you for your fantastic engagement and responses. You've really made it a worthwhile webinar and Dawn is on. She did put her, her email address in the chat box there if you want to email her.
But the messages come through loud and clear. Let's do more of these. So, yeah.
Dawn, over to you to arrange some more of these. Speaking of Dawn, thank you for hosting the questions in the background and making everything work very, very smoothly tonight. From myself, Bruce Stevenson, it's thank you and good night.
Thank you. Bye-bye.