Thank you very much, Anthony, and good morning, good afternoon, or good night wherever you may be or whenever you may be listening to this, lecture. It really gives me great pleasure to be part of this amazing enterprise, the virtual congress, and I thank my friend Dancing Chadwick for honouring me with an invitation to participate in this event. Thank you very much, Anthony.

As Anthony just said, I should note that I'm just one of two speakers at the Virtual Congress Ophthalmology stream. I don't have my camera on, so this is me here on the right and on the left is my friend David Maggs from the University of California, Davis. As Anthony noted, David is my co-author on the 4th, 5th, and 6th editions of Slatter's Fundamentals Veterinary Ephthalmology.

But he's also an outstanding ophthalmologist, a world authority on feline herpes and til diseases and superb speakers. So I urge you all to hear the talks that he recorded for this congress. David and I would like to dedicate our talks to Pip Boydell, another leading ophthalmologist from England.

In fact, Pip and I took our ECVO, European College of Veterinary ophthalmologists board examination. Together, so Pip will always have a special place in my heart because whoever sits for the test with you is someone you've bonded with for life. Pip said it passed away a few years ago and we all miss him.

So, the subject of my talk today, as Anthony said, is the bulging eye. And when we talk about the bulging eye, we are really talking about two clinical entities. The first one is proctosis.

When the eye or the globe comes out of the orbit, the most common reason for that would be traumatic prolapse, which we shall discuss in a few minutes. The other entity for a bulging eye is exopthalamus where the eye moves forward in the orbit, but not out of. So it's and that would usually be caused by a retrobar.

A disease process behind the eye that pushes the eye forward, forward, but not out of the orbit. So it's really a relative distinction, how far is the eye moved forward, . And to distinguish between the two entities, we have to look at the position of the eyelids compared to the equator of the globe.

The globe, the eye has an equator, just like the Earth does, the widest point of the sphere. In exothalmus, the eye moves forward, but the equator is still behind the eyelids, OK, so you can compare these two, you can see here are the eyelids in this drawing, and they are touching the cornea as they usually do. Here in the bottom, the eye has moved forward, so now the eyelids are here, but they are still forward of the equator, which means that the eye is still in the orbit.

In proptosis, the eye has moved so far forward that in fact the eyelids are now behind the equator. Most of the globe is out as you can see in these two drawings, and here is what the two entities look like. In a patient, in two patients.

So over on the left, we have traumatic prolapse. You can see the equator here, you can see that the eyelid margins are trapped behind the equator. This eye has come flying out of the orbit due to a trauma.

Here on the right, you can see that the dog's left eye is obviously displaced forward. It has moved forward in the orbit, but the eyelids still close over it, so the equator is behind the eyelids and therefore this dog has exothalmus in its left eye. So we're going to talk about these two entities, proptosis and exopthalmus, and let's begin by talking about proptosis and then move on to exopalus.

So, talking about proptosis, I would like to begin with the question. Here are two cases of proptosis. One is a dog, one is a cat.

That's all you know about them and I'm gonna ask Helen to turn all the poll question and you can vote on which of the two has a better prognosis. So, do you think that the dog has a better prognosis or the cat? Which of the two, please go ahead and vote?

I'll shout out the results for this run, when er people have had a chance to vote, so do just press on the button, either the dog or the cat, and we'll we'll see what . What Ron thinks. Now, we'll see what they think.

Well, exactly. That's great. So we've got 68%, so about 2/3 saying the dog and about a 3rd, 32% saying the cat.

OK, and as always in a democracy, the majority got it right. They're correct, the dog has much better prognosis than. The cat and that's because if you look at the cat, you know that the eye is sunk deep in the orbit.

It is well protected by the eyelids. When you look at the cat, you barely see any exposed conjunctiva or sclera simply because the eyelids are closed so very well over the globe. And because the globe of a cat is so well protected by the deep orbit and by the eyelids, it really takes significant trauma to cause proctosis.

In fact, if you look at this patient, you see that he's got a fema. In addition to the trauma, blood in the interior chamber, there may be a fracture or the synthesis here. So the cat underwent significant trauma and therefore you would assume that it has a worse prognosis.

The dog on the other hand, especially in a brachycephalic breed like this French bulldog or like a Pekinese or a pug where In this bracketcephalic breeds, the eye is half out to begin with, you know, all the dog has to do is sneeze and the globe will come flying out. So it really takes a minimal trauma to get the eye to come out and there. For the prognosis is much better.

In fact, you can see here, yeah, there is prolapse, but what we see of the cornea and the interior chamber look to be in much better shape than this cat and therefore the majority got it right, the dog has a better prognosis. And in fact, I can back up this statement by numbers. This is a study from North Carolina State University looking at 84 cases of traumatic proctosis.

18 of those cases were in cats. And as you can see, 12 of the cats had to be nucleated due to the severe trauma to the eye as we saw here. In 4 cats, in fact, the trauma was so severe that the cat had to be euthanized.

Only in 2 of the 18 was the globe salvaged and it was salvaged by blind, but blind. None of the 18 cats actually regained vision, and in fact, only 2 globes were salvaged. And this is in contrast to 66 dogs evaluated in that same study.

You can see that, yes, 18 dogs had to be nucleated. You can see that 4 more dogs had to be euthanized, so altogether, we are talking about 1/3 of the dogs being either euthanized or nucleated, but 2/3 of the globes were salvaged. 26 were salvaged cosmetically, but the eye was blind.

But still, as we'll talk later, the owners are very happy if you can salvage the globe, and 18 were actually visual at the end of the study. So definitely much better outcome. 2/3 of the globe's salvaged cosmetically or .

Sorry, cos cosmetically or functionally. And therefore, really, when and, and yeah, this would be the outcomes, the likely outcomes after 10 days, dogs, you'd usually save the globe either functionally or cosmetically. Many of them will have lateral strabismus, as an outcome which we'll discuss in a few minutes, but this would be the most common outcome in a A dog and a cat, as you can see, the most common outcome would be unfortunately, a nucleation.

So really, when an owner presents to me with the patient suffering from, from protosis and asks me, Doctor, doctor, can you save the eye? I really divide this question into two scenarios. Number one, can you save the eye so that it regains vision or maintains vision?

And number 2, if you can't salvage vision, can you at least salvage the globe cosmetically so the dog would have two eyes, even though one of them is blind. So if I'm presented with a cat with proptosis, the answer to both questions is most probably not. You've seen the numbers before, only 2 of the 18 globes were salvaged and both were blind.

So, a very bad prognosis in both regards for salvaging the globe and salvaging vision. In dog on the other hand, the prognosis is much better, as you've seen, a significant number of dogs, we can maintain vision and in many of the dogs where we can't maintain vision, we can still salvage the globe as you're seeing here. You may have noticed that the study I presented from North Carolina State University was From 1995 or 1996, meaning it's a rather old study.

So two years ago, yours truly and my team repeated the study. This is Doctor Oren Per, my resident, and basically, the outcome was very similar to the numbers I have just presented. So you can see that the first prognostic indicator in cases of proctosis is the species.

Are you presented with a dog or a cat? The second prognostic indicator is breed, and I will not ask Helen to launch another poll question as to which. Has a better prognosis because you can already understand that the bracephalic breed has a much better prognosis than the Doberman here who really resembles a cat with that deep orbit and very protective eyelids.

So yes, breed is your second prognostic indicator. Continuing with prognostic indicators and what you should look for before discussing the prognosis with the indicator. The third one after species and breed would be the number of extraocular muscles that were torn during the trauma.

And the number of extraocular muscles is important for two reasons. Number one, it's an indicator of the extent of trauma. Obviously, if there is greater trauma, more muscles will be torn and this dog obviously suffered a very severe trauma.

It seems like all of the muscles have been torn, so obviously very bad prognosis, cause it underwent massive trauma. The second reason is that the Blood vessels supplying the inner tissues of the eye, like the iris and the choroid, etc. Insert into the globe at the same point where the extraocular muscles insert into the globe.

So every muscle. That gets torn means that one blood vessel that supplies the eye has also been torn. So the more muscles that are torn, the greater number of blood vessels that are torn and the greater intraocular ischemia.

And basically, we say that if there are 3 or more extraocular muscles that have been torn, we're going to have a blind eye and due to ischemia and a very grave prognosis for saving the eye due to the massive trauma that you are seeing here. If there are two torn muscles, then we say the prognosis is guarded and if there is just one torn, then Excuse me, the prognosis is rather fair. I know that sometimes looking at a globe like this, it may be hard to determine, gosh, am I looking at 4 or 3 or 2 or 1 muscles that have been torn.

But actually, one muscle being torn is fairly easy to recognise cause it would most often be The medial rectus cause the medial rectus muscle is the shortest and weakest of them all and therefore, as I indicated later earlier, sorry, when the medial rectus is torn, then the likely outcome is lateral strabismus cause the lateral rectus has no opposing force from the medial rectus. I'm going to digress for one slide from the topic of prognosis to discuss this lateral strabismus cause owners are very, very upset by the presentation, even though in fact, they should be thankful that the dog suffered such minor trauma, but still, as you know, cosmetics is a very important consideration for owners, and they will be asking you, gosh, doctor, what can you do about this? Well, Theoretically, we could go in and repair it, right, find the two stumps of the medial rectus muscle and tie them together and repair.

However, this is a very challenging surgery cause you have to find stumps, two stumps of the muscle that it actually is actually very small and minute. The dog just underwent trauma, so there is lots of edoema and haemorrhage, etc. In this area.

We practically never ever tried to repair it immediately. What we can do later when everything is healed is to actually do a permanent medial canthopplasty, suture the upper eyelid to the lower eyelid in this area, 4 or 5 millimetres. Obviously, This would not resolve the strabismus, but if you cover this exposed conjunctiva, then it makes it less noticeable and the owners are happy.

It also this procedure always has the added advantage of. Reducing the risk of repeated prolapse because you are reducing the size of the palpibral fissure, you're making the eyelid opening smaller and therefore it will be harder for the eye to come flying out next time the dog undergoes trauma. And another alternative if the owner doesn't want to go into another surgery is I tell them, you know what, let's wait a few months and see what happens.

And what happens is that this exposed conjunctiva gets pigmented with time, again, it means that the strabismus wasn't resolved, but it will become less noticeable if the conjunctiva gets covered with pigment. OK. So, as I said, the first prognostic indicator is species, the second one is breed, the 3rd 1 is the number of extraocular muscles.

A 4th, oops sorry, very important indicator is obviously the additional trauma we just discussed earlier how it is moderating in a dog and more severe in a cat, but yes, there may Trauma to the body, trauma to the skull. So you definitely wanna perform a comprehensive physical examination, good palpation of the skull, and maybe consider neurological exam based on your findings. Consider radiography if you suspect suspect fractures.

So if there is Pain or facial asymmetry or through bismu, then you may wanna take the patient into the radiography and here you see the fractures in the orbital bone. The facial asymmetry and the strabismus I note here are because some of the exocular muscles can get incarcerated by these bone fragments. Still on the subject of additional trauma, a very important consideration is the duration of a prolapse.

Obviously, if the owners came within 1 hour of the accident, then the prognosis is better. Sometimes, you know, if a dog disappears for 3 days and comes back home, with a proctosed eye, it means that the prognosis is worse cause the cornea has become desiccated, it's dry. I didn't have lubrication of the tears and that's what it would look like.

So, a useful tip here is if owners call you and over the phone describe something that sounds like optosis, is you instruct them over the phone to keep the globe moist with the wet gauze or vam Vaseline all over the eye, do something to maintain corneal health while they make their way to the clinic. So, as I said, there may be trauma to the body, to the head, to the skull, to the orbit, dryness and discation of the cornea. And of course, there may be additional trauma to the eye, maybe the cornea or the sclera perforated, causing rupture of the globe due to The trauma and here actually you can see in in CT that there is a rupture of the posterior aspect of the globe and you can see intraocular contents leaking here.

You'll notice that the cornea may look intact and this is only something you'd notice upon. Imaging. We could have a high femur as we saw in that cat, haemorrhaging the posterior segment lensation, retinal detachment, or maybe in that picture I showed earlier, even a version of the optic nerve if the trauma was severe enough.

So when presented with this patient, you should perform a comprehensive examination of the eye, looking for signs of trauma. You must check the pupillary light reflex to get an indication of retinal function, which is a very important element in prognosis, . For the direct PLR and if you cannot visualise the pupil, for example, due to severe hyema or if the case I showed you earlier of the dog with the desiccated cornea, then look for the indirect PLR stimulated, stimulate the pupil of the proposed eye and check for constriction in the other eye.

The reaction of the pupil, the response of the pupil is important. We used to say that the resting pupil size is indicative. We used to say that if the pupil is dilated, if the patient presents with dilated pupil, then it's bad prognosis.

If it presents with a meiotic pupil, it's better prognosis, but actually now we're moving away from the size of the pupil and look more at the pupillary light reflex. And if you can't see what's happening inside the eye due to high femur, for example, then you should definitely ultrasound the eye to rule out retinal detachment or lens laxation such as you are seeing here in the posterior segment of this . Dog here.

So to summarise the prognostic indicators and the things you should look for when presented with a patient is consider the species, the breed, the number of torn muscles, the extent of trauma to the body, to the skull, to the eye, how long has The I been proposed, you should definitely do the PLR maybe you did an ultrasound, pile them up all together and you can give the owners a very good indication of the prognosis of this case. So now that we've established prognosis, how do we actually treat these cases? My philosophy is summed up in this very important line here.

You can always inoculate later, OK? What does that mean and why do I say that? As they said, owners attach great importance to cosmetic salvage of the globe, even if it's going to be a non-visual eye, they really, really want that.

Dog or the cat to have two eyes, OK. Many of them just can't stand the thought of a one-eyed cat and they will do anything, in order to preserve cosmetically the proposed globe. And therefore, Unless I am 100% sure that the dog needs a nucleation, for example, because of perforation of the globe, then I tell them, you know what, we can.

And let's, you know what, let's try and replace the globe. I can't promise you we'll end up with the cosmetically salvaged globe because there may be late onset complications that will force us to a nucleate. But if you are willing to Undertake the risk of another surgery later on down the road in order to nucleate.

If you're under, if you're willing to undertake the extra expense involved in a second surgery down the road, if we need to nucleate, then I'm willing to play ball with you and replace. The globe and let's see what happens. And as long as you present it that way, telling the owners, you know what, let's try saving the globe, but beware that we may have to perform another surgery later and take it out, then most owners will go along with this proposal.

So once the owners agree to let you replace the globe and try and salvage it cosmetically at least, then we have to anaesthetize the patient, clean the globe thoroughly, especially if it's been proposed for a long time. And then comes the most challenging stage, where you have to pull out the eyelids from Behind the globe and return them to their natural position in front of the equator. This may be done using sutures such as you're seeing here, place sutures in the lids and use them to pull the eyelids out or maybe a muscle hook.

Sometimes it's very tough to get it back into the orbit. Because there is substantial haemorrhage and edoema behind the globe in the orbit, making it challenging to put it, pull it back in, push it back in, and therefore you may choose to do a lateral consultomy to enlarge a palpibral fissure, thus facilitating the globe replacement. And once you have placed the globe inside the orbit, then you suture it with simply interrupted or horizontal mattres sutures to 20 to 40 nylon using tension relieving stents as shown here.

And the most important part of the In this procedure is to carefully place the eyelids on the margin. This is shown here in the next two slides. So we have a case of proptosis.

The eyelids are behind, the equator, this is what it looks like, and then we use the sutures. To pull the eyelids out. Not that we've already pre pre-placed the tension relieving stents here.

Another one, and once both sutures are in place, use a tongue depressor or the handle of your scalpel blade to push the globe in and pull the eyelids up. And once the globe is back in, then you can suture them together and finish your temporarysoy. Take a close look here and I'll show it again at the next slide, how the sutures come out of the eyelid margins.

This is exactly what you want them to do. You want the sutures. Excuse me, going into the skin, through the eyelid margin, through the eyelid stroma, coming out of the eyelid margin, through the eyelid margin, the my boing gland opening as you can see in fact here of the upper lid and outer skin again, and then tie them together.

Obviously, you don't want these sutures to go full thickness. Cause then they will be rubbing on the cornea, but you don't want the suture to be too superficial and come out here at the skin level cause that would cause sort of a secondary entropion. So this is exactly how you want to place them going again as shown here.

Through the stent, through the skin, out the eyelid margin, into the opposite eyelid margin, and out the skin, and the stent shown here as well. And then you can suture everything together. As I said, you want to avoid this scenario of having the eyelids go, and the sutures, sorry, going for thickness through the eyelids.

. Some people, when suturing may also place an underlying third eyelid flap. It's not mandatory, but it may help by giving extra lubrication and an extra layer of protection. Some people tend to leave a medial opening in, for the owners to administer topical drugs.

I usually don't do that cause, you know, the doctor just under one. Severe trauma, the, it is very painful. I don't want the owners trying to hit this small opening with drops.

It's usually they won't make it. The drop will not get to the cornea and it's just a useless struggle with a very painful dog. So the treatment, as you'll see in a minute, is usually systemic.

And if you did a natural consultomy to enlarge the palpbral fissure and And to facilitate the replacement of the globe, please don't forget to close it with a figure of 8 suture for perfect alignment. Post-operative care, yeah, always put it, and it is a bit in colour, always use cold compresses and people sometimes ask me, well, how can I put a cold compress on a, a globe. This is thing to do is send the owners to a supermarket to buy a bag of frozen peas or frozen corn kennels or whatever.

And then when you put that bag of frozen peas. Over the globe, it really shapes itself or moulds itself in the shape of the skull and you get very effective application of cold compressors. Topical or systemic therapy, as I said, I usually go for systemic therapy, antibiotics or, and steroids, maybe a.

Drop of atropine before you close the torsoy for analgesia and to prevent possible posterior sinicia and another very, very important point is to remove the suture sequentially. We don't remove all of the sutures at once after 1012, 13 days. Excuse me, cause the muscles may be stretched.

There may still be significant edoema in the haemorrhage and you risk the possibility of the eye coming out again if you remove all the sutures at once after 12 or 14 days. And therefore, what I prefer to do is to remove them sequentially as it says here. So after 12 days or so, I'll open the first suture just to take a Look inside the eye, look at the cornea, try to get an assessment of how we are doing and in which direction are we heading, adjust medications according to what you're seeing.

Now that one has been removed, maybe you can start applying topical medications, steroids, antibiotics, artificial tears as the case may be. Come back in 2 weeks, we've removed the second suture, come back in another 2 weeks, so 6 weeks in total for the removal of the final suture. So to summarise my talk of proptosis, you have to determine the prognosis by considering the species and the breed, the number of extraocular muscles that have been torn, the duration of the prolapse, and assessing the extent of trauma to the body, the skull and the eye.

Check the direct or indirect PLR ultrasound the eye, and that will give you the prognosis. Remember that you can always nucleate later and remember to remove sutures sequentially and not altogether. So that concludes my talk of the proposed eye, and we want to move on to the second entity I want to discuss, and that is the exopthalmic eye.

But before I talk about exopthalmus, which, as I said, is an eye that is pushed forward in the globe due to a retrobular disease, I want to first talk. About whether the case you're seeing here is exothalmus or boothalus, cause you see that there is something that is obviously wrong with the left eye of this cat, but is it exopthalmus, which, as I said, is a normal eye pushed forward in The orbit due to a retrobar disease, or is it poofalmus, which is an enlarged eye in a normal position due to elevated pressure. And yes, as I said, there is something wrong with this eye, but I'm not sure whether it's exothalus or exothalus, so I'm going to let you help me and ask Helen to launch our second question.

So, what's your diagnosis for the left eye of this cat? Does it have exothalmus or does it have both thalamus? Again, Ron, I'll let you know as people vote, so OK, I'll wait patiently, let's give them time to think.

It's a tricky question. And we've got 40% think it's exothalamus and 60% think it's thalamus, right, OK, so I'm afraid this time the minority got it right. I'll.

As I'll explain in a few, in the next several slides, I'll tell you how I know, but a couple of things we can see in this picture is that there are no signs of glaucoma. There is no corneal edoema or blue eye that we associate with a buoalmus or glaucoma. The pupil, pupils look to be of equal size.

So this is actually a case of exothalus, but let's see how I can determine that. So the first question that you need to ask yourself when presented with such a patient is whether this is a unilateral presentation or a bilateral presentation. And that's because glaucoma may be either unilateral or bilateral, while ophthalmud.

Is nearly always unilateral. So if it's a unilateral presentation, you didn't make much progress on the question of whether it's exothalmus or boothalus, but if it's bilateral, then it is usually glaucoma. The second question you could ask, you should ask yourself when looking at the patient is what is the position of the third eyelid?

You've all seen your share of glaucoma cases and you know the, the 3rd eyelid is unaffected by the disease and it is resting. Peacefully, in the ventromedial aspect of the orbit and it is elevated in exopthalmus cause whatever retro bulbar process is pushing the globe forward, it is also pushing the third eyelid up. However, I'm sure you're all experienced enough to know that for every rule there is an exception.

So here is an exception. You notice that this German shepherd obviously has a bilateral process. Which I said is usually glaucoma, but you see that in both eyes, we have elevation of the third eyelid, which, as I said, suggests exothalamus and retro bulbar disease.

So definitely a Contradiction in what you are seeing here and actually this is a very rare case of bilateral retrobulbar hemangiosarcoma. So yes, for every rule there is an exception and here is one of them, bilateral exopalus. Additional indications and hints as to whether we are looking at exopthalmus or both thalamus is to look at the patient laterally.

This is a case of exothalus, the eye is pushed forward and therefore you are seeing an excess amount of conjunctiva and sclera here. If it was an enlarged eye, then it would expand, but it would be pushed forward. You wouldn't see this excess.

Likewise, you can examine the dog from above in order to detect displacement. Once again, if it's enlarged eye, then it will be enlarged, but it will not be moving forward. You'll not be able to detect this enlargement by looking at the dog from the top.

As it says here sounds strange, but you can tell by estimating the corneal curvature in unilateral cases. Abutalus is expansion of the globe, which means it has a greater radius, and actually in unilateral cases, you would be able to detect a 2 or 3. Millimetre difference in the radius of the cornea.

So in a unilateral case, compare the curvature, the radius of both corneas, obviously this cornea has a greater radius and that means this dog is suffering from glaucoma. Another Strange but very sensitive indicator is what we call the retropulsion test shown here, where we press on both globes. Now what we're doing in this picture is not measuring intraocular pressure.

You cannot measure intraocular pressure with your fingers. You can do many other things with your fingers, but measure. IOP is not one of them.

You need a thermometer for that. What we're doing here in this picture is pressing on the globe, trying to push it into the orbit and determine whether there is something behind the globe resisting this pushing, OK? Now I know that's Sounds like you're walking a very fine line.

Are you pressing on both globes to try and detect whether one is firmer or tougher than the other, or is it a globe with normal pressure that resists being pushed inwards, but try it a few times and you can definitely tell the difference. So these are several hints to tell you whether you're looking at the globe with exothalus or boothalmos, but of course, there are the golden standard tests to differentiate between the two, to diagnose buthalmus and glaucoma, you measure IOP as I said, this must be done with some kind of eonometer. I was once showing this picture in a human ophthalmology meeting and one guy raised their hand and said, yeah.

I can see that this line with the shields is going to the NHS. This one with the tonal pen went to a private practitioner. But one way or another, measure intraocular pressure to see whether it is normal or not.

And the golden standard to determine if there is retrovular disease is obviously imaging, whether by ultrasound, demonstrating this mass here or CT or MRI showing this mass behind the globe. And of course behind, besides or in addition to all the signs I've just described till now, there are numerous clinical signs that differentiate between the two. Glaucoma.

There are numerous clinical signs of glaucoma. If you go to the webinar vet archives, you'll find my talk about glaucoma and clinical signs associated with the disease. And if it's a patient with any exothalus, then the signs of exothalmus will depend on the Cause of exopthalmus?

Is it a retrobulbar tumour or is it a retrobulbar abscess? And now that we know how to differentiate between exothalamus and boothalmus, we can move forward to actually talk about exothalamus and the two causes of retro bulbar disease. So, the signs that unite both To get causes of retrobular diseases, signs that are common to both retrobulbar abscess and a retrobulbar tumour include obviously subthalmus.

I mean, that's what we're talking about right now. As I said, it's usually a unilateral disease. It involves protrusion of the third eyelid cause the mass behind.

The eye is pushing against the third eyelid. You'll have lots of swelling around the eye because the venous circulation is disrupted. You'll have the resistance to to retropulsion that I described, and you may have signs of systemic disease both in Abscess in cases of an abscess with systemic involvement or in a tumour if it's spread in the body, and in both cases, the patient may present with blindness if the optic nerve is involved.

So as you can see, there are many signs that are common to both retro bulbar tumours and retro bulbar, . Abscesses and once again we have to rely on the golden standard and the golden standard here in this case is fine needle aspiration, using ultrasound guidance, you aspirate the mass and you send it to cytology, and you can very easily determine whether it is an abscess or a tumour. So we'll discuss both entities starting with The retro bulbar abscess, which is usually a bacterial infection due to dental disease or to a foreign body.

It may also be due to hematogeneous infection or spread from a nasal sinus. While it is usually a bacterial infection, however, I should note that frequently there may be no growth or anaerobic growth or maybe a fungal isolation, so keep it in the back of your mind. You won't always find the cause.

How does a patient present? It's an abscess, so usually it's very acute onset. A very, very telling sign is pain on opening the mouth cause there is an abscess behind the eye.

And when the patient opens its mouth, the epicondyle of the mandibula goes up and presses against the abscess and it is very, very painful. The dog will present with anorexia and will absolutely not let you open the mouth. I mean, even if It's a small chihuahua or a miniature pinscher, it will fight you to death.

It will scream, it will bite. You will not be able to open the mouth. Again, that's a very telling indicator, and you'd probably have to sedate it in order to successfully open the mouth, and once you do, you may often see a swelling or a fistula of your mucosa behind the last upper molar tooth.

Once you've determined that it is an abscess, well, the patient is already sedated or maybe anaesthetized. If not, you have to proceed to full anaesthesia. You must intubate.

This cannot be intravenous anaesthesia. You must intubate because when we drain the abscess is shown here, then the oral cavity is gonna fill up with lots of Infected and inflamed secretions. You can see that we're also packing lots of gauze around the endotracheal tube, to minimise the risk of aspiration and then if it's a fistula, then you know where it's located.

If there is no fistula, but you see the swelling as you've shown here, you make an incision of the oral, mucosa and you create a, draining tract using a closed hemostat. . Mm, and I emphasise the word closed, you wanna go with a closed hemostat in the tract you've created, open it once, and withdraw it open.

Close it again in the oral cavity, insert it closed, open ones, withdraw it open, close, etc. Etc. Which one don't want to do is insert the closed Simostat and then start opening, closing, opening, closing while it's still behind the eye, while it's still in the track, cause if you do that often enough, I promise that you will clump on the optic nerve.

And you will wake, the dog will wake up with a blind eye, OK? So just insert it close, open one, withdraw it open so that you're not clumping on the optic nerve. You may need to use ultrasound guidance to actually hit the pocket or the abscess.

Sometimes, and once you do, there is great satisfaction. You're seeing all that pus or whatever it is coming gushing out. Even if there isn't This gushing out of fluid, then just creating a tract for cellulitis will often be enough.

You can collect this for cultural insensitivity for cytology, but frankly, it's a waste of time and money because this is going to heal very, very fast. It is one of the most satisfying procedures for veteran ophthalmologist. You flush it with saline, flush it with antibiotics, place the dog on systemic antibiotics, feed it just soft food because, the mouth is painful.

And as I said, the recovery is very, very fast, often before you get the results of any lab tests you have submitted. Oops, sorry, here. On the other hand, when presented with a retro bulbar tumour, the presentation will be different.

We are obviously talking about slowly progressive, presentation. It is non-painful cause there is no abscess, for the mandibula to press on. Obviously, there are older patients and Due to local extent, there may be signs of local extensions.

You can see how the globe is deviated in this picture here. There may be nasal discharge if the tumour is extended into the nasal sinuses. If it extended into the brain, there may be central nervous system signs, or if you look almoscopically, sometimes you may see.

The tumour in pressing on the globe, causing this indentation in this picture that you are seeing here. Unfortunately, most tumours are malignant, so you need to examine the patient for metastasis and depending on the staging, well, maybe you can refer to orbiotomy or accenteration and in order to remove the tumour, if you go down that route, then obviously surgery should be combined with chemotherapy, with radiation, or some other modality. And yes, surgery is possible.

Here, a large tumour was taken out and the orbit is reconstructed using these wires and this mesh that you're seeing here and the eye could be salvaged as you're seeing here. However, this is definitely a referral surgery and as I said, cause the tumours are usually malignant. Which you can see here in this study evaluating 112 cases, then you are seeing lots of adenocarcinomas and you're seeing osteosarcomas and meningiomas and lymphomas.

These are these all carry a very bad prognosis and that is the prognosis for the red bulbar tumour. So take home messages for the The second part of my talk is that periocular swelling, forward displacement of the globe, 3rd eyelid elevation, normal corneal diameter and resistance of retropulsion. All these indicate ensothalus, which can be confirmed with ultrasound and fine needle aspiration, which will tell you whether you're dealing with a tumour or an abscess behind the globe.

If it's an abscess, this is further confirmed by the acute and painful presentation and the abscess should be drained through the mouth after intubation. If it's a progressive non-painful presentation, it is probably a retrovular tumour and the prognosis is not so great. So, this really concludes the two parts of my talk.

I can't really hear you and see you, so I have brought my own applause. I thank you very much for being with me, and I will be glad to take any questions that you may have.