Thank you very much, Anthony. Thank you for having me. While you were talking, I was scrolling through the chat box and seeing where everyone's from and really it's amazing to see people from Canada and the United States, and New Zealand and South Africa, and Mexico and all over Europe and the United Kingdom, so really, really impressive to be part of this global community.
I thank you all for attending. I think the webinar vet for inviting me and without further ado, cause we're short on time, let's launch as Anton said, we are gonna do an interactive slide recognition game. I'm going to show you a slide with a question and usually 4 answers, .
Do behind the scenes, we launch poll questions. Mind you, sometimes we have complaints that the poll questions are hiding the slide, but you can actually use your mouse to move the questions so they don't hide the. Picture, you can look at the picture and vote for the correct answer, and we'll give you about 35 seconds or so to vote for the correct answer, after which we shall discuss the various answers.
So, and at the end of each slide, if you have any questions, please go ahead and ask them. We'll maybe have time for one or two questions. No point in waiting till the end cause the slide will be long gone by then.
So without further ado, here we go. The first question is actually a practise question just to get you used to the format and to shifting the poll questions, as I said. So here is your non-clinical, non-ophthalmic question, which is fake, the owl or the parrot.
If you think the owl, click on the owl. If you think the parrot is fake, click on the parrot, and as I said, you can move the box so it doesn't obstruct your view of the picture. And we'll have 35 seconds or so after which we'll be able to see the way people have voted.
OK, most people have voted for the owl being fake, and most people are correct, and the hint is in the fact that the hand holding the parrot is closed, and that's because the parrot is actually alive, and if the hand were open, it could fly awake, so the parrot is alive. The owl is fake. It cannot fly, which is why the hand holding the owl is open.
So you did very well with this practise question, which brings us to our first clinical question. What would you do with this eye? Would you monitor?
Would you nucleate? Would you treat it with anti-glaucoma drugs or with anti-inflammatory drugs? Please vote.
And again you can shift the box to your left, so you can take a good look at the picture. OK, that's interesting. We've got a good breakdown of all the answers.
So, beginning with the diagnosis of this eye before we move into treatment, obviously, this is the feline eye. We can see that by the shape of the pupil. And the abnormality is in the iris.
We see all these black lesions. Actually, it's a cat that has a diffused iris melanoma. Now, it's always a great dilemma what to do with patients with diffuse iris melanoma, cause it can be very little tumour with a great, rate of metastasis.
So eventually they should be nucleated but not too soon, not, when the I before the tumour has become a problem. It's always a great deal. However, looking at this eye, we can see that it is slightly enlarged, as you can see here, it's definitely a red eye, so it probably has both secondary glaucoma, and or secondary UVIT.
You can see that the pupil is also distorted. It's not a classic shape of a feline pupil. So, This in this eye, we probably have secondary uveitis and secondary glaucoma due to diffuse iris melanoma.
At this stage, there is nothing to do but to nucleate, and the sooner the better before it metastasizes to any other tissue. Prior to that, if we'd caught it earlier, we'd probably monitor it. There is no point in time at which we treat it with anti-glaucoma drugs or anti-inflammatory drugs.
When you have an eye with diffuse iris melanoma and it develops you. Or develops glaucoma, we do not treat the UVitis or the glaucoma, we take it out. If it's a small lesion, small focal lesion, maybe a melanocytoma before it becomes a melanoma, then we shall monitor it, but again, once we develop glaucoma or UVitis, we don't treat, we take it out.
This one, based on what I'm seeing here and on the shape of the pupil needs to come out. Any questions? I'll wait 1 or 2 seconds to see if anyone has any questions about this slide.
No questions so far and if not, let's move on to its canine counterpart. What you would do with this eye monitor nucleate and again, anti-glaucoma drugs, anti-inflammatory drugs send for answers. OK, 80% voted for monitoring and indeed 80%, the majority is absolutely correct.
And the reason I showed these slides one after the other is to bring home the message that cats are different from dogs. In cats, as I said, melanoma is a very lethal aggressive tumour and eyes should definitely be nucleated. In dogs, melanoma behaves differently.
It's very slowly growing. It rarely metastasizes, and you can definitely follow and monitor this eye for a very long time. Most dogs, excuse me, will probably die with a tumour still in the iris.
Yes, if it develops secondary glaucoma or secondary UVitis. Then it may have to be taken out. However, looking here at the exposed part of the conjunctiva and sclera, looking at the cornea, looking at the shape of the pupil, we can see that there is no secondary uveitis, there is no secondary glaucoma at this stage, we definitely monitor it.
Some people may consider the option of actually resectioning this tumour. It can be surgically removed or. Or destroyed with the laser, so that would be another treatment option if you can refer to a specialist.
Otherwise just monitor it. Most cases, the dog will die of other reasons with both its eyes in place. So yeah, melanoma behaves differently in dogs and in cats.
Carolina is asking a very good question. How did they Diagnosed melanoma, just clinical picture. Wonderful question, Carolina.
I had a pathology teacher who said you can only make a pathological diagnosis with histopathology. You're absolutely right. I cannot look at the picture and say this is melanoma.
Only pathologist could, make the diagnosis. However, in CAT, if I go, if I go back to the previous que picture, yeah. I see multiple black lesions.
If I see that they're growing in number, if I see that they're growing in size, if I see that they are elevated, if I see that they are causing secondary uveitis or glaucoma, here too, if it's growing in size and becomes elevated, etc. Etc. That would suggest that it's melanoma.
However, the ultimate diagnosis would be histopathological. How long we've we've got a couple of people who've raised hands and we obviously don't, unmute people, so if, if any of you've got questions, do feel free just to put the question either in the question and answer or in the chat box. OK, .
So, I see just one question. Could this be an I resist ask Helga? Theoretically, yes, for that, I would really have to see the patient.
I resist would transilluminate, so I should be able to see. The iris through the cyst through the cyst, it should be semi-transparent. Frequently they're mobile, so when the dog shakes its head, this would move all over the place.
But even if it was an iris cyst, monitoring would still be the correct answer. Let's move on. What would be affected in this dog?
Would it affect the lipid layer of the tear film, the aqueous layer, or the mucin layer of the tear film? What's being affected in this dog? OK, again, fairly nice breakup of the answers, but again, the majority has it right.
50% said lipid layer, and that's correct. The three layers mentioned here, lipid aqueous mucin are the three layers of the tear film. The mucin is produced by goblet cells in the conjunctiva.
The aqueous layer is produced by the tear the main tear gland, and the tear gland at the base of the third eyelid. The lipid layer is produced by the mybomy glands, and that's what we're seeing here when we are inverting the eyelid, we are seeing engorged myboming glands. So this dog is suffering from mybomitis.
So this is what we call a qualitative dry eye rather than the classic quantitative dry eye. Usually dry eye we associate with loss of . Aqueous production and we diagnose that with a Shimmer tear test which which demonstrates loss of the aqueous component of the tearin.
However, in cases of mybomitis, we have a qualitative dry eye. The aqueous production may still be the same. The way we would diagnose it is.
With a test that is called tear film breakup time, which is what you are seeing here. You put a bit of fluorescine on the cornea just like you would when you're standing in the cornea for an ulcer, blink the eyelids once so that the fluorescin spreads all over the cornea and then you hold the eyelids. Open eyelids open, prevent the animal from blinking.
Look at your at your watch and see how long does it take before these cracks or breakup of the fluoresce layers appear. You want it to be more than 1015 seconds, OK? That would tell you that it's a stable tear film.
If there is a problem in the production of my volume, such as in this dog, the tin will evaporate much faster and you will get this breakup of the A fluorescein staining much earlier, sometimes as early as 1 or 2 or 3 seconds. That tells you that, yeah, it is qualitative dry eye, the dog is best treated just with artificial tears rich in hyaluronic acid or hyaluronate. Syrosporin may help, but it should be supplemented with hyaluronic-based artificial tears.
OK. What's the treatment for the Mybomatis itself, I mean, is asking, should be treated really with a combination of antibiotics, and steroids, maybe even systemic drugs, topical drugs may not reach the mybomine glands, so systemic antibiotics and steroids, perhaps most important of all, lots of warm compresses to. Stimulate the blood flow into the myboium glands to stimulate production of mybomium and unclog, if you will, the mybomian glands.
We have wonderful movies of colleagues in Japan actually training dogs to blink frequently in order to get the pumps of the mybomian glands operating, so that would be another way to treat them. . Based on the photo, how would, based on the photo, how would you determine Clain versus mybomitis, I mean, he's asking, and the answer islain would usually be just one.
He will see all of them my bombing the whole row being affected and then my la. Is really an obstruction of the duct of the mybo. So I would see one of them severely engorged.
These are not really engorged. You just see them distended and you see a whole row of them that tells you it is my bomitis. Let's move on.
This cat is suffering from glaucoma, anterior lens taxation, posterior lens taxation, or persistent pupillary membranes. Please vote for your favourite answer. And maybe it would go down to 30 seconds rather than 35, try to get through one more slide towards the end.
Wow, what the split up of answers. OK, so, we are looking at a cat eye and the most telling significant finding here is really. A lack of interior chamber or a very shallow interior chamber, the Irish is pushed forward, it's virtually touching the cornea, very, very shallow interior chamber.
It is not an interior lens laxation, otherwise I'd see a lens in the interior chamber. I'm not seeing it. If there was a posterior lens laxation, we'd have the opposite picture.
We'd have a very deep interior, chamber because usually the iris rests on the lens. If the lens fails back, falls backwards, the Irish sort of loses its support and it will also become concave instead of convex. We are not seeing the strands are associated with.
Persistent pupillary membranes. This is actually a unique form of glaucoma in. In cats, we call it aqueous misdirection syndrome.
It's said to affect 1% of elderly cats. What happens in these cats is that with age, they develop abnormalities in their vitreous, they develop pockets. In their cracks and then pockets or blisters in their vitreous and equium or rather than making its way into the interior chamber makes its way into the vitreous through these cracks it gets caught or trapped in these blisters.
And therefore the vires expands in volume and expands and expands and pushes the Irish forward, and that's the telling sign here. The Irish pushed forward and a lack of an interior chamber due to an expanded. Creates a form of glaucoma that is unique to cats, not very severe.
We don't get very high pressures. You could treat them with topical carbonic kind drug inhibitors and they could maintain vision, oops, excuse me, for a very, very long time. Frank is asking, would you expect the cat to have a sore eye noticeable to the owner?
No, again, we don't get very high pressures in these cats. If you have a very observant owner, the last owner I had with this cat came cause it noticed, that the pupil was slightly metriatic, so that would be a sign that a very perceptive owner would, . Would notice.
OK, next, this is an early sign of posterioritis of PRA retinal detachment or systemic hypertension. What are we seeing here? Again, it's a cat eye, so we've had a couple of cat eyes now.
OK, again, very nice division of answers, maybe I should have said earlier it's a cat eye which might have led some of you to misdiagnosis as PRA. Anyhow, it's a cat eye. I'm not seeing hyperreflectivity here.
I'm, to the contrary, maybe I'm seeing slight edoema here, and I don't see any attenuation of blood vessels, so it's not, PRA. The retina is not detached. Everything here is in focus, .
So we don't have that and I'm not seeing any granulomas or lesions, choetinal scarring associated with PRA. What I'm seeing, sorry, with chorioretinitis, what I'm seeing here is slight edoema and a couple of. Peteia or small bleedings in the retina.
These are early signs of systemic hypertension or hypertensive retinopathy in a cat, . If an elderly cat presents you with acute blindness and you see a detached retina, then definitely you should check it, check its blood pressure. However, and if it's more than 200/110, it's definitely clinically significant.
However, early. Lesions with moderate hypertension would present like this some edoema, a bit of petechia, and as the systolic, not the diastolic, as the systolic blood pressure, increases and increases. The lesions become more severe, severe retinal haemorrhage, severe retinal detachment, and.
Blindness. However, keep in mind that these cats do respond very well to treatment, and we have a very nice study from North Carolina State University showing us that if you Treat the hypertension with amlodipine and you treat it successfully, more than half of them will regain vision. So definitely they should be treated for the hypertension and definitely you can give the owners a fair prognosis.
Many of them retain vision. This one is obviously still seeing, it's just an early sign. OK.
Do we have any questions here? Is that an I, OK, I'm sorry. There are two boxes.
There is a chat and there is a Q&A. I, I was looking so far the chat, they haven't seen your questions in the Q&A. Lisa, the previous question was aquis misdirection syndrome.
Kate, that could be unilateral or could be bilateral. Amlodipine treatment, yeah, window of melodipine treatment, that I'm not sure what is the window, but as I said, they do regain vision with the melodipine and they may, the study I mentioned from North Carolina State University shows that. That about half of them would regain vision within 3 weeks, but many of them would regain vision after 2 months or more.
So even if the cat doesn't regain vision after 468 weeks, hey, there is still hope, but it doesn't matter. You still have to treat the hypertension, but again, you can tell the owners there is hope even after 2 months. OK, cats don't get PRAs asks, I mean, very rarely.
OK, what would you treat this eye? It comes from an article out of Australia in 2016. Would you change its diet?
Topical EDTA DVD or superficial cartectomy? How would you treat this eye? OK, again a nice breakdown in answers, .
So we're seeing crystalline keratopathy, probably lipids in the cornea, quite a massive crystalline keratopathy. We make the diagnosis based on the crystalline appearance of the lesion, even though here it's not so noticeable because it's really so severe. A change in diet may actually stop progression, but it will not reverse the situation.
EDTA 5% EDTA, that's interesting, yeah, for many years, we'd use it. It's what I call a grandma's medicine. Grandmas have lots of medicines for us, with no scientific basis.
Sometimes they work, often they don't work. So 5% EDTA in the past, we'd use it, didn't work too well, but a couple of years ago, Doctor Saba, who's the next, Here I found a company out in Florida that makes 14% EDTA or rather 13.8%.
I'm putting its name in the chat box now. So if any of you want want to order 13% EDTA, you can contact the company and order from them. That may be more helpful.
And yes, actually this art. That I'm quoting here recommends diamond burring. I'm not saying that superficial caratectomy is the wrong answer.
You could do it. However, and it's definitely a correct answer. You'd get points for it if this was a test, but that's a more invasive procedure.
You need to be a specialist, you need notification. You need to know what you're doing. Diamond birth, everyone should have in their clinic, and it can give.
Good results. Here is the same eye 2 weeks after diamond bearing, you can see the significant change, significant improvement. Yeah, it's not all gone, but this was a non, unlike superficial caratectomy, it's a non-invasive procedure, topical anaesthesia rather than sedation or general anaesthesia.
Again, today, we would first soak the cornea maybe in. 13.8% EDTA for a few minutes and then buried, and we are very happy with the results.
What was the treatment for aqueous misdirection carbonic anhydrase inhibitors? OK, and again, Matilda, the type of glaucoma was aqueous misdirection syndrome. OK.
just one session for DVD. If you, if you're not happy with the results, go for caratectomy. I can't see the name of the 13.8 EDTA.
It's up there in front of you. OK, next question. You could also cause this lesion.
We said it may be due to, hyperlipidemia or diet, but how would you cause it? By treating the eye with steroids, non-steroidals, gentamicin, or prostaglandin analogues? How would you cause a crystalline keratopathy?
OK, the majority is absolutely correct. That could be a side effect of using steroids both in humans and in our animal patients. Steroids may definitely cause steroid, induced crystalline keratopathy, and when you see it, it's time to switch to non-steroids.
That was, the majority got it correct. OK. Mark is asking, should I have tested this dog for systemic hyperlipidemia?
I'm not sure I would. If it's systemic hyperlipidemia, it would have what we call an arcustipoids. The crystalline keratopathy would be in the shape of a crescent in the periphery.
Here, if you can see my mouse, or here, it would be in the periphery, it would be in the shape of a crescent with maybe 1 millimetre of clear cornea between the limbus and the arc, that would indicate a systemic hyperlipidemia or triliterdemia or whatever, in this one, no, I wouldn't test it. What do you think this cat has, rolling of the third eyelid cartilage, cherry eye, her pettic conjunctivitis, or lymphoma. OK, I am so happy that most of you got the answer correct lymphoma.
OK. So, it's not a cherry, it, it looks like a cherry. I agree with you.
It's nice, round, looks like a cherry, but here is the edge of the third eyelid, the margin of the 3rd eyelid, and this lesion is in front of it, or it's really. A congested 3rd eyelid, a cherry eye would be a cherry, poking its head behind the 3rd eyelid. This, as you can see, is in front of the 3rd eyelid, so it's not a cherry eye.
Nor is it scrolling, that you can see that, yeah, it's straight ahead. There is no scrolling here and there is no conjunctivitis. This may look congested, but look at the conjunctiva here.
Look at the lack of secretions. No, there is no evidence of conjunctivitis here. This is lymphoma.
So yeah, I put this picture up here to remind us that. In dogs and cats, not everything that looks like a cherry eye is infected is a cherry eye. Sometimes it can be a tumour.
We had a horrible case in the our teaching hospital about a year ago, with a dog, presenting with retro bulbar hemungous sarcoma, and when we took the history from the owner. He said that, yeah, just a couple of months ago, a doctor operated on the dog for a cherry eye. And while I can't prove it, I bet you that what the doctor thought was a cherry eye was in fact hemangiosarcoma.
They did cherry eye surgery, pushed the hemangiosarcoma back behind the eye and led to a retrobulbar tumour, with traumatic consequences. So not everything that looks. Like a cherry eye is always a cherry eye.
Please be careful. This would be in dogs, your only indication to take out the third eyelid. I hope that everyone knows that the third eyelid should not be resected, for any reason other than a tumour cause you risk the development of .
Of dry eye. Joe is asking, where do you source EDTA for UK use? I can't, I don't know, Joe, what is the, what's available in the United Kingdom, the company that I provided the website, I'm not affiliated with them, but they are in Florida.
OK. What is the first thing you're gonna check in this dog, obviously. Blood pressure, CBC, renal function, or glucose levels.
OK, again, the majority has it correct. I'm very happy no, oh, sorry, sorry, sorry. No, oops.
I didn't look correctly. I'm sorry. No, the majority is wrong.
Let's go back here. What I'm seeing here is actually multiple granulomas. I would check blood pressure if I would see re haemorrhage or retin detachment.
We spoke about it earlier when we saw early signs of cys. Hypertension. These black lesions are multiple granulomas.
They are an indication of posterior uveitis. Posterior uveitis is often due to infectious agents. In fact, this is a case of cryptococ, cryptococcosis, so if you see granuloma in the posterior retina, you should do a complete blood count.
Renal function is something I would check if I had systemic hypertension, but again, I'm not seeing here systemic signs of systemic hypertension. Glucose, again, diabetes may cause retinal haemorrhage. So answers 13, and 4 are associated with haemorrhage.
These are granulomas. Here you can even see how they partially obscure or obstruct our view. Of the blood vessels, maybe this blood vessel is even elevated over the granuloma.
These are granulomas due to infectious agent. Do your systemic workup for infectious disease depending on what's endemic in your area. .
Any questions here? OK. Is there a possibility to have the handout after the meeting?
Yes, I could send a version of the handout, to the webinar vet. I don't know if they can send it to everyone cause I don't think everyone is a member, but if you are a member, maybe they would post it on their website. So another reason to become a member of the webinar vet.
Let's go on. OK. If there is no discomfort and no fluorescine uptake in the, crystalline keratopathy, then I would probably do nothing.
If there is no pain, if there is no ulceration, I wouldn't treat the crystalline keratopathy. I treat it only when it becomes a clinical problem, otherwise, I would just tell the owners to monitor. Thank you for that important question.
OK, . How does diabetes affect retinal periods if controlled? They usually diabetes, as you know, causes cataracts, but, sometimes it may cause retinal haemorrhage.
OK. In this case, How this is a case of oyofi otitis, so you already have your answer filanosyfiotitis is what we're seeing here. Come and we'll take a cytological scrape to confirm the diagnosis.
How many mass cells or eosinophils do you want to see in order to get a cytological confirmation of the diagnosis? Just 1, at least 10, 3 of each, or 20% eosinophilia in the blood count. OK, this time I'm not misreading the answer.
The majority is correct. Yeah, one is enough cause neither einophils nor massess are part of the normal cellular population in the cornea. So one is enough, not 10, not 3, and el keatitis, which is.
What we're seeing here is completely unrelated to systemic eosinophilia or any other sinophilic diseases in cats. I should note, however, as the question states, yes, you see this kind of lesion, in a cat, you do have to take a psychological scrape for two reasons. Number one, you want to rule out squamous cell carcinoma.
OK. This may, you know, you see an infiltrative lesion in a feline cornea with some blood vessels, etc. Yeah, you should definitely consider squamous cell carcinoma, which can only be ruled out with a psychological scrape.
Number 2, felineshilic carotitis is gonna be treated with Steroids most frequently or other immunosuppressive drugs, these may cause reactivation of latent herpes and recurring herpetic keratitis or conjunctivitis. So before I use steroids on these cats, I won't get the justification. The psychological confirmation, I'm not just going to throw steroids at the cat unless I'm sure that, they need it.
So I would need a scrape. How do you take a scrape, Carolina is asking, put a top of tropical anaesthesia and use the distal end of your scalpel blade. We have Very nice study from the University of Florida showing you that this gives you very nice cellularity.
They compared it to a spatula to a cyto brush. No need to go to the expensive instruments, just the distal end of a scalpel blade and it's quite vigorously. Don't worry, you're not gonna perforate the cornea.
And that also answers a means question. I would just use a blade. I'm not using, not a brush, not a scrape, nor am I using a cotton tip, Chantal, that wouldn't give me enough singularity.
No, the blade, not the handle, Cumbria, the thistle, and the one that is mounted on the handle, not the cutting edge. OK, next. Is this an eye with UBI is glaucoma conjunctivitis, or is it a normal eye?
Sorry for Anthony, next time we should have background music. I could play my guitar, I suppose, wrong. OK.
From the next question, go get it. OK. Oh, again, nice, split of the vote.
So, UVIis, glaucoma and conjunctivitis are, and I'm sorry for the misspelling here, are definitely the three differentials for a red eye. However, this eye doesn't have UVIT. Look at the pure cornea, it's completely transparent, so it's the aqueous humour, and there is none of the diffuse red flush that is associated with UVI tis due to ciliary injection.
It's not glaucoma. We do have one prominent episcleral vessel, but it's just one. And for the same reason.
Yeah, I'm not excited by the conjunctable blood vessels. I'm not seeing any signs of conjunctivitis. There is no discharge or anything.
So actually this is a normal eye. I know that when you're in a test or session such as this, saying it's a normal eye is always the most difficult. Answer to provide, but in fact this is normal.
Again, one prominent epicleral vessel does not make it glaucoma. No diffused red flash, no indications of conjunctivitis, no red, porneal edoema to suggest uitis or glaucoma. This is a normal eye.
Wrong, that was a tiny bit mean for everybody. Oh, OK. Take out your guitar and make it up to them.
OK, first thing to check in this cat. Again, maybe it's a normal eye. I said it's a tough call.
Would you take a complete blood count, blood pressure measure blood pressure or urinalysis? What would you do with this eye? OK, excellent.
You are doing very well. Complete blood count. It, what the prominent lesion you're seeing here is all these grey circles, and this is hyperplasia of lymphatic follicles in the cat iris.
I'm also seeing if you're looking carefully some so called dirt on the The inner aspect of the cornea, we call it sporadic precipitates. Maybe that's tough to pick up, but you see all these grey circles, they are very prominent, as I said, hyperplasia of lymphatic follicles. This suggests that this is an eye with uveitis, and if it has uveitis, the first thing to do is take a complete blood count.
Blood pressure, as we said, with something we do if we see haemorrhage, and then if we confirm. Systemic hypertension maybe we test renal function with urinalysis. However, nothing in this pictures suggests we go down this route.
These follicles suggest UVITs work up for . For UVITs, Sayed is asking Boussaka nodules. Wow, Sayed, I must admit I've never heard of Usaka nodules.
If Doctor Sebag is with us, can perhaps he can jump in or else ask him afterwards. It's emphatic follicles. Mark is saying normals are really good to see, very useful.
OK. Anthony, at least one person was not upset, didn't think I was mean by showing a normal eye. So that's good to know.
With this UVI this is the pupil shape abnormal and related. Yeah, thank you for pointing out, Mark. This, pupil shape is also abnormal, and that may be another indication of UVI.
OK, this next one, you have a 50/50 chance of getting it right. You measured tremor of 7 millimetres per minute in this eye. Will you prescribe cyclosporin?
Yes or no? OK, I wouldn't either. 2/3 of you said you wouldn't, and the answer is no, we wouldn't.
When we talk about sherber's values, we say that we want to see them above 15, which is normal, less than 5 millimetres per minute is diagnostic of dry eye. 5 to 15 is what I call the grey zone. Maybe the dog has dry eye, maybe it doesn't.
We confirm or exclude the diagnosis based on the presence of other clinical signs. And in this case, there are no clinical signs of dry eye. You can see there is no discharge, the conjunctiva is not congested.
You can see the bright reflection of the camera flash on the cornea. It's a bright. Healthy looking cornea with no signs of keratitis.
So there are no signs of KCS here and therefore, as I said, in some dogs, 7 could be associated with signs of dry eye, in which case, yes, I would prescribe cyclosporin. In others, 7 would be absolutely fine, and I wouldn't prescribe. I had another teacher who says we treat.
Signs of disease, we don't treat results of tests, OK? And that's true for blood count, systemic hyper blood pressure, a radiography or Shimmer tier test, OK? 7 may be normal, maybe be abnormal.
Look for the clinical signs. Don't just rely on numbers generated by tests. So the 2/3 have it correct.
7. How would you determine normal or something called KCS? I mean, I wouldn't.
I'm just calling it a normal eye. OK, this I previously suffered from corneal perforation, glaucoma, melanoma or uveitis. What did it have in the past?
Anthony, I'm missing your guitar. OK. Again, nice split of the votes, but the majority has it correct, UVITs.
So this is the horse eye, but it could be a dog eye for all you care. Number one, I'm seeing a very dark iris which suggests UVITs, but Really, the telltale sign here is what we are seeing here, pigment on the interior lens capsule. This pigment, which we call iris rests, tells me that there used to be posterior sinicia in this eye.
The iris was adhered to the lens due to uveitis. We were able to pharmacologically dilate the pupil with atropine and sort of tear the iris away from the lens. Maybe we even injected tissue plasm and activator into the eye in order to break down the adhesions between the iris and the lens, but as the iris was torn off the.
Of the lens, it left these rests or these footprints, if you will, fingerprints. It left iris pigment on the interior lens capsule that tells me that it was UVI. It's not melanoma because again I'm just seeing pigment on the.
Lens capsule we've seen before pictures of what iris melanoma looks like. It may be focal, it might be diffused. Here the entire iris is dark so it doesn't look like glau melanoma.
Definitely doesn't look like glaucoma. I'm not seeing any signs of . Corneal edoema, a little bit that I see of the.
A sclero conjunctiva here doesn't suggest any episteral congestion and the cornea looks completely intact, no signs of perforation. So this pigment, the iris rest, is a sign of previous uveitis. I mean, it's asking the previous case of cat ubia, it was hyperplasia of lymphoid follicles.
That tells me it's uitis, hyperplasia, of the lymphatic follicles. OK, I think we've got time just for 2 or 3 more que questions. So we're doing OK for time.
What will be affected in this patient? The dilation of the pupil, the constriction of the pupil, intraocular pressure, or night vision? What's affected in this patient?
OK, again, I split of the votes, but 54% vote for constriction and indeed the majority is right. This is a case of irri atrophy typically seen in elderly sinile patients, be they dogs or cats. I am seeing that the pupil is not completely round.
There is really missing pieces of iris here. And here, and I'm seeing some holes in the Irish here and here and here. So, rather severe case of Irish atrophy.
Now, as we know, the iris has two antagonistic muscles. It has a constrictor and a dilator. The constrictor is a radial muscle, circular muscle that's located here near the pupillary margin.
The dilator is tang tangential muscle that goes all across. Like that OK. And therefore iris atrophy, which, as you can see, affects the pupillary margin of the iris, affects mostly the constrictor muscle, therefore the pupil will not normally constrict.
These patients will present with abnormally dilated pupil because the dilator is healthy but or unaffected, the sphincter. Is mostly gone, so, abnormally dilated pupil, minimal constriction. It doesn't affect intraocular pressure the I I put it here as a red herring.
Yeah, theoretically aqueous could flow through these holes from the posterior chamber into the interior chamber, but it doesn't affect IOP. And actually, if the pupil is abnormally dilated, night vision may be improved. It definitely won't be.
Hampered. So iris atrophy, senile patients, David Bowie would agree, says Carlos. I don't think David Bowie had iris atrophy.
That was actually an injury to his eye at a very young age of 5 or so. But yeah, nice tribute to, David Bowie. Anything we can do for Irish patients?
Asks I mean. I'm sorry if we find a treatment for old age, that would be nice. Please let me know.
OK, normal or abnormal? Yes, no, again, fifty-fifty, no question. Anthony doesn't like the fifty-fifty questions.
He thinks I'm being mean, but Oh, what a nice bit of the vote, by a very small margin, the nays have it, the nays are correct, . This is abnormal, and what's telling me it's abnormal is the fact that the margin of the optic disc is very blurred. It's not as sharp as it should be, and it's also very congested if I follow some of the blood vessels like this one, even though it's a two dimensional picture, you can see that.
The blood vessel really has to climb to reach the surface of the disc. This one too, it has to climb because it's a very congested optic nerve head with fuzzy margins. This is a case of optic neuritis, which leads me to my next question.
What is the most common cause of optic neuritis? GME idiopathic distemper or blasto. OK, majority voted for either idiopathic or a GME and by a very small margin, idiopathic is right.
Yes, when we see a case of Optic neuritis, obviously we need to do neurological and systemic workup looking for causes. They may be infectious, they are very often GME or MUE meaning gophalitis of unknown aetiology, but in fact, the most common cause is idiopathic. We do a comprehensive workup and we find nothing, which explains why the prognosis for optic neuritis is so bad.
Again, a large study from North Carolina. State University, they studied 96 dogs. 72 of them had long term follow up.
50 of the 72 remained blind, so very poor statistics. More than 2/3 of them remained blind. Don, I'm gonna skip through this question and jump with your permission to the last one, so if you can, I know, skip through the answers and, let's see who has the sharpest vision.
I want to conclude with this question. Cat, dog, or horse. Not really a clinical question, but something to chat over dinner or impress your date, next time you are going out to the pub.
It has to be cats. Anthony, the host cannot vote. I can see, but I think it must be the cat.
OK, I will. OK, the, the majority goes along with Anthony, or I should say maybe the majority was misled by Anthony. Most people, when I ask this question, say the cat.
In fact, the correct answer is the horse. The reason I put this up here is to entice you to go to the webinar vet archives if you are a member and watch my lecture on. Vision in the animal kingdom, and then you would understand why the cat actually has the poorest vision and the horse has the best vision.
I'm one minute over the limit, so I know that Anthony is going to introduce the next speaker, but I must, say a word about my friend, my colleague, Lanel Saba. He's French, sorry, nobody's perfect, but he originally from France, but he trained and worked in the United States for eight years, moved to Israel, 3.5 years ago, .
And I couldn't ask for a better colleague, a great teacher, a superb clinician, a brilliant researcher. I'm sure you'll enjoy his talk about a huge pandemic that affects all of us, the brachycephalic syndrome in dogs. Thank you very much, everyone.
Good night, and I will try and send out the handout through the webinar vet if you have an account with them. Thank you so much, Ron, for that, that was amazing and I think it really summarises that phrase which is the eye is the mirror of the soul. Yeah so much interesting information there and I'm sorry for misleading people at the end.
I, I should have been quiet and I should be looking at all the webinars. But Ron, I do er thank you for the, the plug there. We obviously think it's great as well and .
It's a real opportunity for people this week with a with a reduction in the price. We'd love you to try it. Different areas of the world, it's a different price so do go on and have a look.
And if we can help you with your training to make you an even more confident vet or nurse than you are, then we'd love to be able to help. So, really excited to listen to Lionel and I think he doesn't need introducing after Ron's very fulsome praise of him, but I'm gonna fill in the gaps a bit . I actually like the French, so Lionel, you're OK here, I go to France every year.
I think it's a beautiful country with beautiful people as well, so feel us home. Mhm. But, but, Lionel qualified from the, veterinary school at Toulouse.
He then completed a rotating internship at Kansas State University before pursuing a four-year residency in comparative ophthalmology at UC Davis. After his residency, he went to Iowa State to complete a PhD, so he's really crisscrossed the country here. And he completed his PhD in, in biomedical sciences focused on pharmacology and ocular disease models.
As Ron said, he's moved to the Corette veterinary school in Israel and his clinical interests and researcher interests are in ocular surface diseases, te film biology, and innovations in drug delivery to the eye. We know there's a pandemic of brachycephalic dogs, you know, I feel deeply sorry for them because we see them on a regular basis. With terrible eye disease, and Lionel, I'm hoping that you can give us some sort of insights as to how we're able to help these, these dogs, so thank you so much for agreeing to talk tonight.
It's over to you. Thank you very much, Anthony and Ron. The feelings are shared and .
So happy to be in Israel and be able to work, in your presence. So, I hope everyone can hear me and can understand my French accent. It's a real pleasure to be here even if it's virtually with, this audience.
And And over the next hour, I wanted to share with you some insight about truly a pandemic of ocular diseases in brachycephalic dogs. I think as veterinarians, we're well trained about all the respiratory signs and what can we do to improve the respiratory syndrome in these brachystatic dogs, but more and more I think the ocular issues are. A concern to the point that many of these dogs can can lose vision or even their eyes at a young age if we're not careful.
So, I'll, if there are some questions that I can answer in the middle, I'll try to do so, but otherwise, I, I can go over my lecture and in the end we have enough time for, questions and answers. This is the outline of my presentation. I'll go over some background initially and then dive into why ocular disease is so common in brackysyathic dogs.
There are really three main components including anatomical abnormalities, poor corneal innervation, and dysfunction in the tier film, whether it's quantitative or quantitative. And then it's important for us to understand that not every brachycemphatic breed is born equal, and even in every breed, there's some dogs that fare better than others. And really the, the last aspect would be to focus on What can we do as a veterinary community to improve the ocular health of brachycephhatic dogs?
As a background to this topic, I came across this very nice survey from Nationwide, which is the, the largest insurance company in the US and they also provide pet insurance. And a few years ago, they came out with kind of a prevenance study of what were the most common claims. In in their pet population.
And so they really surveyed more than 27 million dogs and they included 24 brachycemphatic breeds that you see listed here on this slide, and they compared the prevalence of different diseases compared to non-brachycemphatic dogs. So it's a very large population that was surveyed and as you can see here, the in green, the most common claims with a significant frequency increase where corneal ulceration and ocular trauma, so an increase in brachyymphatic dogs compared to non-brachyiphatic dogs, and what you see here in blue is really the percentage of how much more likely a dog that is brachycephhatic will have to have a claim for that disease compared to a non-brachycehatic. So really on top of the list you see conjunctivitis as well as other issues that we're all familiar with, such as pyoderma otitis externa.
Well, really on top of the list are actually ocular issues. And when you dive in into those kind of three most common claims that they received corneal ulcers, conjunctivitis, and ocular trauma. In blue, you have the claims from non-brackyiphatic dogs and in green you have claims from brachysephatic dogs.
And in some brachysipphatic dogs were 3 to 4 times more likely. The non-brackyophatic dogs to injure their eye and specifically the corneas, the front of the eye. And that was the highest difference in any of the conditions that they studied, including dermatitis and other issues.
Probably the more fascinating findings are actually many studies coming out of the UK. Now I must admit I'm a big fan of this type of studies. Over the past few years they've been quite popular and a lot of them out of the United Kingdom, I presume that you have a, a, a really comprehensive medical record system of multiple practises and that allows you to, to look at.
Large population of animals. So if you focus on the upper study here, it's a survey of over 100,000 dogs, and they looked at the prevalence of corneal ulcerative disease. And brachyymphatic dogs, it's quite shocking, but they had 11.2 times the odds to be diagnosed with a corneal ulcer compared with a crossbred and non-brachycehatic dogs.
And the study in the middle is the same idea, but looking at dry eye disease or curra conjunctivitisika, and here that survey was on over 350,000 dogs, and brachycephatic dogs had 3.6 times the odds for having dry eye compared to mesosyphhatic or non-brackyymphatic dogs. And the last one, also a recent study from, from two years ago, was looking at the prevalence of cherry eye, and here again it was quite significantly higher, 6.7 times the odds to develop cherry eye in brachycephalic dogs.
So these studies are actually studies from a general practise population, not from specialty practises. So I really like it because it's quite representative of what's going on out there. But, realistically, this issue is even more magnified when you look at specialty practises, whether it's teaching hospitals or multi-specialty practises, and cases referred to ophthalmologists, by far, brachycephhatic dogs are the most common types that are presented to an ophthalmologist with an ocular issue.
And when you look at the many different studies out there on conjunctable grafts and corneal grafts and, and, and autologous corneal transplants and a bunch of corneal surgeries to stabilise the deep corneal ulcer. The vast majority of dogs that are described in these studies are shih-tzus and pugs and bulldogs and all these brachycephhatic dogs. So this is, for instance, an example of of a surgery in a pug that had a deep corneal ulcer.
So I think it's important for us to recognise and better understand why. An ocular disease and especially in ocular surface disease affecting the conjunctive and the cornea. Why is it so Hispanic dogs and I'll start with the main issue which is a confirmation or issue anatomical abnormalities, and the list is very long.
Those are all the issues that brachy symphatic dogs are born with. Not all of them have, you know, all of the issues listed here, but often. Dogs have multiple abnormalities that are listed in this list.
The, the first one is a shadow orbit. If you look at the skull of a brachycephhatic dog. There's really not much space for the eye to to be when you compare it to the skull and the orbit of a doosyphhatic or mesosyphhatic breed.
The the size of the eyeball is actually quite the same and quite preserved among breeds, but since the orbit is much shadower in brachycehatic dogs, then the eye is bulging forward anatomically. Because of the very short skull, it also affects the drainage of the nasolarymal duct and, and the, the drainage of the tears from the ocular surface to the nose. Typically, if you're seen in a normal duct, you should have two cannaliculi connecting into a lacrimosac and then through the maxillary bone, you have that nasal lacrimal duct.
Going into the nasal punctum. When you look at a CT scan, a contrast dryocysto rhinography of a brachycephhatic dogs, you can see that the nasolarymal duct is kinked, it's kind of taking really sharp angles and this affects the efficacy of the, the this drainage apparatus. And that's one of the big reasons why dogs that are brachycehatic have excessive kind of serious discharge out of their eyes.
The eggs of thymus is the bulging outward of the eyeball. And that is primarily because of that shadow orbit that we discussed previously. You can see it quite well if you look at these dogs from the side, you can see how both That I eats and you have to differentiate that from, you know, a dog that has boomus, like a very large globe from chronic glaucoma or a globe that has proptosis where the eye is dramatically come forward out of the orbit.
Another anatomical abnormality is a large palpebral fissure, a large eyelid opening that is called a macro palperal fissure. Seeing these dogs, the diameter of the eyelid opening is actually larger than in non-brackycemphatic dogs, and there's this excellent study from 2015. Showing that merely a 10% increase in the eyelid opening more than triples the risk for a given dog to develop a corneal ulcer.
So even a slight change in how large or small the eyelid opening is can quite dramatically affect the corneal health and the risk for that specific dog to develop a corneal ulcer. Because of the large eyelid opening and the eggs of thymus of these brachycephalic dogs, a lot of these patients have lack of thalmus, which is an incomplete closure of the eyelids. Look at this video here when I'm stimulating the palpibral reflex.
You can see that there is an attempt to blink, but the blinking is incomplete. And you don't see really the upper and the lower eyelids joining together, and this is not related to a facial nerve paralysis or paresis. It's purely just an inability for the eyelids to fully cover the eye because of the large eyelid opening and the eggs of thymus that these dogs have.
And if you take it a step. Owners when, when your dog is taking a nap or is sleeping, do you see the eyelids fully closed? And the answer is often no.
Often these dogs would sleep with their eyes partially open and you If you try to do that yourself, just keep your eyelids open for just 30 seconds, you're gonna start feeling some dryness and irritation. And that's one thing that is just chronically affecting these dogs, that incomplete eyelid blinking is a major concern as well. Another anatomical issue is what we call nasal fold trachesis, which is kind of hairs and fur from the nasal fold that are long enough and they touch the ocular surface.
It's quite prominent in certain breeds such as the Pekinese. But I see it also in shih-tzus and other bracketsephaic. So the tracheasis, those normal periocular hair that are touching the surface of the eye, can also come from the lacrimocharanco, which is kind of a conjunctable fold or a tissue in the medial canus from which you have long hairs that are growing and that they can touch the ocular surface.
You can see a good example in this picture. Some of these dogs also have entropion of the medial aspect of the lower eye. So the middle third of the lower eyelid is often rolled inward, and you can see here in this picture that I can see the iodine margin quite well.
Until this portion of the aid where it's rolled inward and the hairs are rubbing against the eye, and that's another reason you remember that here is the location of the nasolacrimal duct. The opening of the nasolaal duct starts here and here, so this entropion kinks the opening of the nasolaryal duct and participates to that excessive ocular discharge. And not all, but many of these dogs are also predisposed to have abnormal eyelashes that are originating from the Mabomian glands, and then you have the eye.
Yeah, coming out from the ID margin. This is called a dysychia. You see all those hairs, 36.
Those are classic dysychia, and they, you can imagine that they grab against the surface of the eye and cause irritation. And the other type of ya that is even more concerning is those ectopic ya. They also originate from the magbomium glands, but instead of coming out of the ID margin, actually protrude out directly through the palpibral conjunctiva, and that is a stubby eyelash that is a common cause of corneal ulceration in brachycephaltic dogs.
So More on top of these anatomical abnormalities that we see in many brachycepatic dogs, these dogs naturally have a reduced corneal innervation, and I'll explain here why this is important and why this is predisposing them to develop corneal. So, if you remember from Your anatomy classes, the cornea is the most densely innervated tissue in our body. And Just there to sense pain when you have a corneal ulcer.
Corneal nerves have a lot of physiological components and importance in sensing the dryness and stimulating tear production and promoting epithelial barrier integrity and so on and so on. And so You can check as a clinician or a researcher, we can evaluate the corneal sensitivity with a device here that you see on these images called a cachet Bonnet aesthesometer based on on two Frenchmen. It's a device that has a thin nylon thread that you can approach to the central cornea and kind of touch the, the central cornea, and then you can shorten or lengthen the length of your nylon thread.
And the shorter the thread is, the more pressure it applies on the cornea and you can correlate it with a corneal sensitivity measurement. And so here, a study that well. Years ago, evaluated healthy brachycephhatic dogs compared to healthy non-brackycephatic dogs.
And you see here that the corneal innervation, the sensitivity threshold, was nearly 2 times higher in the non-brackyymphatic dogs compared to a brachycemphatic dog. And, and those are studies in healthy patients, not ones with corneal ulceration. So Yeah, again, the corneal nerves are so Key and central in promoting ocular surface L.
You see that the, the corneal nerves that you see here in, in yellow, they're the initial trigger for the for the brain to promote blinking and to promote lacrimation with tearing on the ocular surface. So, when the, when you have healthy corneal nerves, it's very important for the dogs in terms of protection with the healthy blinking. They also release growth factors for the epithelium, and it's the afferent pathway for the aqueous secretion as well as the lipid secretion in, in the tears.
In contrast, when you have poor corneal innervation, whether it's from a disease or physiologically because you're a brachycemphatic dog, then you can have a disrupted epithelial barrier. Yeah, a quantitative cheer film deficiency as well as a qualitative tier film deficiency. And so if we now dive in into the 3rd component of why disease is common.
Because of the quality and the quantity of the tears, which are very important to keep the eye lubricated and healthy. So if you remember from your anatomy and physiology classes, you know, the tears are kind of a complex fluid made out of three main components. The outer aspect of your tears are, are, is a lipid layer that is secreted by the mybomian glands in the ads.
The kind of central component of your tears, and that's the majority of it is an aqueous, a watery portion that is secreted by the glands of the third aid and the larymal gland. With the aqueous layer as well as on the epithelial surfaces, you have the mucin layer that is secreted by the goblet cells in the conjunction. And so you have mostly two types of dryness that we recognise in our patients.
The first and the most common one is the quantitative deficiency where you have an insufficient tear production and that's classically called KCS or keratoconjunctivitis Zika. And you can check it by doing a schmer tear test in your animal. Generally, normal is 15 or above.
Borderline depends on who you talk to. It can be from 5 to 15 or from 10 to 15. To me, if you have a low tier production, below 10 millimetre per minute, as well as consistent clinical signs such as mucid discharge, conjunctivitis, and keratiti, then it's already quite setting for KCS.
I'm not waiting for the tumour tear test to be 3 or 4 to give this dog a diagnosis of KCS. There are many studies showing that brachyymphatic dogs have a genetic predisposition for developing KCS and if you remember from the background slide. At 3.6 times more likely to develop KCS compared to non-brachyceymphatic dogs.
And those breeds that you see at the bottom of the slide, they are your classic breeds that we see with KCS on a weekly basis. But what's more, what's more interesting because the classic dry eye with the low tier production, that's been recognised for several decades now in brackycemphatic dogs, but what we're now better understanding as an ophthalmology community is the, the quality of the tears is also generally poor in brachycephaltic dogs. And there's this new device called mybography that has been used over the past few years in in recent research publications that allows you to look at those mybomian glands, those modified sebaceous glands that secrete the lipid portion of the tears.
And so this is on the top images, that's an example of what healthy mybomian glands look like this is a normal. Elid margin, and you see all those whitish ducts are the myponium bands. And here you have an example of doing the same test and you can bear.
Mybonian lands, they're really atrophied. They they're very few of them, and this manifests itself with a poor quality of the tears and ocular surface disease as you see in this picture. So more and more we recognise that the lipid portion is also reduced in many brachycephalic dogs.
And in fact, that one study in from Japan noted that over 45% of Presumably healthy shih-tzu dogs had mybonian gland dysfunction. And so it's a risk factor for them down the road to develop ocular surface disease. And the last thing for the quality of the tears can also come from the mucins secretion on the surface of the eye.
If you remember, the mucins are secreted from the conjunctible goblet cells, and this is what a healthy population of goblet cells looks like. You're looking here at the histopathological image of the conjunctable epithelium. And all these magenta looking cells are your goblet cells.
This is stained with periodic acid chief. And in here, there's a study from Shih-tzu doing conjunctable biopsies, and this is the type of image that you get. Very few goblet cells on the surface of the conjunctiva.
And what does it manifest into, into a reduced stability of the tears and a poor quality of the tears and clinically, You can evaluate it with a test called the tier film breakup time. It's a bit trickier to do than the Schumert test, and it's quite subjective. But what this test entails is that you, you apply a drop of fluorescine on the ocular surface, and that fluorescine mixes in with the tears.
And then you manually open the eyelids and you look at the ocular surface with a blue light. And what you're looking at is the amount of time it takes for breaks to to happen on the surface of the tear film. You see here in this image all those dark dots are areas where the tear has evaporated.
And so, a short duration of tear and breakup time means that the tears are rapidly evaporating. A normal tin breakup time in dogs should be above 15 seconds, meaning that when you open your eyelids, Take at least 15 seconds for you to start seeing those dark dots on the surface of the tear film. But in bracky symphatic dogs, there's a study that same study I presented in Shih Tzu dogs, with the average of the tear frame breakup time was much, much lower than what you would expect.
And so, if I summarise here just those kind of anatomical and physiological. Of a seven year old Pekinese that I examined earlier this month and the the question here is what is wrong and you have a Front and an image from the side and the, there are quite a few abnormalities here. You have a large eyelid opening that's called a macropa people fissure.
You have prominent nasal fold trachesis. We did a tin breakup time and it was low and the eye is bulging forward called exohaus and all of that. Is promoting the eye to develop this diffuse pigmentation on the cornea, pigmentary keratopathy, and dogs are losing vision from, from, from this pigmentary changes, and this dog is still relatively young.
Another example here, that's a 2 year old shih-tzu dog that we examined earlier this month, and again, what is what is abnormal here. You have a long list, macro pad paper fissure. This dog also had an incomplete blinking called leg of thymus, nasal fold tracheasis that you see from here.
There's currancular tracheasis, medial lower idlid and ropion, and, and you see that all of this develops keratiti on the surface of the eye, those blood vessels and fibrosis that you see on the cornea. And so if I, I, I summarise that section here, you have many Changes that are decreasing the protection of your eyeball, including lack of the and tear film deficiency. And in parallel, you have many changes.
Is the globe irritation such as tracheasis, entropion, dysthychia, and so on and so on. So these dogs are overall at a high risk for developing ocular surface disease or ocular disease in general compared like a proptosis where the eye comes out of the orbit traumatically and that's a common condition for them to lose vision. They also are at risk to develop chronic ocular discharge.
Kerato conjunctivitis Zika, and probably the most concerning for us is a corneal ulcer. You see here three examples of corneal ulceration. The thing to realise is that once these dogs develop a corneal ulcer, these ulcers tend to deteriorate and worsen very, very quickly.
There's a really excellent study out of Japan, that kind of looked, it did a survey of corneal ulcers presented to their specialty practise and they kind of graded the, the ulcers in in three different types. Grade 1, that's an example where you just had, it's a superficial. Non-complicated ulcer?
Grade 2 was you start seeing some stromal loss that's a more complicated ulcer that is deeper. Is your really extremely complicated case with a perforation of the cornea and here you see part of the ua, part of the pupil sticking out. And so they looked at That you see here in dark grey and non brachycephhatic dogs with those dashed lines and the frequency this is at the time of presentation on day one when the dog comes to them.
Most of the ulcers diagnosed in non-brachycemphatic dogs were grade 1, meaning just the superficial uncomplicated, but most of the dogs that were brachycemphatic and came to them for the first visit, they either had a grade 2 or already a grade 3 corneal ulcer. This is another recent study from last year published in the Canadian Veterinary. At risk factors for corneal ulcers in 347 cases.
And here again, that study showed that the brachycehatic dogs had nearly a 2 nearly a threefold greater risk to have an ulcer, but similar to the Japanese study, they also saw that if you diagnose an ulcer, it's more likely to already be a complicated with a deep ulcer if your patient is a brachycephhatic dog. Look here at the different classification of ulcers that they had, whether it's a simple superficial ulcer, whether this is a scab, this is your boxer or indolent ulcer. And a complex deep themeto set and so on.
When you look at those complicated ulcers, your your posterides are the the shih-tzus and pugs, and Boston Terrier, and, and English bulldogs, and, and so on and so on. What's interesting to understand is that not every brachyymphatic breed is born equal. That's a study of brachyymphatic ocular syndrome in 93 dogs, and they looked at what is the most common complaint that each breed had.
So a corneal ulcer was most prevalent in, Boston Terrier, for instance, and they take here the shih-tzu as a reference versus KCS was most prevalent in Boston Terrier and English Bulldog. Pigmentation of the cornea was most prevalent in Boston Terrier and so on and so on. So, so there are different changes on the ocular surface, whether it's scar tissue or pigmentation or a tendency for corneal ulceration that is slightly different among brachycephalic brains.
And I'll take it a step further within the same canine breed, not every dog is born equal. And so these are just city images of a happy pug and a sad pug. Not only because of their smile and and really sad face, but you see here that the anatomy of the eye in this bag is actually amazing for his breed compared to the right picture where the bag has really bulgy eyes and at risk of developing lots of different changes.
I want to take just 2 minutes to focus on on the shih-tzu dog, because by far, out of all the brachycephhatic dogs that we see in ophthalmology, the shih-tzu is the most common. Yeah, in my particular practise, it's about 20% or more of the dogs that we examined total and this trend is also true in other clinics around the world. And so I was particularly interested in why the shih-tzu is even worse than, let's say other brachycephalic breeds and so this is a study that I published a few years ago.
Looking at a lot of parameters in the shih-tzu dogs, including the blink rate, the corneal sensitivity, the aqueous tear production, tearin breakup time, and so. I won't go over the details of everything, but this is just to highlight again something that I discussed earlier. These are healthy shih-tzu dogs, and the average tear frame breakup time was quite low, 5.3 seconds.
And this ties up with my biography studies that I showed you where a lot of these shih-tzu dogs have poor mybomian land health or low goblet cell density and so on, and those are anatomical issues that we're now better starting to understand and that are part of the problem and, and shih-tzu dogs, even if you do a shimmer tear test. And it's OK. It doesn't mean that this dog does not have dry eye.
It could be a qualitative dry eye, and even if he has enough tears, the tears evaporate too fast and they're not protecting the surface of the eye appropriately. So I'd take the last 1015 minutes to hopefully bring some words of wisdom on what can we do as a a larger community to help with that issue. Part of it, is, at the legislation perspective, there are certain countries such as Norway that have recently banned breeding of two brachycephalic breeds such as the English bulldog and the cavalier King Char, because they, assumed breeding these dogs are a breach.
To the Animal Welfare Act, and that's a cruel man-made health problem. And I, I, it's gonna take a while, and I know the UK are a big leader. Kind of legislation as well.
But I really believe that with time and continued efforts, we would get to the point where it's gonna be more challenging to, to. That you would have to breathe them with certain traits that are less problematic. So there are responsible dog breeding guidelines that are published by the European Union and, and those responsible guidelines really recommend some breed health and conservation plans where a certain entity looks at all the health data for a specific breed and all the published scientific research.
And really identifies each great health concern and provides recommendation. One of these possible recommendation is to breed less extreme based confirmation. For instance, finding animals that have a, a, a lower palpyro fissure opening.
If you remember from the from the initial slides that even reducing by 10% the fissure opening, which is not dramatically changing the appearance of the dog, can reduce by threefold the risk for corneal ulceration, and that's very significant. And there are also guidelines set up by specialty institutions such as the European College of Veterinary Ophthalmologists and, and so on and so on. Another aspect of, that can be that, that can be looked at is owner education.
And, and you, are the front line of meeting these owners of a a Shih-tzu puppy or Pug puppy or during the initial visits for vaccinations and, and, and space and so on. And I think this is really the best time to educate. Of the respiratory issues, but also the ocular issues.
And what I, I, I tell them when I get that opportunity, I tell the owners that it's not a matter of if, but really when your dog is going to have an eye issue and there are steps that can be done to reduce the likelihood that it would happen or if it happens, improve the clinical outcome. The key thing that I think all of us should really recommend our owners to do is to get the dog used to receiving eye drops earlier in life. I'm gonna show you here a video of a dog that I'm trying to apply an eye drop to.
And I cannot get anywhere close to this dog, and that's becoming very, very common. I actually just had before this talk, I was in, in, in my practise and I had a one year old shih-tzu with a corneal ulcer, and the owner cannot give him eye drop at all. And obviously the outcome of what I can recommend.
And what can we do, will, will dramatically change if they cannot give topical medications. And so what I recommend is earlier in life as part of the routine care for, for the head and the periocular hair and so on, is to apply artificial tears once or twice a day, make it a positive experience with treats and positive reinforcements and so on. That also helps with the ocular surface health, but primarily it gets the owner and the dog used to putting eye drops and not wait.
Later on in life when the dog is 1 year and a half for 2 years and has an ulcer, and then they cannot treat it at all. So regular, in addition to that, doing regular grooming to keep the periocular hair short, get pet insurance would definitely help even when an issue happens. I ask people to have really a low threshold for concern because of that likelihood of a rapid deterioration of a corneal ulcer.
So if they see a red or squinty eye, maybe not wait 2 to 3 days to come and see you. I really try to get it addressed sooner rather than later. And more and more we get people send us .
Images to our WhatsApp or by email and saying, hey, what's going on? Should I be worried? And unfortunately, unfortunately many of these images are of poor quality and we get a a a a shot from.
Across the room or something out of focus or we can barely see the eye. And so in our service, we really developed some tools and kind of guidelines for people to get better images and that can help with kind of the telemedicine aspect of things. Yeah Marian, what we can do a big portion of it is owner education, just like I mentioned.
I think that doing a a a a routine ophthalmic examination is part of your physical exam for vaccinations or later on in life, and consider doing a Schumer tear test, especially if you have ocular surface inflammation or if the patient is kind of more on the older side, you have a shih-tzu that is 9, 1011. And that is coming for a routine exam, then you can consider doing that because you may find out dry eye earlier on and the prognosis for it would be better. There are prophylactic measures that we can recommend as veterinarians as well, especially, these dogs, if I see a low quality of the tears, or if you see an incomplete blinking when you stimulate the palpibral reflex.
Close their eyelids, then you can know ahead of time that these dogs will probably get some dryness and that they sleep with their eyelids partially, partially open. And so I like using topical lubrication, for instance, and, and ointment such as dras or vitapos, they can apply that before bedtime. And in older patients, if you start suspecting some dry eye.
They can use on the, on, on the daily basis just Tears to help promote a better ocular surface. In many times this owner education and prophylactic measures just with lubrication are actually sufficient, and, and can help really dramatically reduce the likelihood of a coal ulcer and worst case scenario, even if it open, develops, then the owner. can treat it, much, much better.
Sometimes we have to consider anatomical correction, especially if the dog anatomy is quite extreme. And probably the best option that we have to correct this anatomy is a procedure called medial cantoplasty where you shorten the pipal fissure by let's say 10, 20%, but you also address the currancular tracheasis and the medial lower id entropy. It is a procedure that you need to do with magnification because this area has the nasolacomal canna liculi.
But it's not a very complex procedure to do, and this is a procedure I recommend in young dogs. If I see a young animal like a Pekinese or Shih-tzu or a pack with a very extreme confirmation and already with recurrent episodes of ocular inflammation, I can recommend this procedure and you see examples here. This is a shih-zu before the procedure and this is after.
This is the same bag that I showed before and this is after. You can clearly see that now these patients after the procedure can blink 100%. They can naturally protect their eyes better, distribute the tears.
Those are other examples that's an extreme con confirmation that has been improved and this, when you look more closely, that corneal pigmentation is actually now resolving because you improved the ocular surface hemostasis or homeostasis. So rarely I do that last anatomical correction, that nasal nasal for resection. Some sometimes done that rarely in like a Pekinese dog that had prominent nasal folds.
You can also do a resection of that. And the very last one that can be done surgically is to address all those abnormal eyelashes. If I had a lot of dysthychia.
Then you can use cauterry or cryotherapy or different methods to kind of kill the hair follicles and the, the root of all those hair follicles and, and remove permanently those abnormal. So as a summary, ocular disease is very common in brachycemphatic dogs with a higher risk for KCS, cherry eye, corneal ulcers, and so on and so on. Ultimately, owner education is key.
Get the dog used to receiving eye medication earlier in life. Ask the owners to have a low threshold for concern, and for us, it's a good idea to really examine the eyes as part of your annual visits, and consider surgery or referral to surgery if you have a young dog that has extreme eye confirmation and already had recurrent issues at a young age. And and There's a cottage we're working more on breed specific data like the study that I did in Shih Tzu, we did the same in French bulldogs and Bostons and pugs and so on to better understand specifically to each breed, where is the issue and what can we do.
So, thank you for listening and I'm gonna look into the chat here and this. Hi, Anthony, it's the Q and A or the chat? Yeah, I've got some questions here, Lionel, .
Katie's asking what teardrops do you prefer, I think, for the initial ones you were talking about hypermelos, weren't you? Yes, the initial ones to get them used to it doesn't have to be, I, I don't recommend an antibiotic or. Tiers, I do like the products that have hyduronic acid in them, so I'm not sure which ones are commercially available over the counter in the UK, but something that is a bit more viscous than the standard artificial tears, whether it's hydron based, is a good idea to use once or twice a day, yeah, to get the dog used to receiving eye drops.
I I have glaucoma and I'm on Trejolose Duo which I think has some hyaluronic acid in it, so there are definitely drops here that we can, we can use because of some of the irritation of the . Of the medicines that I'm on. We've got Tina asking, are there non-ointment based products that replace assist the lipid portion and qualitative deficiency cases, so I presume she's meaning could we get tablets or anything for that or is it really?
No, that's a very good question. I think that yes, the answer is yes. There are eye drops like based with liposome technology as eye drops that can be replaced that and that's more and more prevalent in.
In the human field, because for us, the most common form of dry eye is that mybomian gland dysfunction. And so yes, there are solutions, eye drops that cover mostly the lipid portion, but since it's just a subs. Syndrome in our veterinary patients.
I don't think it's quite there to justify the costs for it. I still think that a generic kind of hyaluronic-based eye drop or an ointment that would do the trick for the lipid portion. For the average dog.
Wait, Tina's asked another great question. She said, I often see these brachycephalic dogs with the anatomical hair issues, but no lesions or obvious signs of irritation yet. I would love to recommend preemptive correction, but not sure if it is recommended or should we wait for lesions and pain and that's an excellent question.
The the latter. I do not recommend preemptively removing those eyelashes because sometimes those eyelashes are fine. And not irritating, overtly and are not causing much clinical signs, if any.
So in other words, I see that often. In dogs, and it's purely an incidental finding and they never had any ocular issues. Removing those eyelashes can be quite tricky.
It's almost like removing hairs with a laser. It often requires several procedures. It's not a one and done thing.
You. Occurrence is common. The recovery from this surgery can be a bit rough and create corneal ulceration, if you don't do it quite well.
So it's not the most benign procedure to do. So, and more practically speaking, as an answer for your question, if I see those eyelashes and I'm, I'm concerned they may be part of the problem, before I recommend the permanent surgery, I just put it out in a topical anaesthetic. And I take fine forceps and I just manually pluck them.
I do. And I tell the owner for the next 2 to 3 weeks before they grow back, there's not gonna be any eyelashes. I want.
And on whether the clinical signs are resolving or not. And if they come back 3 weeks later and say, you know, All those eyelashes, but I still see redness and ocular discharge and everything. They're probably not a big issue here and I will not go forward with a permanent surgery.
Sure, that's great, thanks, Lionel. Janni is saying thank you for such interesting information today. I really am enjoying the continuing education all the way er in New Mexico.
Nice fresh information. And I must admit, you know, my theory with webinars, webinar that is very much set up for the GP who just wants to get better and become more confident. And I always say if you learn one thing from a webinar, it's and you can take that into clinical practise, it's really useful.
I, I obviously don't practise anymore, but I think if I did the the whole idea, we all know shih-tzus have problems, but actually suggesting to have them on drops from early on, and also, you know, to be examining them regularly with Shermat tests, I think is a is a great idea. So Lionel, thanks for for sharing these sort of top tips with us as . As GPs.
Absolutely. Yeah, yeah, I, I see a huge difference. To me and they're, they're used to receiving eye drops.
It, it just dramatically changed the prognosis for whatever disease I have to manage. Yeah, and If do you think I can still answer a few more questions? I know we're, or is there another.
If you're happy, Lionel, good thing with webinars is it's, it's just up to 9 o'clock, so if people want to freak out, they can do and nobody will notice. So I'll, I'll go over, I'll go over some of the questions that I see here from, Claire Grover. Does, does my Boian grand dysfunction contribute to rapid tin breakup time?
And, yes, absolutely. You have a, a rapid tin breakup time, whether you have a reduced lipid and or a 3 of them would cause a, a rapid tein breakup time. .
Let's see. Yes, so, my human ophthalmologists recommend omega 3 and large fluid intake for better composition of the tier film. The large fluid intake, I'm not sure, but the omega 3 fatty acids, absolutely, there's 2 or 3 publications on, on that that it can help stabilise the tier film as well.
So that, that, that definitely can help. Pigmentary keratiti is being caused by tear qua or tracheosis. Pigment pigmentary changes to the cornea are generally a a nonspecific sign of chronic irritation to the cornea.
So whether it's, it can be from any of the, of the issues that I addressed here. It can be from exposure keratiti because there's incomplete blinking, from dry eye, from tracheasis, from anything that is causing chronic irritation to the surface of the eye. The extra thing is that in, in pugs, where it's the most common, those pigmentary changes, there's presumably also a genetic predisposition for that.
So because some pugs that don't have dry eye or tracheosis or macroreerone and so on, still develop those pigmentary changes. And unfortunately, the, another question is, is there any treatment option for pigmentary keratopathy? Not really.
You can, if you catch it at an early stage, drugs like cyclosporin or tacrolimus can kind of help reduce the progression. They're not strong enough to really fade the, the pigmentation away. But, if it gets to the point that it's 100%.
And, and the patient cannot see, some, including me, have tried doing a superficial keroectomy or cryotherapy. The problem is that the benefits that you would get from removing the pigment with cryo are generally just short-lived, less than 6 months. Comes back again.
So as of today, there's really no good proven therapy to irreversibly remove this pigments. So the best approach is to prevent as much as possible, get the progression to the point that it's not covering 100% of the cornea. There's also a question from Esther, she said maybe I missed it.
Really tough one actually, but for the owners that already have a dog that is aggressive and refuses local treatment, what is the best approach to discuss with owners? It's frustrating is that that's a very frustrating one. Yeah.
One is a pharmacological approach. I've had some luck, you know, with trazodone or gabaptine, or kind of sedatives that they can give by mouth in a treat an hour before applying eye drops. But that's more in, in the short term, if I have an aggressive dog that needs eye drops because of a corneal ulcer that, that sometimes can help.
But if I'm looking at the long term, I think that's really, behavioural, I, I recommend an, an exam with a behavioralist if possible, that, that really, really helps, and that's tricky. I would say that some dogs where the, the options that I can offer to some dogs that I cannot approach and give a single eye drop are quite different. I would go right away to surgery.
Or, or really reduce the prognosis that I'm talking to them. So, a, a behaviourist is helpful, and or Sedation. Hm, yeah.
Lionel, it's great to see so many familiar names. Of course, we don't always see the faces, but, people like Veronica saying thank you for the great presentation. Pally, fantastic couple of webinars, thank you so much.
This is the problem with webinars, you never hear the rapturous applause, but, Casey's saying super helpful. I will recommend starting all my breaky pups, pups on tear replacement drops from now on. Thank you.
Yeah. Awesome. Sally said thank you.
Also, I think remed is a good veterinary HA drop as well as Thalos you over the counter, as Antony said, in the UK at least. Somebody was asking about what you thought about reed, the cross-linked. I'm, I'm, I'm a big fan.
They, finally got to the Israeli market about a year ago, and I've been using that quite a bit even when I was in the United States and, and, and now. I, I, I, I believe it, it's . Because it's a cross-linked hydron that has generally a higher concentration of hydron compared to what you would find over the counter.
For instance, the, the remand, I believe is 0.4% hyduronic acid that is crossing, so it's a bit more stable, and it, it stays on the surface of the eye a bit longer. That was part of my previous research studies where I looked at the retention time of different eye drops and definitely the hydron one or better and cross linked even more.
There's evidence that it can stay for 2 to 3 hours on the surface of the eye compared to 30 to 60 minutes for an average artificial tears. So, it's a good product. It tends to be pricier than other products.
So for instance, it To, to get the dog used to receiving eye drops. I'm not sure that would be right away my go to. You can do that with any cheaper artificial tears, but definitely as the patient gets older or if he has a qualitative or quantitative tin deficiency, that's an excellent product to start using.
Lionel, thank you so much. Also obviously to Ron, two fabulous lectures, the students in Israel are very lucky to have two fantastic ophthalmologists in the department.
