Thank you ever so much for that warm introduction. It's really great pleasure to be back here. And as you said today, we are going to talk about a very, very frustrating disease, phillanchojunctivitis, something that all of us see in the clinic on a weekly basis, sometimes on a daily basis, really a very frust.

Disease, as I'm sure you all know. Hopefully by the end of the talk you'll find it slightly less frustrating, but still a very, very frustrating disease because we have to deal with two factors as it stays here herpes virus and stress. I've been asked to disclose that I have no financial relationship with any products, but actually I do have to make one disclosure which I term shameless advertising.

Many of the pictures that I shall be showing, are from a tech. The book that was just mentioned that I published together with my colleagues David Maxx from the University of California Davis, Paul Miller from the University of Wisconsin Madison, Slater's Fundamentals of Veterinaryology. Last edition came out, a year ago today.

Right, those of you who've been to my former talks know that I always say, if you're going to remember just one slide from my lecture, please remember this one. It's also something I always tell my students and that's all they remember just one slide. And actually I'm going to start my talk with this most important slide.

Which says that really conjunctivitis is one more example of a sentence we always say cat is not a small dog, dog is not a big cat, meaning that our clinical approach to conjunctivitis in a cat and a dog is completely different. Very briefly because we are talking, going to talk about felines, but very briefly, canine conjunctivitis is usually a secondary disease. It's a secondary inflammation enabled in most cases by chronic irritation of the eye, cause the eyes exposed, such as in bracket cephalic breed with a shallow orbit due to eyelash abnormalities such as tracheasis, nasal folds, droopy eyelids, etc.

Elid anatomy such as entropy tropion, dry eye, which is what you're seeing here in this picture. So there is some primary ocular disease causing chronic irritation of the eye that enables overgrowth of the natural flora of the eye, causing this horrible clinical picture of conjunctivitis. And therefore when we are faced with canine conjunctivitis, our primary task is to identify the primary cause of the inflammation.

So perform a thorough ophthalmic exam. Look closely at the anatomy of the eyelids. Look for entropion, ectropion, check the eyelashes, check whether there is the almus, measured tear production.

You can see that obviously tear production is deficient here with the dry looking cornea. Look for the primary cause. I must say, as it says here that I rarely perform cultural insensitivity in canine conjunctivitis because as I said in the previous slide, in most cases, it's really just overgrowth of natural flora of the eye.

In most cases, if I submit cultural and sensitivity, it will come back as staphylococ or streptoco. So waste of my time and waste of the client's money, . Sending cultural insensitivity.

Rather, I'd invest all my time in looking for the primary cause. Once I identify it, I treat it, and if there is any residual inflammation, then you can treat it with topical antibiotics or steroids as the case may be. But the main point in conjunctivitis is that treatment without diagnosing the primary cause will not cure conjunctivitis.

So really in dogs, conjunctivitis is a secondary disease. That's the exact opposite. Conjunctivitis and carot conjunctivitis is a primary disease.

It's caused by primary pathogens that attack, if you will, the cornea and the conjunctiva and therefore in cats, just like dogs, I rarely use diagnostic testing to confirm the pathogens. Going back in to what I just said, in dogs, I don't perform culture and sensitivity because I don't care about the answer. I care about making a about diagnosing the primary disease and treating it.

In cats, I don't bother to do cultural insensitivity. Because I already know the primary pathogens, OK, so that's a big difference between dogs and cats and dogs, I don't care. I care about it and from primary disease in cats, I know what is the primary disease, and really I confirm my diagnosis, based on the response treatment and based on inputs.

So what are the primary pathogens of the, that cause feline conjunctivitis, radical conjunctivitis? Well, we are talking mostly about feline herpes virus, and we'll be discussing it at length today, a bit of chlamydia or chlamydophyla as the case may be, and calicivirus, mycoplasma and blalla are occasionally mentioned. We mention them briefly, but really it's mostly about herpes with a touch of chlamydia.

And I say it's mostly about herpes. In fact, herpes virus is considered the most common cause of feline conjunctivitis. That's because 95% of the cats in the world have been exposed to the herpes virus, and a very important point that I'll return to again and again, 80% of these cats remain latent carriers with the virus establishing lifelong latency in the ganglion of the trigeminal nerve.

So, let's talk about feline herpes disease. Really we divided into 5 stages. We're talking about primary infection, which leads to a primary disease followed by latency, reactivation in the recurrent disease, and long-term complications.

We discuss all of these stages one by one just to give you a better understanding of what you're looking at. At each stage of at each stage of the disease, what should you treat at each stage of the disease. So looking at primary infection, we are talking about the virus being transferred between cats by micro droplets, maybe from the mom, maybe from other cats, especially in cat shelters or households with numerous cats and kittens or contacts with the formites including hands of owners or your own hands.

And In these young cats or young kittens, a primary infection is established and established in three tissues. It's established in the conjunctiva, in the cornea, and in the oral or nasal mucosa, more specifically in epithelial cells in these three tissues. So the virus infects this.

Cells, it replicates in these cells and it causes cytolysis of these cells. And as a result of cytolysis of epithelial cells in these three tissues, we have conjunctivitis, we have corneal ulceration, and we have respiratory disease or rhinitis. So we now have a primary herpetic disease caused by viral replication and by cytolysis in these three tissues in the kuntiva, in the cornea, and in the respiratory pathways and therefore we get clinical signs in these three tissues.

Primary disease, herpetic disease is characterised by conjunctivitis, and we're talking about. Acute conjunctivitis with very dramatic hemosis, conjunctival hyperemia, and severe purulent discharge, such as you can see here. Due to corneal involvement, we'll get corneal ulceration and corneal ulceration can be one of two types.

We can have what's called dendritic ulcers and dendritic ulcers takes you back to what I said earlier that the virus establishes itself in the trigeminal nerve and spreads through the trigeminal nerve and replicates at the dendrites. The trigeminal nerve and therefore you get these dendritic ulcers that you can see here you can see here and you can see stained with rose bengal here and as it says here, sometimes you will see them only with rose bengal, which stains known by the epithelium ulcers have to be deeper and involve the trauma in order to get positive floors in stain. But never mind whether you are saying dendritic ulcers with rose bengal or with fluorescine.

If you see a dendritic ulcer, that's really half anemonic for herpetic ulceration because again of the involvement of the trigeminal nerve. The second type of ulcers that we can see due to herpes is what we call a geographic ulcer, geographic meaning it's a large area of ulcerated cornea, usually superficial and you can get a sense that in both of these eyes we are seeing superficial ulcers. Unfortunately, they can sometimes become infected due to secondary bacterial contamination and infection, and then they become much nastier, they become contaminated, which is what you were seeing in these two upper pictures here, contaminated melting ulcers, and here we have actually dematocele and also reaching all the way down to the membrane.

This guy here definitely requires surgery if you want to save the eye. So, again, we, have ulceration of the cornea, we have also conjunctivitis and sometimes the conjunctiva can also becomes ulcerated, such as what you are seeing here, and this ulceration of the conjunctiva and of the cornea is the basis for simon. Simpleferon is adhesion.

Of the quantum tiva to the cornea, it's a complication of her head infection which I shall be discussing in a minute, but here you can see the basis for it and ulcerated cornea, sorry, cerated conjunctiva coming in contact with an ulcerated cornea, two ulcerated tissues stick to each other and you have adhesions between the conjunctiva and the cornea or yo. So as I said, we have involvement of 3 tissues. We talked about involvement of the conjunctiva and the cornea due to replication of the virus in their epithelial cells, and we also have involvement of the upper respiratory tract again due to.

And yolysis of the epithelial cells and the cat would present with rhinitis or rhinoceitti, lethargy, fever, sneezing, nasal discharge. I'm sure you've all seen these pictures. This is a sick cat.

So really we have a very dramatic disease with dramatic conjunctivitis, with corneal ulceration, with upper respiratory disease, very dramatic disease, but usually a self-limiting disease, self-limiting disease. Usually within 10 to 14 days, the virus will establish a latency. It will establish a latency in the trigeminal ganglion, as I mentioned.

Unfortunately, it's going to be a lifelong latency, lifelong latency in the trigeminal ganglion in up to 80% of the infected cats. Unfortunately, the virus doesn't remain remain latent forever in the trigeminal ganglion. It can be reactivated in the ganglion and as a result of the reactivation, we'll have viral shedding and we'll have a recurrent or recruescent disease characterised both by cytosis, as I mentioned earlier in the primary disease or as an immune disease.

So what causes this reactivation and the viral shedding that disrupts the latency and causes a recurrent disease. In one word it is stress. Stress will cause reactivation and shedding.

It may be a new baby in the house or a new dog or a cat that's been introduced in the house. I frequently hear from clients, you know, I just adopted a new cat and well, he infected my, the cat that was already in the house. No, I'm sorry, you have it.

Wrong. The new cat did not infect the old cat. The old cat was a carrier of herpes virus.

Introducing a new cat into the house simply caused stressful situation to the old cat, and now it has an infection. OK, so it's the stress of a new cat, not the infection due to a new cat. Rehousing.

I, I just recently had an owner come in with a cat. She's renovating her house. It's going to take her 9 months to renovate her house.

So she will, for the next 9 months, she is going to move between her 3 sons, 3 months. The home of each of her 3 sons. Each of her 3 sons has a dog, so the poor cat is going to be moving every 3 months to a new household with a new dog.

Talk about stress, you know, I told her, come back in 9 months. No way am I going to be able to treat this. Pregnancy, parturition, lactation, concurrent disease, and unfortunately, you may be guilty of reactivation and shedding if you administer corticosteroid, .

Obviously, that would activate the glucocorticoid stress, . Axis and I frequently have cases where the vet tells me, well, you know, I, stained the cornea with fluorescine. I saw it was negative, so I felt safe to give steroids.

Please think twice and 3 times before giving topical steroids to cats because of the risk of reactivation, or even if you don't give steroids, you may cause reactivation simply by giving me. To the cat frequently, you know, we have a cat with a mild disease, so you give it what you prescribe eye drops or an ointment, it gets worse. So you say, hmm, that's not working.

Let's add some more drugs. Now the cat is on two types of drops and it gets worse. So you say, hm, something is not right here.

Let's The 3rd drug. Now the cat is on 3 drugs, and it's getting even worse. It's getting worse, you may be giving the right drugs, but by giving it more and more drugs, you are causing more and more stress.

So really, it's all about stress, as I said in the title of my talk, and you know, it's, we're talking about cats. It doesn't take much to stress cats. I always say that, you know, for cats, life is stressful.

So it really doesn't take much to reactivation and shedding. And a recurrent disease. Fortunately, the recurrent disease is milder, you can see that the chemosis and the red eye are not as dramatic as we saw, the discharge is milder than what we saw.

There may or may not be respiratory disease. So again, we're talking about conjunctivitis, carrato conjunctivitis, and right, no, rhino, but it is a minor disease, but it is chronic and it's recurring. And once again, it's not just the conjunctiva and the upper respiratory tract that are involved.

Cornea is also involved, but here we are talking less about, cytolysis. We are talking more of an immune response to the viral particles in the stroma, so we have keratitis. Characterised by cellular infiltration, vascularization, edoema fibrosis, you can see all of these signs here.

So not necessarily ulceration due to cytolysis, but more of a keraitis due to an immune reaction. And finally, and unfortunately, we may have long term complications as a result of the herpetic disease. The first is something I've already mentioned, yhoon or adhesion between ulcerated surfaces of the conjunctiva and cornea.

I showed you previously, pictures of an ulcerated conjunctiva coming in contact with an ulcerated cornea, and here is the result of these pictures. You can see here adhesions between the third eye and the cornea and In both pictures on the right and the left you can see conjunctiva adhering to the corneal surface. If you're not sure, in the eye, take a swab or a Q-tip, and you can freely move this tissue.

You will see that it's evidently conjunctiva. Note here that we have some pigmentation on the corneal. Surface, unlike dogs, cats do not get pigmentation as a result of irritation to the cornea, such as you see in Kenyan dry eye.

So this pigment is from the conjunctiva. This is conjunctta pigment. So that's another sign telling you that it's conjunctivad here to the cornea cause we don't have corneal pigmentation.

A second complication that I'll come back to when I talk about treatment is dry eye. And once again you can see an obviously dry eye in a cat with a dry looking cornea and there are several mechanisms by which we get dry eye in feline herpes disease. Number one, the virus itself actually has tropism to the tear gland, so it attacks the tear gland, causes inflammation, dryodennitis and inflammation of the tear gland.

Furthermore, the conjunctivitis causes scarring of the ducts draining the tears from the tear gland onto the ocular surface. So we have less production, less tears being able to drain onto the ocular surface, and unfortunately, we also have less blinking to spread those tears on the eye, and that takes you back once and the trigeminal nerve involvement, because of the trigeminal nerve involvement, we have reduced corneal sensitivity and less blinking. And as if this wasn't enough.

The conjunctivitis also destroys goblet cells. Goblet cells are those cells in conjunctiva that are responsible, are responsible for producing the min layer of the ear film and their loss would also cause that dry eye. So we have both qualitative and quantitative dry eye.

I think my next webinar, I don't remember when in September or so will be about dry eye. And two other diseases that are associated with feline herpes virus, not necessarily complications of keratoconjunctivitis, but two diseases with which a virus is associated. One is cornea sequestron or necrosis of the cornea, which is the picture that you are seeing here on the left.

I said a couple of minutes ago that we don't. Have pigmentation of the cornea in cats like we see in dogs with bi, for example, this black stain here is actually corneal necrosis, cornea sequesttrum, and feline herpes virus has been implicated in this disease as well as in the pathogenesis of ESMhilic hepatitis, which is this infiltration that you are seeing in the right eye of this here. So, as I said, herpes is the primary pathogen of causing feline conjunctivitis and curato conjunctivitis.

A word about chlamydia or chlamydophila, it causes a milder disease. Again, you can see here, milder conjunctivitis and discharge, with chemosis. You can see very notable promosis here being the most prominent sign.

It can be chronic sometimes if you don't treat it, but Unlike herpes, there is no corneal involvement and there is no recurring disease. Yes, there may be respiratory disease, but no recurrence, and no keatitis. It usually affects young kittens and remember, obviously that it's zoonotic disease, so please wash your hands and instruct owners to do so.

And as I said, we do have other pathogens that are occasionally mentioned in the context of feline herpes. We're talking about mycoplasma, which is an experimental disease, maybe causes secondary infection, in some of the, cases that I've been discussing, but we don't really Worry ourselves too much about lycoplasma because thankfully it's susceptible to the same drugs as chlamydia, letivirus, mostly a respiratory pathogen and common cause of conjunctivitis, maybe mild transient disease, same with Bodella. So really our two main culprits are feline, herpes, and chlamydia or chlamydophila.

And this table here prepared by my colleague, my David from North Carolina State University should help you distinguish between the two. So conjunctivitis is more severe in feline herpes, especially in young kittens, and we can get conjunctival ulceration, like chlamydia. A big difference is the involvement of cornea, which we see in feline herpes but not in chlamydia, and the recurrent nature which we see in herpes but not in chlamydia, respiratory disease, yes, also more dramatic than in Chlamydia.

So basically, if we are talking about elderly cats or a young cat with a very severe conjunctivitis, you're talking usually about feline her disease, young cat with mild disease, we are probably talking about chlamydia, especially if there is no corneal. So yes, this may help you distinguish between feline herpes and chlamydia, and some of you may feel inclined to do further diagnostic workup such as bacterial culturing or viral isolation, but unfortunately, chlamydia is an organism that is very difficult to culture and viral isolation of herpes is even more challenging cytology. Well, yes, if you see lymphocytes, then you are inclined to think more about viruses and neutrophils.

You're inclined to think more about chlamydia. Sometimes you may be lucky in seeing intra cytoplasmatic elementary bodies such as you are seeing here. Yes, we could do PCR for chlamydia and for herpes.

We could do immunofluorescence serology, which, poses a problem due to vaccination, so. Testing out there, but I will quote here two of my friends and colleagues. One is David Maggs, UC Davis, my co-author on Slater's Fundamentals, who says it's better to save money on the tests so that you can spend money on the best therapies, and I actually David in UC Davis for a whole year.

I spent a sabbatical there. I should note that David has the world's leading, research lab for feline herpes, and next to it is clinic. And when David sees a cat with suspected herpes in the clinic, he doesn't sample it and doesn't send a sample to his Research lab, which is 10 ft away literally, and even though the lab could earn income from that test, because really, as David says, it's better to save money on these tests which are very, very problematic, have the owner spend the money on the best therapies, which, as we'll see in a minute, are rather expensive.

Or once again quoting Mike Davidson from North Carolina State University, establishing the diagnosis of feline herpes versus chlamydia in CATs doesn't really change the treatment. The treatment is going to be more or less the same, and I'm gonna base my diagnosis, as I said earlier, based on the clinical signs and on the response to treatment. So what's a treatment?

Obviously we're talking about, herpes virus as a primary pathogens, so we are going to, need to provide cats with some sort of antiviral therapy and if you want to read a wonderful review. About antiviral therapy in cats with conjunctivitis, I refer you to this paper from 2016, a wonderful review once again by Max, a couple of very, very important points that you should remember regarding antiviral therapy. Number one, all drugs are very static, not veridal, meaning you are not going to kill the virus.

You will not be able to eradicate the virus. All you're hoping to do is cause the virus to return to latency. You cannot cure cats from herpes virus.

That's a very important point. Another important point that will keep coming up again and again is that because these drugs are very static, you need to administer them very frequently, sometimes 5 or 6 times daily, and that takes me back to a point I mentioned earlier, the importance of stress. I challenge you to prescribe a topical drug to a cat to be administered 6 times daily without causing stress.

OK. So first time, yeah, we can grab the cat, put a drop in the eye. Second time, we have to grab the couch cat from behind the sofa to put a drop in the eye.

Third time, we had to take a ladder and climb to the top shelf. In the closet to grab the cat to put a drop in the eye. 4th time, get the cat from behind the refrigerator to put a drop in the eye, and please do all of that without causing any stress.

OK. Sometimes it is impossible, which takes me to this next very, very important point, do no harm. Ask yourself, and I'll repeat this point again and again, am I benefiting the cat by prescribing more drugs, or am I causing harm by increasing the amount of stress that might posing to the cat?

Think about stress all the time and remember its role in the recurrent disease. So that's why I'm saying that antiviral drugs should be reserved for severe disease, persistent disease, or recurrent disease, or when you are sure there is herpetic disease due to corneal involvement, if it's just conjunctivitis and there is no corneal involvement, maybe it's not even a case of herpes as I mentioned. Another very important point to remember regarding antiviral therapy is that most available drugs are compounded or are extra label use, meaning that they are drugs intended for humans, meaning that they may not be effective against feline herpes virus, and this is, or they may not be safe for cats.

This is a table I always like showing. It's from the paper I mentioned in the previous slide showing the efficacy of drugs against feline herpes virus and the human herpes virus. The lower number.

Means that the drug is very efficacious and this arrow here points to cyclovir or Zovirax. Most of you know it because it's a very commonly available drug for human herpes, as you can see, it's a very effective drug for. Treating human herpes virus, it's totally useless or has a very low efficacy against feline herpes virus.

So not everything that is out there is necessarily effective as you can see by the table or it's not really safe as you will see in a minute. So what do we have out there? Well, two of the most commonly and readily available antiviral drugs are refluoridine and doxoridine.

Both are topical drugs that are effective against feline herpes virus. Prefluoridine down here at the bottom is probably more efficacious and has better penetration, but more expensive and more irritating. Doxoridine.

Be tolerated and cheaper, so maybe it's preferable, but again, both of them are very static and they need to be given 5 times daily, which is, as I said, a huge problem because we are introducing lots of stress. Therefore, your life will change dramatically if you have. Access to efficacious drugs that can be given only twice daily.

Sir. Sir is An orphanic solution that is very well tolerated, very efficacious, wonderful drug because it has to be given only twice daily. Unfortunately, it is hugely expensive.

I know we have people from different countries listening in. The average price in the world is about $150 for a 5 mL bottle. I don't have too many cat owners who can afford or who are willing to spend $150 on a bottle of eye drops for their cat, and it must be compound.

So a verification drug, but these are two shortcomings. Another very interesting possibility and one that is widely used by many veterinarians is from cyclovir, an oral pro drug of encyclovir. We're not sure exactly how farcyclovir is converted into encyclovir, which is the active antiviral drug, against herpes virus, but there is mounting evidence to suggest efficacy the dose of 90 milligrammes per kilogramme twice daily.

An off-label because I should say that the metabolism and pharmacokinetics of pharmcyclovir and its conversion into pencyclovir is unclear, has led us in the last couple of years to use pendixs, which is a dermatological cream, surprisingly enough, . That contains pencyclovir, and the logic here is why deliver the prodrug, which is an oral encyclovir, when you can deliver the actual drug, the pencyclovir, directly to the eye. I can say that yes, we are having wonderful, wonderful results with its if you can prescribe it.

Other antiviral drugs that are out there, you may be able to get rearabine or Gancyclovir. Both of them are reasonably efficacious, but we don't have a lot of data on them. And two drugs that, you hear often.

Or we used to hear often in the context of feline therapies are this in which may reduce shedding in carriers and improve clinical signs in primary infection, but this is mostly experimental work. There is no data in client-owned acts. But it is a safe drug as a bolus.

Do not sprinkle it on food, but if you give it as a bolus, it may help reduce shedding and interferon, we used to give it before we discovered the wonderful dove and some cyovir potential, as the article says, rigorous prospective studies showing efficacy of interferon are black. Drugs that you don't want to give to your feline herpes patients are cyclovir, and I showed you the table proving that it really isn't efficacious in cats, even though it is readily available. So it's really a very frustrating situation where the available drugs are non-efficacious and the ficacious drugs.

Are not available or horribly expensive, but it's the way it goes. But acyclovir are readily available, but you'll probably kill your patient because it's nephrotoxic and toxic, and as I said, you do not want to give steroids because you will activate latent herpes infection. How long do we treat cats with antiviral drugs?

Well, you treat them until the signs have improved. And another 2 weeks. So there is no set formula.

You wait until the signs have improved and another 2 weeks in order to establish latency. OK? Once again, remember you will never cure herpes.

Your aim of the aim of your treatment is to return the virus to its latent state and you have to warn the owner that recurrence is possible. Also, another very, very important component of treatment is to reduce stress, so maintain adequate nutrition, hydration, tender loving care, etc. Etc.

Isolate affected cats again, not because they will infect the other cats, but simply because you want to reduce their stress, and help them and As I hinted previously, maybe we should consider reducing or even stopping treatment in some cases. This is really going against what owners expect. Owners come to us expecting us to treat the patients, and it takes lots of guts and bravery, to tell the owner, you know what, go home and don't treat your cat.

But actually, sometimes that may be the best advice you can give and if it's an intelligent owner who can grasp the importance of stress, they may go along with you. I realise it's easier for me as a diplomat to say, tell people, yeah, don't treat your cat because I've got a diploma showing them specialist on the wall. Sometimes really, cats come to me, they've Into 3 different vets, each vet prescribing 2 or 3 different drugs.

Many of them are efficacious drugs, but poor cat, you know, he's been treated so often, so many times a day by so many drugs for so long. I tell them to stop treatment and within 2 or 3 weeks, the cat is cured, actually not cured because we don't cure them, but the symptoms have resolved. Please think about stopping treating.

So, we spoke at length about the antiviral treatment cause it's so frustrating, but there are other components to the treatment. One is re-establishing the tier film, and I spoke at length about how herpes is involved in the pathogenesis of feline dry eye. Loss of the quantum type goblet cells that they mentioned reduced the mucin, tin layer, tear layer, and therefore we want to reestablish the mucin layer by prescribing hyaluronic acid-rich artificial tears.

I should mention that it's very, very difficult to diagnose dry eye in cats, tumour the tests, and other diagnostic tests that are very diagnostic in dogs are not so diagnostic in cats due to the huge range of normal baseline values. And therefore, I once again, this is another example of skip the diagnosis, just give the cat these artificial tears rich in the hyaluronic acid and make them. As I said, chlamydia is another, pathogen that you have to worry about.

Maybe mycoplasma. Thankfully, both of them are susceptible to tetracycline. So tetracycline is our antibiotic of choice in cases of injunctivitis with erittis.

That tells me that there is no herpes, that tells me that it's just chlamydia. If there is a corneal ulcer and I worry about it being contaminated, I prescribed tetracycline, and in cases of respiratory disease, yes, you may. One prescribed systemic doxycycline and it has to be rather long term, as you can see here, otherwise you may not be able to cure the persistent chronic conjunctivitis and studies out there show that doxycycline is preferable to azithromycin.

As I mentioned, cats, may have ulcers, and some of them are geographic ulcers that will debride with a loose epithelial lip that can debride just like the boxer ulcer or the so-called scad that we see in dogs. We take a swab or a Q-tip and we can really debride a large portion of the corneal epithelium, so we are tempted to Do a great rotectomy or a punctate rootomy just like we treat a boxer ulcer. Please do not do reed or punctate because it's a sure way of establishing of causing corneal sequesttrum.

If you do see these superficial ulcers with a loose epithelial lip, just deep right them as I suggested earlier and maybe place a contact lens in the eye. You can see here a contact lens. Manufactured for animals.

It has 4 dots on it to help the owner know whether or not the contact lens is in place. And as I mentioned, some ulcers, despite our best efforts may become contaminated or very, very deep, in which case we will have to perform surgery on type of flap to save the eye. So to summarise the treatment, please give tetracycline for suspected chlamydia cases, which are the young cats with mild conjunctivitis, no cornea involvement, and if it's resolved, there you go, you confirmed your diagnosis of chlamydia.

No need for all these fancy molecular testing like. IFA, etc. Etc.

Tetracycline also for corneal ulcers and respiratory disease, topical or systemic tetracycline, and the antiviral treatment should be reserved for recurrent conjunctivitis, which Tells you that there is a current disease, so that has herpes or severe, sorry, here, severe corneal disease, and please remember to add these artificial teardrops to make the, cat happy. As I said, in mild herpetic cases, no treatment may be the best option, and I bring here my own personal beloved cat, Buzz as an example. You can see that obviously he's slightly squinting in his left eye.

He's somewhat painful. Yes, he's got a mild case of herpes virus here. So I'm faced with two options either give him antiviral drugs, in which case I'll probably have to treat him for 4 weeks or do nothing in which case it goes away within 4 days.

So I bring my own cat as an example. I do not treat it in these mild cases. That is the best option.

As you know, in many, many diseases, conjunctivitis in one of them, our guiding principle is do no harm. Sometimes feline therapists treatment will be more harmful than no treatment. And finally, please remember that a cure means re-establishing latency and recurrence is possible.

So take home messages from this talk is that feline, herpes virus, and chlamydia are the leading pathogens of feline keratovitis. Base your diagnosis on clinical signs in response to therapy rather than fancy and expensive tests. Conjunctivitis with no recurrence of keroitis suggests the media.

If there is recurrent conjunctivitis or corneal involvement that suggests herpes virus. Some cyclovir and cidofovir are becoming the drugs of choice simply because they are very efficacious and can be given twice daily and they are replacing lizine, and please remember it's all about stress, treatment will worsen the disease and recurrence is possible. Those of you who have been to my previous talk know that since I can't hear you, this is the time where I bring my own applause slide and thank you for your attention.

Oh, Ron, that is brilliant. Folks, I promised you an amazing webinar and Ron didn't disappoint us. And yeah, Ron, I'm sure if we were in a, in an auditorium there would be thunderous applause because that was really brilliant.

Thank you so much. Thank you. Thank you for these words and I see we have 4 questions.

We have some questions coming through. One of the questions that I'd like to ask is, is, you know, the, you mentioned lubricants in the eye and that sort of thing. Do you find that lubricants are less stressful than some of the other products.

And, and where I'm going with this is thinking if we're gonna stress the cat by putting lubricants in, would we not be better to be stressing it with lubricants and something else or should we just go for the mild case, no stress, no treatment? My case, no stress, no treatment, but if you are treating, yes, you know, we don't have general rules, but as I showed you in some of those, if this cat present and I showed you some of these dry looking corneas, take a look and yeah, that cat may benefit from artificial. Tears and the nice thing about artificial tears is that unlike some of the antiviral drugs, they are very non-irritating.

They're very, very well tolerated. So if it looks like a dry cornea, the cat may benefit from it, if it's severe enough, yes, depending on the presence of sight. Excellent.

Laura wants to know, with the zoonotic implications of the chlamydia, what does that look like in humans? Oh, that's a very interesting question and I'm really not sure. I think it's also causing conjunctivitis, but you got me there, Laura.

I'd have to look it up. Sorry. OK.

Gordon wants to know, is recurrent herpes eye infections always bilateral or can it be a unilateral condition? Thank you. In the recurrent stage, it's it's frequently will start a maybe you Unilateral.

The primary disease is mostly bilateral. The recurrent 1 may very well be unilateral or start out as unilateral and the second I becoming involved at a later stage. OK.

Rob is asking, excuse me. Rob is asking apart from the systemic tetracyclines, are there any topical treatments effective for the chlamydia? Well, we also have topical tetracycling.

It's available as ointment in many, many countries, so I, I use it both topically and systemically. OK. Just on that topic, one of your slides you were talking about using the the active ingredient of the skin cream and that.

I did notice that the, the concentration of that said that there's 10 milligrammes per gramme. And if I remember correctly, your recommended dose was 90 milligrammes per kilogramme. Does that mean that we have to put 9 grammes into a 1 kg?

Oh no, no, no, no, no, no, because the 90 milligrammes per kilo was the fromcyclovir, which is the pro drug. Every little of it gets actually converted into the encyclovir, which is why we have to go into such large doses. So definitely not, you know, half a centimetre of the cream into the eye will be more than enough.

And, and you just use the, the that specific skin treatment into the eye. Yes, and we that was actually the idea of one of my residents and it's a wonderful idea. We have superb results with it.

We presented it last year at the European Congress soothalmology and it really works magic in some cases, obviously, not in others, unfortunately. Nothing works magic in all cases with herpes. Michael's got an interesting question.

If a cat has no obvious signs of feline herpes, but it has severe atopic or allergic skin disease, what are the risks of using prednisolone in those cases that you then suddenly get a precipitation of feline. A very important question and actually I'll go back to this slide here. It was in keratitis, which is an immune disorder that is treated by anti-inflammatory drugs such as steroids, and many people will advocate.

Treating cats such as you are seeing here with steroids and concurrent. Herpetic medication, antiviral medication just to prevent the the reactivation in the shedding of the virus. So that would be true for this case here and it would be true for the ectopic dermatitis that the listener was asking about or any other feline disease.

Yes. If you are going to treat the cat with steroids. You may consider giving concurrent antiviral therapy and inviting it for frequent rechecks just to look whether we have recurrent conjunctivitis.

Thank you for an important point. Ron, while you're on that slide that you've just gone back to, one of the questions that came in and I'm just looking for it now, I think it was Martha that asked it. .

I think there's been a bit of confusion. Oh, here it is. Can you explain the black dot on the contact lens again?

I, I didn't get the lens, OK, so the lens was here. That's simply put by the manufacturer or to allow the owner to see whether the. Is still in place or not whether it has fallen out, because you know some of these cases are bracketcephalic cats and very, large lag of thus or eyelid opening contact lens may fall out and these points dots help the owner double check whether or not the contact lens is still in place.

Excellent, excellent, right. And Martha goes on to say, what, contact lenses do you use in cats? OK, some commercial companies, will have a whole range of, contact lenses.

I, OK, let me backtrack. These are veterinary contact lenses, OK, cause they have these dots on them. Humans obviously don't need.

Contact lenses with dots. If you go and buy veterinary contact lenses, I'm, I'm not gonna mention companies by name. If you go to their website, they will have a range of sizes based on whether it's a Kitten, a juvenile cat, whether it's an adult cat, domestic charter or brachycephalic cat with differing corneal curvatures.

So you will have a whole menu of sizes to choose from. If you want to know, you buy 2 or 3 of each, and then you'll always have the right size contact lens in stock. However, I should mention that these are rather expensive and there are a couple of papers out there showing that you would get equally good retention.

With human contact lenses that you can buy off the shelf in, any pharmacy, cause the curvature of the human cornea and the feline cornea is rather similar and human contact lenses, disposable contact lenses are a lot cheaper than this veterinary. They just don't have black dots on so you can't see easily, but you don't feel as bad if they fall out because they are very cheap. Ron, I have to tell you that your your disclosure to us of fen lips is creating quite a stir and a lot of excitement.

So there's loads of questions, one of which comes from your, fellow veterinarians in Israel. But the questions are Basically, how often do you use it? That's a big question that's coming through and then.

There we go, 2 to 3 times daily folks. And then your colleague in Israel with you says, can you get these products in Israel under that name or is it under a different name? That's the name.

There you go. So that's perfect. And the contact lenses Hannah wants to know, are they also available in Israel?

They have to be ordered. The veterinary contact lenses need to be ordered. She can contact me after, tomorrow or next week, and I can give her contact information.

There you go, Hannah. Local phone call to Israel for you. Speak to Ron and he'll help you on that.

And the primary disclosure slide was other than my book, I'm not gonna advertise any other. Yeah, perfect. No, that's all understandable and that just fits in with your usual professionalism, Ron.

We appreciate that. Loads and loads of comments coming through about how Absolutely fabulous has been. How wonderful, and as I said, you brought your own applause, but I wish I could give you the applause that I'm reading on the screen here.

It really has been fabulous, Ron. Thank you so much for your time. We really do appreciate it and I look forward to seeing you again.