I like to go on to the next speaker, Matt Gurney. Matt, are you there? Yes, you are.

Hello. Thank you very much for, for helping with this effort. Matt is, the president of the European College of Veterinary anaesthesia and, analgesia.

So we really have here really top speakers. That is, Matt is also a local colleague, he's working for Anderson Moore's veterinary specialist. Just around the corner from me here in Winchester and I have to say, great that you guys are there.

I was so lucky when I had my clinic here that you were around the corner because I had a few cases that I referred to you. Matt is speaking about local anaesthetics, and I have to say, I mean, if you don't know these volumes here this Is the, the, BSAVA guide to procedures in Small Animal practise. It also contains an article actually on the use of local anaesthetics.

And for me, it has, it had, when it came out really revolutionised sort of the way I treat my patients. Pain relief is just, well, so important, but I'm the wrong person to tell you that. Matt is the right person to tell you that.

Matt, thank you very much, and I hand over to you. Take care. Thanks very much.

Good afternoon everybody. I'm just gonna share my screen and bring my presentation up. OK, so I hope you can all see my screen now.

Yes, I'm representing Zero Pain philosophy. Our aim here is to bring the world of analgesia to everybody, so thank you so much for joining. I'm, I'm really pleased to be here, part of this fantastic cause.

Some of those videos are incredibly moving, seeing those, those poor pets, with those refugees, so that's, that's a great reason to be here to help these people. OK, so let's get started. We've got 30 minutes.

I'm gonna fill 30 minutes with telling you about how to use and why to use local anaesthetics. So let's start with our temple of analgesia here. So with every single anaesthetic plan.

When, whenever we anaesthetize a patient and they're undergoing a painful procedure, we should be thinking about incorporating nonsteroidal anti-inflammatories, opioids, and local anaesthetics. So, how do we do that? Let's take a case example.

I want to start thinking about the young cats, trauma hit by a car. There's a pelvic limb fracture, so let's say femoral fracture, how are we going to provide analgesia for this case? And I tend to think about not only a preemptive approach, but what we call a preventive approach.

So we want to provide analgesia for as long as that patient is painful for. I know we're all very familiar with multimodal preemptive analgesia, but where we're moving this onto is what we call preventive. So let's think right across the pre the intra-op period and the post-op period and make the most of what we have on offer.

So where are we gonna start? Pre-op, even before we think about an anaesthetic, this cat, this cat's been hit by a car, when it arrives at the clinic, we're gonna start using an opioid, so my preference would be a full new agonist such as methadone. Methadone may not be available in your country, morphine may be your go to opioid in this circumstance.

For me, methadone, I'm thinking 0.2, 0.3, 0.4 milligrammes per kilogramme.

We can use that IM, we can use that intravenously, depending on the temperament of the cats, and we can start to produce really good analgesia. And what else can we introduce into our pre-med? We, we combine our opioids in our pre-medication with sedative agents such as Aceromazine.

Remember Aceramazine doesn't have any analgesic benefits. I'm not a huge fan of aromazine in cats, but I really like the alpha 2 agonists, meatomidine, dexedatomidine, provided we have cardiovascular stability in our, our feline patient here. Let's think about using one of those drugs because they do have an analgesic effect and combined with opioids, they have a synergistic effect.

During that procedure, let's have a think about which local anaesthetic technique we're going to use, and I'm gonna come onto that in the next slide. Once we've done our local anaesthetic procedure, we're gonna take our patient through to theatre. Once that patient moves through to theatre.

We're going to get them settled under the anaesthetic, you're gonna take a baseline heart rate, respirate, blood pressure, if that's available to you. If at any point, once the surgeon starts, those parameters, heart rate, res rate, blood pressure, increase above 20% of the baseline that you started with, let's say that cat's heart rate was 100, we verified its depth of anaesthesia is appropriate. The surgeon starts, heart rate jumps up to 130, for example.

That's evidence of noticeception. And what we need to do in those circumstances is provide further analgesia. Because we've already worked out the patient is suitably anaesthetized, so we don't actually need to turn our volatile agent up our isofluorine, our sevofluorine.

We need to provide more analgesia. But hopefully, if we've managed to incorporate a local anaesthetic technique, then that technique is acting. We've provided complete anaesthesia to that surgical region and our patient's not going to respond intraoperatively.

In my experience, if we provide a, a complete and extremely good local anaesthetic technique during surgery, our patients are far more comfortable in the post-op period. Let's say for argument's sake we're going to use an epidural in this cat. We've done our epidural, we've incorporated a local anaesthetic, a long acting local anaesthetic like buppivacaine.

It's gonna give us 68 hours of anaesthesia. We're going to monitor that patient in the post-op period. In my hands, we tend to use the short form of the Glasgow composite pain scale in dogs and for cats.

So we have a Glasgow pain scale, we've got validated pain scales for using in our feline patients. And we're gonna pain score that patient in the recovery period, and we can provide further methadone or morphine, whichever is your go to opioid when the pain score increases, and we want to provide further analgesia. Let's think about our non-steroidal.

We hope that after the RTA we've stabilised our patients, their volume status is appropriate. We don't have any increase in renal parameters, and we can think about using a non-steroidal at an appropriate stage. So you can see how we can incorporate all three of those components into our cat fracture.

Let me just show you this video. Just make sure I turn the sound off, yeah, sounds off. This is a video of us performing, or one of our residents performing an epidural in a cat.

Now normally in the clinic we would have the cat draped, but for the purposes of teaching, if we drape the whole cat, then all you see is a needle going through a drape. So the needle goes through the skin, this is a lumbosacral epidural. And we're popping a drop of saline there in the hub of that needle.

And as we advance, did you see that tail twitch? I'm just gonna whiz that video back. Because the tail twitch is a positive sign that we've placed our needle in the epidural space in a cat.

You don't see it all the time, but every now and again you see it. I'm pointing that out to you because if that happens to you, I don't want you to worry that that's a bad thing. Can you see how easily that injection goes?

And that's just an injection of saline, let me just whiz back again. So the first thing we're doing, once we're happy our needle's in the correct place, we're using a test injectate saline just to check that that injects really easily. What we're doing here, we're trying to see if we get a hanging drops, so there's another test that tells us that we are in the epidural space, because the epidural space is under negative pressure.

So a drop of saline should be aspirated, but it's not happening here. It's something we see in about 80 or 90% of dogs. It does happen in cats, but obviously not in this case.

And when we inject, we've got an air bubble just above our solution there. And if again, another test, if we're in the wrong place, that air bubble will compress. We don't have any compression with that test of saline, so we're confident we're in the right place.

We pick up our morphine and bpivocaine injection and we're gonna inject this nice and slowly. Nice and lady. Into the cats.

And by the time this cat gets to theatre, so you can see the leg has already been prepped. We're gonna move through to theatre, re-scrub the, the patient. By the time the surgeon starts, the buppivocaine that we've used in this epidural injection will be active.

And like I say, that's going to give us 6, maybe 8 hours of anaesthesia and then the morphine that we've incorporated in there is gonna give us a longer duration of action. So actually, a cat id is actually a really easy thing to do. We touched on the non-steroidal, didn't we?

And thinking in a multimodal sense, let's think, well, actually I'm not confident with doing an epidural yet. I'm worried about this cat's stability. I don't want to use a non-steroidal at this stage.

How else can I analges this cat? Well, for me, ketamine is a perfect analgesic for these patients. And it's something that we can use as a continuous rate infusion, and you could use this right at the start, when this cat's submitted, let's say you give the cat some methadone.

And then an hour later we go back and pay his school the cat once it's admitted to the clinic and it's still not happy, it's still not comfortable. Ketamine is a perfect infusion for those circumstances in cats. You can read about this in the pain update section on zero pain, so we haven't produced notes for this session today, but everything I talk about, you'll find in the pain update section on zero pain, and I update those on a monthly basis.

So please take a look at those, and you'll find all the information about low dose ketamine infusions there. But in my experience, that is a perfect adjunct for these cats where we need to give them something other than opioids. So this case, this is our, our little case summary from this cat, pelvic limb fracture.

Creatin a presentation was elevated, but that did come down with stabilisation of fluid therapy, so we're less worried about renal function in this case. Our initial analgesic was 0.2 mg per gig of methadone IV and we repeat that every 3 to 4 hours.

Like I say, there's an option for a ketamine infusion there as well. And again, if we're not confident with giving a non-steroid at that stage, we have case reports. We don't have any prospective studies documenting the analgesic benefit of gabapentin, but we have got some case reports and I would.

Say in my experience, if we're looking at another option for analgesia in cats, trauma cats, gabapentin, 10 megs per gig, perros, BID or TID. I've written TID on this slide, but BID is often sufficient. If local anaesthesia is your thing and you're confident with epidurals, then I would by all means encourage you to perform an epidural in this cat.

If that's something that's on your list of, of learning, then there are plenty of courses available now where you we run practical courses on performing epidurals and local anaesthetic techniques. So if that's something you're interested in, you can get in touch with me and I'll point you in the right direction to the next course. And of course to consider a non-steroidal once you'vevolemic.

And really my view on non-steroidals in these cases is any pet, any dog or cat in acute pain or chronic pain, I say should receive a non-steroidal unless we can find a very good reason not to. And of course a trauma case, we're not gonna give a non-steroidal the minute they come into the practise, but once we're confident that the that patient's stabilised, we're gonna provide a non-steroidal as soon as we possibly can. And that really is a totally multimodal approach.

We have our non-steroidal working to reduce our inflammatory mediators in the periphery, that's transduction. We've got our local anaesthetic, our bpica in our epidural, providing anaesthesia, blocking transmission of that stimulus in our primary afferent nerves. And then we also have the methadone that we've already administered to the patient.

We've got the morphine that we put in the epidural acting at the dorsal horn of the spinal cord to provide that modulatory effect. And also our opioids are going to affect the perception of pain. We can't often tell that in our feline and canine patients, and we know a lot of that from our human experience.

People say, well, I knew it still hurts, but I just didn't care so much about it. Just a quick shout out for the DeR AVA anaesthesia app. So if I may mention things as I go along, you think, oh, actually, I need to know a bit more information about this.

This is a free app that I was involved in creating. I it was involved in creating the initial version about 5 years ago, and we've just released the update this year, so please go ahead and download that if you need any help and tips with your anaesthesia plans. Case study 2, OK, so more local anaesthetic techniques.

We have dental extractions to do in a 9 year old German Shepherd dog. It's Healthy dog but intolerant of non-steroidals, so already we're thinking, well, actually Matt says any patient, unless you can find a very good reason not to, this dog's teeth are probably in a bad condition. We already have inflammation.

What can we do to, to improve our analgesia or optimise this patient's analgesia when we can't use a non-steroidal. And thinking about local anaesthesia, these are the drugs that we typically have on our shelf. And and the some mores where I work day to day, we have lidocaine, bupivvocaine and ropivicaine.

Some of you may have levobivvocaine. We used it for a while when buppivocaine went on and off the market, so sometimes you order buppivocaine, you get sent levo buppivocaine. We use these drugs, the three drugs bivvocaine, levobupivocaine, ropivicaine, very similar profile as far as onset, duration of action, similar toxicity as well.

So we tend to use those interchangeably. So if I say buppivocaine for something and you've got ropithecaine on the shelf, that's absolutely fine to use. The main differentiator here is that lidocaine is a shorter acting drug, so it has a rapid onset of about 5 minutes, but duration of action is 1 to 2 hours, whereas bupivvocaine, levo buppivocaine, repivocaine, there's a longer acting local anaesthetics.

So really, we want to be using one of those in preference for our dental cases because we're gonna get a much longer duration of action. And let's think we pick our local anaesthetic off the shelf. How do we decide how much to use?

Well, let's fast forward to the right hand side of the screen here. We know from some clinical audit work that we did at Anderson Moors with Matthew Oxford, our dentist, that for the maxillary and the mandibular or inferior alveolar nerve block that we perform in dogs and cats, our mL per kilo. Volume of buppica or lidocaine, if that's available to you.

The volume we want to be using is 0.03 mL per kg for each block. So in this 25 kg dog, then we're gonna use 0.75 mL per nerve block.

That's quite a useful thing for you to have in your head. If we go back to that previous slide where I said this is the dose of buprecaine or this is our maximum dose, I would pick 2 migs per kg as my maximum dose of buprevicaine, but we've got a range of 1 to 2 mg per kg. That gives us 25 to 50 milligrammes of drug for this 25 kg dog.

Buppivacaine, the one on the right hand side of the picture here, the 0.5% is 5 milligrammes per mL. So actually that gives us 5 to 10 mLs of local anaesthetic that is a safe dose to use.

But you can understand from what I've just told you with your mLs per kg dosing, we never need to go near that. So we've actually got tonnes of local anaesthetic to safely use in this dog, even if you thought, oh well, I'm, I'm not so confident with my local anaesthetic technique. I'm gonna use a bit more.

And that said 0.75 male, I'm gonna use a male, you're still well in your safe dose limits in this case. So that's quite a good thing.

When you start doing these techniques just to practise on your first few cases and then you just get it ingrained in your head as to what your normal dose of local anaesthetic is going to be. And which block? There are a number of blocks that we can perform in dogs and cats, and there are a few differing opinions, let me just say that.

However, the two that I tend to perform, I'm just gonna see if I can pick up. I can't actually see, oh, here we are, I'm trying to pick up a pointer laser pointer. OK, right, here we go.

So for work on our upper arcade, I'm going to choose the maxillary block. This is our maxillary nerve here, it runs across the terrigopalatine fossa through the maxillary foramen, through the infraorbital canal. It emerges through the infraorbital framemen as the infraorbital nerve.

And I know it looks like the infraorbital nerve is causal to the canine tooth, so it's probably gonna be effective. But actually if we block the infraorbital nerve at this point, it's not effective anaesthesia for the canine tooth. So we do need to be blocking further back.

And the, the sensory innovation for the molar teeth emerge from this nerve within the infraorbital canal. So there are three nerves that emerge there. So my top tip for you for upper arcade is a maxillary nerve block.

I'll look at one of the approaches in a video with you now. And for the lower jaw, for our mandibular arcade, we're going to block the mandibular or inferior alveolar nerve back here. It runs through the, the mandibule, and it merges as the, the mental nerve, but the mental nerve is a sensory afferent to the incisors.

We don't tend to do just incisor work. So for me, maxillary and mandibular or inferior alveolar nerve are the two that I choose. All right, let me just put my pointer away before we move slides.

There we go. OK, so in this video I'm gonna show you the sub zygomatic approach to the maxillary nerve, and this is the nerve block I tend to prefer. You'll see that this dog is clip, this is a cadaver dog that we made this video on, so we clipped it just to demonstrate exactly where we're going.

I don't normally clip these in practise, so right, let's have a look at this video. This video is all of the videos I'm showing are available on the video section, the nerve block section of Zero Pain philosophy, so you don't have to memorise this today. So we've palpated the zygomatic arch, we have inserted our needle.

And we're going to inject, I'm gonna be critical and say I injected too fast. It's a really simple block to perform. So as I said, if I, I think I can use the laser pointer at the same time as the video, our nerve is running across here.

You can see that our needle is coming in under the zygomatic arch, so we palpate the zygomatic arch and our needle goes in under the zygomatic arch. I'm just going to, oh, right, let's see if we can replay the video. Mm.

But it's a bit of a challenge, my biggest challenge today is putting the laser pointer away. And starting the video again. OK.

So I know that I'm palpating the zygomatic arch and just below the zygomatic arch, my needle goes in. Maybe I could angle that needle slightly rotrally. I'm gonna attach aspirate, so golden rule of local anaesthesia is aspirate prior to injection.

The last thing we want to do is inject intravenously. Yes, we use lidocaine intravenously for treating ventricular tachycardia. It dissociates away from the sodium channels very quickly.

Our longer acting drugs, levobpica, Ropivocaine, bivvocaine, they bind avidly to sodium channels and they can cause cardiac arrest. So we never want to inject those drugs, IVs. So we always aspirate, and I think you might have caught at the end of that video it says do not wiggle the needle around.

If you wiggle the needle around, there's a chance you hit a venous sinus, in that specific location in the terrigopalatine fossa, and we don't want to, to cause any, intravenous spread of our local anaesthetic. Great, so let's move on. This is the mandibular nerve, so if we're doing some work on lower teeth, on the, the lower jaw in this dog, we are aiming for this point here.

This is our mandibular foramen. So our nerve is coming down the vertical ramus here and it's entering the mandibular foramen here. This technique I'm gonna show you is the extra-oral technique whereby you'll see me palpating that foramen internally.

I'm actually, OK, I'm actually blocking the left hand side of this dog's jaw, the, the jaw that's uppermost on the table. So I'm palpating that internally and then I'm gonna direct my needle externally. The other approach, you can do this as an intraoral approach.

It really just comes down to whichever one you find easiest, so I think personally this is, this takes a bit of practise to work out which one works for you. Great, so we're just going in. I'm directing that needle up towards the bone on the medial aspect of the mandible, advancing forward, trying to meet the needle tip of my finger.

Wiggling that around, getting that in the right place, so what we're then gonna do is aspirate and inject. What we want to do is where we've got our finger, we want to feel a lab of local anaesthetic forming around our finger. So please take another look at those videos, hop on to zero pain and have a look at those videos, and if it comes to Tuesday and you've got a dental case, you think, oh, hang on, how did Matt do that?

Just get the video on your phone right before you perform that local anaesthetic technique. We do have videos on Zero Paint on cat dentals as well. Obviously this is a a speedy half an hour lecture, so I'm not gonna cover the cat videos today, but the techniques are very similar in cats.

And we produce those, if you read the latest ISFM guidelines on analgesia, acute pain management in cats, there's the link to those there as well. So a summary of that case, we've got a healthy dog that's intolerant of non-steroidals, pre-med, methadone 0.1 mg per gig, Dexamedatomidine, premed 5 mcg per kilo IV we get beautiful sedation.

You might want to increase your methadone dose there, you might think, well, that's a bit low. I'm not so confident in my local anaesthetic techniques, but I'm going to increase my methadone just in case my local doesn't work so well. Pivoca maxillary block, mandibular block, duration of action 68 hours, so our patient's gonna be really comfortable.

What about non-steroidals? So we said this dog's intolerant, what do we do instead? I'm a big fan of paracetamol in dogs, so 15 mg per gig IV would be my choice.

Probably not time to delve into any more information about paracetamol, but there's plenty on the zero pain website about paracetamol. So if that's something you want to look at, and I've just finished writing an article for BSAVA Companion as well on paracetamol, so that should be appearing fairly soon. OK, how are we doing?

I've been talking for 23 minutes, but we've got 2 minutes to go to 1 o'clock. Shall I, 00, are you wanting me to wrap up by 1 o'clock? Yeah, I, I would say I have a couple of questions here.

I think we possibly go through these and, then, we, go over to the next speaker. Matt, there was a question here, how should we use catsula in cats, please? So I assume keam meaning saxine in cats, .

Should we use it at all? We, we, we always say familiarity is best in anaesthesia, so if that's what you're used to and it works for you, I would carry on with that. Let's think, OK, ketamine is a fantastic analgesic, xylazine is analgesic.

Quite short acting. Let's do those two things, but let's add an opioid in with that as well. So you could add, we talked about morphine or methadone in that cat.

So, yes, I would say ketamine xylazine, if in your hands that works, but let's think about opioids, non-steroids, we can be multi-modal with that combination. How is that with Atipam and Sulaine works actually quite well on sullaine as well to reverse it, or? I, I would say it does, yeah, I guess if you've got a really short procedure, then perhaps the zylazines worn off and you don't need to antagonise it, but yes, yer atipamazole is effective for antagonising Xylazine, yeah.

There are a few more questions. May I suggest, Matt, that you, you answer them, in writing sort of just after this presentation. Thank you so much for, for this really useful and really practical, presentation and obviously Cyril.

Pay website, I certainly will take a closer look at that. I wasn't aware that this was existing and I mean it's so fantastic and it's really practical, and that is, I think what what most of our viewers here want to see is the stuff that you can use right away in first opinion practise. Yeah, and we will, we, we will create for for any Ukrainian vets, we are going to create a free membership for zero pain, so a lot of the content's free, some of it's paid, but for anyone in Ukraine working as a vet professional, we will provide that for free for you.

So watch this space. Very good. Matt, thank you very much.

And it's time for me now to introduce our next moderator, and it's no one less than Kat Henstridge, which most of you will know as Kat the vet. Hello, Kat. Hi.

Thank you so much for having me. Aren't we having a fabulous day? I think this is just the most amazing thing, and I think Wolfgang, you've done such a great job.

So, in a month. It has been the last, the last 4 weeks, you wouldn't believe how much fun I had because I could communicate with all these amazing people and I mean, it's just brilliant and I mean I have, I had as soon as I approached somebody about this idea, so they also, yep, I'm on, I'm on, I mean you, you, I send you an email and you've, oh yes, great idea. I'm on count me in.

And that's so refreshing. It, I mean, I've, it really made my day for the last 4 weeks. So it was just this, the same thing with the webinar vet team.

I mean, sort of they are, they're working here sort of in the background at the moment, getting everything together. And I can see as soon as there's a problem, they are added right away. They are real pros.

Yes, they are extremely good at this, aren't they? I should point out two things. The first thing that you are a typical multitasking mom.

You have 3 kids around you somewhere. Then you have a husband who is rugby playing, so you might have to stitch him up between, presentations. So, and, then obviously you're practising that, and you have a huge sort of social media.

And I mean, if, our viewers haven't checked it out, please check out Cats the vets as so useful videos, especially for pet owners. Sort of, I mean, it's absolutely brilliant and, the work also you do as an educator for the general public on, on veterinary subjects. So it's a great job.

Thank you very much. But what I do is nothing compared to what our colleagues, do who are lecturing us today. I would never feel like I could speak to my peers like these guys do.

They are the genuine experts and from all over the world. Our next speaker is coming from Sydney, Australia, which is just the power of Zoom blows my mind. You get the international section now, I leave it to you.

Take it away. Thank you very much. So everyone, our next lecturer is the phenomenally impressive Kirsty Sexel, who is coming to us all the way from Sydney, Australia.

Well I say all the way, I'm here in. The north of England. Maybe some of you are sitting in Sydney just down the road from Kirsty, because this is an international event with international speakers and international delegates.

And Kirstie is going to talk to us, about behavioural medicine. She graduated from the University of Sydney, and she is a fellow of the Australian College of Veterinary Scientists of Animal behaviour, a diplomat of the American. College of Veterinary behaviour and a diplomat of the European College of Veterinary behaviour.

So she is also international in her approach, and she is the person who set up Puppy Preschool and Kitten Kindy, which are both, educational programmes for veterinary professionals to give to owners for socialising of puppies, which I think we're all used to. But kittens as well, which I think is really interesting, and I, I know you've been doing that for years, Kirsty, but I think still that one hasn't quite reached as, as big an audience, and I think it's a great idea. So, and Kirsty also writes for magazines, appears on TV, appears on radio as well, so is a consummate professional.

So please, Kirsty, take it away. We'd love to hear what you've got to tell us today. Thank you.

Thank you, Kat, for that introduction. And, and I have to say, thank you very much for for asking me to be part of such an important event. To be honest, I'm so, so sorry that this event is on, because the fact that it even had to happen just breaks my heart.

So, from the bottom of my heart, you guys have done such a fabulous job putting it on, but please donate and let's help our colleagues. It just brings tears to my eyes when I think about what's happening in the Ukraine at the moment. I'm gonna share my screen and hopefully it'll all work beautifully, which technology sometimes does and sometimes doesn't.

So, So the dog has a behaviour problem. Who to refer to and what? And I, when I thought about what I wanted to speak about, look, I could have talked about how I treat this or how I treat that.

And then in the last few months, or in fact, for the last few years, I've had students, and veterinary students, when they come and see practise with me, what the biggest problem is not What they've learned at university is, that they can diagnose some problems and help them. But when it gets to a certain point, they don't know what to do with it. You know, who do I refer to and when.

So I decided, after being a specialist for over two decades, I would give you an overview of where I see the biggest problems are. Not so much in, you know, how you treat separation anxiety, because you can Pick up textbooks and papers and you know, hopefully my book will be out shortly. My colleagues are all writing books.

There's lots of information you can get, but my concern is, OK, you've got this information when you need to back out and refer. And I, when I talk about behaviour problems, I talk often about behaviours of concern, because until that point, you don't really have a diagnosis. You don't know if it's separation distress, separation anxiety, you know, there's a, you know, noise phobia, noise sensitivity, but the owners are concerned about their animal's behaviour, and they're often a loss of where to seek help.

So where do they go? The owners go to the internet or Doctor Google. I don't use Google anymore.

As a vet, I use duck duck because I think duck ducko just appeals to my sense of humour. But they can go to the breeder, they can go to friends, they can go to the pet shop, they can listen to TV, radio. Not that anybody ever watches TV much.

So my students tell me these days, they can go to books, they can go to their neighbour, they ask people in the park, they go to dog trainers, they go to vets, and there's a question mark behind that because a lot of people do not go to their vet. For the first, as their first choice of where to seek help. What information are they getting?

Is it truly fact or is it fiction, and what do we need to do about it? And all of our clients need help, you know, regardless of where you are. And I can remember, when I first started doing behavioural medicine, it wasn't really thought of as veterinary medicine.

It was some that other people did. We didn't even talk about emotions or motivations in animals. We didn't even talk about pain, really.

You know, sure, we would give pain, you know, analgesics, I guess, to animals that have been run over who needed orthopaedic surgery. But my goodness, we never considered, analgesia. Well, I wasn't taught about it last millennium, anyway, about, you know, things hurt.

And, and even Being desexed, neutered, spayed, wow. You know, who would want to go and have a hysterectomy or have, you know, any sort of surgery done without analgesia. So, things have moved a long way.

Now it's time to move a long way with behavioural medicine as well. Everybody wants a happy outcome, and they want guarantees. Certainly in Australia, people ring up and they go, Well, can you guarantee an outcome?

And I loved, some of the lectures before where, yeah, no, sometimes we just can't guarantee things. And there isn't always a happy outcome, but we need to be able to help people as much as possible. So what can you do to actually help your clients?

And I'm gonna only touch on 5 things that I think are really important. I think it's really important to learn to read body language of your patients. Actually, Read what the body language means.

Now, there's a lot of good stuff out there on, you know, the internet, but there's a lot of not such good stuff out there about body language either. So stick to reputable resources and sources, and we'll have a look at each of these in turn. Recognise signs of fear, anxiety, and what is an anxiety disorder, because that's a very, very different thing altogether from just fear and anxiety.

Determine if it's a behaviour problem or a problem behaviour. And people always go, oh, I don't understand the difference. Well, hopefully by the end of today, you will understand what I mean, that there's very big difference between a behaviour problem, which is a medical problem, or a problem behaviour, which is problematic to the owners.

You can intervene early, and then what this whole lecture is about is refer to the person who is best placed to help. That's really important. So reading body language, it's really important to take time to observe, to see what's actually happening.

And so often, body language of dogs and cats, but this is about dogs, is very subtle. It's very quick. It's all over and done with.

And people will tell me, Oh, I didn't even realise that the dog was getting tense. I didn't realise that it was getting upset. And Before you know it, you've actually ended up in trouble.

The dog's bitten you, bitten your stuff. And really, if you'd just taken the time to watch and observe, maybe that wouldn't have happened. The other thing I like to do, I guess, with my background, with two degrees in human psychology, I love watching human body language.

I just find we learn so much from watching other humans respond to what we do as well. Look for neurotypical behaviours. I can't speak for Europe, but in Australia it is politically incorrect to talk about normal behaviours.

So we talk about neurotypical behaviours. So, is this something I would naturally expect that dog to do? Is that what a dog would generally do in that context?

And it's always about context? Look for signs of fear and anxiety and pain, and they overlap. That's the difficulty.

When people use pain scores and grimmer scores, some of them are identical to animals that are fearful and anxious. It doesn't mean they can't coexist at the same time, they often do. And explain what you're seeing to the clients.

I'm just amazed, even though I've been doing this for a long time. When I point out subtle differences in body language to the client, the owner has no idea, like, no idea that this is what this behaviour means or this is what that behaviour means. The second thing that is really important is look at signs of fear, anxiety and anxiety disorders.

Now there's a dog lip licking, everybody, talks about that being a sign of anxiety or fear, but it isn't always. It can mean lots and lots of things, so you have to look at it in context. And fear and anxiety can be normal and appropriate and adaptive.

And it really worries me that we're getting so far down the track of, oh, that's a really scared dog, a really anxious dog. Yeah, it might be, but maybe it's perfectly normal and appropriate in that particular context. I'm scared of heights.

OK? You're gonna see me act fearful in that particular situation. But it's normal and adaptive, so I don't go bungee jumping.

I don't go. And do all sorts of things that I don't have to face my fears. It's perfectly appropriate evolutionary wise to do that.

But anxiety disorders are totally different. They're totally maladaptive. And we have to be able to tell the difference between it when an animal has a transient fear or anxiety about something that's perfectly appropriate, to when the animal has an anxiety disorder, which is maladaptive and it cannot live a normal life.

And the signs of fear and anxiety, and I keep stressing this, are very similar to pain. So sometimes I see people treating an animal that's fearful or anxious, when really, all they need to do is treat the pain. And if we treat the pain, so many of these things are no longer problematic.

Oh, I'm not going to spend a lot of time on the brain and behaviour, but there are parts of the brain that are really, really important when we're talking about, behavioural, problems in animals, and certainly when we're talking about fears and anxiety. So the prefrontal cortex, the amygdala, the limb. System, the hypothalamus, the, HPA access are all involved in the regulation of fear and, and anxiety.

And that's important to recognise that we do have to understand that this is part of how we deal with animals, with anxiety disorders. And the way I explained to my clients, and I love this slide because it kind of summarises it for me in a way that they can understand, that our patients are going to be hearing things, smelling things, touching things all the time. And that goes to the part of the brain called the thalamus first.

And the thalamus, then relays things to, first of all, the limbic system, which is the primitive brain, where the amygdala is, and that's the part of the brain that's gonna keep you alive. That's the part of the brain that's the flight or fight response. It also sends that same information to the neocortex or the modern brain, the thinking brain that allows you to make very rational decisions about things.

And what happens if you have animals with an anxiety disorder, is that the primitive brain, the fight or flight response, that amygdala takes over, and it doesn't allow the thinking brain to suddenly make a Conclusion like, wow, we don't have to worry about, there's a noise out there, but it's only a door banging, it's not a bomb going off. And animals with anxiety disorders hear gunshots and bombs going off and really their doors banging. And, I'm sorry about that analogy, but really, I think we're going to see a lot of these patients, in the Ukraine, in people and in animals where really they are going to have anxiety disorders about things.

That perhaps, they wouldn't have ages ago. Now, neurotransmitters are really important. Again, I don't have time in a very short presentation to talk about that.

Serotonin, noradrenaline, dopamine, GABA are all involved in the development of fear and anxiety. And understanding which neurotransmitters are involved, how they work in the brain will also help us when we're thinking about treating these animals. And this is one of the reasons that to go into treatments or me.

Or what's the latest. You know, I thought about that, just giving, giving lectures to students about that. But I thought in 25 minutes, this is really the most important thing from my perspective, my perspective, to give you an overview of what's going on.

In general practise, you're going to see cases with recurrent medical problems, and you've already heard a whole pile of them this, this morning for you, this evening for me, such as vomiting, diarrhoea, elimination disorders, thin. Problems. And a lot of these animals actually have an underlying medical problem, which is anxiety or the stress response.

I remember seeing cases when I was in general practise, where this dog would appear every Monday with recurrent diarrhoea and had really severe problems. When I looked into it, the dog was going to dog training every Sunday, and therefore it was stressed, and we would get a recurrent medical problem every Monday. And the underlying reason for some of these disorders is anxiety related, and that's a wonderful thing.

Now, when I work with specialists in neurology, dermatology, internal medicine, we recognise that the stress response is really important. And when people talk about behaviour, it's not just separation anxiety or noise, noise phobias or aggression, but all of them are medical conditions, and we need to start thinking about that. We need to recognise the four Fs.

Fight, flight, ee, freeze, and fiddle, some people call it fidget. And I like that terminology, because when I use that, the clients know what fight and flight is. They don't have to go into a lot of explanation about it.

And I like talking about behaviour as an emotional state. So when you're in the green emotional state, you can think from them. And learn.

When you get to the orange state, the middle, this is when you see the freeze and the fiddle behaviours, and we're all familiar with those behaviours of the animal that just sits on the table and lets us do anything. What does the lip licking and yawning. And then when you get in the red zone, it's about flight and fight.

And fight doesn't necessarily mean biting, it can be over arousal as well. The fiddle behaviours or fidget behaviours are really displacement behaviours. They're normal behaviours.

They seem out of context. They indicate internal conflict and stress, and we all know about yawning, lip licking, grooming, and sniffing. Sleeping is one I think people often forget that these animals that just shut down, like people with depression do, they are also maybe anxious and stressed.

Well, the third thing, is it, is it a behaviour problem or a problem behaviour? And this is really important if you're going to work out where you're gonna go and who you're gonna refer to. So, what's the difference and does it really matter?

And in my opinion, there's a big difference, and it really, really, truly matters. Problem behaviours or problematic behaviours, are normal neurotypic behaviours, but they're undesirable to owners. So this is lack of understanding of what is neurotypical for that dog to be doing, OK?

Often they're training problems, or lack of training, or inappropriate training. And that is really important because we do see animals that are trained using fear-based methods and what people call the four quadrant, that is going to lead to problematic. Behaviours.

But they're behaviours that really trainers can do with. They're normal behaviours like jumping up, mouthing in puppies, barking, growling. I, I like dogs that growl.

Many of you don't, but hey, I love the dog that growls. It's telling me, don't come any closer. I know we're not talking about cats, but scratching is another one, spraying.

They're all neurotypical behaviours, but it all depends on the context, whether they jump ship. And regardless, people find them unacceptable, and then they lump them all together as behaviour problems, but in my opinion, they're not. The problem behaviours, training is going to help resolve the problems.

Someone just needs, needs to teach the dog that if you have 4 ft on the floor, you can't jump up. This is the context. You can jump up.

My husband loves it when our dog jumps up. I'm not so fond of that, but it's really, it's on cue. We put the behaviour on cue up, she can jump up, and then if she doesn't hear that cue, if she's got muddy feet, she doesn't jump up.

And this is where I think if we're talking about referrals, vets, non-veterinary behaviourists, qualified vet nurses, or vet techs, depending on what country you come, well qualified positive reinforcement dog trainers should be able to give appropriate advice. It should be really simple for them to give the appropriate advice to help that animal, and that owner restore the bond between them. And if there's a problem, then refer to a veterinary behaviourist.

Delaying referral is a welfare issue, when people keep trying to strain dogs out of diseases, which anxiety is, that's a welfare issue from my perspective. Behaviour problems are medical problems, this is the realm of veterinarians. Behaviour problems are not due to the lack of training or inappropriate training, or owners not being assertive enough, or, God forbid that dominant word we hear.

Behaviour problems are generally due to neurochemical imbalances in the brain, which is why understanding the brain is really, really important. Behaviour problems include things like anxiety disorders, not fear and anxiety in and of itself, that's a different category. Noise phobias.

I think we use the word phobia incorrectly incorrectly in a lot of cases, but that's what most people think about it. Obsessive-compulsive disorders. I like to think of an obsessive compulsive disorders, not just compulsive disorders, because my patients generally obsessed.

Most types of aggression come under behaviour problems, and elimination issues, is certainly all about context, whether it's going to be a behaviour problem or not, but often they are true medical issues. The 4th thing you need to be aware of is early intervention. Over 50% of questions asked by new puppy owners at the first consultation are asked about behaviour.

They ask about teething, they ask about mouthing, they ask about toilet training, and therefore, knowing the answers to those basic questions that puppies may not have full bladder control until they are at least 6 months of age, is absolutely neurotypical. There's nothing wrong with that dog. When can you recognise anxiety?

Now again, there's lots of studies on this, but you can see them at the first veterinary visit, you know, I'm gonna show you what, what happens in a minute, in one of the studies that my friends looked at. Puppy preschool. That's why I'm so passionate about puppy preschool, because we know more than 20% of dogs have an anxiety disorder, and some studies indicate that it's up to 80% of dogs have an anxiety disorder.

I don't think it's that high. I think certainly 20% of 80% of dogs might have anxiety, but only 20% actually have a disorder as such. And this particular study looked at what you see in the bed, the first puppy visit.

So they're yawning, they're panting, they're lip licking, their ears are bad, and most of them defecate. And they persisted into adulthood. And, Martin Godbau and Diane Frank, when they published this actually recommended early intervention and early identification.

They looked at these dogs years later, 2 years later, to be exact. They haven't published that study, but the same behaviours that you saw in the first consultation, you're going to see the same dogs doing the same thing. Couple of studies that came out quite a few years ago now, but 68% of clients that attended a veterinary practise for any reason, even to buy dog food, want to ask questions about canine or feline behaviour.

So again, familiarising yourself with behaviour and whether it's a behaviour that needs to see a vet or help needs to see a trainer is really important. So, the whole point of the lecture is referring, who do you refer to, when do you refer, and why do you refer. Well, many people think they know about behaviour.

I've been to dinner parties where people go, they're there, dear. I, you know, you think you know about dogs, but, you know, I've had dogs all my life, and I guess most of us as veterinarians have heard that. Well, they think they know about behaviour, but they don't know the science.

Many of them call themselves experts or specialists, and certainly in Australia, if you're not a vet, you can call yourself a specialist. You can't call yourself a specialist unless you're a vet. How can the public tell who to who to refer to?

How do they tell the difference? And how can you tell who you refer to? So trainers, some have no qualifications, some have many.

There's no regulatory body as far as I could find anywhere in the world about behaviour, about trainers being regulated. There is for veterinarians, but not for trainers. .

Trainers cannot and should not recommend medication. Yet so often I hear they do. There's some great trainers out there, and I work with a lot of great trainers, but you can't you can't listen to a trainer telling you this dog needs to be on medication.

And in my opinion, they should be positive reinforcement trainers only, only reward-based trainers. I think you should be familiar with their work, if you're referring to trainers, I know the trainers I work with really well. Watch them train.

Do they? Walk the walk, not just talk the talk, and they're a great adjunct to practise. In Australia, we have the Delta Dogs, they're fabulous.

This is my conflict of interest. I sit on the board for Delta at the moment, but really, qualified trainers are fabulous people to refer to. Why do we use only positive training methods?

Well, there's lots of studies that show that if there's better there's not only better. Obedience, but fewer behaviour problems, just the animals are trained using positive reinforcement, but if you use positive reinforcement and punishment, you get the highest rates of aggression, and punishing animals increases aggression to unfamiliar people, dogs, and increases avoidance behaviours. There's veterinary specialists in behavioural medicine, vets, there were veterinary specialists are obviously vets.

They can recognise and treat medical issues such as anxiety and pain. And I can tell you a lot of my patients, I refer on to another specialist because I need their pain treated. I mean, I will give them basic pain trials, I'll do all that.

But if I think there's a skin problem or an orthopaedic problem, I will certainly refer them on and Have their pain treated. This is not what non-veterinarians can do. Most of us have qualifications in behavioural medicine, whether it's in the Australian, New Zealand, American or European colleges, but really these days, we are the psychiatrists of the animal world, and this is where behavioural medicine is going, just the same as human medicine, because we're dealing with the animal's mind.

And we manage the people and their pets. It's important that behaviour problems, and this is when we're talking about the medical issues, you cannot train pets to resolve behaviour medical problems. Just as you can't train dogs out of diabetes or thyroid disease, or you can't train them out of epilepsy.

We had a fabulous lecture on epilepsy earlier on. You can't train them out of that. But as you heard in that presentation, minimising their stress, minimising their anxiety, looking at their diet, we can make a difference, but it's not training.

And, you know, I don't know any veterinarian in the world that has a bad skin case and sends them to a dog groomer for the dogs skin to be fixed. They send it to a dermatologist. I love this.

Complex solutions do not have headline, complex problems do not have headline solutions. That is out of a New Zealand newspaper about something entirely different, but it's true. Behaviour is complex, regardless of how many people still offer guarantees, quick fix solutions to many behavioural issues, it is complex.

So, Who do you refer to? It depends on your diagnosis. When do you refer them?

As early as possible. People ask me, how early do I see the patient, as early as I need to. I have patients that are 8 weeks old, 10 weeks old.

We need them to be treated early if they have medical problems. And why? Because it's a welfare issue if you don't refer it to the right person.

So in conclusion, veterinarians can play a vital role in addressing behaviour problems. By recognising anxiety, recognising when it's an anxiety disorder, giving good behavioural advice, it's correct, up to date, scientific, and humane, treating behaviour problems early and referring early to the right person. So, I don't have a crystal ball, I don't have a magic wand.

Even though a lot of my clients want me to have that, I tell them my, my wand broke last week and the crystal ball went foggy a few weeks ago, but I'll do my best to help your animal be the best animal it can be. So once upon a time, yeah, it'd be lovely if we could sprinkle fairy dust, but what I do want them to do is live happily ever after. So thank you, and I think I'm on time, Pat.

I've tried very hard to do it in the 25 minutes I was allotted. That is seriously impressive. Yes, you're absolutely bang on schedule or possibly even a little bit early, which might be one of the first times a vet has ever been early for anything, so that's amazing.

Thank you so much, that was a really brilliant talk and certainly one, I'm a first opinion vet in practise. And I have an interest in behaviour, but obviously I'm no expert, and I think it it is such a fantastically unregulated field here in the UK. You know, anybody can take a weekend course and set themselves up as a dog behaviour specialist or trainer, and it's actually very, very difficult to pick out who that we can send them to because obviously there's, there are organisations who try to be, you know.

More responsible, but there's quite a few of them. So even picking out over here anyway, I don't know if that's the case in Australia, it is, it is actually quite challenging, and a lot, a lot of vets will want to refer to a veterinary, or ideally a veterinary behaviourist, but there's not very many of them are behaviourist, so finding the right person to send these patients to, and you're right, to recognising when they need to be sent is fab, you know, is, is can be very challenging. We haven't had any questions come in that I can see for your talk, but I have one, if, which we'll see how quickly you can answer it.

I'd be really interested in your opinion on the impact of diet on behaviour and whether you feel that there are any diets that you tend to reach for or any that you find dogs in general are worse or better on, cos that comes up an awful lot, particularly in my work on the in the online world. Yeah, yeah. Look, years ago there were studies, not particularly good studies, even the authors admit on looking at the amount of protein in diets, if that helped with certain types of aggression.

I think the use of alphacazozepine in the diets that you have now, because there's a lot of commercial diets out, different brand names, different countries. We have some in Australia that are not available elsewhere, and vice vers. So, but those diets can make a difference.

I think pheromones can make a difference as well. But to me, if you have a true anxiety disorder, they're probably not enough. I like using, fatty acids in diet, you know, to help them.

I like doing everything I can to supplement them. And I think for the minor fears and anxieties, absolutely, they're fabulous. They really help.

But when you get To really severe anxieties, they're probably what I call the icing on the cake rather than the cake. So you kind of got to build the cake first, and then you can put the icing on. But, you know, I've, I've just changed my dog to a, a, a calm diet.

She finds it really palatable. I think she's gonna fit out the door soon is the way she keeps eating it. But at the end of the day, I think it is helping along with her other medications that she's on.

Interesting. So the pre you find those calm calm prescription diets are helpful, but you don't necessarily see a relationship between, I guess it would more be problem behaviours rather than behavioural problems between what diets dogs are fed generally. Mm.

Well, a lot of them are based on, tryptophan, and tryptophan is a very large amino acid, and it competitively competes cross the blood-brain barrier. So if you have a tryptophan diet, you have to keep the other amino acids low to get it across the blood-brain barrier. So, It's much more complex than people would lead you to believe.

I actually think the microbiome's got a lot more to do with it than than we actually, we think about at the moment. And, that's certainly where my latest sort of delving into looking at things is, is, what effect does the microbiome have? Because I think that's going to be the next big thing that we look at.

Yes, I think it is a very interesting area of research and actually what our next speaker is an expert in, so thank you, that was an an amazing segue. However, we have had another couple of just a couple of questions. Somebody has asked when your book might be released.

Good question, hopefully by the end of this year. So we've got most of the chapters in, I'm still working on it. You know, it takes a while.

Well, you can probably revise and revise forever, and eventually the the publisher has to wrench it out of your hands and send it to the printers. And then another question, do you recognise cocker rage syndrome and spaniels? That's something I used to hear about at the beginning of my career, but, for a long time.

Yeah. Me personally, no. I think it's, it was convenient.

It was a way of, sort of like idiopathic. We don't know what it is. If it's a cocker spaniel, that's going to be the problem.

I don't think I see that as such. And then there was a phase where people went through looking at what colour the cocker spaniel was. Certainly, in springer spaniels, they've shown that it's actually genetic, that when they actually changed.

Where the animals were bred, their breeding stopped, because there were 2 or 3 kennels that that won all the major dog shows in the US. When they bred from those size, it went right through the breed. When they stopped breeding from the size, it went away.

Is it rage as such? I think it's a convenient label. We probably don't know enough about it, but I do think there's a genetic predisposition, and there's epigenetics involved.

It's much more complex than just giving it a, a glib label. Very true. Right, thank you ever so much.

We have to move on because from being early, we're now actually starting to run a little bit late. But thank you, that was an amazing talk. If you could have a quick look at the Q&A and answer any other questions that might be in there, that would be fabulous.

And we will let you go to bed cause it's 10:30, probably coming up to after 11 o'clock where you are now. So thank you very much for staying up to join us. Right, so our next speaker.

Is Ingrid Hang, and she's actually coming to us from her home deep in the Estonian forests, which sounds amazing. So we've gone from cosmopolitan Sydney to Estonian forests. Now, Ingrid, graduated from, the Estonian University of Life Sciences.

In their veterinary veterinary department in 2006, and then during her studies, she went to Portugal, England, Norway and Sweden, which just shows the international er nature and generosity we have in this profession. She completed a PhD, on the intestinal microbiome, which is such a buzzword at the moment, and I'm really excited to, to learn what she has to say. And then in 2015, she went back to the University of Estonia where she lectures now in the small Animal gastroenterology department.

She's also the president of the Estonian Small Animal Veterinary Society and therefore is part of AAA and WSAVA as well, which I think is, Amazing, and she's gonna talk to us today on the chronic GI patient which in first opinion practise we all see an awful lot of. So please, Ingrid, take it away. OK.

Thank you. Hello, everybody. Thank you, Ken, for the introduction.

First of all, I have to correct you that I am not the current president of Estonian Small Animal Association, Yulia Abram is now. So, but still, yes, I was the president, but not anymore. So, yes, I'm very honoured to be here, so, thank you for, inviting me.

So I will now, try to, share my screen with you. Oh So, OK, here we go. So, today, I will try to go through really logical and easy diagnostic approach to the chronic gastrointestinal patient.

I think we all have had them. It's, it can be a total nightmare. So, let's see, how far we can go because the time is running, so.

Anyway, all of you have seen, a lot of those, vomiting, patients and, who also have diarrhoea. So they are actually the most common symptoms, in chronic gastroenteropathis. So, it can be, it happen in any age, breed also including mixed breeds.

So all of them, can, be. So, and I'm pretty sure that you all know that chronic gastroenteropathists, they are really time consuming and expensive, and they can be really expensive and you have to have really good owner compliance, so. So that is something what you really have to invest your time.

And of course, there are a lot of additional symptoms also with chronic gastroenteropathis which of course vary a lot depending on the case. So the animal could be anorexic or hyperexic. There can be abdominal discomfort or even pain.

So, and the pain also can cause behavioural problems, as, Kirsty was, was also mentioning. So, and of course in severe cases, we see, heavy weight loss. So, and many, many other symptoms as well, so I'm not listing all of them here.

So, and as you know, that vomiting and diarrhoea, the main symptoms and also all the other symptoms I also already mentioned, they are not specific for chronic enteropathies. So it can be also a lot of Extra gastrointestinal diseases like renal disorders, hepatic disorders, endocrine problems. So, what, at the appointment, we really should look the animal from the nose up to the tail.

So, I'm not only focusing on gastrointestinal part, when the animal is vomiting or having diarrhoea. And having said that, just a quick overview that we can have primary and secondary gastroenteropathis and, of course, also in chronic gastroenteropathis, we should take into account bacteria, parasites, fungi. But then on the other hand, we should also think about, obstructions, namely foreign body, and, neoplasia, and I have seen also, quite many, chronic foreign body, cases, so, foreign body here as a chronic gastroenteropathic cause should be listed as well.

So, and, and chronic inflammatory enteropathies like food responsive enteropathy, antibiotic responsive, or immunosuppressive responsive enteropathy. And then, as I mentioned, all the other organs or disorders of other organs can also cause the same symptoms, so we have to rule out all of those extra gastrointestinal diseases as well. So what is chronic actually?

So chronic is when the symptoms last more than 2 or 3 weeks, or if the symptoms are intermittent. So, chronic is also a case where there is, let's say, once in a week, vomiting but already, 2 months, 3 months. So this is also a chronic case.

So, and why it is important to understand what is acute or chronic is that the chronic cases usually and actually always, I would say they need more comprehensive diagnostic workup. So we will go that through now. So, the first step on the diagnostic workup is actually the detailed an amnesis.

So, this is really, really important to understand what is actually, the symptoms, what is going on with this, animal. So I would, suggest, to ask a lot of questions about that, the background, housing, vaccinations, deworming situation, other, concurrent disorders, medications, . And super important is a nutritional history.

So, I spend a lot of time at my appointments to ask about nutritional history and does it, get any Streets, any raw food, any home, leftovers. So, I spent a lot of time and I don't know what about, in your country, but at least in Estonia sometimes owners are not willing to speak a lot. And they don't tell right away everything, so I always have to ask a similar kind of questions, especially about the nutrition, and then I get really detailed data about nutrition.

So, Yes, so, this all is really important and I have here also the rough estimation about the age that in puppies and kittens, we see a lot of infectious diseases as a cause of chronic gastroenteropathies. So, viruses, parasites, parasites, namely. But also it can be a foreign body, chronic foreign body, or food responsive gastroenteropathy.

In young or middle aged, animals, food responsive enteropathy or antibiotic responsive, there is a question if that, is, something that we have, caused, but I will leave it for that because of the time limit. And of course in dogs, especially young middle aged dogs, we should rule out high pattern. Because this disease has the same symptoms as a primary chronic gastroenteropathies.

So, and in aged animals, they more often have immune suppressive responsive enteropathis, neoplasias, and, in those really skinny old cats having diarrhoea, we should also rule out hyperthyroidism. So, this is, but this is a roughly estimation, so, maybe it helps you, in the clinical practise. So, and, the physical examination.

Is also very, very important. I see a lot of referred cases, where I actually think that they shouldn't be, on my table because if, then, local vet has been maybe more thoroughly, palpated, already, especially in those skinny cats, you can feel, you can get a lot of information just by physical palpation. So it may seem old fashioned, but that really helps.

So, and of course, . The diagnose or the differential list, you can also do, just, focusing on the main complaint. When it started, is it acute, chronic, intermittent.

So if the main complaint is, vomiting. Then, we all know that, that, it should, it is active process, so, and it, then we could, localise it, if you talk about primary gastrointestinal disease, maybe we could. Localise it to the stomach, small intestine, or then proximal large intestinal programmes.

So, but it's very important also for you as a vet to understand if this animal is actually just, just, regurgitating or vomiting, and, what I see in my practise is that, very often the owners don't know, and, the owners don't know what is the difference between those three, issues and, very often I kindly ask owners to make a video. And that's very straightforward. So if the animal has a regurgitation, so this is the most probably esophageal problem, but vomiting, as I already said, stomach and small intestine or proximal large intestine.

So, there are differences which matter. So localization important because it helps you, further make the diagnostics. So, maybe you should then focus on gastric ultrasound or small intestinal ultrasound.

So that's why it's important to understand what is going on. But if the main symptom is diarrhoea or includes also diarrhoea, it's also helpful to understand is it a small intestinal or large intestinal, and there is this nice table which helps you to understand or also the owner. But very often, it's a mixed, it's not only small intestinal or large intestinal diarrhoea.

And often also, the owners actually don't know. I had a case where there was a large breed dog, and he was defecating like 15 times in a day. And it was the first dog for that owner and the owner just thought that that's normal.

That's normal if the dog wants to go out during the night. So, but we know it's not normal and it's most likely large intestinal problem if you have ruled out all the extra gastrointestinal issues. So, Also, what is really helping in everyday clinical practise is a faecal scoring system, because it really helps you as a vet also to understand how severe chronic case it is, and if you start the treatment, then it also helps you to assess the efficacy of your treatment plan.

So, but again, here, when I show that, to the owners, or they actually send me photos to my emails, so this is how I start my morning. I don't know if you start with coffee, but I start with faecal, pictures. So anyway, the same, owners think that the soft faeces is normal because this is something what they have only seen and that is the problem.

So, about the localization of the diseased area I already talked about, so we will not focus on here. But yes, again, just mention that there are a lot of extra gastrointestinal diseases which we also have to rule out before we call it primary gastrointestinal disease. So, yes.

Also, the, the first step of diagnostic, included, physical examination, as I mentioned, the, so, Sava has made a nice body condition score and also muscle condition score. Which should be measured in each chronic case. Why?

Because it gives you a lot of information because I have had quite many of those fluffy coated dogs, a lot of hair and when I palpate, I, I measuring the body condition score and the muscle condition score. It comes as a surprise for the owner that there are no muscles, and if the owner is touching in the same way as I am, they are surprised, OK, where are the muscles met. So how is this patient so skinny?

So, owners who are living every day with their pets, sometimes, of course, we have also dogs living outside, cats who are going outside and living inside. So they don't notice and and at the appointment, they are just really, really surprised. So this is also something that is helping, so you get all those little details together on the first diagnostic step.

So, The second step of diagnosing chronic gastrointestinal disease is lab work. So if you have already gathered, hooananesis, you have the nutritional database made very nicely, physical examination, then the lab work comes as the next point. So blood sample, haematology, very often in chronic cases, we see, anaemia and, this, those animals are also dehydrated, so, there is hema concentration.

I do recommend you take a full, biochemistry, your own biochemistry profile, meaning liver, kidney values, glycose, electrolytes, proteins, albumin globulins, of course, and, . Triglycerides and include also GI panel, gastrointestinal panel, which means also folate, copolamine, and pancreatic specific lipase and in dogs also basal cortisol. And because we want to rule out high paternal cortices in dogs.

And if you have, as I told you already, old skinny cat with diarrhoea, then T4 hormone would be also the choice to measure. Folate and cobalamine, are very needed in chronic cases, because if they are both decreased, then you should supplement them. And if they are both decreased, then it shows that there is a heavy ma absorption going on and they both actually, mm you can then focus the disease, of course, more into small intestine.

But it's not always the case. It's not always that strict, always. So, usually, the animal should be fasted, 10 to 12 hours, before, especially, before measuring pancreatic, specific lipase and, .

TLI, as well. If you see, in the lab, work, you see aotemia or hyperproteinemia, then, of course, and the liver values are normal. And then, you should perform also urine analysis because, the protein can be lost, through intestines, through kidneys, or through, the liver.

But if the liver values are fine and you still have aotemia or, or hyperproteinemia. Then the urine analysis is, is something what should be done. If the specific gravity or especially if the UPC is normal, then you can rule out, probably you can rule out any urinary tract or kidney disease.

Yes. So, there are also, . Acute phase proteins, for dogs, C-reactive protein and for cats, SAA, so serum amyloid A, they are both acute phase proteins and, this is, something, what, I see that a lot of people also measure.

It is OK to measure also in chronic cases. But, those acute, phase, proteins, they don't, they are not, specific, for intestinal inflammation. Of course, there are studies which have shown that C-reactive protein in dogs have been more increased in chronic inflammatory enteropathy cases, versus totally normal dogs.

So you can use them, and probably, they, they are more used as prognostic value or as for longitudinal, assessment, of the, of the disease. So, and as mentioned, diagnosing the chronic gastrointestinal, disease, also we should rule out the pancreatic diseases. So measuring in chronic cases, measuring specific lipase or tripty-like immuno TLI, it is also in place.

So about cobalamine and folate, I already, talked about, so I will not go through that here. And then, yes, for dogs, basal cortisol, is something that we should also put in our panel, because, Addison disease is actually Nowadays, we see a lot of non-classical Addison diseases. So there are no imbalances in electrolytes.

So, and if the basal cortisol is low, then ACTH stimulation test should be performed. And T4, especially in cats as I mentioned. Here is a nice paper if you want to read any extra.

It's a review article about C-reactive protein in chronic GI cases in dogs. So you can have a look at that. So, the faecal sample on the second step of, diagnosing is, of course, we have to rule out also the parasites, the fungi, and, viruses, but especially parasites, so always use fresh samples.

You can also, have, measured, microbiota that does this biosis index, which actually, helps you, to understand also the severity of this chronic enteropathy and also. Helps you to assess the efficacy of, your, treatment because very often in chronic gastroenteropathic cases, there is, this biosis, going on, but of course there can be debiosis also, in cases of exocrine pancreatic insufficiency, for example. So, yes, but it is a, a useful tool both for dogs and also for cats, and, it can also give you the the hint or, or the further explanation for using faecal microbial transplantation as one of the adjuvant treatment.

Culture, cytology, or thesis, this is something that I am not doing nowadays, but I know colleagues who are still doing. But this is it can be quite misleading and also if you take, let's say, say for example, salmonella, if you culture for salmonella, it comes back positive, then what, we know that most of those animals with salmonella, they don't have clinical signs. So, but if you have the patient with clinical signs and you make the culture, you get back salmonella positive.

Then you still need to make more workup. So, yes, here is also a nice paper from Jan Sohodolsky about the microbiome biosis index which actually shows that that, here in healthy, dogs, the this biosis index is, is, really normal, so below 0 is normal, and in chronic enteropathic cases, the this biosis index is is quite high. So, and the same for cats, also from the same group from Texas AM University Gastrointestinal, Laboratory.

So here the same healthy cats, normal biosis index and cats with IBD or small cell lymphoma, which is also one form of chronic gastroenteropathy in cats. They have high dubiosis index. So, and, also additional reading for you if you have time during the night.

The, biofecal cultures are not so, useful, anymore, so you can't really distinguish between healthy and diseased animals and there are high interlaboratory variation and of course, cultural results, for antibiotic sensitivity can actually lead to unnecessary antibiotic usage which we don't want. So, yes. Also, with, chronic enteropathies, I recommend you to use also, clinical activity indexes, this one is for dogs, and, I have one for cats as well.

So, this also helps you to, understand first, on the, baseline first to understand the severity of the case, and then later when you have diagnosed, and started the treatment. Then it helps you to really quickly understand if your treatment plan is working. Of course, it is the same as with acute phase proteins.

Of course, you will see with symptoms. If the symptoms are getting better, probably the animal is getting better. So, so, and then also this index should get better as well and acute.

These proteins should be decreased as well. So we actually, in chronic cases, we have those tools, but of course, we don't treat the numbers we treat animal and it's symptoms. So, the first step and then going through the second step of the diagnostics.

So, the first step was an amnesia, physical examination and nutritional database. And the second step, we already mentioned the lab work and now, the next, for the second step, would be the X-ray. So, always take 3 views, and with plain radiographs, you cannot say anything about the structure, of the stomach or intestines.

I very often see that, . vets, they want to say, on a plain radiograph that, OK, this has inflammation in the intestines because the wall of the intestine is really thick, but this is something what we can't say. So for the structure, you, need, if you want to say anything about the structure, then go for ultrasound.

So, and, for ultrasound also, the animal should be fasted. And with ultrasound, you can see a lot of, a lot of, other, organs as well in detail. So, and with ultrasound, you can see the structure of, stomach, small intestines, and other organs, and, ultrasound is actually also telling you if you want further to take biopsies, what type of biopsies.

Full thickness biopsies, you should go. If you see changes in outer layers like muscularis or serosal layers or you see changes like here throughout all the layers, but then if you see on ultrasound, you see changes only on mucosal layer, then you should or could think about taking endoscopical biopsies. So, and the third and the last step of diagnostic is actually everything would includes anaesthesia.

So, this, it would be a malpractice if you go for endoscopy and you see this little fellow here. This actually happened and and this is really not. Nice.

So some, some steps, wasn't probably taken. So, endoscopy is a third step and then with endoscopy, as I said, you can take biopsies, you can remove the foreign body polyp, but if you make endoscopy, then always one should take biopsies as well. Laparoscopy, of course, also, possible, especially if you have to take biopsies from different organs, especially in cats with triaditis, syndrome, and you can get a full thickness biopsies with laparoscopy, the same, with laparotomy.

And the CT I would go for really giant breed dogs, which ultrasound is sometimes maybe not so detailed and also if you suspect any masses, especially esophageal or or a large intestinal outside the large intestinal masses or this back area. So, Yes, a nice paper from Karen Allenspa also taking the same kind of steps, for diagnosing chronic gastroenteropathy. And what about the future?

Do we have a happy future because now we don't have any specific marker for chronic gastroenteropathy, but the future is really sunny. Scientists are working and nowadays, at least preliminary studies, show that certain short chain fatty acids, could be a good non-invasive indicators for at least chronic intestinal inflammation, . Like, in cases of food responsive, enteropathy.

So, take home messages be stepwise, localization really helps you to make further diagnostics. So really, you know where to focus. Nutritional data and microbiome are really the key factors, rule out all extra gastrointestinal diseases which could give the same symptoms because all those symptoms are not specific for gastroenteropathy.

And make all those puzzles together, so use all of those 3 steps, the results of those three steps, and we always treat the animal and symptoms and not the numbers. So, thank you. I hope I was in time.

So, and I hope you got some valid information. Thank you, thank you, Ingrid, that was amazing and so fabulously practical for first opinion vets. I think we all love.

A diagnostic track to go down, don't we, and a list of things that we should do and rule outs and all the rest of it. And I think the microbiome, I'd love to talk to you all day about that because I think that is just such a fascinating area of research and, and the impacts it has on guts and brains and, and all sorts of things and how we can manipulate it, to make, make animals better and test it to see how they're poorly. I think it's, it's fascinating, but unfortunately, we are, out of time.

But we didn't, if you could keep an eye on the Q&A box, but I think your lecturer obviously answered it. Everybody's questions because nothing specific, nothing specific. No thank you.

Thank you very much. Just before we move on to the next speaker, I just want to say hello to Mary, who is actually listening to us from Ukraine, which is amazing. She says that she's, safe, in the west part of the country, but she is, really personally appreciative of us and all of her colleagues that are supporting her and her fellow countrymen.

So it's. Wonderful. I'm so pleased that you're able to join us, Mary.

And, you're absolutely right. We are all here for you and, and for Ukraine. So please, if you haven't already, please don't forget to donate, because the causes that we're supporting are genuinely doing work on the ground to help the people that need it right now.

And that's why those charities were chosen. But let's move on to our next, speaker, who, I don't know how Wolfgang knows. So many impressive people from so many different places in the world, but we are now heading over to America to Santa Cruz, where Boaz is speaking to us from.

And apparently he's off surfing as soon as he's finished. So we have to keep, I've been instructed to keep the questions short because he needs to get down the beach, which, you know, looking for some, isn't he? So Boaz is, the professor and chief of dentistry and oral surgery.

At, the UC Davis veterinary school. And his special interest is in oromaxillary facial disorders and the regeneration, the regenerative treatment of them for dogs and cats, and particularly, he likes, the one health aspect that we have for the, the treatment of those disorders for animals and also for people. So.

And he's gonna talk to us today about the management of retrovular disorders in dogs, which is clearly his expert subject. So please, Boaz, take it away. Thank you so much, Kate.

And thank you so much for including me in this really exceptional and humane initiative. I'm, I'm proud to be a part of this. What we're gonna do this morning is talk about retrobal disorders.

I'm gonna review a little bit of the anatomical structures of, of the area, and we'll talk about type of disorders and also about how we diagnose this and how importance are diagnostic imaging in particular CT and, and MRI. And then we're going to talk about how to manage them. Before we start, I want to tell you that, you know, diseases of the retrobar area are, are very painful and can be a conundrum, from a clinical perspective.

This dog that you see here is one of my patients, and the dog was treated by a veterinarian for masticatory muscle myositis without imaging, without knowing what's happening. And what And what you saw here is an unfortunate outcome for this dog. So we're gonna talk about how to avoid this.

First of all, the retro bulbar area is, what we consider from a surgical perspective, a hostile environment. We have a lot of blood vessels and nerves. All are very significant, supplying the eye but also coming out of the brain.

Any Manipulation in this area can become catastrophic very quickly. And that's another example of how much business is happening in the retrobble area. And we distinguish between two types of retrobal disorders.

The first one being a primary and the second one being secondary. The primary meaning that the disorder started and is confined mostly to the retrobulbar area. The secondary disorder, meaning that the disorder started elsewhere and extended to the retrovulbar area, like you see on the right, this big mandibular tumour that extended into the retrovulbar area.

Other type of disorders that we see there is our neoplasia. Cellulitis or abscess typically from foreign bodies, salo cell can be also congenital and developmental disorders, myositis, hematoma, and trauma. We are all veterinarians.

We are all doing our best, but sometime, people, veterinarians can cause the rogenic arogenic damage, to the eye, to the retrobulbar area. And what you see here is a catastrophic, accident from, somebody that they did, a dental procedure on this dog, slipped with the instrument, went to the retrobbar area, caused a slight abscess, but also destroyed the eye. Another option is traumatic, and that is a stick injury, pharyngeal stick injury.

Dogs like to run with a stick. Sometimes the stick hits another object and gets shoved directly into the retro pharynx or into the retro bulbar area. And that's what you see clinically, this dog had stick, stuck straight into the carotid artery, and also devastated the retro bulbar area.

Secondary disorders, as I mentioned, Or it can be ingrowth of neoplasia, metastatic disease, and spread of nearby infection or inflammation. So how do we see this clinically? And the first thing that comes to your mind is pain on opening the mouth.

It's, it's super painful. The coronoid process will be pressing on the retrobar area once you start opening the mouth and that's super painful. We see exostomos.

Decrease ocular electropulsion and I'll talk about it in a second. It's not what you think. Protrusion of the third eyelids, strabismus, chemosis, glaucoma, and blindness.

All of these can be seen with retrovial disease. So when I say pain on opening the mouth, every time the dog opens the mouth, the coronoid process that you can see here on the right is starting to press on the retrobalal area. So from a clinical perspective, what you will see is that you can open the mouth a little bit and then when you hit a certain point, The dog starts screaming.

So it's not a subtle pain. It's typically a severe pain and it's sharp pain, it comes at once once you start opening the mouth. And to distinguish this from other disposals like TMJ ankylosis, and, and bony changes, one way of looking at this is if you have a hard end feel like an ankylosis, with the bone, let's say it's a bone disorder or soft and feel, which means we have a soft tissue problem.

So you can play with your hand, you know, flex it and extend it, and you will have, you will see exactly what I mean as far as the soft and hard and feel. Soft and field typically indicates a soft tissue disease, typically retrovi. From an image imaging perspective, CT is the main, imaging modality with contrast.

Contrast is essential. It's almost a must. And with the emergence of con beam computer tomography, in the, in our field, I would say that it's not appropriate to image a dog with retrovial disease withOBCT because COVCT have very good bone and teeth resolution, but not soft tissue resolution.

Ultrasound is amazing and it's also in a good adjacent tool. I'll show you in a second. And MRI of course, it just takes longer, and a little bit more expensive than CT.

Ultrasound can be very useful, especially when we talk about foreign bodies. So what we see here is, is a foxtail. Foxtail, that was lodged in the retro bulbar area, we could see it, we can then approach it and remove it.

MR, I guess I mentioned earlier, also very useful, especially in this zygomatic syo cell, and it really honestly depends if, which service pick up the retro bulbar disease, if it's us, if it's ophthalmology service, we typically do CT in contrast. If it's the neurology service, they typically do MR. If at all possible to obtain biopsies from this area before, Then, You know, biopsy is very, is very important, as everywhere elsewhere, you know, to take a punch biopsy or to incisional biopsy.

In this case, you see cancer and we also see a situation where we have foreign bodies. Cytology, especially for infection, absolutely essential if possible, because many of these disorders are resistance, resistant to, to many common bacteria. The environment there are not only hostile, it's, it, it's a prime place for anaerobic infection.

In 2018, we published this big paper on the clinical and and CT features of retrobar disease, and we wanted to see what, you know, to kind of go back and see if we can learn from, from our experience. And I'm showing you the results now. And what we've seen here is the primary retrovi, we have primary and secondary, and mostly it's primary.

And then, as far as aetiology, infectious inflammatory neuroplasia almost go half and half, and we have a small proportion of trauma and secondary and disorder is mostly noplasia. As far as neoplasia, mostly coming from nasal tumours that extend into the retrobulbar area, but also from mandibular and maxillary tumours. And this is, this is, this is a Venn diagram is fairly interesting.

And the clinical presentation. It can be complex. It can be ocular, it can be oral, it can be nasal, and it can have all three components.

So, please make a note of that, that, what the owner is telling you, it can be something fairly different. OK, if the owner say my dog have problem with nasal discharge, it can actually Projected to be in a retrobal disease, the same for oral pain and the same for eye, eye disorders. What we found is that only 1/3 of the doggoso had decreased ocular retropulsion.

OK. We typically know that all, you know, retroviral disease, one of the hallmarks is that there is decreased retropoulsion, only 1/3 of the dog had it. So dog does not have to have this issue in order to be considered for retrobal disease.

And then, other significant finding is that what you see here and the presence of retrobbal mass, orbital ostolysis and stuff like that, and the funinopathy. From infection OK, as you can see here, just a few examples of this infection here. And the thematic arch or on the left when you see no pleasure, you see the periosteal reaction coming from the bone.

These are all indicators of infection versus cancer. As far as treatments, I would say before we start talking about surgeries and stuff like this, do no harm. If you're not comfortable with this, if you don't have good imaging, if you think that you're gonna cause more harm than good, don't do it or refer them.

As I mentioned earlier, and this can go sideways very quickly. So premium nonure and do no harm. So, surgical approach is possible with this dog, and we work together with the ophthalmology service to remove a tumour that was in the retrobal area from a lateral approach.

You can see here we walk with precision instruments like the piezotome. I do like to have the eye in the surgical field so that we don't damage it. Following removal of the zygomatic arch, we were able to approach the tumour, remove it, and we create a flap from the temporal fascia, to recreate the orbital ligament.

And that is the dog in 4 months and it's 18 months recheck. So fairly favourable outcome for this dog and there were no cli clinical recurrences to date, to my knowledge. Again, for premium no no, do no harm, always ask yourself, can I access the area with an acceptable risk.

And you may need to go in to just remove to get sample for culture and sensitivity, histology and stuff like that. Remove foreign bodies and relieve pressure. If we need to relieve pressure, we use Jackson Pratt and drain.

As you can see here, it's an abscess. We went in, removed the abscess, removed the lining. And placed the Jackson Pratt.

Drink Foreign body removal, the same thing. Only if you click, can clearly see it. You don't see the foreign body, don't go after it.

Take sample for cultural and sensitivity if you can and give a long-term antibiotics. I'll talk about it later. Here is a dog I showed you earlier, that had a foxtail, stuck in the retrobulba area.

We tried first to go from extraoral approach to the zygomatic arch. We couldn't get it. We went intraoral approach and removed it.

But you need good imaging, you need good technique, and . And it can be done as long as you see it on, on imaging. Infection surgical.

So this is the dog I showed you earlier, the first dog. With the abscess that we encountered during the approach to the retro bulbar area from the dorsal approach. Again, this dog was treated for masticatory myositis without any imaging, without any profound diagnosis.

So the dog received immunosuppressive dose of steroids that accebrated the retrobar disease and also cause osteomyelitis of the brain case. And that is the dog post op. Segomatic yo cell can be approached externally.

We actually use an intraoral approach for this, if we can get this and, and resolve the retrobal, this is this way. Medical treatment. You know, we talked about infection, that's a systemic antibiotic therapy.

I'll talk about it more precisely in a second. No steroidal anti-inflammatories, frequent eye lubrication. Multimodal pain medication, so no steroidals and opioids and stuff like that.

And consult with the ophthalmologist about The eye medication after me, Doctor Katherine Good is from Davis is also gonna talk, so you can definitely talk to her and ask her what to do. That's what I do. As far as bacteria isolates, from our survey, most dogs had, this type of cats had this kind of, cultures, and you can see that there is anaerobic culture on both dogs and cats.

The initial antibiotic of choice for us is amoxicclabulaic acid, followed by cephalosporins, . I actually like to give also clindamycin if possible, if amoxi carbolaic is not It's not feasible. And we give at least 2 to 3 weeks, often 2 to 3 months depending on the infection.

As far as medical treatment for the eye. Frequent eye lubrication, as I mentioned earlier. And this is, this, and the next slide is, I received from Doctor Good from Davis artificial tears, you know, and you can see here the data applied for 2 to 6 hours.

Topic anti-glaucoma if, if, intraocular pressure is elevated. And, and, and in summary, talk to an ophthalmologist because that's, it's very important to save the eye if possible. As far as treatment again.

Non-steroidals are important, opioids and tramadol, together with an acids, IV fluids. I typically give IV fluid in the 1st 24 to 48 hours until the dog is able to drink and eat. My take home message for you is as follows.

Decrease ocular repulsion is not always present for retrobar disorders. So don't rule out the disease if you, if, if it's normal. CT imaging is critical, and with contrast.

And bacteriology, cytology, biopsies very essential to, to know the nature of the disease and do it as a team approach if possible. And we typically work with our radiologist, ophthalmologist, neurologist, depending on, on the clinical sign. Surgical management only in selected situations and know your anatomy and medical management is essentially what we do for most inflammatory infectious processes if we cannot find.

The, the culprit. So thank you so much, Kat. If there is a question in the time, I'm happy to take it.

. Oh, no, thank you. That was, that was fascinating and on time. So clearly some surgical precision has been brought to your lecture.

Thank you very much. We don't actually have any questions that I can see, but, so I'm again, a first opinion vet in practise. And slipping during dental, a dental underneath the eye is just one of those things that just terrifies you, because you don't, you don't know it's coming until it's done, is it?

And then the, the, the elevator disappears and you just hope you've not caused any damage. So for those of us who are. In that situation with your dentistry hat on.

Have you got any tips to prevent that from happening? Do I know it's more dental than retrobul, but and also, if it does happen, how do you know if you have, you know, worst case scenario? Does the eyeball immediately deflate, or does it take a bit of time for that to become obvious?

OK, thank you so much. That's a good, great question. I'm actually managing a case like this right now as we speak in the hospital.

I would say that first of all, dentist, dental procedures should be done sitting. Not standing. One of the reasons is that if you sleep, you don't apply, you don't sleep with your body weight.

You sleep only with your hands. And much, much of what I've seen is people sleeping with their whole body because they're going into it. Second, if you need to apply so much pressure, you've done something wrong.

You need to remove more bone, use dental instruments, properly, remove more bone like velo alveolectomy. Make your life easier. No need to, no need to put a lot of pressure, especially when you go to the caudal area that you know that you work in the right under the eye, and especially in brachiocephalic dogs.

And if you did sleep, First of all, the most important is to acknowledge it and, and take a deep breath because if you eat something, it's gonna bleed profusely, to put a lot of pressure and already start putting the dog on, on a, on antibiotics. Not the eye does not necessarily always get damaged, but, but it does in, in a good chunk of the cases that I've seen, including the case we're managing now. But I think that the most important one is to be honest with the owner and let them know it happened and send them to ophthalmologist.

Or, or a macrophageal surgeon and or as soon as possible. . At one time, one time that I've seen that the whole eye became bloody fairly quickly.

So you will know that it happens, if hopefully it will never happen, but it can be avoided by doing the dental procedure, sitting, using appropriate dental. Instruments, I like to use a laxator and not an elevator. Elevators seem to slip in my experience more than laxator because you have to apply more pressure.

And that's it. Oh, that's really helpful. Thank you.

That's such a practical tip. And yes, brachycephalics and those silly little mouths with no space and 3 times as much cheek as they need, and, yeah, awful. Luckily though, their teeth tend to be so bad, that they just fall out.

They don't often require a huge amount of work, in my experience. Right, fabulous, thank you so much. That's wonderful.

. Really, really great. So you're welcome. So while we wait for our next, speaker to just, get her screen up, oh, she's already done it, how efficient.

I just wanted to remind everybody again of the charities that we're supporting today. We are supporting the Disasters Emergency Committee in their Ukrainian effort, and they are literally on the ground at the borders, scooping up the people as they cross. They're providing medical support, food, shelter, trauma support, because obviously, the families and people that are coming out of Ukraine have been through some awful, awful things.

So they really are on the ground, charity. We're also supporting, obviously because we are vets and animal people, a charity called Four Paws who are supporting the pets of Ukraine, the animal shelters, some of whom I don't know if you've seen. In the news have had a really hard time feeding and caring for the animals that they have in them, and also the communities of Ukraine and the animals that they have.

So if you haven't already, please do donate. Please share this conference with your colleagues and friends, let them know, they can log in and register, and the lectures will be available for the next two weeks, so you don't have to watch us live in order to be able to enjoy all of this. So now we are going.

To, Doctor Katherine Good, who, is a certified veterinary ophthalmologist and a clinical professor of veterinary ophthalmology at UC Davis. So also at UC Davis, veterinary school, clearly Wolfgang has some contacts out there, and. So Doctor Good spent 6 years in private ophthalmology practise before joining the faculty at UC Davis in 2008.

And she really enjoys, teaching and training the, the students there. And she is also doing something outside and sporty today because clearly the weather over there is fabulous and she has to get her daughter. To do a training session.

So again, we will keep the questions short to let you get on with your life, Catherine, but please tell us all about infected corneal ulcers, tips for diagnosis and treatment. Oh, happy to stay on as long as needed. This is early enough that I have plenty of time to get the kids where they need to go.

So, as Boa said, I'm absolutely honoured to be here this morning. It's such an amazing cause to be supporting. And, thank you so much for allowing me to be a part of it.

So, today, we're gonna be talking about, infected corneal ulcers, and hopefully giving you some tips, for both diagnosis and treatment that you can take back to your, practises right away. So, as I said, happy to answer any questions that you might have. So these are situations where we truly feel are emergencies when you have an ulcer that you feel may be infected, and the reason for that is how quickly an ulcer can deteriorate if it does get infected.

When an ulcer happens, if bacteria jump in there, it can eat through that stroma relatively quickly, really sometimes even within 12 to 24 hours. So it's absolutely critical that we address it, quickly. The clinical signs of infected corneal ulcers, the three that you see here are some of the main ones that you'll see that would tip you off that you've got an infection present and you don't have to have all three.

Just one, is one that will, make you suspicious that you've got an infection present, and we'll talk more specifically about each one of these. So, stromal loss, any sort of stromal infiltrate, and I'll show some pictures of what that might look like and the many different variations. And if there's any stromal melting, and we'll show pictures of that too.

What can be infecting the ulcer, well, it can be anywhere from bacteria, which definitely is the most common for sure. Fungus though can affect the corneal ulceration. Some of that's geographically influenced here in California.

We rarely see, fungal infections in our small animal patients. But definitely see a lot of it in our equine patients, and, but I've got colleagues who are across the, the US and I'm not sure how it is out in in the European countries, but, some parts of the the US certainly we see fungus more prevalent in our small animal patients. And then a viral presence as well.

Certainly in cats, herpes virus is a big player that can be concurrently present when you have an infection of an ulceration with, say, bacteria. This is a classic picture of an infected ulcer where we do see stromal loss where you see this really deep ridge here. You can kind of, with your imaginoscope, see that you've got that big divot in the cornea.

If you are ever concerned, is there a little divot? Is there not a divot, just assume there is because you're better off being aggressive and you won't lose any ground if you are versus if you're not aggressive enough, so. Again, we'll show lots of pictures today.

Just a really quick picture of anatomy here. I know oftentimes get a little bit boring when we see anatomical pictures, but I think it's really important to, to kind of drive the, the point home. This is an enlarged picture obviously of a piece of corneal tissue.

And it's broken down into its, several, components here. The majority of the cornea is made up of the stroma, over 90% of it, as you see here. We've got, a few cellular layers that make up the epithelium.

And then we get down to these two little thin layers, the first one being decime's membrane and then the last one being the endothelium. Really important to remember that our cornea is not even a millimetre in thickness. It is 0.6 millimetres in our canine patients, and feline as well.

And so just slightly over 0.5 millimetre in thickness, or I should say thinness, right? It's really, really thin.

So when you get into a situation where you think you've got a really deep ulcer, and this photo here is illustrating a desmetocele with a classic staining pattern where you have this donut appearance of stain where you have all of this stromal tissue lost. So you're down to just these last two layers of the cornea. And that's why it's such an emergent condition when you suspect you've got a deep ulceration because you don't have a lot of reserves.

It's not long before that eye ruptures, if, if it continues. And so, that's why these, ulcerations are, are so emergent. Again, this classics, staining pattern of a desmatocele that's kind of illustrated here, how we've got the stain taken up in the stroma only, but decime's membrane will not take up fluoresce stains.

So if you have a nice clear window in the centre and it looks deep, that's probably what you're dealing with, and that's when you'll wanna get some, some input on right away to see whether surgical intervention can occur. So, first clinical sign that we're looking for is stromal loss again, these are some instruments that you might consider utilising when you're doing your ophthalmic examination. I think that magnification, is really, really important.

Any form of mag magnification doesn't matter. Even sometimes readers can be really helpful, the little fashionable readers that you see all over social media now, those can actually be really helpful too. This happens to be one that we have several of in our clinic here.

They're they look very outdated, but they're very useful still. It's called an optivir, comes in multiple different, magnification. So that's super helpful for, for us and our students when we're teaching them.

This is just your standard direct ophthalmoscope, and you'd utilise it on the slit beam setting here. And when you're putting it across the surface of the cornea, you're just looking to see if it's nice and smooth. If all you have is that top layer of epithelium lost again, relatively speaking, in just a 0.6 millimetre, you know, thick.

This piece of tissue. If you're, if you've lost just that top layer of epithelium, relatively speaking, that's not a lot of tissue loss. And so it should still look very smooth when you're putting that slit beam of light across it.

Again, just very, very superficial ulceration here versus an ulcer that has stromal loss. If you're going across with that beam of light and you see any sort of divot, like you see in this blown up image here, you've got loss of stromal tissue. And it can be just 5% stroma loss.

It doesn't have to be 80% or down to Deimme's membrane for you to be concerned. If any, any suspicion that any degree of stroma is missing, you've got the potential that infection is present, so we want to act on that really quickly. Stromal infiltrate here, just some varying pictures of, of how stromal infiltrate can present.

We've got, you know, kind of a greyish hue, . Very foggy appearing cornea. This one was definitely infected.

And how you tell this from just corneal edoema, which any ulceration, you're gonna see edoema in the cornea because that top layer of epithelium, if it's gone, that epithelium is your barrier to your tears getting into the cornea. So that epithelium keeps your cornea nice and dehydrated so we can see, stay clear so we can see through it. If you've lost it, you're gonna get edoema.

But edoema looks very blue in coloration. Not this grey, definitely not this yellow or tan. So that's how you can tell the difference.

So the central one here, the central photo is a bit more what we typically see when we see infection, more of this kind of yellow discoloration. And this photo here on the right is kind of a combination of having yellow here, but also this brown. Oftentimes when you see brown in the cornea, it's just corneal melanosis, which is a sign of just chronic irritation to the eye.

It doesn't tell you why the eye has been chronically irritated, but melanin will grow in if it's not had enough tear supplies. So dry eye patients get corneal melanosis. Just chronic keratitis from, you know, past, ulceration, you might eventually get melanin to grow in.

But if you see melanin that's more acute in nature, and certainly if it's associated with this yellow discoloration too, fungus likes to turn brown sometimes like that, that yellow, that brown infiltrates, so that should be up on your list if you're in an area where you see more fungal ulcers, than we do here in excuse me, California. Now the last chemical sign we're looking for, and again, you don't have to have all three, just one is enough to make you worry that you've got infection. Is Malaysia.

So malaysia is just when you, when the proteases and colagenases that are normally secreted by the, the corneal cells themselves, but they get overactivated when we're worried about infection being present, and they're also secreted by the neutrophils. They're secreted by certain organisms more than others, and I've listed those two here that we tend to see a bit more melting with than others, and that's pseudomonas. And fungus.

So certainly if you aren't in a situation where you can get a sample to find out exactly what organism is present and you've got melting, within the, the ulcer bed, then you definitely wanna make sure that your antimicrobial choice is covering organisms like pseudomonas. And again, if you're in an area where you're worried about fungal infections and the species that you're dealing with, consider covering for that as well. So melting just takes on this very soft appearance, and it is Anywhere from just a mild bit of softening that you see here to, you know, almost looking like the tissue is dripping over the edge of the the eyelids.

Sometimes this gets confused as just being mucus, so that's not something that you just wanna try and wipe away, so you just have to be careful in in interpretation with regards to that. This happens to be a horse and they love to do pretty significant melting, . So, melting usually creates a lot of angst and rightfully so, because this tends to be a very rapid process.

And so we need to jump on this really, really quickly. If you see any sort of melting, we've got to start therapy that stops those proteases and colagenases from just eating through that, that stromal tissue, and we'll talk about what we wanted to use for that. OK, diagnostic goals and therapeutic goals.

So two main diagnostic goals. One is we want to make sure, why did this ulcer go down the route of getting infected in the first place? Because most ulcers, if your dog was to go out, run into a little bush, within, you know, a few days that ulcer will be on its way to healing.

Completely without us intervening whatsoever. So why are some animals getting infected and why others? Well, there might be a compounded cause present, and we'll go over, several of those that you wanna make sure on your examination you rule out, because if you don't treat those concurrently, you're gonna have a hard time getting that ulcer to heal.

And then just like an infection anywhere else in the body, you want to try and determine what is the organism that's causing the problem. OK, the compounding causes that we need to be worried about, I've listed them here. So dry eye, big one.

Probably one of the most underdone diagnostic tests out there is, is evaluating the tear production in your patient. Dry eye is pretty common. And even if you've got a situation, say this photo here, which we'll talk about more specifically in a second here.

This too is a Desmatocele. As you can see, you've got a very clear window in the centre. When you've got a clear window and depth to that ulceration and the surrounding tissue is more cloudy for whatever reason, be it, be it fluid, be it the infiltrate, or be it what we'll talk about in a second here, which is mineral.

If there's a clear window in the centre, you're down to Desume's membrane. Now, that would be an I'd be a little bit worried about sticking a little piece of paper in to measure the tear production. So I probably wouldn't.

I probably wouldn't do it in this eye. So how do you know that you've got dry eye present then? Well, don't forget to check the other eye, even if it looks clinically normal to you, make sure you measure the tear production in the other eye, because even if it looks OK, you might get a borderline number on your measurement.

So normal tear production in dogs is 15 and above. Say you get a measurement of 11. Well, 11 might not be enough to cause a lot of, you know, clinical signs in a patient, but 11 isn't normal.

And so that would tip you off that, OK, this one's, you know, not normal, it's subnormal. Maybe the other one is actually a lot lower than this one. And when we get that ulceration healed, we're gonna measure that tear production to see if that patient has dry eye.

And in terms of treatment, if there is concurrent dry eye present, what I'm gonna recommend that you do in terms of how you treat these infected ulcers, you'll be covering for the lack of, of moisture on the eye cause I'm, we're gonna have those clients be applying medications really frequently. So you're gonna be keeping that eye lubricated during that period of time. That you don't exactly know what the tear production measurement is.

So foreign body, make sure that you're sweeping around the surface to look for any sort of material that might be stuck in there. Boaz showed a picture of a foxtail, which is really common out here in California in certain times of the year. Those things love to get lodged up.

And deep into the conjunctible forex. Best way to do that is to put some topical anaesthetic on the eye, take a sterile cotton tipped applicator or Q-tip, and just put it up and deep into the forex and sweep it all the way around. And things oftentimes like to get caught up on that dry cotton tipped applicator and you can can pull that out if there is something present.

They also love to hide behind the third eyelid. So certainly, if your ulcer is deep down in the ventromedial region of the cornea, make sure you're pulling that third eyelid out and looking for something that might be embedded there. Exposure keratitis, those are just your big buggy-eyed brachycephalic breeds, so even if they can, they can blink OK, maybe they're not blinking fully, or certainly those are ones that when you ask a client if their eyelids are open when they're sleeping at night.

They oftentimes say, yep, I don't know, he never looks like he's sleeping cause he never closes his lids all the way. That's something that if they're not closing their lids all the way when they're sleeping, they're drying out in the middle of the night. And so that's gonna be really challenging to get an ulcer to heal in that environment.

If they've got any rolling in of the lids, so ropeon, you gotta fix that, even if it's just temporary until the ulcer heals. If they've got any facial nerve paralysis, if they're not closing all the way, sometimes what we have to do is actually do a temporary torsoy, or partially close those lids, temporarily just to, to cover the cornea a bit more, during that healing period. Ecoppicilia, which are little hairs that usually at 12 o'clock position on the palpibral conjunctiva, the upper upper lid, they'll pop through and they'll just rake on the cornea.

And cause an ulceration and prevent it from healing. Corneal degeneration, which is a photo here, corneal degeneration usually shows up as these white spiculated deposits, very, very common in older animals, particularly older dogs. And what can happen is that it's, they can be trucking along just fine with no clinical signs, but if they've got a really deep dense, mat of this, this mineral deposition in the cornea, they can be normal one day and the next day they slough that entire thickness of degenerated cornea.

And they can walk in acutely with a very deep ulcer like this particular patient did. And so that's something that we can usually we'll have to surgically stabilise the cornea, but then we've got to be talking about potentially putting on a mineral chelator, something like EDTA topically to you know, decrease the density of that mineral and try and prevent more from being laid down. And certainly some of our immunosuppressed clients have a hard time getting those ulcers to heal.

So our next diagnostic goal is to, as anywhere else, if it's there's an infection present, you want to try and figure out what that what that organism is. And so cytology and culture is really important, and then I will admit that that in several cases, clients aren't able to to move forward with that cause it, it is a financial investment certainly to send those samples in and to get an answer. But it's really nice to have.

Particularly in those patients who don't end up doing well initially on the medical therapy that you've chosen, so you've got that answer right away to, to change it appropriately. So these are some of the instruments that we utilise to get samples, just your standard Dacron swab, very straightforward to use. Usually people feel fairly comfortable utilising a swab to get a sample, and I'll show you a picture in a minute on how to do that.

This is a more advanced instrument that I don't think anybody needs to run out and buy. It's a chimaera spatula, but if you ever hear its name, this is what it looks like, almost looks like a little shoehorn. Back end of a blade, very useful to use.

And actually, this is my preferred method of getting a sample. This is kind of the old school way, and, and the way that I've always done it and feel very comfortable doing it. So that's, that's an option also.

And then this newer method is, is with a yo brush, and many of you might be doing this already. And it's a really nice method to get a sample too. The reason why is, one, they're pretty soft nylon bristles, and they have micro cider brushes out there as well.

Sometimes in a really small ulcer, this, the, the standard size one can seem a little bit big, so there's the micro brushes out there. But the nylon bristles are really soft, so usually your patients tolerate it well, especially if you've already put a drop of, of topical anaesthetic, so either proparrica or tetrachine are the ones that we utilise the most frequently. But it also, what's nice about these side of brushes is they usually create a really nice monolayer of cell, for the cytologists to be able to look at the sample.

So they really like those samples cause they're easier for them to read cause the the cells are just laid out much nicer. So how do we get those samples? The big important thing to to remember when you're getting your cytology sample is to try to concentrate on the edge of the lesion because that's where you've got the greatest density of chance of getting those microorganisms.

So try and do that as long as it's not the deepest part, right? That can be scary to get a sample. And I'll tell you, if you're worried that the, the, the ulcer is too deep, and certainly if you're Convinced you got a dematocell just bypass this stage.

It's not worth the risk of the patient maybe, you know, suddenly jerking when you're getting that sample and then your instrument going through the eye. We don't want that to happen, right? So the risk of a rupture is, is too high.

Don't do it. Cause the medications I'm gonna recommend for you and that you might already be doing, usually it's a pretty rare patient that isn't gonna respond to them. And so I'd much the, you know, the risk versus benefit ratio.

Certainly if it's too deep and worried about rupturing, just bypass this stage altogether. But if it's not too deep, we should try and get a sample if we can. With a swab or a side of brush like you see here, it's just a matter of when you're holding your instruments.

The main thing is that they're parallel to the ocular surface, that you don't want to have an angle where it's pointing towards the eye itself. Seems pretty intuitive, but just really making sure that that that's the angle that you're doing it at. And make sure that somehow you've got a handle on that patient's head when you're getting that sample, versus having your hand free out in space, cause we just don't have as much control that way, and we don't have much control on a patient who's gonna, as I said, suddenly jerk.

So make sure that your hand is on them when you're getting that sample. So if they move, you move with them. And same thing with the with the back end of the blade here, nice and and kind of parallel to the ocular surface in terms of the, the angle of that blade, and then you're doing more of a brisk scrape when you're using the back end of a blade, versus more of kind of a rolling action, like you're rolling some spaghetti in between a, a, a fork there and you, when you're using that swab or that side of brush.

This is an alternative though to consider if you're just not comfortable enough based on the deep deepness of the ulcer itself, to get a really valid idea as to what organisms might be present, and, within that, ulceration bed. And that is, instead of going directly onto the cornea, just getting a conjunctible swab. So using that that swab, the the culture swabdacron tip here.

And just sweeping it in the deep ventral conjunctible fornix, and you're done, not even touching the cornea at all. As you can see by this study that was done just a couple of years ago, there was a 75% direct correlation of the organism that was infecting the ulcer and the organism that was cultured within the conjunctible forex. So a really, really good alternative, if for whatever reason it's not feasible to get a direct corneal sample.

Now your therapeuticals, there's a lot here listed, and so I'll go through each one of these separately. So first one, that list of compounding complications, compounding problems that could have led to this ulcer getting infected. We gotta treat those, right?

If you got a patient, your classic Shar Pei here, you've got to dig, dig, dig, dig for days to see the eye cause the lids are rolling in so much. We've got to roll those out. We've got to put in some staples, even if it's a 6 month old puppy and you're too worried about it being too soon to permanently correct them, you gotta temporarily tack them out either with staples here or with sutures.

As I said, if you think that it's got the patient has dry eye, you're gonna be making sure that the that eye is lubricated as much as possible during that healing process. If we've got facial nerve paralysis, then we gotta make sure maybe we wanna do a temporary torsoy. If they're a big buggy-eyed dog, you know, and they're sleeping with their lids open at night.

Again, make sure you ask that on your history. Then guess what? We're gonna make sure that we're putting a huge dollop of medication on the eyes right before bedtime or maybe you've got to continue it through the night.

So make sure that you're treating that as well as the infection. But just like an infection anywhere else in the body, we gotta use the antimicrobials, right, to treat it. So two primary principles of treatment when we're worried about corneal infection.

One is that correct antibiotic and that's where your culture and sensitivity really come into play. And 2, the appropriate frequency. So utilising an antibiotic, you know, 34 times a day, which is what we usually do prophylactically, when we have a superficial corneal ulcer, that usually is not gonna be enough to handle that, that bacterial organism in the cornea or that fungal organism.

Remember that the cornea is at a huge disadvantage when it gets infected, unlike anywhere else in the body because it doesn't have a blood supply. So it's really reliant on those concentrations in the cornea being high enough to kill off that that organism. So the only way we can do that is by increasing our frequency of applications.

So oftentimes we're having clients, you know, or in the hospital, we're having the students or our technicians give a drop of that antimicrobial every 15 minutes for the first hour or so to load the cornea, and then we're sending them home every 2 hours to be applied. By the client. So it's a big commitment, certainly, but if you can do that at least in the initial stages of this, treating this infection, you're gonna see great, outcomes in your patients.

Which antibiotics do we choose? Well, if we're worried about gramme negative and if you've got your cytology sample and you, and you've got some suspicions based on the organism that you see, or certainly if you're worried that there's melting and pseudomonas is gonna be on your list, make sure that we, we choose an appropriate antibiotic for that. So, our drug of choice is the fluoroquinolone.

No doubt. Every single Patients that we're worried who has an infected ulcer is going home on a fluoroquinolone. And I started the ones that we use the most commonly, which are Ofloxacin or ciprofloxacin.

I realised that there's different antibiotics available, you know, across the world. That's what we choose most commonly. And usually, based on finances, how expensive the drop is, it's one or the other of those.

Moxi moxifloxacin are also referred to as Vigaox, that's the the brand name here in the states, is also a great alternative. It just tends to be like 4 or 5 times as expensive where I practise and so it's not the one that I choose right off the bat. Back in my day of training 25+ years ago, Amacain, was probably our first go to.

That was before Floquinolones hit the market. So we were kind of compounding Amacaisin to do it. But fortunately, we don't have to do that anymore.

Gentamicin and Tobramycin are great. The only thing I, I caution about that is they're used very commonly in prophylactic situations. So from a resistance standpoint, if they're already on something like that, and you've got infection looking like it's present, I would switch to a fluroquinolone.

Floor quin loans also get some staffs and streps, which are great, but if we're worried about gramme positive and if or and or if we're not sure, oftentimes we're increasing our spectrum of, of coverage by adding in something else. And we oftentimes will compound cephalosporin at this concentration here, but I realised that isn't easily done in, in many situations. So if they're not already on something like a triple antibiotic, that's fine too.

And again, you might have other alternatives based on wherever you practise to get more gramme positive coverage. The important thing also, again, is that frequency, you know, every couple of hours at least initially. If you suspect fungal fungus, boconazole is our treatment of choice because it absolutely will penetrate through an intact cornea, which is really important from a fungal perspective because fungus likes to be really deep in the cornea, and oftentimes they heal the epithelium over it, so they end up getting an, an abscess, and so we need something that penetrates really deep into the cornea.

So warconazole is a great one. Now cats, just a couple considerations with regards to cats. As I said early on in the presentation, we want to consider that that the presence of of herpes viruses is kind of a comorbidity for them.

We know that herpes virus is extremely prevalent in cats, you know, conservative estimate maybe 90. Percent of the cat population. It's probably a lot more than that, actually.

I'm fortunate to work in a, in a, in a university where a lot of the, the research has been done, for herpes virus. So I get kind of that firsthand feedback, based on the, the bench top work. And so, I've over the years kind of changed my methods of treating herpes virus.

I used to be a big proponent of using topicals cause they're easier for clients and when Sidoabir came out. You know, being just twice a day, a lot more convenient for clients, but I've really over the years, migrated towardsamcyclovir as my treatment of choice for herpes virus. So I've got a cat who has an infected ulcer.

I've cultured a bacteria, but they've got a history of upper respiratory disease, of intermittent ocular disease over the years. I bet your herpes virus is probably why the ulcer happened in the first. Place, and then it got secondarily infected.

And so I'm oftentimes gonna concurrently treat for the herpes, and usually I'm gonna grab thecyclovir. And that's the current dosage that we recommend, 90 mg per kg twice a day. And I know Gancyclovir, actually, I didn't put that on here.

Gancyclovir is a newer one, and it actually colleagues out in Europe have utilised it a lot longer than we have here out in the States. And from what I'm hearing, it's actually pretty effective also. And then lysine, just remember for lysine, it's not something that we actively treat herpes virus with lysine, but it's something that can decrease the episodes of herpetic outbreaks and we can decrease the severity.

And this is just a quick little picture showing you how well cats can heal their infected ulcers. This is an infected ulcer that one of my residents came out and said, I think we need to a nucleate. I was like, is it a cat?

Let's just wait. Let's give it some time. And sure enough, you can see how amazing two months later, this little focal scar after cornea that looked like boas could surf off that, I mean it's a huge wave.

So they they actually healed extraordinarily well. So don't ever give up on cats. Just a quick little take home with regards to here.

It might be about a month or so of treatment, but they're gonna heal it. So at least give them the option anyway. Stromal melting, make sure you add in some serum every couple of hours as well.

Keep it refrigerated, discarded after about a week or so. If it's really bad melting and they're not responding to the serum, add in some doxycycline, that is anti-alaginase activity as well. Don't forget to treat the uveitis.

Infected ulcers have inflammation inside of the eye. So you look for signs of aqueous flare, which this, this photo is showing here. You see that normally you don't see this transmittance of light through the anterior chamber.

If you do, you've got flare present. Hypopion or white blood cells, or if the intraocular pressure is low, you've got uveitis. So make sure you add in some oral anti-inflammatories.

You don't wanna put any topical steroids on the eye when you're ulcerated. I avoid topical NSAIDs too cause they can slow down epithelial healing and, and actually promote melting. So oral is the best way if you've got a systemically well patient.

Atropine too, just be careful if you got a lot of uveitis, Their pressures can can secondarily elevate, so just make sure their pressures are appropriate. E collar, this one played holiday songs. I feel bad for that little dog.

And then K dress, keep them nice and quiet, and then definitely keep him on some analgesics. Recheck in a couple days, remember that, you know, They can go go bad quickly. So you wanna get them back soon, know that even if they're more comfortable, it doesn't mean that they're better because the deeper you go into the cornea, the less nerves you have, so they can actually look more comfortable if they get deeper.

So get them back in, don't just rely on a phone call. And then you're waiting for those blood vessels to grow, grow in. Once they get there, you can breathe a little bit of a sigh of relief.

They're gonna do a lot of our job for us. And that's when you can start backing off a bit on your frequency. And then some of these guys just need surgery if they're too deep, but it depends on the ophthalmologist when you jump in with surgery, 50 to 75% stromal loss is usually where people are talking about surgery.

I'm OK with 50% loss, but 75% loss, we're talking more seriously about surgical intervention. These are the more common surgeries, some conjunctable flaps that you see here. This is a corneal graft which is better for clarity if you can do it.

And this is just a newer option, amnion grafts. They tend to heal with a bit, even though it looks, this is the early stage right after it was placed, but they tend to heal with less scarring. All righty.

Thanks you guys. Thanks so much for for having me be a part of this amazing day. I really, really appreciate it, and certainly happy to answer any questions if there are any.

Yes, there are. OK, that's fabulous. And I love it when lectures are are relevant to us vets in first opinion practise.

That was absolutely full of really, really, really useful tips. So thank you very much. So yeah, so we do have a few questions, so we'll try and run through those quickly, .

So Dara asks which fluroquinolone topical antibiotic has the least cho cholinogenic. At least lytic properties on the collagen. I, I'm not even sure I pronounce that anymore.

No collagenolytic maybe. Yes. That's a hard word.

Most of the words in ophthalmology, it took me years to to get down, let me tell you. So don't worry. You know, that's a really interesting question, and I don't know if that's actually been looked at with regards to like to how much it will cause breakdown in terms of The, the fluoroquinolone.

So that's something that we, you know, I think all of them are probably fairly similar. So that wouldn't, I wouldn't worry too much. I'd go more about what's available and maybe cost effective, in terms of choosing which fluoroquinolone.

Yeah. Well, that's really helpful. So, somebody asked, just wondering how long, as in how many days you give the topical antibiotics every 2 hours.

Yeah. So that's a really good question. And that's where your recheck examinations come into play.

So, usually we're doing it at least a couple of days. We're warning a client, if you can do it. Now, they come in pretty haggard looking after those first couple of days.

It's like having a new baby if you've had children. And so, but it's amazing how dedicated clients are. So if you can do that at least the first couple of days, and when you're rechecking them, If you notice that if there was some melting initially and that looks like it's gotten under control, if you have made sure that it doesn't look any deeper at that point in time, the big thing again by getting them back into the recheck is to make sure that they're not worse.

They may not look better, but if they're not worse, you're on the right track and you can oftentimes maybe Cut out the evening, the, the overnight stuff. So maybe just keep up the Q2 hours during the day. Stop the overnight stuff so the clients can get some sleep, and then get them back in in a few days after that.

And if they're still looking better, maybe you can go down to every 4 hours during the day. So it depends on how they're looking, but I would at least, if you can get a client to commit to a couple days of that, you will likely have increased the concentration in the corneas enough to where you're getting a good handle on it. Yeah, I, I thought your tip about every 15 minutes was fascinating.

I've, I've never heard that before, and that's so useful. And so Anna asks, do you have to treat an ulcer with both topical and systemic antibiotics, or are we not doing that anymore? Yeah, very good question.

There's so no, so that we're very fortunate with ocular disease that we get to put the meds directly to the organ that needs it, right? It doesn't have to go through the rest of the body. So oral antibiotics, actually we rarely, if ever, will utilise with a with an ulceration.

The only time we're considering using an oral antibiotic is if I'm worried that the ulcer has ruptured and therefore the bugs within the cornea have the chance to get into the eye and then spread to the rest of the body. Or if you've got a dense blood supply into the infection already, the corneal blood vessels have reached it, and I'm not getting a good enough handle on the infection with the topical meds, then maybe I'll add the oral medications cause I've got a rout of those blood vessels getting to them. But if neither of those scenarios are present, an oral antibiotic is not gonna help you much.

Some of them might get into the tear film a little bit, but not like the concentration that your topical is getting there. So those are the only two times that you consider using an oral. Hm, I guess it's a bit like using systemic antibiotics for ears then, isn't it?

You know. Just get them where they needed to go. So Sally asks, I'm just gonna read this out verbatim cause it's quite a long question.

Slightly left to field question. In dogs that seem prone to conjunctivitis, you must do a Shermat text to check for mild dry iron if borderline, recommend daily or regular use of a carbama containing. Lube, so I think, you know, the ones that seem to get like recurrent conjunctivitis and, and have got a borderline Sherma, you know, should we just be lubing these eyes up as a regular thing?

Yeah, good question. And so the big thing is, why did, you know, is the conjunctivitis they have because they're not making enough tears, or is some other cause causing the conjunctivitis, be it allergies, you know, things like that, and that's leading to the conjunctivitis. And if you That severe enough conjunctivitis, what can happen is you can get crimping of the ducts that transfer the tears to the eye.

And so your Schmert test is measuring lower, but once the conjunctivitis is resolved and they've opened up those ducts, your tear production is normal. So first, what I would do, if you've got conjunctivitis, you've got an itis. So let's stay in the eye, make sure there isn't an ulcer, but let's use an anti-inflammatory to clear the inflammation.

If the conjunctivitis resolves, recheck the Shermat test. If it's still borderline low, you're not making enough. And so we need to give them a medication to stimulate tear production.

So a topical cyclosporin, here we, it's, you know, optimmune or you can get it compounded. Topical cyclosporin, we should be utilising to stimulate the patient to create more tears. In the meantime, a topical lubricant, and we like ones that have hyaluronic acid in them.

Cause those have been shown to really help the ocular surface parameters. You can use that in the interim time until the patient creates more tears. So, just remembering that if the borderline Shermer tear test, if you've gotten the conjunctivitis under control and it's still borderline, then that is not making enough tears, so we want to jump on that quickly to get them to make more because the longer you wait, the more damage to the lacrimal gland that's gonna be happening, cause most of the time it's an immune-mediated cause.

And then you might get to the point where there's no gland left to respond to the medication for them to make more tears. Oh, that's fascinating. You'd almost expect it to be the other way around, wouldn't you, that if you've got conjunctivitis, your tear production's gonna go.

Up with the irritation, and it might, it absolutely might, but it can be the reverse. And so we wanna make sure that that's not happening. Usually, it's when the conjunctivitis is really severe.

They're usually chemotic if it's gonna be lowering that tear production, but just make sure that, just know the alternate can happen too. And that's a good point too when you've got an ulceration. Ulcers are painful.

You should have a patient who's tearing. If they don't have a lot of that, you know, have a watery, good watery portion of their tear, and they look really painful, I'd be worried that potentially they're not making enough tears and that could be the reason why their ulcer went south. Yeah, cool.

We're now eating into the break because we're supposed to breaking now, and also I don't. Yeah, I'm happy to look at the Q and A. But yeah, the, the questions are coming through thick and fast.

And I think that's because eyes are such a, you know, an, an interesting topic and one where we them a lot, don't we? And, you know, sometimes they're simple and sometimes they're sometimes they're not. Yeah, absolutely.

I betcha. I'm happy to look at those. Yeah, so if you wouldn't mind, going through the rest of those questions, so if you have asked a question in the question box, Katherine will go through and answer those.

That's, that's amazing. Thank you so much.