Thursday, December 30, 2010

282. Neutering big breeds and fluroescein dye in eye ulcers

Dec 30, 2010

INTERESTING CASES

2nd last day of 2010. Today was the low season (as in tourism) as I had only a handful of cases. But I could spend more time with each individual and this is the best part of veterinary medicine. If the vet has 40 cases a day, it is not possible to get to know the clients well since the waiting queues and dogs barking at each other in the very small reception room would be harassing.

Case 1. Neutering of big breeds
A young man in his 30s came with a big breed for neutering. He had been to the Surgery before. Since there are now over 40 veterinary practices in Singapore and the practice of vet-hopping is common and he lived in Changi which is a 30-minute drive to Toa Payoh Vets, I expected him to choose a vet based on proximity, not on reputation or skills. Therefore asked him: "You have several practices closer to your residence. Why do you come so far away to neuter your Golden Retriever?"

"Actually I phoned up Vet 1 (which is an established practice nearer to his residence than mine). The girl said that the practice does not neuter big breeds. So I come here."

I was surprised as I thought all vets in Singapore neuter all dogs irrespective of size. Neutering is a most common surgery in veterinary practices all over the world. Well, life is full of surprises and changes.

As to why Vet 1 does not neuter big dogs, I can only hazard a guess based on my observations and said to the young entrepreneur: "In big dogs, the bleeding complications after surgery can be very distressing. The scrotal sac swells to as big as a tennis ball if there is bleeding. Some dogs bite and lick the operation area vigorously and this is one cause of bleeding. The profuse bleeding leads to a lot of blood inside the scrotum and the owner becomes worried when they see it becoming a huge tennis ball." Big dogs seldom wear e-collars to prevent licking as some owners don't want it. E-collars should be worn for the first 48 hours but big dogs and owners don't like it. The dog finds it difficult to eat and drink properly. However, I have cases where e-collars do not prevent self-trauma licking and injury of the operation site. In such cases, pain-killers may not be effective or the dog is highly sensitive and clean.

In this case, I share with the vet students my surgical approach to get a good outcome of no post-operation trauma of the surgical site after neutering.

ANAESTHESIA. Golden Retriever, Male, 3 years
Domitor 0.3 ml IV. Wait 5 minutes. Isoflurane gas 2-3% maintenance. Intubated. Excellent surgical anaesthesia.

SURGERY. 2-cm incision in skin above scrotal area. (Some vets in Singapore incise the scrotal area apparently according to one of my clients). I took out one testicle. Then I clamp the tunica as a whole sheath enclosing the spermatic cord and blood vessels. 3 forceps are used to clamp.

TRANSFIXING LIGATURE. Below the lowest clamp (3rd forceps), I inserted the suture needle (2/0 absorbable) into the sheath away from the blood vessels. Then I ligate the blood vessel end. After that I ligate the opposite end.

DOUBLE LIGATURE. Then I release the clamp. I wrap one suture round the clamped area of the sheath and ligate. In this area, the suture is unlikely to slip. In any case, I knot on one side. Then I knot again on the other side.

I cut off the sheath between the lst and 2nd forceps. Push back the sheath into the inguinal canal. Checked for bleeding. There was none. I repeated the procedure on the other testicle.

SKIN INCISION. I put in 2 horizontal mattress sutures using the same 2/0 absorbable suture. There was profuse bleeding from the skin. This is quite common and not serious. I put on plaster to stop the bleeding which will be obvious.

POST-OP PAIN-KILLERS AND ANTIBIOTICS. Tolfedine and Baytril are given SC based on 10 kg post-surgery. The dog was OK. There was no need to give Anti-sedan to reverse the Domitor as the dog woke up after 10 minutes since I had reduced isoflurane gas go zero in the last 3 minutes before completion.

5 HOURS AFTER SURGERY. INSPECTION BEFORE GOING HOME. The owner and his wife came. The dog wagged his tail. There was no pain and he did not lick the area since tolfedine was effective. The owner rejected the e-collar. So I advised him to give tolfedine tablets 12 hours later (the next morning) and therefore for 7 days at one dosage per day. Antibiotics were prescribed. There ought to be no problem.

STITCH REMOVAL 10 DAYS LATER ADVISED. The owner was advised to wash the operation area and thigh with warm water as there was some blood stains.

TEETH SCALING AFTER NEUTERING. Some tartar in the back teeth. Teeth scaling was $100. This was a big discount to $250 since the dog was already under anaesthesia for neutering. Tooth brushing will prevent tartar formation.

This was a very friendly Golden Retriever. I took some pictures of him and tried a close up picture of his eye with my 18-55 mm lens. It was a most happy outcome for everybody as the dog appeared normal and happy.

Case 2. Shih Tzu with left eye corneal ulcer (generalised superficial keratitis).
"Vet 1 said that my dog must use artificial tears as my dog has dry eyes. She used a green dye on the eye and said it had dry eyes and conjunctivitis," two young ladies presented their Shih Tzu with a red left eye. Her father was present with her. The left eye was cloudy while the sclera was intensely red. It is unusual for a young dog to have dry eyes as this was what the young ladies reported as to what Vet 1 had said. However they had no medical report from Vet 1 with them and I did not want to go into the hassle of phoning Vet 1 to ask for medical records. Some vets would do it.

A simple eye examination would be practical and even if the dog had dry eyes, it would be possible and that would be some time ago. In any case, it had no dry eyes now. I asked: "How long has this left eye been so red?"

"Only 1 week." the older sister said.
I shone the torchlight on the eye. The cornea was cloudy for around 70% of the area esp. on the top half. I asked my assistant Mr Saw to put the fluorescein strip into the eye as part of my mentorship. He would be returning to Myanmar in 2011 to be involved in a new practice and as he has been working for me for 3 years, I wish him well and am sure he would be a better vet in Yangon after 3 hard years in Toa Payoh Vets.

Mr Saw came into the room and went to take a syringe, filled it with saline and squirted some onto the eye. Then he applied the fluorescein strip onto the eye. I was puzzled as why he did it this way. He had seen me doing it the direct way and here, he did it another way*.

The fluorescein strip started to disperse green dye onto the eye. However, the greenish was not so obvious as the saline squirted onto the eye was making the stain less green. In any case, the owners could see that the top half of the cornea was greenish, indicating ulcerations. I advised stitching up the eyelid for 7-10 days to enable ease of healing of the cornea which had been exposed to sunlight and wind and caused the dog to rub the left eye till it was red.

Domitor 0.1 ml IV was given. Isoflurane gas. The eyelids were stitched up. The dog went home. Eye ointment to be applied. Stitches should come out by itself in 7-14 days and there ought to be a good outcome. "Eye injuries are emergencies," I advised. "They should be treated within 24 hours of injury. The Shih Tzu commonly gets eye injuries. Sometimes it is the prominent nasal fold's hairs irritating the eyes," I said as I showed the illustration from the Ophthalmology book. "How much it costs for the surgery?" the father asked about the stitching of the eyelids. "Around $250." He was agreeable.

P.S. *I asked Mr Saw later as I showed him the direct way. He said this was what my associate vet did and therefore he did it. Mr Saw's friend came to visit, saw the faint green dye and said: "Nothing serious with the eye ulcer, no need to do surgery to stitch up the eye lids." This was his opinion as he clipped the dog bald including the eye area for my surgery.

During anaesthesia, I re-applied the strip directly onto the eye and this time, Mr Saw could see the intense green covering more than 50%of the cornea. The ulcers were obvious now since the green dye sticks onto the pitted cornea from 9 o'clock to 4 o'clock of the cornea mainly. I took a picture for record and educational purposes. "Show rather than tell" is the most effective way to mentor a person.

Life is full of surprises and changes. I told Mr Saw that the best way is to apply the fluorescein strip under the upper eye lid and there was no need of saline flushing first. I don't know whether he will remember but hands-on experience is the best way to learn. Nobody is perfect but sometimes I expect perfection in my veterinary assistants of procedures they have had seen done successfully. However, there are other ways to do a procedure in veterinary surgery and sometimes a new way is much better. So, it is hard to say that my way is the correct way and be narrow-minded.

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