Thursday, June 16, 2011

473. Deep eye ulcer in a 3-month-old Shih Tzu puppy

Yesterday, Jun 16, 2011, I operated on a 3-month-old Shih Tzu with corneal ulcers on both eyes. The owner was referred to me by the sister who had sent the hamster with the large cauliflower ear wart to me 3 days ago.

I am still much worried about anaesthesia of 3-month-old puppies as they are not strong enough.

"No injection?" Mr Min asked me as he has been used to vets giving sedation and then gas anaesthetic for the last 2 months or so. He had replaced Mr Saw and was new to the small animal veterinary world although he had some experience in Malaysia and had graduated some 10 years ago in Myanmar.

"Only isoflurane gas," I replied. "If you know how to do it." I showed him how to hold the puppy and give anaesthesia gas via the mask. "Hold the scruff of the neck, angle the head at 45 degrees and give the mask," I said. Yet he did it his way and when I corrected him, he said "I don't want the mask to touch the corneal ulcer!"

It needs a lot of impatience to teach the young ones and sometimes I feel that they just want to do it their own way. I said: "At 45 degrees, the puppy can breathe normally. At 90 degrees (to the mask), it is unnatural and the gas cannot flow through smoothly!". Teaching Min is important as he assists my two other associate vets who have their own styles. But there must be one standard operating procedure which is safe, efficient and least costly (wasting of the very expensive isoflurance gas).

My previous technician, Mr Saw had learnt what to do after 3 years of working with me, but he had decided to retire to greener pastures in Yangon where he was promised a "partnership" in a practice. So, a new technician had to be supervised and mentored again.

For this puppy, the owner is very worried, as do all owners of puppies and parents of babies. The anaesthetic risk is so much higher and it was no surprise that the vet near her apartment had prescribed just antibiotics eye drops and atropine eye drops and vibravet oral tablets. Then she was referred to the parent company's vet who was unfortunately fully booked. So, that was how the case came to me from my successful handling of the hamster with the large ear wart with Dr Vanessa 3 days ago. Well, if the hamster had died under anaesthesia, I doubt this referral would come. So much depends on the anaesthetic outcome in veterinary anaesthesia.

HOW THIS CASE WAS DONE
1. Isoflurane gas by mask at 5%. Observe signs of surgical anaesthesia by me. Don't depend on inexperienced vet technician Min. Proper angle of the neck and nose at 45 degrees.

2. Intubate just when the puppy was not fully anaesthesized. Be alert. There was a "vomiting" sound. I quickly pulled out the endo-tracheal tube but there was no vomiting. If negligent, the vomitus goes into the lungs.

3. Give 2% isoflurane. The temptation of the technician or vet is to give 5% via the tube as the puppy moves. Close the mouth with hands and be patient. It takes time for the puppy to be under surgical anaesthesia.

4. Flush hairs and debris off the eye thoroughly. Ensure the 3rd eyelid is opened up and irrigate all hairs trapped inside.

5. Check eye is clear of debri. I put in terramycin eye ointment and the atropine drops.

5.1 In infected eyes, I do inject subconjunctival gentamycin but not in this case as it was 4 days old.

6. A horizontal mattress suture, 3/0 absorbable sews up lower and upper eyelids. Eye-lashes must be completely shaved off.

7. E-collar. The puppy wakes up fast as if she has a short nap.

DISCUSSION WITH A 5TH YEAR VET STUDENT FROM MURDOCH UNIV
Each vet has his own approach. The student, Daniel said he would swab the ulcer, get a bacterial culture. Give appropriate eye drop antibiotics, atropine, e-collar and let the ulcer heal. NSAID pain-killers. Perhaps an eye patch.

IN REALITY
The first vet had essentially prescribed what Daniel had proposed except for NSAID. The owner had great difficulty putting eye drops on the puppy as the naughty one shifts right and left. Both corneas were ulcerated (will show images later). Puppy's sclera gets redder by the day. Itchy, rubbing eyes.

LEFT EYE
Deep ulcerative keratitis. The cornea ulcer of the left eye was deep. A red blood vessel forms at 11 to 2 o'clock above this ulcer.

RIGHT EYE
Superficial ulcerative keratitis from 6 o'clock to 11 o'clock.

So, the owner is worried that the puppy will become blind.

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