1064. Standard Operating Procedure - corneal ulcer + tarsorrhaphy in the dog

I have written a SOP for vets in Toa Payoh Vets as regards the diagnosis and treatment of corneal ulcers in the dog.





Standard Operating Procedures - Eye Corneal Ulcer & Tarsorrhaphy
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
06 July, 2012   toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0129 A video will be produced by Toa Payoh Vets

1. Examine the dog's eyes in detail including ophthalmoscopy. 
2. Fluorescein eye stain test on both eyes is mandatory for all eye cornea injuries. Record extent and depth of the ulcer and surrounding areas and take digital images (side view and front view) of both eyes showing the results of the fluorescein eye test. 
3. If the eye ulcer is not infected, is recent (less than 2 days),  >3mm in diameter and is a deep ulcer, advise tarsorrhaphy or 3rd eyelid flap.
4. If there is infection, wait for 3 days before attempting tarsorrhaphy.
5. AMA - Against Medical Advice. Write in the case file your advice for tarsorrhaphy if the owner does not accept your advice and just want some eye drops and the e-collar.
6. Superficial and small ulcers <3mm can be treated with eye drops and e-collar.
7. Conjunctival flap may be necessary if the ulcers are large.
8. A 3rd eyelid flap and tarsorrhapy may be useful in cases of extensive and deep ulcers but there is the problem of not being able to apply the eye drops.

Tarsorrhaphy.
1. Clip hair off face esp. around the eyelids and facial area.
2. Clip off all hairs from the eye lids.
3. Sedation and general anaesthesia.
4. Forceps to lift up 3rd eyelid. Use a 10 ml syringe to flush debris and dirt from inside the 3rd eyelid.
5. Thoroughly irrigate the eye with clean water a few times.
6. Subconjunctival injection of antibiotics and minimal anti-inflammatory at two spots on lower and upper eyelid.
7. Apply antibiotic eye ointment liberally before sewing the eyelids 
8. Sew up the eyelids with 3/0 absorbable sutures or 3/0 nylon. Two horizontal mattress sutures to evert the eyelids.
9.  Leave a 3-mm gap at the medial canthus for eye-drops.  
10. Three eye drops 3 times/day and clean off discharge for the next 14 days.
11. Stitch removal 14 days later.    

Post-op
1. Ward the dog for at least 3 days. I prefer 10-14 days as most Singapore dog owners are unable to crate the dog and provide proper eye care.
2. Prescribe 2 bottles of eye drops (not one bottle) if the dog goes home on Day 3.
3. Prescribe  pain killers for 4 days.
4. Follow-up 3 days post-op. Record in your case file your follow-up with the owner 3 days after the op to check if the eye-care has been done properly. If the owner complains of eye discharge and dry exudate, advise the owner to bring the down back as the owner is not able to provide good nursing care. Record this advice given in your case file and also not being able to contact the owner by phone. You can send an text message instead. 

Repeat tarsorrhapy
Wait for 3 days before attempting repeat tarsorrhaphy as the eye is usually severely inflamed and infected due to poor eye care and nursing by the owner. Ward the dog for the next 10 days.

Poor post-op nursing care at home.
One case is at: tarsorrhaphy - Against Medical Advice.
 

5448 - 5450. Tarsorrhaphy - Against Medical Advice. The owner is unable to provide proper post-op nursing care at home and the right eye ulcer did not heal uneventfully as the left eye ulcer.

The webpage is:
http://www.sinpets.com/dogs/20111214tarsorrhapy-stitch-breakdown-7days-dog-at-home-tips-singapore_ToaPayohVets.htm

9. As at July 6, 2012, Singapore does not have resident approved veterinary eye specialists. It may be wise to refer the case to other vets if you don't wish to perform tarsorrhaphy, 3rd eyelid flap or conjunctival flap and deal with its post-op complications.

10. Some cases are illustrated in Eye Problems seen at Toa Payoh Vets. The webpage is at:
http://www.bekindtopets.com/animals/20081201PAGE3_Dog_Surgery_Anaesthesia_Eye_ToaPayohVets.htm

11. One case where the mother experienced in keeping dogs, takes excellent care of the Pekinese is shown below.

UPDATED WEBPAGE AND MANY MORE IMAGES
ARE AT:
http://www.sinpets.com/dogs/20120706tarsorrhaphy_standard_operating_procedures_toapayohvets.htm