Saturday, March 30, 2013

1345. A red dot in a Shih Tzu's eye (descemetocoele)

tpvets_logo.jpg (2726 bytes)TOA PAYOH VETS

Date: 02 April, 2013
Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits
A red spot in a Shih Tzu's eye - Descemetocoele
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVSDate: 02 April, 2013
Be Kind To Pets
Veterinary Education
Project 2010-0129
"I apply the eye ointment & my Shih Tzu wore an e-collar for the last 7 days," the couple said to me. "But the red spot is still present. What's the problem and what is the solution, Doc? (SHOW VIDEO OF THIS DOG IF ANY)
"A Be Kind To Pets" Educational Video
Veterinary Surgery Comes Alive To Vet Students & Pet Owners
What happened to the right eye of this active 4-year-old male Shih Tzu?
A red bulging spot persisted for over 2 weeks. As there were financial budgets over medical expenses, I prescribed an eye ointment and the dog was to wear an Elizabeth collar (e-collar) 7 days ago. At this stage, any advice to perform eye surgery would be rejected by most Singapore dog owners owing to the costs and so conservative treatment is recommended in this case.

However, the red bulging spot persists and this time, I advised surgery.

"Your Shih Tzu has a Descemetocoele," I sketched an illustration of the cross section of the eyeball and cornea. (SHOW THIS ILLUSTRATION of the 4 layers of the cornea - basement membrane, Descemet membrane, stroma and epithelium).

"His cornea has been seriously injured resulting in a very deep ulcer. However the cornea has not ruptured yet or all liquid from inside the eyeball will flow out.

"The pressure of the liquid inside the eyeball pushes out the Descemet membrane and from your point of view, you see a red bulging spot. (SHOW THIS ILLUSTRATION OF CROSS SECTION OF THE EYEBALL WITH BULGING LUMP). " "The solution is to stitch up the eyelids so that the ulcer can heal without the dog rubbing the eye as an ulcer is very painful. An exposed ulcer is irritated by the dust, breeze and light and will not heal well if the dog keeps rubbing his eye with his paw or against the wall or bed."

The surgery requires anaesthesia and there is always an anaesthetic risk of death on the operating table. Do you accept the risk and approve the surgery?

"How much is the cost?" the wife asked.

"Around $400 for the anaesthesia, surgery and hospitalisation."

"$400 just to stitch up the eyelids?" the wife asked.
"The cost involves more than just stitching up. There is the anaesthesia cost, the hospitalisation for at least 3 days and the nursing costs."
Cat, Ulcerative Keratitis, Management & Surgery, Toa Payoh Vets SOLUTION(WILL PROVIDE AN UPDATED ILLUSTRATION AS THIS ONE IS FOR THE CAT)

The eye surgery called the 3rd eyelid flap & tarsorrhaphy. This involves stitching up the eyelids to cover the ulcer so that it can heal without dust or dryness causing eye pain. (SHOW THE ILLUSTRATION OF THE SURGICAL PROCEDURE)

Elaborating on the surgery with script below.
Day 1. After the surgery. Eyelids stitched up to let
corneal healing take place. E-collar is worn. The dog is hospitalised for at least 7 days as the owners will not
be able to provide good nursing care. The dog bites or moves during eye treatment..
Day 3. A very high standard of veterinary care of the eye
by the vet is required
Day 3. Dog has been sedated and blood clots removed. Twice daily inspection & treatment of the eye is done.
Day 6. Stitches loosen. In most cases, stitches break down between 7-10 days, due to the eyeball movements
Day 7. No more red bulging spot Day 7. White spot is a scar plugging the ulcer. Dog
goes home
Day 7. A good surgical outcome in this case. The sclera is not inflamed while the cornea healing is excellent. The owners are happy. E-collar and eye ointment for another 30 days.
CONCLUSIONNo post-op complaint from the owner for the past 30 days. The white spot will remain on the cornea but has no significant effect on the dog's vision. Good surgical outcomes are not guaranteed in all cases of deep corneal ulcers (deep ulcerative keratitis).
shih tzu, deep corneal ulcer, ulcerative keratitis, tarsorrhaphy, toapayohvets singaporeEYE INJURIES ARE EMERGENCIES


Left Eye Descemetocoele. Shih Tzu, 7 years. Toa Payoh Vets 1. Eye drops & e-collar as the treatment will not give good healing as the dog wants to rub his itchy and painful eye all the time. The Descemetocoele will rupture, leaking out liquid from inside the eye. Bleeding and infection will occur as in one case (image, left).

pug 7 months, injuries serious, deep central ulcerative keratitis, leakage aqueous toapayohvets singapore2. Early treatment before the cornea ruptures gives good healing results but many owners are reluctant to pay for the anaesthestic and medical costs. So many vets prescribe eye drops and e-collars. This was what I did for the case study before the eye surgery option is accepted by the owners.

Left Eye Descemetocoele & Ulcers. Shih Tzu, 7 years. Singapore. Toa Payoh Vets3. If the owner insists on bringing the dog home instead of hospitalisation, the surgical outcome is usually poor (inflamed sclera and cornea) as the owner is unable to apply eye drops and clean the eye. Some dogs bite or shift their head during nursing or rub their eye and e-collar against the wall and bed when they are at home.

suddenly eye itchy, acute conjunctivitis poodle toapayohvets, singapore4. Some vets are against the 3rd eyelid flap, saying that the 3rd eyelid flap obstructs the application of eye ointment or drops as it covers the eyeball. I make sure that the eyeball and the inside of the 3rd eyelid is well irrigated and clear of debris before stitching.

Eye ulcer, distichia, ectopic cilia, young shih tzu, tarsorrhapy, toapayohvets singapore5. Tarsorrhaphy (stitching of the upper and lower eyelids) may be another procedure without the 3rd eyelid flap.

Deep ulcerative keratitis dog tarsorrhapy toapayohvets, singapore6. A very high standard of veterinary nursing is required. Good outcomes are usually due to excellent and experienced nursing. The vet must examine the eye twice a day and not just leave the case to the nurses who may not be experienced in nursing such cases. Sedation is required to clean the eye area on Day 3.

7. Stitches loosen from Day 6-10 and are removed. Stitches can't stay for long due to the eyeball movements and tension.

8. Horizontal mattress sutures are advised. Practise placing horizontal mattress sutures to close the skin during the sterilisation of the dog and cats and the vet will have the necessary experience to perform tarsorrhaphy well. However, most vets will not use horizontal mattress sutures for skin sutures in sterilisation.

As in all professions, practice makes perfect. If a vet does hundreds of horizontal mattress sutures during sterilisations, he or she will have honed his skills which prepare him or her for tarsorrhaphy. Tarsorrhaphy is not a common surgery for most practices in Singapore and much success depends on good placing of the horizontal mattress sutures.
(show a before and after tarsorrhaphy treatment case in a Pekinese)
Pekinese, first-time corneal ulcer, 3 days, toapayohvets, singapore deep ulcerative keratitis, corneal ulcer, pekinese, singapore toapayohvets



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More info at:
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To make an appointment:
tel: +65 9668-6469, 6254-3326
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Clinical Research
Copyright © Asiahomes
All rights reserved. Revised: April 02, 2013

Toa Payoh Vets

1346. Follow-up on the Caesarean section - young don't talk, she sms

For the past 2 days, I phoned the young lady but could not get through her mobile.
Today Sunday, Mar 31, 2013,  I texted her: "Is CC OK? Pl tel me. Dr Sing. Toa Payoh Vets."

She texted immediately: "Hi dr sing. CC is fine. Nursing well."

That is how the young Singaporeans communicate. Sure saves a lot of time.

Below are the images of the Caesarean section from
An intern will produce a video later.

tpvets_logo.jpg (2726 bytes)6054 - 6064. >Six hours' delay resulted in two distressed

Friday, March 29, 2013

1344. A Good Friday's miracle (Mar 29, 2013)

I don't believe in miracles. This 5-year-old male neutered  Jack Russell was rushed in by the father on March 27, 2013 panting and unable to stand since 12 hours ago.

His neck was skywards. His four limbs were extended as straight as a ramrod. Panting and panting non-stop. His rectal temperature skyrocketed to 41 deg C. This scene reminded me of a dog under domitor IV anaesthesia. All muscles stiffened. Or a dog with tetanus with all 4 limbs straight but in this case, the jaws were not locked.

Was there any hope? The father gave permission for blood sample and I took a urine sample to test. Evidence-based medicine should be used as the family will want to know what is the cause of these symptoms and should the dog die, much allegations of incompetence will be insinuated if the vet does not practise evidence-based medicine.

Recently one retiree dog owner did not want the blood test or X-rays although his female dog had been lethargic for 2 days and her abdomen was bloated. His dog had fever. He came towards closing hours and the dog was given a drip and therefore needed to be warded overnight. His daughter objected to the dog being hospitalised as "none of the family's sick dogs had ever been hospitalised over the years even by the vets of a well-known big practice."  In other words, no dogs need to be hospitalised. Just give an injection and medication and the dogs go home. I discharged the dog home the next day. He phoned again to ask what was wrong with his dog and what caused the abdominal bloat as his dog was sleepy again. I asked him to seek a second opinion from another vet.

For this dog, the blood and urine test showed a bacterial infection. The bacteria would have invaded the brain and meninges causing the stiffness. It was not a stroke as the father postulated. There was an explanation for the cause of this stiffness of limbs and neck.

I gave this dog intensive treatment to prevent dehydration, reduce the stiffness and medication. On the 2nd day, he still could not stand. He started crying non-stop all the morning and afternoon. He would drink when a bowl was held to him. He would not eat. Bloody stools stained the thermometer when I took his rectal temperature. His moaning was loud and neighbours wondered why there was dog abuse. I injected sedatives but his loud crying would recur soon as the IV drip diluted the sedative effect.

So I phoned the owner's father to let him know of the poor prognosis and asked him to visit the dog. In one  experience, I had not phoned the owner to view the sick dog and it died leading to scoldings from the owner. I did not expect it to die, but some owners are quick to vent their anger. In this case, I expected the dog to die and therefore contacted the owner urgently.

A dog crying continuously, in my experience, is a sign of intense pain affecting the brain. I had seen such cases in puppies infected with distemper virus encephalitis. The crying just goes on and on.

"Nothing can be done till my son come back from overseas," the father said that euthanasia would require the son's permission. He had visited the dog and attributed the crying to his visit. But the dog had been crying for three hours before his visit. Sedatives seem to have no effect. A half-dose domitor and ketamine lasted less than an hour. The IV drip was still on. Oral sedatives. Rectal sedatives. No effect. Feeding of water temporarily stopped the crying. He did not want to eat.

Finally I decided to give another type of IV sedative to let him sleep through the night. At 8 am on Good Friday, Day 3 of the hospitalisation, there was no more crying. The dog could lift his head and stand when placed on the ground. He lapped water from the bowl. My new assistant placed a bowl of canned food in front of him. "Feed him using the spoon," I said to this young man who is under training by me in dog nursing. The dog swallowed the food. I got a video of the dog outside the clinic, standing and walking a few steps, of sitting upright on his chest. Then I placed him back to rest.

The son and his wife and father came. "What is the cause of his problem?" the father asked again although I had told him. "It is a bacterial infection of the blood and brain," I said. "What type of bacteria?" he asked.  I said I had not got the bacteria cultured. Economics played a big part in the heartlander's veterinary practice and more tests meant higher veterinary bills. If my practice was situated in a prime area where money was no problem, I would have done MRI costing a $1,000 and other tests. The overall bill would add up to at least $3,000 or more. This would not be much appreciated by the heartlander client. 

The daughter-in-law  took out her card to pay the bill. The dog was alive, eating and drinking. I advised the son that the dog would do better when nursed at home. It would also cost less. The medication and management, if complied with, would lead to his recovery. There was no blood test to show that he has recovered from the bacterial infection. This ought to be done as the father asked whether the dog had recovered. As this is heartlander practice, the minimal costs would be appreciated.

If the dog could eat and drink and was able to stand and walk for a few seconds, there was progress and recovery. MRI would be excellent in such cases to aid diagnosis. In economics, the important thing is to deliver. And this was the miracle on this Good Friday, March 29, 2013. There are miracles one can't help but believe in.


1343. How to produce an interesting C-section video?


tpvets_logo.jpg (2726 bytes)6054 - 6064. >Six hours' delay resulted in two distressed pups bare

Wednesday, March 27, 2013

1342. Seamstresses in Myanmar

tpvets_logo.jpg (2726 bytes)TOA PAYOH VETS

Date:   28 March, 2013  
Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits
Seamstresses from Myanmar
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date:   28 March, 2013 
Be Kind To Pets
Veterinary Education
Project 2010-0129
Yesterday, March 27, 2013, I visited Khin Khin who operates a licensed employment agent as I have had known her and her husband for more than 20 years. 

Times are very hard for employment agencies as the Singapore Government has sharply cut down the quota of foreign workers for all employers. Many employment agencies have closed down in her building and in other parts of Singapore. Many retail operations including restaurants and cafes that are more reliant on foreign workers have to close down or stop expanding. Even the Housing & Development Board's construction of new HDB apartments is delayed by several months.   

Khin Khin said she would close shop at the expiry of the lease in December 2014 as she had fewer successful closing. "Can I close earlier?" she had asked me. "Yes, if you continue paying the office rental of $1,600 per month from March to December 2014." I said. "All businesses have ups and downs. It is up to the owner to persevere. If every start up business is successful, everybody will start their own business. Why be an employee?

"In this difficult time when others are closing down, you should be around and be well organised. You need to know how to manage the employment agency business. You have a special advantage over Singaporeans as you can speak the Myanmar language and English. So, you have many Myanmar prospects as they prefer their own agent who can communicate with them. But you are unable to connect them to Singaporean employers."

Employment agencies supply maids too and they are numerous in the past 3 years as Singapore was very welcoming of the foreign workers contributing to an economic boom. However, the locals become dissatisfied as they lose bargaining power in getting well paid and not working long hours as much as 10 hours a day. Not all foreign workers will tolerate the long hours too as I could see from the new prospective job applicants at Khin Khin Employment Agency. Some will change employers to get shorter hours and seek help from Khin Khin. One Filipino worker change employer for higher pay but soon find out that the hours are not short. So she resigned as she wanted Sundays off. Soon her one-month extension of stay after termination of her "S" Pass expired and she had to go back to the Philippines as she could not find an employer. Many employers with "S" Pass quotas get their applications rejected as the MOM deemed that the quality of the prospective hires is not up to standard or for some reason. Such rejections have become very common nowadays. In this way, the foreign worker population is reduced to resolve the problem of overcrowding in subway trains and public places upsetting the locals.

The way I see it, such policies are good for the small companies with lower overheads, such as that of Khin Khin who focuses on Myanmar workers. "You can upgrade to a higher quality of workers desired by Singaporeans," I said. "You can expand to include workers other countries."

It is easier said than done. For example, there is a demand for male "maids" to help the aging men with strokes. There is a demand for nurses but this is a world wide demand. Can she provide such workers? Many start ups don't last 5 years. Some don't even last 1 year but Khin Khin had gone past one year. It is best for her to be well organised and do marketing to survive. It will not be easy but it can be done as she has this special niche - a knowledge of the Myanmar language and English. She can be a bridge for Myanmar businesses which are now booming in Yangon and needs services in Singapore. So much to do if she knows how to do it.     

There was a Myanmar maid who visited her office yesterday but she was not in as she was coughing. This maid had a job with an English family through Khin Khin employment agency. This was a personable girl who understands and speaks good English. "How come you know how to speak good English?" I asked her. She had worked for a Singaporean family earlier. The English employer likes her very much. Her Thai maid had walked into Khin Khin's office and asked for a maid subject to being paid a commission on success. So this was how the Myanmar girl in her mid 20s got a job.

"Are there many seamstresses in your village in Myanmar?" I asked her and showed her one "Alteration Shop" near Khin Khin's office in the office building to ensure that she knew what I meant. "So many," she said. I was looking for a seamstress to make some uniforms and operating clothes.  "My mother makes the dresses for me," she said. I thought her mum is a seamstress but she is a secondary school teacher employed by the Myanmar government . "How much does a teacher earn per month?" I asked her. "One Lak," she said. "One Lak" is the figure of 10,000 kyats. Something similar to the Chinese of "One Mum" which is equivalent to $10,000. Dividing "One Lak" by 700, it is equivalent to S$420.

"So you are earning more than her!" I said and she smiled. The English employer pays her at least $450 per month with 4 days off per month. The Singaporean employer in general prefers the maid not to take a day off per week and pays the $20/day compensation. Some Singaporean employers allow one day off per month. 4 days off are important for workers in my opinion. It is to refresh their minds and to meet their country folks. Unfortunately some become pregnant and that is where the employer thinks that he has to pay $5,000 penalty to the MOM.

On the subject of seamstresses, a prospective candidate came looking for a better job than being a maid. She wanted to earn more than a maid and she has a degree from Myanmar University. "It is very difficult for a maid to get a 'S' Pass," Khin Khin said to me. I don't agree with her as such ex-maids will have a better knowledge of Singapore's culture and can understand English. It may be MOM's policy to reject maids applying  for 'S' Passes but I don't know what MOM officers think.

This slim lady wore a peaked cap, dressed in black blouse with sequins and a white jacket. She took off her peak cap and Khin Khin asked me to contact a Singaporean lady who could be interested in employing her as a maid and to do some sewing. "You had your own sewing shop in Myanmar for 10 years," I confirmed with her. "Did you sew dresses for fashion departments in Yangon?"

"No," she said.
"They don't do such things in Yangon," Khin Khin who had arrived at 4.30 pm said. "The best way to test her skills in sewing is to ask her to make a dress for the prospective employer."
I phoned the prospective employer and left a message for her to call me. Many people are such that they don't return calls unless they require something from you. So, I had not received any return calls.
To test her skills, the seamstresses need a sewing machine and so Khin Khin went to the neighbour to ask how much they will charge for her to sew a dress.

"$20 for renting her equipment for her to sew a dress" she told me. "Sewing machine and threads and scissors. The neighbour wants to rent half of my office as she intends to close her shop. No business at all. She wants to sell her sewing machine to me for $400. Actually I have a good Japanese sewing machine in Yangon. For rental, I can partition half of my office."

I can understand that Khin Khin is also trying to cut costs as she would get $800/month. Office rentals are high in Singapore compared to other countries like Malaysia.

"You don't rent to anybody esp. trading and sewing shops," I advised. "Your office is so small at around 300 sq ft. Prospects need to come in to discuss with you and you will not have space for them. It gives a poor impression too."

So Khin Khin shelved the idea again. The solution is to get more cases closed, not to rent out half the small office! This solution applies to all businesses including veterinary practices.
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All rights reserved. Revised: March 28, 2013

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