1363. Final script for video production - Descemetocoele

TOA PAYOH VETS toapayohvets.com Date:   13 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), MRCVS Date:   13 April, 2013   toapayohvets.com  Be Kind To Pets Veterinary Education Project 2010-0129   SCRIPT FOR VIDEO PRODUCTION   HOOK "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)     INTRODUCTION "A Be Kind To Pets" Educational Video Veterinary Surgery Comes Alive To Vet Students & Pet Owners     FLASH BACK       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 time needed to perform the surgery, the hospitalisation for at least 3 days and the nursing costs."     SOLUTION - Tarsorrhaphy-Nictitans Membrane Flap   The eye surgery is called the Tarsorrhaphy-Nictitans Membrane Flap. This involves stitching up the upper and lower and 3rd eyelids to cover the ulcer so that it can heal without dust or dryness causing eye pain. HOW THE EYE SURGERY IS PERFORMED Elaborating on the surgery with script below.   Day 1. After the surgery. The upper and lower eyelids and the 3rd eyelid (nictitans membrane) are stitched up using 3/0 nylon. This allows fast corneal healing take place. An elizabeth 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. The loose stitches are removed on Day 7 in this case.     Day 7. No more red bulging spot Day 7. White spot is a scar plugging the ulcer. The 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. No complaint >14 days post surgery.. CONCLUSION No 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).   EYE INJURIES ARE EMERGENCIES CONSULT YOUR VET WITHIN 24 HOURS OF INJURY TO SAVE YOUR DOG'S EYE-SIGHT TIPS & ADVICES 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).   2.  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. 3.  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. 4. 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 are well irrigated and clear of debris before stitching. 5. Tarsorrhaphy (stitching of the upper and lower eyelids) may be another procedure without the 3rd eyelid flap. 6. 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.            P.S.       BE KIND TO PETS                         EYE INJURIES ARE EMERGENCIES                      SEEK EARLY VETERINARY CARE (show a before and after tarsorrhaphy treatment case in a Pekinese) BEFORE SURGERY EXTENSIVE CORNEAL ULCER AFTER EARLY SURGERY ULCER HAS HEALED CLEAR CORNEA WITH FAINT WHITE SCAR   EARLY EYE SURGERY (TARSORRHAPHY) HEALS THE DEEP CORNEAL ULCER PREVENTING RUPTURE & LOSS OF VISION IN THIS PEKINESE   CREDITS FOR MORE INFORMATION judy@toapayohvets.com +65 9668-6468, 6254-3326 www.toapayohvets.com (AUDIO-MUSIC) Update will be on this webpage: www.kongyuensing.com/folder7/20130401descemetocoele_ShihTzu_toapayohvets.htm More info at: Dogs or Cats To make an appointment: e-mail judy@toapayohvets.com tel: +65 9668-6469, 6254-3326 Toa Payoh Vets Clinical Research

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