Be Kind To Pets, Vet case studies, Photography tips, Travel Stories

Thursday, January 31, 2013

1270. Skin disease - why no demodex injection from her own vet?

TOA PAYOH VETS
toapayohvets.com
Date: 31 January, 2013

Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits

Veterinary Surgery & Video:
Anal sacculitis & rupture in the dog and cat
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
First written: 12 December 2008
Date: 31 January, 2013

toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2013-0131

1270. Skin disease - why no demodex injection from her own vet?

"I don't know why your vet does not give the old dog an anti-demodectic mite injection," I said to the mother who "inherited" the 15-year-old Shih Tzu from her daughter. The daughter, in her late 30s, had brought her to consult me for a second opinion was the owner of the dog but had migrated to Australia.

The mother said: "My daughter in KL asked me to consult you. My dog had skin diseases for so many years except for one year 3 years ago. I feed salmon and other good food. Every time, the itchiness would recur after some time after my vet had given a steroid injection. I hear steroids are not good for my dog."

"I don't know why your vet has not or will not give the anti-demodectic injection," I said. "Did you ask him why? Did he do a blood test to screen the health of this old dog, esp. the liver and kidney functions? If these organs are not normal, he might not want to risk giving the injection. You can ask him to fax to me the blood test results."

"Do you vets get along well with one another?" the mother did not want to upset her regular vet by asking for clinical records. So, I did not insist.

"Some skin diseases are not easy to cure unless the cause is known," I checked that this slim Shih Tzu did not have hair loss, little scales, four black paws with big skin warts, clean ears, teeth with little tartar despite no dental check up, a broken tail end with grey skin as if it had partial gangrene and very swollen anal sacs.

"Now the paws are not so itchy," the mother showed me a "poisonous" white cream that her regular vet had given her maid who must wear gloves to apply to the paws. "After applying the cream, the mites die and so the dog does not bite his paws so much. He also does not have that red flush of the skin in the evening causing him to cry and whine now."

The cream was formulated by her vet and so I would not be able to tell whether it included a steroid, hence accounting for the cessation of inflammation.

"Listen carefully to the client," I said to my intern from 4th year the Vet University in Kuala Lumpur. "What she wanted was to get an anti-demodectic injection." The mother had said that her vet had done skin scrapings and showed her "cigar-shaped" mites under the microscope. "These are demodectic mites," I referred to a chart drawing of demodex and her daughter took an image with her hand phone.

The consultation was nearly one hour long as the mother wavered on whether to get another blood test done or get her vet to give me his results and thereby offending this good vet. "I have a bottle of 100 tablets of Eltroxin tablets," she showed me and I have given half of the bottle. My vet said my dog has low thyroid hormones." She was reluctant to get a thyroxin blood level test done.

"A thyroxin test will show whether the medication is effective or not and on the status of the low thyroxin level," I said. "In fact, a repeat blood test is always advised to monitor the disease some 4 weeks after the first and the first blood test was 3 weeks ago." It was hard knowing what was the situation since the mother did not want to upset her regular vet.

So, this back and forth conversation took nearly an hour. "How to cure the demodectic infection?" the mum asked again and again.

"Demodectic mites are normally present in the dog's skin," I said. "When its immune system is below normal or low as in puppies and old dogs like yours, the mites multiply and cause skin itchiness and disease. So, increasing the immune system would have helped considerably."

"How about giving my dog the anti-mite injection?" she asked me. "A blood test is necessary to screen the health of your dog before I give the injection," I am not surprised that Singapore dog owners nowadays are sophisticated to know that some vets give regular anti-mite injections to kill the demodectic mites. However, this was a very old dog and the injection might kill him.

"If the owner wants the injection, the vet ought to give it," I said. "But educating the owner is difficult. The best way is to boost the immune system of your dog. Why does your dog lick all four paws till they are black?" I had explained that the large skin warts on and above the paws irritate the dog as he tried to lick them off. "Continuous licking to get rid of the paw warts, cause the skin to break, become inflamed, infected and ulcerated. After some weeks, the melatonin skin pigments get inside the skin, causing blackness of the skin of the paws. Excising the warts would remove a stress for this old dog and hopefully the demodectic mites will not cause disease."

"But my dog is so old and will die under the general anaesthesia," she replied.
"A blood test will show whether this dog is fit for anaesthesia," I said. "The electro-surgery to excise
the skin warts off the paws takes less than 5 minutes and I can say that the dog has a very high rate of survival since anaesthesia is so short."

The daughter seemed to know what I was talking about. The mother was pre-occupied with the possibility of recurrence of the red skin flush and loud whining in the evening, probably stressing her so much. So we were at different ends of the world. The dog was much better now due to the variety of medications, the skin cream and the fatty acid oil supplements but this skin flush and whining might recur. Her daughter would be going home to Australia in a few days' time.

It needed a lot of patience. What the mother wanted was a treatment to cure the disease once and for all as she had spent a lot of money with so many treatments by her regular vet.

What I proposed was to remove the stress factors as treatment involved steroids and anti-mite cream and/or injections which could harm this old dog.

"I will pay for the blood tests," the daughter suddenly volunteered. Chronic skin diseases are costly to treat and in this case, it was not only the recurrence of itchiness and whining but also money matters. Unless the cause can be identified and can be easily treated, skin diseases are hard to cure in some dogs. In this dog, the ventral groin area is no long black, due to previous steroid jabs. But the paws were still black. On detailed examination, I would say the big skin warts on the four paws would be due to the spread of these viral warts by the dog licking as the body seemed free of the warts unlike other old dogs. The dog's anal sac was voluminous with dark brown thick viscous oil. I asked my intern to express the glands and she managed to get 5% out. I showed her how to do it and expressed over 3 ml of the oil while another intern videoed the procedure. The broken tail needed to be amputated. This was another advice I gave and the mother said: "Earlier the tail was black. I massaged it till the colour returned." That meant the tail had become gangrenous and is now half alive. The hairless tip and broken angle of the tip would be an irritant to this dog, decreasing the immune system and encouraging the demodectic mites to overwhelm his body causing red flush and pain of whining. If only dogs can talk.

So, the first advice would be to remove the warts and in most cases, the dog would become much happier and no longer need to get rid of these "dangling" tumours. Simple solution if the dog was young and not an anaesthetic risk. "Warts seldom appear in young dogs," I said to the mother. "I had an old pug in which I removed 50 skin warts."

"Is the pug OK?" the mother asked.
"Yes," I said. Skin warts do irritate the older dog but many owners are oblivious to this discomfort of the old companion.

This webpage;
http://www.asiahomes.com/petshotline/20130131demodectic_mites_old_dog_toapayohvets.htm

Toa Payoh Vets
Clinical Research

1269. Veterinary surgery & video: Anal abscesses in the dog and cat

TOA PAYOH VETS
toapayohvets.com
Date: 31 January, 2013

Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits

Veterinary Surgery & Video:
Anal sacculitis & rupture in the dog and cat
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
First written: 12 December 2008
Date: 31 January, 2013

toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2013-0131

CASE 1
Case written: Dec 12, 2008 6.57am

The left anal sac area was hard, painful and swollen on the first day of consultation. Around 10% of the infected area was soft but it was best to treat this dog with antibiotics and anti-inflammatory injection to let the abscess "point" or ripen.

On the 2nd day, the young lady owner came saying that there was a big hole. The dog was put under general anaesthesia gas and operated. The oil was expressed. Some oil shot out from the right anal sac as well.

The deep hole was irrigated and flushed to clear all dead skin debris and pus. The edge of the wound was jagged. I used scissors to undermine the skin. Then I trimmed away the jagged edges of the skin and obtain fresh skin edges with blood supply. After that, 3/0 absorbable interrupted sutures to stitch up the wound.

Fortunately, it was easy to stitch up this wound compared to the one in the cat (CASE 2) as there was more skin. The dog went home wearing an e-collar. No complaint was heard for the next 7 days and I presumed the wound would heal well.

CASE 2
Case written: Jun 26, 2007 3.17pm

What to do with such a large infected oval wound near the anus? The cat had licked out the fatty tissues under the skin. A big gap of 0.5 cm deep and 2 cm long was presented. She had stopped pooping. How to close such a big gap successfully?

1. Ideally, put the cat on antibiotics for a few days. Was the wound. But the wound is large.
2. The cat was fat, at 5.5 kg. Would she be able to survive the injectable general anaesthetic?
3. Anaesthesize the cat using xylazine and ketamine at 0.2 ml: 0.8 ml one syringe, IM
4. Clip the hairs, wash the areas. Syringe in 6% hydrogen peroxide.
5. Debride --- cut off dead skin edges and remove dead tissues from inside.
6. Relieve anal sacs of oil. Greyish brown oil seen from left gland. Right gland must have had ruptured resulting in a big hole.
7. Trim edges of wound --- convert to diamond shaped wound.
8. Undermine tissues to get loose skin.
9. Cut lowest end to extend the wound. Z-shaped wounds sutured.
10. Avoid anal sphincter (near the anal ring).
11. Elizabeth collar size 10.
12. Best to ward cat for 10 days but owner wants her home.
13. Warn the owner to confine the cat and if she runs around the home, she may rub stitches off.
14. In 14 days, wound will heal and stitches to be removed.




Case 3: Written in Jan 31, 2013 A Jack Russell had a ripened anal abscess Video produced by an intern from Raffles Institution Pre-University 2nd year, in Jan 2013: 5890. Video: Anal abscesses in a Jack Russell	Initially a hard lump, I gave antibiotics for 2 days. The lump softened and burst. The abscess was cleaned up by Dr Daniel Sing and stitched. The process was videoed by an intern. No further complaints from the owner.
This webpage: http://www.kongyuensing.com/animals/20071228Vet_Tips_Cat_anal_wound.htm

Toa Payoh Vets
Clinical Research

Wednesday, January 30, 2013

1268. Two dogs with head tit.

Jan 28, 2013.

Recently I had two dogs from different owners.

A female unspayed Maltese 6 years old, head tilted to right. She could not stand up.

A 13-year-old Terrier X with full cataracts had a right head tilt but was able to stand. So, what were the causes?

Some lesions had affected the brain. A stroke?

For the Maltese, the male often pounced on her and I suspected trauma to one part of the brain or the ear area.

"Don't charge me too high. I come to you because the breeder refers me to you," said the lady with diamond ear rings and Mercedes.

The Maltese was hand-fed and given IV drips and medication for 3 days. She could lift up her head but was unable to stand. No spinal pain. Has strong pain reflexes from the paws. Blood tests showed nothing abnormal.

The Terrier X owner wanted the dog home 24 hours later. Blood test done showed nothing abnormal . It was hard to diagnose what caused the right head tilt as the owner did not want to pay for tests. A CT scan would cost $1,000/scan.

These two dog owners will not want to pay for these tests.

1267. Metaplasia of a terrapin's eyes?

TOA PAYOH VETS
toapayohvets.com
Date: 30 January, 2013

Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits

A terrapin's eyes are swollen
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
First written: 22 January, 2013
Date: 30 January, 2013

toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2010-0129

METAPLASIA OF THE EYES DUE TO VITAMIN A DEFICIENCY?

5831 - 5837. Hypo-vitaminosis A. Metaplasia of the eyes?

Not all cases of swollen eyes can be cured when the disease or deficiency of Vitamin A had progressed for a long time. In this case, it took a very long time and the eyes were not back to normal. Early cases of swollen eyes are curable provided there is no upper respiratory tract infection, pneumonia or chronic conjunctivitis. Hospitalisation for treatment is usually needed as most Singapore terrapin owners are not able to treat cases of swollen eyes.

This webpage:
http://www.asiahomes.com/petshotline/201301130terrapins_swollen_eyes_toapayohvets.htm

See 3 other cases of swollen eyes in terrapins in a video::
http://www.youtube.com/watch?v=XO_kpCLGr0I

Jan 30, 2013

Dear Dr Sing,

Here is this link to the video that has been completed! http://www.youtube.com/watch?v=XO_kpCLGr0I

Cheers,

Gina

YouTube - Videos from this email

COMMENTS BY DR SING

Thanks for a good job done. You have favourable comments from a third party which shows that you produce an entertaining and educational video. However, please take note of copyrights to images. You will need to get permission to use images from other sources as there are issues of litigation for copyright infringement and we will then have to remove the video. It is best not to use them but create your own.

TumblingUpTheStairs 5 hours ago

A very educational video

·
fmylife164 6 hours ago

hi

· in reply to imaphonyhehez (Show the comment)
imaphonyhehez 6 hours ago

Nice educational vid! Well made and entertaining! Keep up the good work.

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

1266. Enucleation of the eye in a dwarf and a Syrian hamster

TOA PAYOH VETS
toapayohvets.com
Date: 30 January, 2013

Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits

Veterinary Surgery: Enucleation of the eye in 2 hamsters
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
First written: 22 January, 2013
Date: 30 January, 2013

toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2010-0129

CASE 1. A DWARF HAMSTER HAS A POPPED OUT EYEBALL

Jan 22, 2013

"She is going to die," the young lady wiped her tears as her 2-year-old female dwarf hamster was sleepy unlike others. The hamster just would not move when held on the palm of her hands. She took her out several times and this would stress out the sleepy hamster which had not eaten and drunk water in the past 2 days and was in great pain.

"Two days ago, the right eyeball just popped out," she said. "Before that there was a white spot in her right eye. I thought it was a cataract."

The hamster's shoulder skin stood up when pulled indicating severe dehydration. The protruded eyeball must be very painful as the hamster can't talk. She just sat still most of the time. The owner was quoted $400 by another vet to do surgery. "I don't have that much money," the student said. "Normally I charge $100-$250" for hamster surgery depending on how complicated it is and the time it takes.


Eyeball prolapse 2 weeks after observation of "white" corneal ulcer	Painful eye. Continuous rubbing of the right eye		Lethargy & dehydrated. Subcutaneous injection of dextrose saline

Anaesthesia - isoflurane gas in a small container as required	Illustration of Surgery to educate owner & for medical records	Right eyelids snipped off and stitched. Excellent and fast recovery (video)	48 hours after eyeball removal. Owner's e-mail image of a bleeding wound to the left of the surgery area. "This could be due to self-inflicted rubbing before or after surgery as it is not possible to put on an e-collar for hamsters, unlike in the dog," I explained. "Bring the hamster down for examination." No further complaint from the owner as at Jan 30, 2013.

PRE-OP DEXTROSE SALINE
"What are you injecting?" Dr Daniel saw me preparing a small injection of 0.05 ml in a 1-ml syringe and thought I was overdosing this hamster. "It is dextrose saline as he is so lethargic and weak."

ANAESTHESIA
"This is a very sick hamster," I said to Dr Daniel when we discussed anaesthesia. He proposed 1 drop of Zoletil IM. "The safest is just isoflurane gas," I said. "The vet needs to be very observant as it is hard to tell when the hamster is fully anaesthesized.

We put the hamster inside a plastic container infused with 5% isoflurane gas. "Count up to 10 and take out. Repeat," I said. Dr Daniel did say 1,2,3...10!" once. The dosage was not enough. He tried again. "Use the mask," I said. But the mask was not effective as it was too big.

SURGERY
Basically the surgery of enucleation of the eyeball is similar to that for the dog. I incised a 4-mm area on the lateral canthus to enlarge the orbital area. Then I clamped the base of the right eyeball with curved forceps. The normal left eyeball suddenly popped out and the hamster squeaked.

I ceased the procedure and gave the hamster more anaesthetic fas. I scrutinised the hamster inside the plastic container. Once she could not move, I quickly took her out within a second. I clamped the eyeball again and excised the base with scalpel.

Unlike the dog, it was not possible to ligate the optic stalk and blood vessels as there was insufficient exposure in the dwarf hamster. Without ligation, profuse bleeding ensued. I swabbed off the blood and quickly cut off the upper and lower eyelids with scissors. Now, there would be two skin wounds which would heal well when I sutured with 6/0 sutures. The hamster was under gas anaesthesia which was just sufficient but would be short in duration. So, the hamster wriggled as she was waking up. I stitched the eyelids fast using 3 interrupted sutures.

"Hold on to his front paws, the scruff of his neck," I said to Dr Daniel. The dwarf hamster is so small that there is no space for both of us with 4 hands manipulating the dwarf. Finally, I sutured the eyelids.

The intern was trying to focus her camera to document the surgery. It was too cramped for the intern to take a video of the surgery. "The surgery needs to be very fast as the hamster's chances of survival on the operating table are good. Therefore, you can't video as this will delay the process." The intern left the operation room.

However she videoed 30 minutes post op and the hamster was busy cleaning himself. This video would be shown in the production of the video.

Surprisingly, the hamster became much more energetic after removal of the eyeball. It would be attributed to removal of pain and the dextrose saline. This was one of those cases which I think that the hamster would die on the operating table as he was not active and severely dehydrated. So, the owner and I were glad to see him much alive. She took him home in the afternoon and was given medication.

FOLLOW UP: 1 DAY AFTER SURGERY
On Tuesday, Jan 22, 2013, I phoned the young lady. She was most happy. "The hamster drinks a lot," she said. "She is much more alive." It was good news.

PHONE CALL FROM OWNER 2 DAYS AFTER SURGERY
Yesterday, Wednesday, Jan 23, 2013, the owner phoned me to say that there is a big hole. "Is it normal for hamster in such operations to have a big hole in the eye? What should I do? Can I send you the images of the eye by iPhone?" I said it was difficult to know what she meant and it is best to examine it as she thought there was a stitch breakdown exposing the eye wound.

She brought the hamster to the surgery in the afternoon. I was out and some driver had suddenly swerved into my parked car opposite the church and public library, damaging the right fore lamp area. So Dr Daniel examined this hamster.

"What happened?" I asked Dr Daniel.
"The swelling was due to the bleeding after removal of the eyeball. It has become a clot. The owner did not give the pain killer and the hamster scratches the eye area. But the hamster is normal, very active, eating and running. Is it possible that you did not snip off the eyelids but had just stitched up the eyelids?"

Dr Daniel was assisting me in this surgery to remove the eyeball but he was on the other side of the op table holding on to the hamster while I stitched up the "eyelids". As the hamster was a dwarf, he could not see me using a pair of scissors to snip off the upper and lower eyelids, as per standard operating procedure in eyeball removal surgery. In fact, it would be professionally incompetent not to do.

SNIPPING OFF THE UPPER AND LOWER EYELIDS
His palm is 4X in area compared to this dwarf and unlike the surgery in the dog or cat, he could not see much. He saw me using the scissors to cut off the 6/0 sutures after stitching the "eyelids". Actually, I had trimmed off the eyelids before putting in 3 stitches to close the eye. "I had cut off the eyelids, otherwise the eye would not seal off when the stitches dissolve," I said to him patiently.

CASE 2. A SYRIAN HAMSTER HAS A BLIND SHRUNKEN EYEBALL Sep 20, 2010
The same surgical procedure of eyeball enucleation is illustrated in a Syrian hamster below. The 3rd eyelid is not so prominent in the hamster unlike in the dog but is should be removed if it can be seen.

Shrunken blind eye	Illustration of surgical process to educate the hamster owner and for medical record	Isoflurane gas anaesthesia given by mask	Eyeball has been taken out. Eyelids snipped and the new wounds are stitched with fine sutures

Hamster wakes up fast when given gas anaesthesia	Post-operation	Stitches are absorbable. No need to return for stitch removal. No further visits or complaints from the owner since the surgery.
ADVICES & TIPS: 1. Eye Injuries Are Emergencies in Hamsters. Consult Your Vet Immediately 2. The vet must deliver a hamster alive at the end of surgery. Therefore, the vet must know what to do and complete the procedure of enucleation in less than 1 minute in order to deliver a good outcome. Sick hamsters can't survive long anaesthesia and surgery (>2 minutes usually). 3. EYEBALL REMOVAL SURGERY IN HAMSTERS COMPARED TO THE DOG AND CATS The anaesthesia and surgery to remove the eyeball in the hamster can be completed in less than 5 minutes unlike in the dog or cat owing to the small size of the eyeball. The same principles of surgery apply to the hamster as to the dog and cat, only that the operation is on a miniature scale and the anaesthetic risk of death from isoflurane gas is 10x higher as it is difficult to monitor the depths of anaesthesia. 4. SAVING THE EYE USING TARSORRHAPHY This hamster had a "white spot" in the right eye earlier. The owner thought it was a cataract. This would be a corneal ulcer which tend to be painful and itchy. The hamster would have scratched so hard that her right eyeball popped out permanently and caused great pain. In the dog and cat, it is possible to "save the eye" if it is not badly damaged or infect. This is done by doing lateral canthotomy (which I did in this hamster) to enlarge the ocular space, push back the eyeball, give antibiotics and anti-inflammatory, stitch up the upper and lower eyelids (tarsorrhaphy) to protect the eyeball and keeping it moist. In 14-21 days review the eyeball and remove the stitches. In tarsorrhaphy, the eyelids are not snipped off. An e-collar is then worn. All these are not possible for the hamster esp. the post-op care as the hamster hates the e-collar and will get rid of it in no time. The hamster may not eat or survive after such a drastic surgery. So, removing the popped out eyeball is the practical option.
This webpage is: http://kongyuensing.com/folder7/201301123hamster_eyeball_enucleation_toapayohvets.htm