1065. Tarsorrhaphy - Poor post-op eye care by owner

The Shih Tzu is the most common breed in Singapore getting eye injuries. It is also the most popular breed purchased in the past years.

Many Singapore dog owners are unable to provide proper post-op eye-care. It may be better to get the dog hospitalised 3-14 days to achieve a good surgical outcome. Compare the two cases. The Pekinese is well cared for because the mother is experienced in dog care and the dog is very easy to handle. The Shih Tzu was not cared for well.

Details of the case are at:

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

I have introduced the Standard Operating Procedure for all cases:
http://www.sinpets.com/dogs/20120706tarsorrhaphy_standard_operating_procedures_toapayohvets.htm

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

1063. Medicine for stray dogs and cats in Cambodia

Hi, I'm Agnes. I was in Siem Reap, Cambodia recently, distributing stationery, clothes and food to the children.
I'll be visiting again from 27th July to 5th August. The purpose of this email is to enquire if you would be able to donate some much needed medicine to Katie, the only Western vet nurse in Siem Reap, she's rescuing and treating dogs and cats on a voluntary basis. I can link her up in the email if necessary, she's requesting the following:


Drontal worming preparation
It’s in tablets – for deworming cats
Over the counter
Nutrigel (vitamin paste/syrup)
It’s for dogs and cats
Over the counter
Calcium in the form of small bones
For dogs
Over the counter


Clavulanic acid/amoxicillin (clavulox) 50mg
It’s in tablets form. It’s an antibiotic for cats
On prescription? Over the counter?
Cephalexin 50-60mg
It’s also in tablets form, and also an antibiotic for cats
On prescription? Over the counter?

Hope to hear good news, thank you!


Regards
Agnes


E-MAIL REPLY FROM DR SING DATED JUL 6, 2012
I am Dr Sing from Toa Payoh Vets. We spoke today. There are generic drugs which can be used rather than branded ones as requested by Katie and are much less expensive when sourced from Thailand.
Pl ask the vet nurse to contact me by email and let me know more about her work with stray dogs and cats. 

1062. Acute tick fever in a big white dog in Singapore

1062. Acute tick fever in a big white dog in Singapore July 4, 2012 Wednesday Deaths of pets are part of my veterinary work since I graduated in 1974. Yet, after almost 50 years in practice, I feel much sadness in the death of this beautiful snow-white big dog that died 4 hours after arrival in my Surgery yesterday, despite treatment and fluid therapy. She was middle-aged and quite plump, as cuddly as a miniature polar bear. Not a brown stain on her white coat. No skin disease unlike some others. I had taken a blood sample and did the tick-fever test for Babesia and Ehrlichia. The cause of death was babesiosis (identified as Babesia canis by blood smear), known as tick fever. The Ehrlichia test was negative. "Would she have lived if Vet 1 had diagnosed her with tick fever 8 days ago?" the lady in her 40s had been referred by her brother to consult me thinking that her dog had liver failure and no chance to live. I had told her that liver diseases are not a death sentence but it may be cured if the liver is infected. Vet 1 had given her many liver supplements and so she presumed her dog had liver disease. "It is hard to say whether your dog would have lived if she was diagnosed as having tick fever instead of liver disease 8 days ago," I replied. Babesiosis is a direct and an immune-mediated haemolytic anaemia. The immune response is said to be more lethal than the parasites (merozoites or piroplasm) inside the red blood cells. "Why didn't you consult Vet 1 if your dog is not well after 2 days of medication?" "Vet 1 did not tell me to do that," she replied. "He gave me 14 days of the green tablets (doxycycline 100 mg/tablet), to give two tablets two times a day and other medicine. But my dog stops eating and drinks little yesterday. She was unable to stand up. She vomited brown stuff and passed black stools and brown urine. So, my brother asked me to consult you." "The antibiotic you gave is ineffective against babesiosis," I said. "Your dog needed the anti-tick fever injection." "Why didn't Vet 1 diagnose tick fever?" she asked. "In his case sheet faxed to me, he did write 3 diseases. They are pyometra, tick fever and liver failure." "Why didn't he treat for tick fever?" she asked. "He has written that you did not want the tick fever test to be done. So, it is your decision." "Why didn't he tell me that I should do the tick fever test? Why did he ask me to take the antibiotics for 14 days first?" "He did advise you about the test and had written down in his case sheet that you did not want the test done," I said. "It is up to the owner to decide as the owner pays for the test." "Then why he did the blood test and the blood smear for? The ultrasound too." "He did the blood test to screen the health of your dog esp. the liver and kidney functions. Your dog had been sick for one week before you saw him. The total white cell count was high. The platelets, red blood cells and haemogloin were lower than normal. "But the values were not excessively high," the lady said to me. "So, there was not a big worry." I noted that Vet 1 had written "refractile inclusion bodies seen in the red blood cells." This seemed to give a clue that it was possible that the red blood cells had Babesia parasites. However, a blood smear with the stains would reveal the parasites.  According to Dr Daniel, the blood smear under Gram stain showed lots of red blood cells with Babesia inside.  But the owner had not wanted the "tick-vector test" and so the dog went home with liver medication, anti-abdominal fluid swelling (ultrasound had detected abundant fluid which was sucked out and examined by Vet 1) and vitamins. "My dog could hop into the car when I brought her to see Vet 1," the lady said. "Now she just lay on her chest and refused to stand up." "What is her normal sleeping position?" I asked. "Belly up, like people," she said. Eight days had passed. My blood test showed kidney failure, elevated liver enzymes, a very high total white cell count of 46 as compared to 20 when tested by Vet 1. The normal range is 5-17). The platelets were 26 as compared to 166 earlier (200 - 500). Red blood cells were much lower. "What are the purplish spots on her belly?" the owner asked me when she came to see the dog at 9 pm yesterday. The dog had passed away at around 7 pm.  "Those are areas of skin bleeding as the platelets are very low," I said. "Your dog had difficulty breathing and vomited blood before she passed away peacefully." The dog first showed lethargy 15 days ago. The owner said that the dog had never gone downstairs and had never got any ticks for the past 6 years. Since this dog was so well groomed and never went downstairs, I could believe her that the dog had no exposure to ticks. "Did the dog go to the groomer?" I asked. "Yes, 2 months ago," she said. "I brought her to a new groomer. But she had no ticks on her body when she came back from the groomer." "Why didn't you go to the old groomer?" I asked. "He has stopped grooming since his groomer left." "It is a strange case as a dog must be bitten by an infected tick to get tick fever. Since you were so sure that your dog never had ticks, Vet 1 might have ruled out a high possibility of tick fever infection and went for liver failure diagnosis." CONCLUSION In many cases, owners do not want laboratory tests. However, the vet must be forceful in warning the owner of the fatal consequences of tick fever if the dog is not treated early. Refractile inclusion bodies in the red blood cells were the clue as blood parasites like Babesia can cause refractile inclusion bodies to be formed. It might be wise to treat as if the dog had tick fever rather than following the protocol of confirming tick fever, if economic reasons prevail. The interest of the dog is paramount and if the owner cannot afford the test, it may be advisable to strongly advise it being done. Did the vet phoned the owner 3 days after consultation? I believe he had done so and he had recorded in the case file. "He could have added this in after I asked for the medical report," the lady owner had a very difficult time getting the report to be released to me and therefore had her suspicions. What was the cause of death in this dog? Only an autopsy would find the answer but the owner would not want one. The dog was sent for cremation by her relative. As to the possible cause of death, one experienced vet said it was kidney failure rather than liver failure, Dr Daniel told me. As for me, I would say that the immune-mediated haemolytic anaemia reactions of Babesia canis was the primary cause of the dog's quick death rather than the destruction of the red blood cells. Kidney and liver failures were the consequences. My hypothesis is that the reaction caused platelets to be extremely low and the dog would bleed internally to death. In the evening when the owner came, she pointed to several bruised like spots on the shaved abdomen where the first vet had done his "abdominal tap" to take out the peritoneal fluid. "These are bleeding spots caused by the tick fever parasite reactions," I said to the wife. The dog had coughed up some blood before dying. It was one of those unusual cases as the dog was said not to have been exposed to any ticks over the past years as she lived in the apartment and never went done for walks. If there was definitely no exposure to ticks, the first vet was distracted and went for liver failure diagnosis, disregarding the clue of the presence of refractile inclusion bodies in the red blood cells. Singapore pet owners are getting more sophisticated and demanding and therefore, evidence-based medicine and defensive medicine must be practised nowadays. All advices and client's objections to tests and advices must be recorded properly in the case file as a good habit. In this case, medical negligence would not stand in court, I believe, as the vet did advise an anti-tick vector test and the owner had been informed and had objected to it. The burden of proof is on the owner when negligence is alleged and the proof was not there in this case.       UPDATES & MORE IMAGES WILL BE AT:  http://www.sinpets.com/dogs/20120719Babesia_canis_samoyed_toapayohvets.htm

 

1061. Solution to chronic ear problems in the dog: Toa Payoh Vets Video

July 2, 2012

I have commissioned an educational video on the surgery of the lateral ear canal done at Toa Payoh Vets. This video provides some information for dog owners whose dogs keep scratching and is very smelly for many years. The surgery resolves this problem and is shown in the video at:

http://www.youtube.com/watch?v=ycYKJbB4dYM&feature=youtu.be

The surgery is called Lateral ear canal resection.

For more info
judy@toapayohvets.com
+65 9668 6468
www.toapayohvets.com

Sunday Jul 1, 2012 interesting cases

Jul 1, 2012

1. Pekinese with right eye ulcer. Owners had run out of eye drops. Around 10 days since tarsorrhapy done by Dr Daniel.

Eyelid stitches removed. Dr Daniel used fluorescein eye stain. NO more staining indicating ulcer had healed. I took some images of pre- and post-injury corneal ulceration. I wil use this as a case study for video production. Excellent surgical outcome in this case. This was because the owner's mother knew how to care for this dog. The eyelids did not have any discharge or dirt on Day 12 when I saw him as contrasted to other dogs with similar problems and being cared for at home.

2. Foul-smelling "decomposed dog" case Shih Tzu had been warded here for 15 days. No more bad smell. Main problem is an intense ventral contact dermatitis. Dog just had to scratch belly -- traumatic injury and smells. Will follow up. 

History. Shih Tzu, Male, Born Sep 2004.

Seen other vets in Dec 5, 2009, Apr 16 10, May 10, 10, Aug 6 10, Oct 31 10, Apr 5, 11, Jul 10 11. 
Wanted to send dog to SPCA if I can't cure this "smell like dead dog" lower half of body. "The decomposed dog smell comes back 2nd day after bathing," the serious gentleman told me. "Not all skin diseases in the Shih Tzu are curable," I said to him. "Hospitalise the dog for a few days and let me observe him." The dog had a full coat with no hair loss. Some scales drop off from the lower belly and chest areas which were inflamed. I expressed the anal sacs.

They were filled with dark brown oil and very smelly. The flies appeared from nowhere and landed on this oil when I took the tissue with the oil for photography outside the Surgery. "Can't be the anal sac oil causing this smell," the owner disagreed with my findings and the fact that the flies were so interested in this anal sac oil. Normally, flies don't come at all. My hypothesis was that the oil might have licked out and stained the dog with the smell of dead flesh. The owner was not convinced as he said the groomer and the other vets had expressed the glands. Well, I had the pictures of the flies but it was poinless to show him since he had discounted this as a cause.

I smelt the dog's body on Day 3 of hospitalisation with medication given and skin washes done. There was a faint oily smell but not the decomposed meat smell. "Not that smelly," I said to the owner. But I observed that the dog's lower body was very red. As if the dog had rubbed it or more likely scratched it vigorously. The inflamed neck and groin was seen on and off. So, this was the problem. My hypothesis is that the dog just could not help scratching the lower body, due to conditioned reflexes. He had been scratching it for months as it was a way to relieve the itchiness. Some anal oil would have contaminated this traumatised skin and made the skin much more itchy and infected. So, 2 days after bathing, the rancid dead flesh smell came back.

Altogether, I hospitalised the dog for 14 days. "How much it will cost me?" the owner asked. "Not much," I said. "Since there is no surgery done." After 14 days of medication and washing, I sent the dog home with instructions that he wear a shirt to protect his lower chest and groin. The owner did that and on July 9, 2012, I phoned him. He was very happy as the dog did not smell anymore. Before sending the dog home, I expressed the anal sac. Another lot of dark brown anal oil came out.

This dog was not sent to the SPCA now and should live a normal life much loved by this serious gentleman. Dogs with skin diseases are sent to the SPCA to be put to sleep usually. Skin diseases in Shih Tzus are more common than in other breeds, in my practice experience. It is possible that the busy and time-pressed Singapore owners don't have time to do the daily brushing and grooming. This leads to skin infections and continuous itchiness. Many of these skin disease cases need reviews and strict compliance with medication prescribed. But this owner said that his dog passed blood in the stools when the other vets prescribed oral medication and so he did not do it. He did see 7 vets in 7 times as the vet practice has different vets on duty at times he went.   
     
UPDATE:
Yesterday, July 9, 2012,  I phoned the owner to find out the fate of this Shih Tzu.  He said: "No smell,"
"Did you buy the shirt for him to wear?" I asked. "Yes," he sounded quite happy. I hope this Shih Tzu's anal sacs don't produce more of the stinking oil again. I doubt the owner will come for review when there was no apparent skin problems!  

1059. Carnaissal tooth abscess, bone cyst or tumour?

I am reviewing the following case at Toa Payoh Vets on Sunday Jul 1, 2012 at 9.11 am as this time is peaceful, being located aways from lots of residents.

The 12-year-old Golden Retriever had a big hard lump on the right face, below the eye, in the position of a carnaissal tooth abscess fistula. At first sight, I diagnosed a carnaissal tooth abscess as this is the most common location and problem in older dogs that do not have any dental work done in 12 years! Dr Daniel said it could be a bone cyst or tumour.

As the owner did not want any X-ray to be done, Dr Daniel extracted the right maxillary 4th premolar.

I noted that the roots are shrivelled and blackened but I was not present during the dental work. According to Dr Daniel, this would not be a carnaissal tooth abscess. "I have seen two cases of bone cysts in Australia" he was doing internship then.

"Did you see the bone cyst in a similar location, below the eye?" I clarified with him later.
"Not in this location but bone cyst can occur in anywhere as a hard swelling from the bone. Bone cyst is a differential diagnosis."

"I have seen none in my past 30 years of practice," I said.

99% of my cases are small breeds as over 80% of Singaporeans live in apartments and so Golden Retrievers are uncommon patients and so I have not seen one with carnaissal tooth abscess in this breed.

So, is this a case of a carnaissal tooth abscess or not? The owner did not want histopathology or biopsy but agreed to X-rays after the tooth extraction. I have cropped the X-rays to focus on the relevant areas and to scrutinise them. What do you think?     

X-ray after extraction of the maxillary PM4 showed a large dense globular lump (Y). It is hard to say whether it is a bone cyst, bone tumour or encapsulated abscess of the root of the carnaissal tooth.

MY HYPOTHESIS
Due to its unique location, I would say this hard lump is associated with the carnaissal tooth infection going on for many years. This dog did not have dental work for the last 12 years and the tooth root had rotted away sending bacteria into this area, infecting the bone. The reaction is a hard lump which the owner noticed recently. The dog was still "eating" and the owner consulted us for the lump.

FOLLOW UP