2900. Continuing education: Recent Advances in Ocular Therapies by Robin G Stanley

July 31, 2016

I attended Continuing education: Recent Advances in Ocular Therapies by Dr Robin G Stanley, Animal eye Care, Melbourne today.  His website is animaleyecare.com.au. An excellent presentation.

1. Acute Glaucoma


PROSTAGLANDIN AGONSITS - increase outflow, decrease production of aqueous
a. Xalatan - lantanoprost
b. Travatan - travaprost
Not for luxated lens in anterior chamber (2nd glaucoma)
Not effective in cats

Lantaoprost is very very effective for acute glaucoma. IOP of more than 40 mm Hg back to normal within 90 min (new aqueous production every 90 min)  after a single drop in most cases. Used once daily. Ineffective after 6 weeks in most dogs, possibly related to receptor saturation. Ineffective in cats as cats have no receptors.
Expensive. A$25/2.5 ml. Use generics. Check IOP

2. Secondary Glaucoma

TOPICAL CAIS (carbonic anhydrase inhibitors) decrease production of aqueous, no effect on outflow. More effective than oral CAIs and no systemic toxicity. He seldom use oral CAIs as topical CAI are very effective, not good for primary glaucoma, work better for 2nd glaucoma and seem to be more effective with time.


a. Azarga - Brinzolamide/Timolo (recommended, newer drug with anti-inflam properties)
b. Cosopt - Dorzolamide and Timolo (mainly used to treat ocular hypertension - slightly increased IOP, reduces IOP by 15-20 mm Hg. More effective in reducing IOP when drug is used longer.
Used for the other eye (predisposed eye) to reduce the risk of glaucoma when one eye is affected as this glaucoma develops few months later.


c. Trusopt - Dorzolamide
d. Azopt - Brinzolamide

Technique in taking IOP important as dog struggles, increase IOP.
Uveitis - IOP should be low.  IOP can be a guide to effect of anti-inflam therapy.

SYSTEMIC CAI eg. Daranide or Diamox.

OPTIC NERVE DAMAGE IN GLAUCOMA. No drug.


GLAUCOMA PROPHYLAXIS
1. Do not use prostanoids due to receptor saturation ie. lose their effectiveness over time
2. Other vets use Timolo and Pilocarpine
3. Cosopt  --  mainly used to treat ocular hypertension - slightly increased IOP, reduces IOP by 15-20 mm Hg. More effective in reducing IOP when drug is used longer.
Used for the other eye (predisposed eye) to reduce the risk of glaucoma when one eye is affected as this glaucoma develops few months later.

FELINE HYPERTENSION
1. Amlodopine is very useful. Cats 5 mg tablet. 1/4 to 1/8 sid. More effective than fortekor, enalapril. Retinal haemorrhage (scope)
most old cats have high BP, not treated -- retinal haemorrhage. use Amlodopine. Bubbles intapetum. Measure BP
cat fundus uniform unlike dones.

INFECTED CORNEAL ULCER

Image - eye hypopyon,ulcer melting. swab for culture, gram staiing, sensitivity

Can melt - keratomalacia
Usually Pseudomans or a B Haemolytic Strept. Do culture and sensitivity
Causes excess release of collagenase that dissolves/melts the cornea.
Use fortified gentamicin OR
fluoroquinolones with Conoptal (fusidic acid)
Need to use 6-8x/day

Rather than fortifying
use drops frequently
use every 5 min for the first hour and then hourly for the first day.



THERAPY FOR MELTING CORNEAL ULCER EYE SHOWN IN SLIDE
fortified gentamicin 6 x daily
doxycycline 5 mg/kg bid
atropine Minims a drop to keep pupil dilated
Oral NSAIDs
Nowadays, less use of conjunctival flap surgery (cut off cornea, put flap in) and more use of drugs for melting corneas.
Chloramphenicol eye ointment used by some vets
Gentamicin is toxic in eye drops?

INDOLENT ULCERS IN CATS
usually viral cause
some related to poor quality tears

VIRAL KERATITIS IN CATS
feline herpes virus
stress seem to be important factor e.g. been to cattery, behavioural causes
FELOWAY - feline appeasing pheromone.

Viral keratitis
- dendritic ulcers (slide shown of branching ulcers due to viral spread)
-geographic ulcer (slide showing large ulcer on surface of cornea, like country in a sea as seen in a map)

TOPICAL ANTI-VIRALS
CIDOFOVIR most effective. 1 drop bid. 98% heal within 10 days
Idoxuridine
Acicylovir (Zovirax)
Betadine (Iodine) eye drops

ORAL ANTIVIRALS
Famciclovir 40 mg/kg tid
Compounded by pharmacists with fish paste but some cats dislike it.
Use artificial tears
Use lysine 500 mg orally bid. long term once daily. minimize rate of recurrence. increase to bid if stressed.

interferes with viral replication


ORAL DOXYCYCLINE FOR VIRAL KERATITIS, CORNEAL ULCERS AND CONJUNCTIVITIS

Many cats with viral keratitis have chlamydia infections
5 mg/kg bid
No need topical meds according to Dr Stanley as doxy is sufficient.

Feline conjunctivitis
As in viral keratitis 5mg/kg bid rather than 2.5 mg sid. Sufficient conc in cornea and conjunctiva, so no topical therapy.

Chlamydophyla is a systemic disease and need systemic therapy.


INCREASED RISK OF INFECTION

eg. dry eye, stromal ulcer etc
topical Abs are also needed
- triple AB combination
conoptal
NOT gentamicin or fluoroquinolones unless the ulcer is infected.

FELINE CONJUNCTIVITIS
Zithromax (azithromycin)
useful in a cattery situation  large no. of cats
but doxycycline more effective, has anti-inflam effect which may promote corneal healing. May have some anti-corneal melting effect.
cytology  culture

ANTI-INFLAMMATORIES
1. Topical NSAIDs - voltaren (diclofenac) or Acular (ketorolac) eyedrops
2. Mainly used to reduce  corneal scarring after vascularization in corneal ulcers AND for management of lens-induced uveitis.
3. cornea at risk of ulcerating   eg. keratitis
4. not use for ulcerated cornea.
5. can potentiate corneal ulceration
6. in keratitis treatment, not as effective as topical cortisones e.g. Pred Forte and Maxidex
    esp. diabetic cataract.
7. use topical NSAIDS in viral keratitis in cats. Topical cortisones can reactivate a patent herpes keratitis
8. Oral NSAIDS 80% as effective as systemic steroid. Start on oral doxycycline.

Systemic NSAIDS
Dogs:  Carprofen 2.2 mg/kg bid 3 days then sid
Cats:  Metacam suspension seems to work well in controlling uveitis and ulcers in cats


SEVERE UVEITIS
He will initially use cortisone by all routes e.g. topical, systemic and subconjunctivally
(Image - eye with miosis, hypopyon, inflame uvea)
Sedate and given subconj depot cort e.g. dexa forte. Makes a big difference.  Atropine to dilate pupil

DRY EYE
1. Clear eye of all pus etc before applying optimimmune


ARTIFICIAL TEARS
1. in human studies, better corneal health
2. Refresh Tears Plus
3. Hyaluornate-based drops e.g. Luxyal or Hyloforte (comes as a pump, last longer, more viscous preparation)
Replace quantitiy of tears and increase quality
Systane Hydration Tears for cat flu
4. last only 1-2 hrs on the cornea.

TACROLIMUS
Next wonder drug for dry eye?  Better than Optimmune.
Effective in dry eye cases unresponsive to cyclosporine.
3x/day if cyclosporine not working.
Like cyclosporine, Tacrolimus is used for stopping graft rejection. Trade name is Profraf, FK506
3x/day if Optimmune is not working

Unresponsive Dry eyes
Use Tacrolimus and cyclosporine together
Tacro 3x/day, 15 min later, cyclo
4-6 weeks to get results

Tacro used in inflamed corneal ulcers. makes a difference.





EYE SURGICAL INSTRUMENTS
1. (Thin narrow forceps)
2. Needle driver.
3. Ziegler cilia forceps
4. Thorton open wire lid speculum with lifting wings - better than usual eyelid retractor which is heavy.
5. Stevens tenotomy scissors

PREMEDICATION
1. Premed with injectable NSAID esp. corneal  intraocular surgery. send home with oral NSAIDs
2. Prem with broad spectrum antibiotics.. Generally no follow up with oral antibiotics.

SURGICAL DISINFECTION
3. Betadine iodine solution, not the one type you use for scrubbing
4. dilute 1 part betadine to 9 to 25 parts saline. Not to use water as the ionic nature of the diluent makes the iodine more active.
5. Prep in usual manner.

WATERY EYES
Entropion, puncta atresia (slide of Golden Retriever). extra eye lashes. Schmir tear test 15 is normal.

TEAR DUCT FLUSH
Watery eye - lack of nasolacrimal fluorescein passage
Fluorescein dye appears at nostrils (slide shown).
use lacrimal cannulas or hypodermic needles bent over and the tip broken off and filed smooth or use IV catheters (plastic part of IV cathether).
Under GA esp. for cats or sedation. Large dogs c b flushed with local anaesthetic
Flush thru to the nose so, point the nose down
If unable to flush, try passing suture  down the N/L duct and in large breed dogs, try a retrograde flush from the nose back into the eye (like in horse).
(Image of illustration of needle flushing superior puncta and fingers pressing eye area shown).

If still blocked, flush eye again a couple of weeks later.
lazy tear ducts - tell client that some breeds, the tear ducts are not blocked. but the eye is watery with no N/L fluorescein passage through to the nose.  eg maltese, poodles, Persian cats. difficult case to resolve.

TEMPORARY TARSORRHAPHY
Can be very useful to protect cornea eg. inflamed cornea, superficial ulcer with a dry eye or large eyelid opening.
Split thickness thru the eyelid edge so suture does not rub on cornea. Can be left for months if needed.
TT can be useful in inflamed cornea  (image cornea with lower area vascular vessels)

3RD  EYELID FLAP
Very very useful for corneal disease
If in doubt, flap it
Scarify the bulbar (inside) surface of 3rd eyelid so that it bleeds
monofilament nylon & IV tubing     4/0 cats   2/0 nylon
He is still in favour of 3rd eyelid flap. In Hong Kong, he was expert witness in a case where a HK vet was to be de-registered for using 3rd eyelid flap. Said only 1 case of 3rd eyelid stuck to cornea in 5 years.


(Illustration 3rd eyelid flap -  iv tubing, nylon into upper eyelid, go under upper eylid, across cornea, go above 3rd eyelid and then into tissue of 3rd eyelid, U-turn still  inside tissue 3rd eyelid, back inside tissue eyelid, go  across cornea,  towards upper eyelid and tubing.

Can be a problem in brachcep. the TEF pulls medially, so exposes the lateral cornea. Use TT as well.
IV tubing at lateral canthus?
Concern that flap may stick to cornea. Very rare in his experience. 1 case in 5 years.
Concern that meds may not reach the cornea. yes in theory. give subconju med (gentamicin) and vibravet

INDOLENT CORNEAL ULCER
(Image)
Slow healing
look for underlying casue
Do a STT in all cases of conjunctival and corneal diseases
Check eyelids using magnification
breed predisposition e.g boxers, Samoyed, GR, corgis

MANAGEMENT OF INCOLENT ULCERS
A cotton bud to debride loose epithelium
Grid keratotomy
  Make small incisions into the corena
  DO NOT GRID ODEMATOUS OR INFLAMED CORNEA (Use conj graft).
  90% heal within 10 days
  Image
  25mm needle. Grid 2 mm out into normal cornea
  No need to be well cut grid. Messier, better outcome.
  Grid whole cornea
  Use TEF or TT
Superficial keratectomy
  Refer out troublesome ones

Do not grid non superficial corneal ulcers e.g. stromal ulcers
NEVER GRID A CAT. Get seqestra





Image








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2899. INTERN RI. A dwarf hamster has 2 very itchy red elbows and knees

July 30, 2016

ELBOW AND HOCK JOINT FOLD INFLAMED

AND ITCHY

Uncommon case. I saw around 3 in the past 10 years. I got this case videoed.

Elbows and knee joint skin inflamed and very itchy. 2 months. -  Cause is likely allergic reaction.

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OLD IMAGES FOR REFERENCE

Consultation at Toa Payoh Vets with Dr Daniel
You can see elbows prominently inflamed and swollen. 
However, hock joints are inflamed and starting to swell.
Allergy suspected, but there is no allergy testing for hamsters

Clipping bald for ease of cleaning of skin of joints
Need anaesthesia to prevent accidental clipping of skin
but anaesthesia is high risk
hamster is 1.5 years old and 55 g. 

2898. A Jack Russell has lymphoma

July 28, 2016

Referrals are very important to a doctor. I thank this groomer for referring this case to me. The Jack Russell has large lymph nodes under his jaws, in front of his shoulders and back of his hind knees. This could be lymphoma or inflammatory.

A popliteal lymph node is excised and sent to the laboratory in the US for analysis. This takes around a week.

X-rays shows enlarged spleen which could be palpated as a lump of 10 cm across in the lower abdomen.

Blood test by Vet 1 showed increase in liver enzymes.

"This case is detected early," I said. "The blood values are normal except for the liver enzymes which are twice as high."

The owner will wait one week for the lab result. This dog meant a lot to him as he sought a second opinion from his trusted groomer,

2897. A Shar-pei has acquired entropion

Jul 30, 2016

I have not seen a Sharpei for many years as they are rare in Singapore. There are around 80 vet practices and so the chances of seeing a Sharpei patient are much slimmer.  So I was surprised when a Sharpei showed up.

"I want a second opinion," the gentleman with 3 Sharpeis did not want any blood test to screen the health of the dog. "I will speak to my family members regarding surgery and let you know if we want surgery."

This patient has eyelids closed and he had consulted a vet earlier. His friend had surfed the internet and he came to Toa Payoh Vets.

"Your Sharpei has acquired entropion of both upper and lower eyelids in both eyes," I said. "His eyes were normal when he was young. Hence the entropion is 'acquired.'" 

Social media can bring in new clients if the surfer is convinced that the vet can do the job. 

2986. A new successful Medial Patella Luxation surgery by Dr Kochi fujii

July 30, 2016

I read the below from a blog. 

 http://vetexchange.nobivac.com/blog.aspx

TOKIO-TOWER, TEMPLES AND APPLES

Posted on November 13, 2014 by drroelandwessels

Every wednesday (the third day of my visit to Fujii-Vets) the clinic is closed. This gave us the opportunity to spend some time to discover the interesting Tokio-area. I’m very lucky having Dr. Kochi Fujii being my guide. He arranged an awesome program.
Dr. Fujii is a remarkable colleague. Not only is he (as British people would say) in every inch a gentleman, he’s also very innovative, open for new ideas and easy to communicate with. But above all, he’s a very intelligent and educated man. Besides DVM, he’s also a MBA and a PhD.

He developed a new, successful operation on MPL (Medial Patella Luxation). Instead of deepening the trochlea, he changed the kneejoint by taking a v-shaped piece out, turning it 180 degrees and putting it back in place. In this was the trochlear rim becomes higher, preventing the patella luxating. He came up with the idea while cutting an apple. He cutted out a v-shape piece, turned it half and placed it back. Eureka! Maybe Koichi is de next person becoming famous due to an apple, after Isaac Newton, Robin Hood and Steve Jobs

2985. INTERN RI. Diagnosis of leptospirosis in dogs

Singaporean scenes - condos, people charity fund-raising
Dog parks, dog care facilities with swimming pool, boarding kennels, rivers, parks,

stagnant waters, pools, URINE, wildlife, rodents, infected dogs, bats

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SNAP LEPTO TEST

ZOONOSIS

NOTIFIABLE DISEASE
procedures to AVA

1. Isolation kennel/Quarantine

2. Collect blood, urine

3. Dog has died

    Cremation
    Hygiene

OTHER TESTS

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July 29, 2016

EMAIL REPLY TO AN AUSTRALIAN EXPATRIATE
1. Prozac or Lovan 20 - for your dog's nervousness. Did you find them effective?

2. Elbow sores in your Golden Retrievers (large breed) are very common.  . The challenge is to prevent daily licking of the elbows which may become an obsession in many big breeds. The elbows become infected and more itchy and then black pigmented.

One way is daily cleaning and drying and applying moisturer. Also to wear an "elbow guard" to prevent further licking or contact with floor.

Or wear e-collar for few weeks of anti-inflam medication while the skin heals and hairs regrow. This is possible if the sore has not become thickened like crocodile skin.  This is easier said than done as many dog owners in Singapore  lead hectic lives or have too many distractions in life to monitor their beloved dog daily. 


3. I don't know about your Australian vet's vaccination concept or whether he had given lepto vaccine. For Singapore, we use combined vaccines including 4 serotypes of Lepto and we advise yearly vaccination, not 3-yearly, individual vaccines as in Australia.

Singapore does not import individual vaccines e.g. Lepto only as it is too expensive. The Singapore Government needs justification and then imposes a hefty registration fee for every drug or equipment imported and many suppliers just cannot cope with these fees to import vaccines.  

2984. INTERN RI - A repeat X-ray shows lung tumours have compressed the windpipe of the coughing Schnauzer

Tuesday July 26, 2016


This 15-year-old male Miniature Schnauzer was adopted as a 3-year-old and was much loved as evident by the couple seeking a second opinion at Toa Payoh Vets and following up with us to resolve the daily coughing.

"He did cough up blood 2 months ago. A dry hacking cough. I thought it was kennel cough and brought to Vet 1.  Vet 1 did X-rays and said that there could be lung tumours. He proposed $4,500 to do surgery."

So, the couple came to Toa Payoh Vets for a second opinion as they were not convinced of Vet 1's diagnosis of possible lung tumours.

"The dog must have something inside his throat," the husband said yesterday as the dog came in collapsed and coughing. He was warded in a veterinary surgery with 24-hour nursing care overnight and brought back to Toa Payoh Vets today by me.

My vet proposed a broncho-scope to see inside the windpipe and a referred vet quoted $1,600 for the procedure.

"Are there lung tumours on not?" I asked as Vet 1 seemed to have said that lung tumours were present but the owner was not sure. I asked for the veterinary report from Vet 1 but the wife showed me the X ray images on her mobile phone.

X RAYS BY VET 1 AT THE ONSET OF COUGHING
As the white opaque mass on the left upper quadrant of the chest could not be determined to be lung cancer or note, Vet 1 proposed scan which would cost around $800 and referred to Vet 2 for the scanning. Vet 2 said scoping the lungs and MRI scan would cost $4,000 - $5,000.

So the couple googled "vets" and chose Toa Payoh Vets for a second opinion. 

In late July, the dog's condition worsened. He coughed badly at night on July 25, 2016 and came to Toa Payoh Vets. My vet advised scope to check on "something in the throat" as suggested by the owner.


"It may be lung cancer. It is better and cheaper to get another X-ray done since the one done by Vet 1 was 2 months ago," I advised. The couple agreed and I got the dog X-rays done. Scoping would cost $1,600 from another vet.

The X-rays showed massive lung tumours and pushing up of the windpipe and narrowing of the windpipe.

"More coughing and lack of oxygen in the blood causing cyanotic tongue yesterday indicate that the lung tumours have badly affected this dog compared to 2 months ago,"  I could see the couples' smartphone video shown to me. The dog was not coughing, ate like a horse and was normal lifting is leg to pee in this video taken by the wife in May 2016.  So, that was the reason the couple did not think that the dog had lung tumours.

The repeat X-rays shows the progress of the lung tumours. "It is likely lung cancer since the dog got much worse in the last 2 weeks, could not breathe well due to lack of oxygen in the red blood cells causing cyanotic tongue and nearly died from collapse yesterday. There is the windpipe being pushed upwards by the tumour in front of the heart as seen on the lateral X-ray."

"Is there a cure?" the couple asked.
"No permanent cure even with chemotherapy."
"With chemo, the dog will have a poor quality of life," the wife said. "How long will the dog live?"
"I can't say. Maybe 2 weeks. He had fits and probably metastasis to the brain causing minor strokes yesterday. I had given anti-fit IV for the past 2 nights and the fits were controlled.  However the dog could not stand up and be normal."

July 27, 2016. Dog had seizures at night. Sent to emergency clinic. Decided that it was humane not to let him suffer more by undergoing ozone therapy as suggested by the vet. Euthanasia was the last resort and kindest to the beloved companion of 12 years.  He lived to a ripe old age of 15 years without skin and ear diseases and urinary stones which affect many Schnauzers in Singapore. 




Veterinary investigations like MRI scans can amount to over $5,000 and this is expensive for most owners.


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12 years ago, found on void deck. Abandoned likely. Very thin. Very hungry and shaggy.
Nobody responded to advert on void deck to claim the dog
Sent to grooming
Still no response to advert.
Adopted.
No illness for the past 12 years till coughing in July 2016 and sent to Vet 1.




The owner brought the dog back to decide what to do. The dog had seizures again.  He was sent to the emergency clinic for hospitalisation.