Dry eye

Re: Dry eye

Anthony Dennison — Fri, 04 Apr 2014 15:00:22 GMT

Sorry Robert, you're right. The article was well written and did seem very positive on it (of course, it's an advert). My girlfriend came back with a huge amount of ophthalmology info from BSAVA yesterday, and it has opened my eyes (if you'll pardon the pun) to ulcer treatment.

Re: Dry eye

grumpyoldman — Thu, 03 Apr 2014 22:34:24 GMT

[quote user="Evelyn Barbour-Hill"]

What's the fashionable view of parotid duct transposition these days?

[/quote]

I have done 2-3 per year and as long as you get a 4-0 nylon in the duct before you start its relatively easy, but its also worth flushing out the NLS with a cannula and a nettleships dilator before you start , and do not leave too much tension in the transplanted duct . Also do one side at a time or have a break or a coffee between sides as it is quite a fiddly dissection better with a good light and a 4.5x loupe. Better to test the duct patency and functionality with some injectable Atropine

I do them on those none sojgrens syndrome neurogenic cases where optimmune and 2% both fail or Bulldogs when someones butchered their cherry eyes. Do not put maxitrol in them any short term improvement will be lost by accelorated melanosis and keratitis.

Re: Dry eye

ChrisBVSc — Thu, 03 Apr 2014 21:54:44 GMT

Hi Robert, interesting to see a specialist view on the 'magic drops'! I did get the impression from the article that he was still emphasising the need to search for & treat any underlying causes of an ulcer, but that the hyaluronic acid drops may 'speed up' the healing process more effectively than other lubricants - which surely can't be a bad thing? I'd be tempted to try it in a case that was progressing slowly (after looking for underlying causes etc). Going back to the original thread on KCS I can definitely think of a case where I may at least try these drops to see if they're more effective - no response to Optimmune, reacts badly to more concentrated ciclosporin (formulated by referral centre), owner refuses surgery or tacrolimus due to bad experience with drops so far, currently managing with regular lubricants.

Re: Dry eye

Robert Lowe — Thu, 03 Apr 2014 18:14:20 GMT

[quote user="Anthony Dennison"]

I read that article - 'David's Magic Drops'! The stromal ulcer treatment sounds amazing.

[/quote]

Oh Lordy. Perhaps I feel compelled to pen a reply because I am just about to go into theatre to repair a ruptured ulcer. Perhaps DW himself peruses these boards and can offer a reply to what I am about to offer.

If a stromal ulcer is not healing then there is a secondary problem. This might be dry eye, entropion, calcium keratopathy to name a random selection. Giving tear replacements helps. Funnily enough hyaluronic acid is a tear replacement so amazingly the ulcers have improved and it also seems to help for dry eyes. Blow me over with a feather. Treat the underlying issues and no mid-depth sterile stromal ulcer should need surgery.

Writing a article in the veterinary literature that claims "magic" properties borders on the highly irresponsible at best. Using some statistics on a n=2 "case series" is appalling.

Advising treatment with magic drops without describing how you might want to assess for underlying issues is beyond my comprehension.

I really despair at the thought this and I pity any undergraduate who comes out with the impression that this is ophthalmology at its best.

Re: Dry eye

Anthony Dennison — Thu, 03 Apr 2014 15:32:37 GMT

I read that article - 'David's Magic Drops'! The stromal ulcer treatment sounds amazing.

Re: Dry eye

ChrisBVSc — Thu, 03 Apr 2014 14:16:39 GMT

There's a new drop coming out (Bayer I think) which is supposed to be a good lubricant for dry eye - recently read a David Williams article about it & there's an advert for it in the Vet Times today. Looks like they're doing one for dry eye & one for ulcers that sounds quite promising.

Here's the article: http://www.veterinary-practice.com/issues/2014/02/vp_02_2014_ulcers.pdf

Re: Dry eye

Rob Loxley — Wed, 02 Apr 2014 23:40:21 GMT

[quote user="Charlotte Lusted"]making a stronger solution of 2% cyclosporine[/quote]

Most 'recipes' are for Neoral and corn oil

[quote user="Charlotte Lusted"]tacrolimus... ...what are the contraindications as BSAVA manual doesn't have a huge amount of information in it?[/quote]

on a practical note, as far as I'm aware the only source of proper, ophthalmic tacrolimus is from South Africa and the shipping makes one or two bottles massively expensive, in fact it was cheaper to refer the dog I had to the AHT who import it in bulk. otherwise you're applying protopic cream to the eye

Re: Dry eye

Charlie Lyon — Wed, 02 Apr 2014 15:27:35 GMT

Know this post is a few months old but I have a further question - have a 5y English Bull Terrier that was diagnosed with KCS in September last year, initially good response to optimmune bid but now tear production is getting worse and clinical signs are reappearing. No real reponse to maxitrol in the past but haven't tried pred forte.

How does one go about making a stronger solution of 2% cyclosporine - not something we've ever done here?

Tacrolimus seems to be another option - what are the contraindications as BSAVA manual doesn't have a huge amount of information in it? This dog has been started on apoquel for the past 3 weeks for allergic skin disease as well, will that matter?

Re: Dry eye

Yantha Smyth — Sun, 22 Dec 2013 08:23:13 GMT

I was at a CPD on ophthalmology last year with Rick Sanchez, and he recommended 'celluvisc' 1% for ongoing lubrication. I also got a couple of samples of 'optixcare' eye-lube + hyaluron when at the London vet show, and this has proved very popular with clients and in-house for use under GA.

Re: Dry eye

Ceri Gruffudd Jones — Sat, 21 Dec 2013 16:07:41 GMT

I work with a Cert VOphthalm who quite often feels optimmune is great for a couple of years then seems to stop working. So long as fluorescein -ve we often use pred forte qid with lacrilube at bedtime. Personally (contact lens wearer with dry eyes) I find carbomer gel preps provide longer moisturising action than hypromellose. Boss still does the odd PDT as well.

Re: Dry eye

Rob Loxley — Thu, 19 Dec 2013 22:50:51 GMT

[quote user="bob lehner"]know what the differences are[/quote]

My understanding is that hypromellose doesn't last long at all, viscotears ideally needs to be done at least QID, and lacrilube lasts longer still but significantly blurs the vision hence the suggestion to use last thing at night.

However none are really a substitute in true KCS cases for specific treatment e.g. ciclosporin

And my understanding that PDT is really a last resort - given we have good medical therapies and given the potential for complications as saliva is a relatively poor substitute for tears (though most of our current 'lubricants' are lacking also)

Re: Dry eye

Dinu Catilina — Thu, 19 Dec 2013 18:31:27 GMT

Just some questions about Protopic. Even though I saw great results in dogs that were non responsive to Optimmune I don't feel comfortable when I prescribe it. I have checked for some evidence for it's use and all I could find was some articles in which the solution has been used but not the ointment. Even more, on the tube is written: do not use in eyes. As some dogs with dry eye will end up developing eye ulcers regardless the treatment used, what if an owner will complain that the treatment has caused the problem? Can I defend myself if DC will question my treatment?

Re: Dry eye

Gillian Mostyn — Thu, 19 Dec 2013 15:50:33 GMT

[quote user="bob lehner"]I was chatting yesterday to a client about her little dog with dry eye - she was buying artificial tears from the chemists (cheaper) and asked me which was the best. I had to confess that I was not sure - all are human products - most vets stock a range - viscotears, lacrilube, hyporomellose etc. Does any clever person out there know what the differences are and which might be considered the best for our cases ?[/quote]

My Gandma is on permanent eye lubricants (corneal transplant and recurrent ulcers) and she is on carbomer gel (generic), of which the only one in your list is viscotears. It seems to be quite long-lasting. I don't know whether generic 'carbomer gel' is available over the counter, as a cheaper option.

Re: Dry eye

Martin Atkinson — Thu, 19 Dec 2013 15:34:27 GMT

[quote user="Evelyn Barbour-Hill"]

What's the fashionable view of parotid duct transposition these days?

[/quote] I used to perform them quite confidently but like aural resections I've not had to do one for years because of responsible and effective maintenance treatment, The one dog that came close and/or the owner was threatening to have it euthanased relatively recently is doing very well on Protopic. I would happily do one if the there was no other choice but it would be last resort.

Re: Dry eye

bob lehner — Thu, 19 Dec 2013 15:18:58 GMT

[quote user="robloxley"]Also worth considering lacrilube at night over viscotears.[/quote]

I was chatting yesterday to a client about her little dog with dry eye - she was buying artificial tears from the chemists (cheaper) and asked me which was the best. I had to confess that I was not sure - all are human products - most vets stock a range - viscotears, lacrilube, hyporomellose etc. Does any clever person out there know what the differences are and which might be considered the best for our cases ?

Re: Dry eye

Andrew Kent — Thu, 19 Dec 2013 11:13:07 GMT

[quote user="karen jones"]Today's discussion has been on whether atopic a would help a large gsd with dry eye who hasn't responded to opt immune probably because the owner is having problem applying it ! Has any one tried it or think it might help?

[/quote]

Hi Karen,

Our ophthalmologist performed a (currently unpublished) study looking at oral cyclosporine for KCS and found it was just as effective in these dogs as a standard dose of topical cyclosporine. So if you have a dog that won't tolerate topicals oral is another option (and if you have a dog that is on oral for another reason you wouldn't need topicals). It hasn't been compared to higher concentration cyclosporine or tacrolimus etc.

Andy

Re: Dry eye

Bob Russell — Thu, 19 Dec 2013 10:19:18 GMT

Our last poorly responsive dry eye dog is doing really well on Protopic. Stronger cyclosporin was no more effective than Optimmune. O loves the cost because she keeps the tube going for months!

Re: Dry eye

Evelyn Barbour-Hill — Thu, 19 Dec 2013 01:55:13 GMT

What's the fashionable view of parotid duct transposition these days?

Re: Dry eye

Rob Loxley — Wed, 18 Dec 2013 19:43:13 GMT

[quote user="Laurence Webb"]It is not that cheap to buy but as a tube lasts months (assuming owner's don't discard it after 28d) then it works out as very economical over time[/quote]

Much cheaper than importing the ophthalmic stuff yourself from South Africa. However I'd go for stronger 2% cyclosporin 1st. Also worth considering lacrilube at night over viscotears.

Re: Dry eye

Hannah Wynne Richards — Wed, 18 Dec 2013 19:04:44 GMT

Oops Didn't read the OP properly. Try increasing the viscotears to qid.

Wynne

Re: Dry eye

karen jones — Wed, 18 Dec 2013 18:24:02 GMT

Today's discussion has been on whether atopic a would help a large gsd with dry eye who hasn't responded to opt immune probably because the owner is having problem applying it ! Has any one tried it or think it might help?

Re: Dry eye

Martin Atkinson — Wed, 18 Dec 2013 18:13:15 GMT

Lawrence beat me to it (well I have to work occasionally)! +1 for Protopic,, client applies a tiny dot into the lower conjunctival sac with a cotton bud, it has saved the eyes of a dog which otherwise would be blind. The down side is that it is intermittently available from the wholesaler so last time we had to write a prescription. I cannot comment on whether or not you should recommend the client discards it after 28 days but just say I don't have to supply it very often!!

Re: Dry eye

Laurence Webb — Wed, 18 Dec 2013 17:58:36 GMT

Protopic (tactolimus)? It's a skin ointment with a warning not to aply it to the eyes, which always takes some explaining. It is also a pretty potent immunosupppressive so owners need to be careful about self administration but i have had it work in a couple of cases when Optimmune hasn't .

It is not that cheap to buy but as a tube lasts months (assuming owner's don't discard it after 28d) then it works out as very economical over time.

Re: Dry eye

Mark Holmes — Wed, 18 Dec 2013 17:54:35 GMT

To be honest if they are fl-ve I find maxitrol works wonders.

Re: Dry eye

John Flynn — Wed, 18 Dec 2013 17:41:31 GMT

Make up a stronger ciclosporin solution and use that instead - will also be cheaper than opptimune, so client will like you, but NB is carcinogenic, so little care in preparation...

Failing that for few weeks, tacrolimus?