Cataract Quandary

Re: Cataract Quandary

mariette asselbergs — Tue, 29 Jul 2014 23:39:19 GMT

[quote user="Michael Woodhouse"]

I ask because we are having ongoing problems with calves born with cataracts and I discussed with an ophthalmologist lens removal and was told that the only way was to fill the eye up with some very expensive gel that killed the possibility of the procedure on economic grounds.

[/quote]

Just for what it is worth: Once I had a farm in Africa with cattle and I was given a calf that had been born with cataracts. We raised it on goat milk and although totally blind, he attached himself to one of the cows and always followed her. They went out in the forest with the rest of the herd to graze all day and you wouldn't know that he was blind. He served very well as our breeding bull (it obviously wasn't hereditary) and lived to a good old age of 14, even though his original mate died years earlier. So just as dogs, I have the impression that over time the other senses sort of take over to create an alternative image of the world, almost equivalent to vision. I know blind people sometimes describe the same.

However, I do think this takes time. So for QOL a cataract op may be a good thing for who can afford it.

Mariette

Re: Cataract Quandary

John Flynn — Tue, 29 Jul 2014 19:47:30 GMT

[quote user="Michael Woodhouse"]I ask because we are having ongoing problems with calves born with cataracts and I discussed with an ophthalmologist lens removal and was told that the only way was to fill the eye up with some very expensive gel that killed the possibility of the procedure on economic grounds.[/quote]

Could you do discission-aspiration if they're soft, congenital cataracts? (I'm asking, not suggesting)

Was the ophthalmologist suggesting an extracapsular technique? If so, as I understand it, then an air bubble to re-inflate anterior chamber works fine (as an alternative to very expensive gel)?

I have no idea whether intracapsular techniques are an effective an option in the calf or not?

Unless they're expensive calves, I guess nothing's going to be economical, but what an interesting question!

Re: Cataract Quandary

Michael Woodhouse — Mon, 28 Jul 2014 23:24:36 GMT

[quote user="Martin Atkinson"]

If the owner can't afford a referral or they are too mature for phacoemulsification anyway then lendectomy* is actually not that difficult. Its another of those things that it is easy to get scared about but in fact technically is easier than a bitch spay which we all perform daily without much of a second thought, although it is important to get an ophthalmic kit (NB these are not redundant at other times because the instruments are very useful for other micro-surgical procedures).

* Robert is much better qualified than me to tell you the technique.

[/quote]

I'm intrigued. Can one of your briefly describe the technique?

Re: Cataract Quandary

Anthony Todd — Mon, 28 Jul 2014 08:43:57 GMT

[quote user="Robert Lowe"]Hope this helps[/quote]

Rob, thanks for the considered and balanced posts.

Still a difficult decision for someone who isn't insured to make I think, particularly when the dog is "racing round the garden"....

[quote user="Robert Lowe"] I also agree that blind dogs can have a good quality of life; its just a different quality of life. [/quote]

I refer all to the title of the thread??!!??

Re: Cataract Quandary

John Ellis — Sun, 27 Jul 2014 23:16:18 GMT

As a vet, but more and as someone who has owned a dog that went blind with cataracts and subsequently had them removed (by Rob, actually - thanks!), I would definitely recommend cataract surgery. My dog had rapidly progressive cataracts secondary to PRA (she was a cocker spaniel), which were markedly impairing her vision, though she was not totally blind. Her quality of life post surgery was definitely improved, and I feel she was happier with her vision restored.

The reason I opted for cataract surgery, despite her PRA, was that the PRA was caught very early, so it was felt the benefits outweighed the fact she would eventually go blind anyway. In actual fact, her day vision was perfectly fine until the day I put her to sleep, approximately 2yrs later, due to a large forebrain tumour.

I would definitely have cataract surgery on my own dog again, and I recommend it to my clients.

John

Re: Cataract Quandary

Robert Lowe — Sun, 27 Jul 2014 22:37:42 GMT

Hi Anthony

Certainly can tell if the eye is capable of vision by assessing for retinal function (electroretinography) and position (ultrasonography). Also eyes that have immature cataract, no other ocular disease, not in a Yorkie or a Border Terrier (based on my caseload), and no predilection for glaucoma are going to be more successful.

My figures are on a per eye basis so dogs that have surgery are likely to retain vision in at least one eye. Out of 133 dogs that had surgery in 2009-2010, 5 ended up blind in both eyes at last review (mean follow up of 606 days) and 81% of eyes were visual at 2.5 years based on a Kaplan-Meier survival curve.

So the question is are visual dogs happier than non-visual dogs (assuming that surgery is only being done on dogs that will definitively loose vision (which we try to stick to)? I can't directly assess a dog's happiness. However, my opinion is that there is a significant difference in quality of life if vision is present. This is even more obvious if the dog has any hearing issues. I have very strongly opinionated owners who would bore you to death with how their dog's life has improved beyond measure since getting vision back.

The flip side is that I also agree that blind dogs can have a good quality of life; its just a different quality of life.

Hope this helps

Rob

Re: Cataract Quandary

Anthony Todd — Sat, 26 Jul 2014 00:02:00 GMT

[quote user="Robert Lowe"]Eyesight will be significantly improved if successful and in a recent abstract we presented at ECVO our data shows that 83% of eyes are visual 2 years post surgery across all cases.[/quote]

Rob, sorry, I misinterpreted, or extrapolated, your figures totally.

Would it be fair to say that the 83% of dogs that were visual were "happier", as judged by the owners, and the rest had no change in demeanour or "happiness"?

This would be a good reason to consider cataract surgery or not, depending on the answer.

Can you tell which cases are likely, or more likely to be post-op "visual" before surgery and therefore give the owner some indication of prediction?

I only persist because I have seen a few dogs that are blind and seem "happy"; certainly dogs that have lost an eye, or a leg, for that matter, seem as happy as ever.

Re: Cataract Quandary

Robert Lowe — Fri, 25 Jul 2014 22:55:28 GMT

[quote user="Anthony Todd"]What reasons did the 17% who were dissatisfied give?[/quote]

We didn't look at satisfaction we looked at vision as an objective outcome. We didn't ask a question, it was based on clinical data as a retrospective study.

If I had a dissatisfaction rate of 17% I would be mortified and probably not in business.

Not removing cataracts has its own disease implications - dogs with progressive cataract are far more likely to required enucleation if they don't have surgery compared to if they do based on the only study looking at this. They are also guaranteed to go blind.

The better outcomes are achieved if the surgery is done before the cataract is mature so even if the dog has some visual function now the option of surgery should be considered fully.

Re: Cataract Quandary

Anthony Todd — Fri, 25 Jul 2014 19:16:42 GMT

[quote user="GrooveJet"] My experience of referrals for this has been good and both client and patients have been really happy, despite the high costs. [/quote]

Ignoring the cost completely:

At the moment the dog "grabs a ball and races round the garden with the owner's two other dogs".

I am still wondering whether the "83% satisfaction" is related to the uneventful surgery and post op. rather than the actual improvement in behaviour and life for the dog.

What reasons did the 17% who were dissatisfied give?

Not having a shot at the poster but rather suggesting that, different questions can give different answers to the same question...

My experience of totally blind dogs is that, provided you don't move the furniture etc., they seem to be rather unconcerned and carry on as pretty normal, even with bumping into unfamiliar things.

Re: Cataract Quandary

Rob Loxley — Thu, 24 Jul 2014 18:23:16 GMT

On a tangent, what's the thought on just doing one eye - less cost and less risk of complications or not half as good?

Re: Cataract Quandary

Miriam Lodewyks — Thu, 24 Jul 2014 18:07:54 GMT

Whether it's "worth it" is something only the owner can decide. My experience of referrals for this has been good and both client and patients have been really happy, despite the high costs. Except perhaps for the 4-year old rabbit who had both lenses removed.... then died of unrelated issues a month later. That was sad.

Re: Cataract Quandary

Malcolm Ness — Thu, 24 Jul 2014 16:32:02 GMT

[quote user="Bob Russell"]Shop around! [/quote]

Great advice. Apparently there is a practice near Bolton that will do it for free, or at least without profit which must be nearly the same thing.

In my experience, those who know the cost of everything and the value of nothing eventually find what they are looking for.

Re: Cataract Quandary

Martin Atkinson — Thu, 24 Jul 2014 12:20:08 GMT

[quote user="Robert Lowe"]No cataract is too mature for phacoemulsification. [/quote]Interesting to know but that doesn't really address the issue in the OP which was the cost of referral so I would just encourage people to give lendectomy a go if there is not another choice as it isn't as scary as it sounds.

Re: Cataract Quandary

Robert Lowe — Thu, 24 Jul 2014 11:13:37 GMT

[quote user="Martin Atkinson"]or they are too mature for phacoemulsification[/quote]

No cataract is too mature for phacoemulsification. Modern machines (i.e. technology less than 10 years old) are more than capable of phacofragmentation of even the toughest lenses. I have never had to convert to an extra capsular procedure due to cataract density in 10 years of doing phacoemulsification. If the lens is unstable due to zonule breakdown then lendectomy by intracapsular removal may be indicated.

Re: Cataract Quandary

Bob Russell — Thu, 24 Jul 2014 10:58:22 GMT

Shop around!

Re: Cataract Quandary

Braden Collins — Thu, 24 Jul 2014 10:23:24 GMT

That's bloody pricy! In Oz (which is normally more expensive) you get both eyes done for $2500 (1500 pounds).

from what I have seen of these cases they do very well on the whole and I definitely recommend surgery. The thing I think we always have to be very conscious of is to not project our own belief of "that's a lot of money for an old dog", but rather advise on benefits/risks/downsides of surgery and allow the client to decide if they see it as value for money. That being said if I had someone I would normally refer these cases to for at a lower cost I would steer the client in that direction.

Re: Cataract Quandary

Martin Atkinson — Thu, 24 Jul 2014 10:19:55 GMT

You don't say how mature these cataracts are. If the owner can't afford a referral or they are too mature for phacoemulsification anyway then lendectomy* is actually not that difficult. Its another of those things that it is easy to get scared about but in fact technically is easier than a bitch spay which we all perform daily without much of a second thought, although it is important to get an ophthalmic kit (NB these are not redundant at other times because the instruments are very useful for other micro-surgical procedures). If you're concerned wait until the dog is blind in at least one eye then perform the surgery but do warn the owner that the risk of failure and post-operative complications is much higher than in humans due to the anatomy of the dog's eye. Quite frankly there is little to lose if the dog is blind already.

* Robert is much better qualified than me to tell you the technique.

Re: Cataract Quandary

Robert Lowe — Thu, 24 Jul 2014 09:30:44 GMT

Not going to comment specifically on the quote given (feel free to look at our website as we publish our costs for this) but we get the "well it cost me less to get my cataract done with BUPA" occasionally. Once I have pointed out that the kit costs the same, the lens replacements are maybe more expensive and there is a full GA involved as we can't do it under local even if Fluffy is very well behaved then there is usually less of a quibble about value.

It is difficult to objectively give an improved quality of life score for having cataract surgery done. I have a large thank you board and more testimonials than I know what to do with from owners who have had it done but this is all subjective.

[quote user="Anthony Todd"]the eyesight may not be significantly improved and I would be reluctant to recommend the ops as the dog is getting on a bit and therefore the time of possible benefit is shorter.[/quote]

Eyesight will be significantly improved if successful and in a recent abstract we presented at ECVO our data shows that 83% of eyes are visual 2 years post surgery across all cases. In an 11yo Bichon I would say that there is quite a lot of reward for doing the surgery but as Malcolm says this needs to be tempered with the risks of surgery in a discussion with the specialist.

Re: Cataract Quandary

Malcolm Ness — Thu, 24 Jul 2014 08:47:53 GMT

I would want to know who will be doing the surgery and then discuss options, risks, benefits and prognosis with them.

Re: Cataract Quandary

Mark Hedberg — Thu, 24 Jul 2014 08:24:23 GMT

£5000 for cataract surgery? blimey...