What alternative to Vicryl 6-0 for cherry eye repair?

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Vikki Halliday LLB — Tue, 20 Nov 2018 22:02:05 GMT

[quote user="Arlo Guthrie"]Vikki Halliday (vikvet) - was just thinking to myself that I haven't seen you round these parts for a while ... welcome back, and thank you for your recent contributions to the ophthalmology gallery.[/quote]

Thanks Arlo

Yes I have to admit I've been a little busy - you know getting my second Ophtho Cert, becoming an RCVS AP in Ophtho and setting up my own referral business, that I had almost forgotten the joy of verbosity in clinical forums on here.

Yes, I agree I'm not too keen on being called arrogant, and had I more time I would also have gone into detail about what I thought was the arrogancy ( if that is allowed) of Mr Mills post which suggested that my clinical experience lacked substance next to a very narrow study on the subject by my colleague David Williams. David Williams is the first to generally agree he also likes to provoke a bit of controversy, however in this case, he did not go so far as to convince the entire membership of BrAVO, that this was a good evidence based procedure. As i carried out a quick straw poll of the eye geeks at the BrAVO autumn conference week before last, there were some rolled eyes and unmentionable comments when I tried to find out if anyone recommended removal in their professional sphere these days.

Sadly, I have been too busy to be much bothered by someone who clearly has too much time on their hands and likes to keep people on their toes!

RE: What alternative to Vicryl 6-0 for cherry eye repair?

grumpyoldman — Fri, 16 Nov 2018 15:35:41 GMT

[quote user="Sarah Mark"]Another example here though. Annoying, isn't it?[/quote]

Very , I once did a very successful Mustarde's eyelid transfer on a WHW that had been left with keratitis epiphora and recurrent corneal ulcers after a sliding lid canthoplasty elsewhere for a tumour removal. Everything went well the patient was comfortable happy and had a normal palpebral fissure. The client however got really pissy because the grafted skin above the lid margin did not regrow any hair.

They warned me about my communication skills (not informing her that the graft may remain less hairy or bald) which was of course enough to let the bitch off without paying. C'est la vie.

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Sarah Mark — Tue, 13 Nov 2018 15:34:06 GMT

[quote user="Gillian Mostyn"]

[quote user="Sarah Mark"]After several months I received advice to improve my client communication skills![/quote]

Earlier this year Arlo Guthrie

asked for feedback on how the college was responding to complaints, as there seemed to be a standard 'you must do better next time' reply, even when there was no case to answer. He got very few replies at the time (I think people are reluctant to discuss their RCVS complaints) so it didn't seem as big a problem as I suspect it is/was.

Another example here though. Annoying, isn't it?

[/quote]I was pretty cross at the time, yes.

RE: What alternative to Vicryl 6-0 for cherry eye repair?

bob lehner — Tue, 13 Nov 2018 13:03:11 GMT

[quote user="Neil Wheadon"]

[quote user="Francisco Gomez"]Why don't you ban him for a bit? [/quote]

NO!!

I also put a comment about excision arthroplasty and I was called Mr Wheadon (I had to look around the room to see where my father was ) but David comes from a charity practice and this needs to be taken into account. Along with Grumpy Old Man, this forum badly needs vets that are quite prepared to stand up and give an honest opinion.

Best to move on folks

Neil

[/quote]

I agree - I've never met DM - but his advice on here is always very down to earth, sensible and above all based on experience in the real world as well as current science and EBM. Too bad if he ruffles a few feathers by being blunt.

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Gillian Mostyn — Tue, 13 Nov 2018 12:35:51 GMT

[quote user="Sarah Mark"]After several months I received advice to improve my client communication skills![/quote]

Earlier this year Arlo Guthrie

Another example here though. Annoying, isn't it?

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Bob Russell — Tue, 13 Nov 2018 12:11:00 GMT

Of course you did! There, there!

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Sarah Mark — Tue, 13 Nov 2018 10:09:04 GMT

After several months I received advice to improve my client communication skills!

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Clive Ansell — Tue, 13 Nov 2018 09:49:59 GMT

Our local referral centre, with a team of diplomat and rcvs specialist ophthalmologists advise against removal, unless there has been repeated replacement failure.

It would be interesting to see data relating to KCS, comparing unaffected dogs, those that have had excision and those that have had replacement surgery.

I can't help but wonder if the gland is as functional after failed and repeated surgeries?

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Clive Ansell — Tue, 13 Nov 2018 09:44:01 GMT

[quote user="Sarah Mark"]By the way, a few years ago a client put in a college complaint about me for refusing to amputate out a prolapsed gland. Fun times.[/quote]

What was the outcome?

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Sarah Mark — Tue, 13 Nov 2018 09:01:39 GMT

This is very interesting - spent some time last night reading the Sapienza paper - got a Bulldog in this morning for bilateral repair, I usually do the Morgan pocket but the last couple I've done (Bulldogs) have popped back out again, the first time I've has a failure for years then two, one after the other?! I don't have a Goss passer but I'm going to have a little look at the landmarks etc during this op and get myself a Goss for the next one. Morgan pocket today, crossing fingers these stay in.

By the way, a few years ago a client put in a college complaint about me for refusing to amputate out a prolapsed gland. Fun times.

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Francisco Gomez — Mon, 12 Nov 2018 20:15:52 GMT

[quote user="Neil Wheadon"]

I was called Mr Wheadon (I had to look around the room to see where my father was

[/quote]

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Neil Wheadon — Mon, 12 Nov 2018 20:07:22 GMT

[quote user="Francisco Gomez"]Why don't you ban him for a bit? [/quote]

NO!!

Best to move on folks

Neil

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Francisco Gomez — Mon, 12 Nov 2018 19:38:56 GMT

[quote user="Arlo Guthrie"]

You could alternatively, for example, have written:

"How do you justify telling a good proportion of the profession (including some experts...) that they are being unethical by practising a technique that has been carried out uneventfully for years, to the benefit of patients?"

That would have allowed Vikki to reply without being made to feel quite so defensive.

[/quote]

Why don't you ban him for a bit?

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Arlo Guthrie — Mon, 12 Nov 2018 18:17:09 GMT

[quote user="Vikki Halliday"]In reply to Mr Mills - no I’m not arrogant and I don’t appreciate that kind of accusation from a fellow professional.[/quote]

Vikki Halliday (vikvet) - was just thinking to myself that I haven't seen you round these parts for a while ... welcome back, and thank you for your recent contributions to the ophthalmology gallery.

[quote user="David Mills"]This must be a wind up. No one would be so arrogant, surely, to both propagate unsubstantiated dogma and tell a good proportion of the profession (including some experts...) that they are being unethical by practising a technique that has been carried out uneventfully for years, to the benefit of patients, surely? Astonishing.[/quote]

Vikki ... don't mind him.

I'm sure David Mills's remark stung. It would have stung me.

You might be surprised to know that he's actually a decent bloke in real life. But it does seem to touch a nerve when he sees what he thinks is opinion/dogma presented as fact without evidence. Sometimes his disagreement gets expressed a bit, shall we say over-enthusiastically for a forum.

I allow Mr Mill's occasional outbursts for a few reasons. Firstly, because I think we are lucky to have someone challenging stuff. Keep everyone on their toes. Secondly because I think we are lucky to have him challenging stuff: his posts are invariably thoughtful, considered, knowledgeable and add to the discussion.

David Mills. Sorry for talking about you in the third person! I do think you could have made your point equally strongly without saying you find someone's words arrogant.

The problem with that accusation is that it is such a fine line between writing: "Your words are arrogant", which might just about be OK, at a push, and the reader reading: "You are arrogant", which is an awful thing to accuse someone of. Especially a member of a caring profession.

You could alternatively, for example, have written:

That would have allowed Vikki to reply without being made to feel quite so defensive.

Hey ho ... one small consolation ... things had been so much friendlier in the forum I had started to think I was obsolete. Maybe not quite yet!

RE: What alternative to Vicryl 6-0 for cherry eye repair?

grumpyoldman — Sun, 11 Nov 2018 20:01:32 GMT

May I suggest hooking a goss passer under the ventral rectus muscle having already dissected out the gland and opened the potential space with a vertical incision rather than a horizontal one, tying the gland into the space with 4-0 PDS suture ,use 6-0 silk or monocryl to repair the conjunctiva in a continuous pattern but leave 1 knot on the palpebral surface and remove the suture in 2 weeks if its causing a problem with some local. See J Sapienza review of over 100 cases . the ventral rectus tie down gives 100% success.

You do need good magnification to do this properly if you do not have a loupe or an operating microscope it probably needs to see someone who does. The arm twisting comes from breeders and skanky clients who do not want to pay for referral and know someone who is prepared to just hack it out for not much ££.

Its one of the many bad situations in practice where trying to do the right thing for the wrong clients gets you sharted on.

33% of tear volume comes from this gland . D Williams study only followed a small number of Bulldogs for less than 6 months , lots will be lost to follow up, change hands after breeding or die of something else before they get KCS, but lots do get it.

I have also seen Iatrogenic corneal damage from Cherry eye remnants that remain abrasive and granulate with fibrosis after incomplete scissors removal.

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Rob Loxley — Sun, 11 Nov 2018 17:29:53 GMT

[quote user="Judith Archbold"]

The questioner merely asked opinions on suture material.

Why does ”The Permanently Offended Brigade” have to turn every discussion on this forum into a “ I am a better vet than you” monologue?!

[/quote]

And the thread went quiet in February and was only just resurrected, far beyond suture material

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Judith Archbold — Sun, 11 Nov 2018 14:34:40 GMT

For crying out loud people!

The questioner merely asked opinions on suture material.

Why does ”The Permanently Offended Brigade” have to turn every discussion on this forum into a “ I am a better vet than you” monologue?!

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Rob Loxley — Sun, 11 Nov 2018 12:38:49 GMT

[quote user="David Mills"]Instead what we have is dogs developing KCS years later. So what's the theory here? Because KCS is autoimmune.[/quote]

Isn't the theory that if a dog is going to go on to develop KCS, preserving as much of its tear-producing apparatus might help mitigate this?

RE: What alternative to Vicryl 6-0 for cherry eye repair?

David Mills — Sat, 10 Nov 2018 21:22:15 GMT

[quote user="Vikki Halliday"]no I’m not arrogant and I don’t appreciate that kind of accusation from a fellow professional.[/quote]

Ms Halliday, your words I found offensive and arrogant.

You said that removing the gland was less ethical than pocketing. If this was based on strong, overwhelming evidence that harm was caused by removal cf replace, or that outcome was significantly better with replacement so as to make removal obsolete and unsupportable, then you may have been justified in your ethical argument. It is clear however this does not obtain - your "evidence" is "in my opinion".

A lesser point is your assumption that those who remove glands do so not for the animals, but to placate clients, in some sort of collusion where the animal is less well off somehow. This is a wild, inaccurate assumption, and I personally find it offensive and arrogant.

The kcs following removal of the gland lacks scientific logic in terms of the pathophysiology.

If they develop a dry eye due to reduced tear production, this would

1. Happen almost straight away

2. Not be KCS.

I've never seen 1) happen following removal.

Instead what we have is dogs developing KCS years later. So what's the theory here? Because KCS is autoimmune. So somehow a mildly reduced tear volume (not withstanding some increase from other areas to compensate) causes an autoimmune condition, presumably just in the operated eye. I haven't any idea how this might happen. Further, we have nothing beyond opinion that this actually happens clinically to a greater extent in these dogs!

Blessed be the dogmatic.

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Clive Ansell — Sat, 10 Nov 2018 15:08:51 GMT

[quote user="Vikki Halliday"]Um.... Do you chop off broken legs also?[/quote]

Yes, I do sometimes.

I work in many practices in deprived areas, and referral just isn't affordable in many cases. Assuming a cast won't suffice, I will attempt simple orthopaedics, but many practices now don't have the kit. Only remaining options in those cases are amputation or pts.

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Clive Ansell — Sat, 10 Nov 2018 15:00:10 GMT

[quote user="Vikki Halliday"] What is not ethically acceptable in my opinion is the current bulldog owner preference towards use of local anaesthetic only to carry out the excision.[/quote]

What is your objection? removal of the gland, or carrying out the procedure under local ?

I always advise trying to preserve the gland where possible, but will excise if the procedure(s) has/have failed or there are costs constraints. Would only perform under full GA, not negotiable I'm afraid.

One of my regular practices deals with a lot of Bulldog and French Bulldog breeders' , and most of these arseholes clients won't pay so simple excision it is. Luckily, most of them will only see the bossman and not me.

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Vikki Halliday LLB — Sat, 10 Nov 2018 10:56:58 GMT

In reply to Mr Mills - no I’m not arrogant and I don’t appreciate that kind of accusation from a fellow professional. In the bulldogs I have seen, the numbers of animals with KCS and zero tear production is heavily biased towards those that have had a gland removed. In reply to Mr Wheadon , agreed excisional arthroplasty for femoral head fractures is fine because there isn’t really a good alternative. Perhaps I should have qualified my comment with the pout that if there exists an alternative to retain the gland, why should this not be considered ethically preferable to potentially hastening kcs by removing it? Sorry but I stand by my opinion that we should at least be trying to replace them . What is not ethically acceptable in my opinion is the current bulldog owner preference towards use of local anaesthetic only to carry out the excision.

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Beats — Fri, 09 Nov 2018 13:33:19 GMT

[quote user="David Mills"]abstract by David Williams (I think) at BSAVA in ?2015 that showed no increase in incidence of KCS in dogs that had undergone removal - it was a fairly large study with a reasonable long term follow up.[/quote]

Any more details?

David Williams current(ish) opinion can be found here:

http://www.scienceinquest.com/open-access/pdf/jcoo/canine-keratoconjunctivitis-sicca-current-concepts-in-diagnosis-and-treatment.pdf

"The aqueous later of the tear film is produced, in the dog, by the lacrimal gland and the gland of the nictitating membrane, also termed the nictitans gland. Studies removing the latter gland have suggested that around 30% of the aqueous tear production rises from the nictitans gland [7]. The general view of veterinary ophthalmologists is .that for this reason removal of the nictitans gland in cases of prolapse for instance, is strongly to be discouraged This is however based on one paper by Dr Rhea Morgan who developed the very valuable pocket technique for replacement of the gland in such cases [8]. She showed that in dogs where the gland had been removed there were a significantly higher proportion of cases of KCS seven years after surgery but not before. Years before Dr Lloyd Helper had experimentally excised nictitans glands and or lacrimal glands for dogs and shown KCS to occur only when both glands were removed.7 Subsequent studies on epithelial cell pathology following nictitans gland removal have similarly not noted substantial effects [9]. A potential confounding effect here is that breeds predisposed to nictitans gland prolapse are also predisposed to KCS. This itself is an important factor in recommending replacement of the gland. If KCS does occur having as much remaining lacrimal tissue on which cyclosporine can have its beneficial ."

with no new data of his own being mentioned.

RE: What alternative to Vicryl 6-0 for cherry eye repair?

Neil Wheadon — Fri, 09 Nov 2018 13:29:27 GMT

[quote user="Vikki Halliday"]Um.... Do you chop off broken legs also?[/quote]

Excision arthroplasty on cats

Is this not the 'perfect' comparison?

Neil

RE: What alternative to Vicryl 6-0 for cherry eye repair?

David Mills — Fri, 09 Nov 2018 12:38:59 GMT

[quote user="Vikki Halliday"]There are more ethically appropriate methods of dealing with this,[/quote]

Based on...

[quote user="Vikki Halliday"] a larger number of these do go on to develop dry eye, in my opinion[/quote]

[quote user="Vikki Halliday"]I say I think all you are doing is pandering to clients![/quote]

This must be a wind up. No one would be so arrogant, surely, to both propagate unsubstantiated dogma and tell a good proportion of the profession (including some experts...) that they are being unethical by practising a technique that has been carried out uneventfully for years, to the benefit of patients, surely? Astonishing.

To bring this round to something more sensible and befitting a professional discussion, there was an abstract by David Williams (I think) at BSAVA in ?2015 that showed no increase in incidence of KCS in dogs that had undergone removal - it was a fairly large study with a reasonable long term follow up. Other studies have shown an absolute decrease in tear production, but with no obvious clinically significant effects.