Packing eye after enucleation

RE: Packing eye after enucleation

Anthony Todd — Thu, 26 Jul 2018 15:08:53 GMT

[quote user="Mark Hedberg"]True, and because they're overtight, they cause discomfort, making it MORE likely the patient will interfere with them![/quote]

Nah, it's an "infection" from licking, nothing to do with over tight sutures......... Buster collar stops the infection...... [even Noel uses them]

BTW, how many these days send C/Ss home with a collar?

RE: Packing eye after enucleation

Mark Hedberg — Thu, 26 Jul 2018 12:52:35 GMT

[quote user="Martin Atkinson"]

My pet hate is people who over-tighten the sutures and cut them so short there's nothing to hold on to in the mistaken belief the animal will be less likely to interfere with them, especially when the wound is in a inaccessible place in a wriggly or aggressive animal. Surely they must take them out themselves sometimes and realise how difficult it is.

[/quote]

True, and because they're overtight, they cause discomfort, making it MORE likely the patient will interfere with them!

RE: Packing eye after enucleation

Nicola Cole — Thu, 26 Jul 2018 12:42:57 GMT

My least favourite is nylon horizontal mattress sutures that have been placed too tightly. You don’t even have something going over the surgical site to try and nip!

RE: Packing eye after enucleation

Evelyn Barbour-Hill — Thu, 26 Jul 2018 11:55:11 GMT

[quote user="Martin Atkinson"]

[/quote]

It's rare I don't take out my own sutures. Why wouldn't you? No particular difficulty and no-one can claim that the eye site is inaccessible.

Over-tightening is a crime, but I cut them what some people it seems would think pretty short. I hate to see great clumsy sutures with long waggly ends; university surgeons are particular offenders. They look awful and they can irritate (the sutures, not the surgeons. Though come to think of it....)

Many troubles with skin sutures come from using the wrong gauge of material. 5/0 is plenty thick enough for an eye removal site. 6/0 would be good in a cat.

What's wrong with nylon sutures for dog castrations?

RE: Packing eye after enucleation

Martin Atkinson — Thu, 26 Jul 2018 11:25:13 GMT

RE: Packing eye after enucleation

Robin Grimmer — Thu, 26 Jul 2018 10:57:38 GMT

I don't have any problem removing these sutures but one of my pet hates is vets that put nylon sutures in dog castrations!

RE: Packing eye after enucleation

Martin Atkinson — Thu, 26 Jul 2018 10:03:51 GMT

[quote user="David Mills"]Vets using skin sutures in these should be shot (unless they take them out themselves, Esp cats). [/quote]I use Vicryl Rapide.

[quote user="David Mills"]My worry with Atkos technique is it is fiddly and leaving conjunctiva behind can produce a discharging sinus. I can't see the advantage for what is a 10 minute op. [/quote]Its not any more fiddly. The advantage is, as said twice already, that the haemorrhage is greatly reduced as most comes from the bodies of the orbital muscles and I'm transecting these as they attach to the globe as tendons so at that point they have very little blood supply.

I remove much of the conjunctiva so I don't leave much in - I guess whats left is the orbital sac, just enough to be able to suture it closed to leave some natural packing.

The only time I've had a discharging sinus is when I've not dissected out the puncta of the nasolacrimal duct aggressively enough.

RE: Packing eye after enucleation

Evelyn Barbour-Hill — Thu, 26 Jul 2018 01:02:06 GMT

[quote user="David Mills"] Vets using skin sutures in these should be shot (unless they take them out themselves, Esp cats). [/quote]

You have trouble removing skin sutures? P'raps you need some better suture scissors?

RE: Packing eye after enucleation

David Mills — Wed, 25 Jul 2018 20:58:05 GMT

We do a lot, still transpalpebral, have never seen packed except in cattle (rolled bandage across the front so not really packing). Don't use lysosopt, digital pressure with adrenaline soaked swab always stops them, helps if you've got an alpha 2 (never acp!) on board. You need a bit of ooze to heal it via organising clot anyway. One sq layer and intradermals. Vets using skin sutures in these should be shot (unless they take them out themselves, Esp cats).

My worry with Atkos technique is it is fiddly and leaving conjunctiva behind can produce a discharging sinus. I can't see the advantage for what is a 10 minute op.

RE: Packing eye after enucleation

Robin Grimmer — Wed, 25 Jul 2018 18:38:54 GMT

I guess the technique I described closing the orbital sac also stops the eye sinking back too.

Though I do it mainly to stop or limit any haemorrhage. Definitely since I've been doing it that way they do much better post op - very little swelling or bruising etc.

RE: Packing eye after enucleation

Anthony Todd — Wed, 25 Jul 2018 15:13:08 GMT

[quote user="Robin Grimmer"]As I said earlier, I close orbital sac with pds as described in the bsasva manual. It's quite hard to do as at first it seems the socket will never close, but eventually it comes together. [/quote]

Why do you "bother" then, [wish I'd known how yonks ago].....??

I'll bet comparative pictures of my sunken and your smooth give the answer.

RE: Packing eye after enucleation

Evelyn Barbour-Hill — Wed, 25 Jul 2018 14:43:45 GMT

Agreed. I've always done this (with catgut or Vicryl, too).

[quote user="Robin Grimmer"]I don't know why some people get so bothered about the socket sinking in, doesn't bother the animal.[/quote]

No, but it is a bit unsightly to some owners, and if you can avoid it without special measures, why not?

I like to put one or even two pieces of Lyostypt in.Not as a haemostatic measure, but to ensure the orbit is filled nicely with a healthy blood clot (HBC). The HBC is essential to good healing as it goes through the classic process of organisation and eventually turns into solid collagen. The analogies are not exact, but there are parallels here to tooth extraction or digit amputation.

RE: Packing eye after enucleation

Martin Atkinson — Wed, 25 Jul 2018 08:42:10 GMT

[quote user="Anthony Todd"]

I never packed as I hoped [with no success] that it would organise and prevent the sunken socket that every one I've ever seen has!

Have modvets found a way of avoiding that? I tried sort of "closing" the socket. tightening the skin with surrounding tissue etc. but nothing helped me.

[/quote]

The essence of this lies in the technique. Like you probably Anthony I was taught (or at least learned) to sew the eye closed then dissect out the eyelids, conjunctiva/orbital sac and globe all in one unit. As said, I now dissect sub-conjunctivally very close to the globe which not only results in much less haemorrhage, as most bleeding is from the muscles and the tendons of insertion are relatively avascular, but leaves a lot of conjunctiva/orbital sac to close and at least partly fill the socket. The eyelids are then dissected out and the hole closed. There is much less sinking this way.

RE: Packing eye after enucleation

Robin Grimmer — Wed, 25 Jul 2018 06:55:11 GMT

As I said earlier, I close orbital sac with pds as described in the bsasva manual. It's quite hard to do as at first it seems the socket will never close, but eventually it comes together. I don't know why some people get so bothered about the socket sinking in, doesn't bother the animal.

RE: Packing eye after enucleation

Anthony Todd — Wed, 25 Jul 2018 00:15:36 GMT

I never packed as I hoped [with no success] that it would organise and prevent the sunken socket that every one I've ever seen has!

Have modvets found a way of avoiding that? I tried sort of "closing" the socket. tightening the skin with surrounding tissue etc. but nothing helped me.

RE: Packing eye after enucleation

Mark Hedberg — Mon, 23 Jul 2018 19:22:24 GMT

[quote user="Niall Taylor"]

I did once correspond with a vet who used to go to the local toy shop, buy a kid's glass marble, autoclave it and bung that in the socket - mad!

Niall

[/quote]

Still hot, used as cautery????

RE: Packing eye after enucleation

Robin Grimmer — Mon, 23 Jul 2018 13:32:03 GMT

[quote user="Anthony Dennison"]

I usually put a bit of lyostypt in to limit any oozing or bleeding.

[/quote]

Exactly what I do!

RE: Packing eye after enucleation

Anthony Dennison — Mon, 23 Jul 2018 09:18:06 GMT

I usually put a bit of lyostypt in to limit any oozing or bleeding.

RE: Packing eye after enucleation

Evelyn Barbour-Hill — Sun, 22 Jul 2018 17:04:02 GMT

[quote user="Niall Taylor"]I think that was the rationale but having done one that way it is pretty clear it's actually an excellent way of maximising the chance of infection. The bandage becomes soaked in blood which after a day or so becomes a disgusting smelly mass which directly connects the exterior to the empty socket offering a nice route in for any bacteria in the vicinity.[/quote]

Yeah, but that was why you had to pull a bit out each day.

[quote user="Niall Taylor"] I've a feeling it was a hangover from the highly and needlessly interventionist practices of yore, when it was beneath the dignity of a surgeon or medic to admit the best thing to do was to leave something alone.[/quote]

Depends what you mean by "of yore" of course.... Remember children asking "What was it like in the Olden Days, Grandpa?"

I think probably in all ages there have been private practitioners who felt that some of the more extreme orthodoxies were pointless and harmful, but they dared not disagree openly with the professors, still less with the owners (hmm, some things never change....) Certainly, Mayhew tells us that some practitioners would only pretend to bleed a horse: you send the groom off for a bucket of hot water and some clean soap (he'll have to go to the kitchen for that); while he's away you make a superficial scratch in the appropriate spot, and when he comes back you are putting in the proper figure of eight suture. "All done, Joe. I had to tip the blood on the midden straight away. Remember to keep his head tied up for a day".

RE: Packing eye after enucleation

grumpyoldman — Sat, 21 Jul 2018 20:04:57 GMT

depends whether its a dog or cat , and whether its just an enucleation or extenuation , whether there is retrobulbar pathology etc . Generally I avoid using anything at all to pack the orbit , tend to find that with a sub tenons block it hardly ever bleeds and if it does it stops with 5 minutes digital pressure. Its an easier dissection in a swollen globe with a 0.2 ml aqueo-centesis and vitreocentesis pre operatively , it doesn't affect the path report and gets rid of BP fluctuations from the OC reflex.

RE: Packing eye after enucleation

Niall Taylor — Sat, 21 Jul 2018 12:46:04 GMT

[quote user="Evelyn Barbour-Hill"]... it was common – normal – practice 50 years ago. I think it came from the days when asepsis was probably not too good and there were fewer antibacterial drugs.[/quote]

I think that was the rationale but having done one that way it is pretty clear it's actually an excellent way of maximising the chance of infection. The bandage becomes soaked in blood which after a day or so becomes a disgusting smelly mass which directly connects the exterior to the empty socket offering a nice route in for any bacteria in the vicinity. I've a feeling it was a hangover from the highly and needlessly interventionist practices of yore, when it was beneath the dignity of a surgeon or medic to admit the best thing to do was to leave something alone. We were actually taught about firing and bleeding too , but from the perspective that some people did it but it wasn't to be advised.

Niall

RE: Packing eye after enucleation

Evelyn Barbour-Hill — Sat, 21 Jul 2018 12:17:45 GMT

[quote user="Niall Taylor"]We were taught to pack a sterile bandage into the eye socket then draw it out gradually over a period of days post op.[/quote]

We weren't taught that, 'cos we weren't taught anything about eye removal, but it was common – normal – practice 50 years ago. I think it came from the days when asepsis was probably not too good and there were fewer antibacterial drugs. And then people just went on doing it.

RE: Packing eye after enucleation

Rob Davis — Sat, 21 Jul 2018 11:50:36 GMT

[quote user="Niall Taylor"]

[quote user="Rob Davis"]I remember seeing this in a horse when seeing practice as a student long ago... it was not pleasant drawing it out, and I have never used anything to pack them.[/quote]

Interesting to hear that - it's one of these things that seems so bizarre and inappropriate I occasionally wonder whether I had mis-remembered what we were taught!

Niall

[/quote]

I was asked to pull the packing out, and having never seen this before, I pulled it all out and got in trouble with the nurse who panicked that I'd done untold damage.... Must have been around 1995

RE: Packing eye after enucleation

Niall Taylor — Sat, 21 Jul 2018 11:39:25 GMT

[quote user="Rob Davis"]I remember seeing this in a horse when seeing practice as a student long ago... it was not pleasant drawing it out, and I have never used anything to pack them.[/quote]

Interesting to hear that - it's one of these things that seems so bizarre and inappropriate I occasionally wonder whether I had mis-remembered what we were taught!

Niall

RE: Packing eye after enucleation

Rob Davis — Sat, 21 Jul 2018 11:36:28 GMT

[quote user="Niall Taylor"]We were taught to pack a sterile bandage into the eye socket then draw it out gradually over a period of days post op. What ancient lunatic came up with that one I will never know but needless to say after doing the first one that way and seeing how distressing the 'pulling out' process was I abandoned it in favour of no packing and it works fine.[/quote]

I remember seeing this in a horse when seeing practice as a student long ago... it was not pleasant drawing it out, and I have never used anything to pack them.