Non healing ulcer

RE: Non healing ulcer

Robert Lowe — Thu, 29 Nov 2018 21:59:24 GMT

[quote user="David Mills"]

More over, Rob's comment was somewhat tetchy about the speaker/'playing the man' - the speaker's bio clearly shows he has been hevaily involved with referral practice for decades, which backed up my point.

Some become defensive. I find it odd.

[/quote]

I suspect quite strongly that the speaker involved is different to the one you identified later on - https://www.londonvetshow.co.uk/speakers/david-nutbrown-hughes

If I come across as defensive then it is because there is an antispecialist undercurrent in some posters contributions. I find this odd. There is much to learn both ways.

RE: Non healing ulcer

Neil Wheadon — Thu, 29 Nov 2018 18:28:15 GMT

[quote user="Arlo Guthrie"]

[quote user="Neil Wheadon"]How about a Q and A with a referral practitioner

We pose the question, they answer it, no discussion Neil[/quote]

The only thing is that's a solution to a problem that shouldn't exist in the first place and concerns a very small number of people. And let's face it, the alternative solution, which is to ask questions politely, isn't effing rocket science!

But maybe that could work. Maybe, actually, it could tie in with the new discipline-specific groups I'm setting up.

... thinking ...

[/quote]

One of the most interesting things I read are VetCT reports, referral reports etc.

In these cases a primary practitioner has posed a problem, the expert has answered it. Some are superb. I include Robert's answer to pugs ulcers in that category

Now if we could figure a way to share these, what a library that would be

Neil

RE: Non healing ulcer

Arlo Guthrie — Thu, 29 Nov 2018 17:55:23 GMT

[quote user="David Mills"]I would expect someone in authority (or otherwise) giving an opinion (controversial or otherwise), to welcome welcome and expect questioning and discussion. Most do. Some become defensive. I find it odd.[/quote]

Mostly I think it is down to the style of writing. Most people welcome questioning and discussion when asked nicely.

But you've got me thinking. I wonder whether we can build some extra functionality to somehow differentiate between opinion and fact.

It's something I've been thinking about for a while, actually.

Something which, before you post, asks if you would like to support your argument with a published study, and if yes, allows you to add a link. Posts with links to studies are colour coded.

Ergo uncoloured posts are opinion and should be treated as such.

Or is it overkill?

The alternative is not to jump on people. In Vikki's case, in your shoes I would have said something more like: Hang on, are you saying my approach is less ethical? What evidence do you have for that? (not those precise words), which would have perhaps brought the discussion round - instead of: "pah, what arrogant thinking", which just shuts everything down.

RE: Non healing ulcer

David Mills — Thu, 29 Nov 2018 17:38:12 GMT

[quote user="Arlo Guthrie"]On the other hand, there are those people who feel that anything a referral practitioner says needs to be scrutinised and questioned to the nth degree, often in a style that can be read terribly negatively.[/quote]

I don't think this is a fair reflection of what has happened here.

[quote user="Arlo Guthrie"]Saying some referral practitioners are just self-interested (in a discussion thread to which a referral practitioner is contributing) is a pretty negative starting point. [/quote]

I never said this.

[quote user="Arlo Guthrie"]Describing Vikki Halliday's thinking as arrogant was pretty, well, horrible. [/quote]

I'm not about to go back to that, but I found it offensive that she implied, based on her and others opinion that the procedure I was talking about was somehow ethically less sound. So this is not simply disagreeing with my opinion (as it happened), but doing so it fairly strong terms, with little to back it up evidentially.

I don't expect referenced replies or pieces of advice. My argument is not with referral practitioners at all, who I greatly respect. Its more nuanced than that. It's in the transfer of knowledge and the effect of that on the recipient. Transfer of knowledge from a recognised authority is more likely to be taken at face value, and affect the recipient's doxastic attitude. Now in a lot of cases this is fine, as they are speaking sensibly.

The issue comes when the knowledge transferred is opinion, based on a skewed population, and taken at face value. That is dangerous. If one is being cynical, it may improve the referral centres fortunes (cruciates being a case in point - there was a particularly good example of this at LVS last year), but that is not my argument - it is rather that the knowledge is still opinion-based, and this opinion is based, partly to largely, on the population the practitioner sees. To suggest a lot of pugs with non-healing ulcers have dry eye is interesting, but is unsupported by the very many dogs seen in primary practice. The rather inoffensive sequel to taking that comment at face value is needless testing for dry eye (with potential financial cost to the client).

It's why I talk about responsibility. I have no truck with opinion (sometimes its all we have), as long as it is highlighted as such, and the population whence it comes is obvious. We have a responsibility to question opinions, as practitioners, on behalf of our patients (and clients). I would expect someone in authority (or otherwise) giving an opinion (controversial or otherwise), to welcome welcome and expect questioning and discussion. Most do. Some become defensive. I find it odd.

RE: Non healing ulcer

Arlo Guthrie — Thu, 29 Nov 2018 17:38:02 GMT

[quote user="Neil Wheadon"]How about a Q and A with a referral practitioner

We pose the question, they answer it, no discussion Neil[/quote]

But maybe that could work. Maybe, actually, it could tie in with the new discipline-specific groups I'm setting up.

... thinking ...

RE: Non healing ulcer

Neil Wheadon — Thu, 29 Nov 2018 17:20:31 GMT

How about a Q and A with a referral practitioner

We pose the question, they answer it, no discussion

Neil

RE: Non healing ulcer

Arlo Guthrie — Thu, 29 Nov 2018 12:10:09 GMT

[quote user="Michael Woodhouse"][quote user="David Mills"]I don't know why people (ophthalmologists?) get so defensive. Intelligent discourse requires opinions being questioned, debated and justified. To expect that people will take what you say at face value insults both parties' intelligence. It's nothing more than this.[/quote]

We have this thread and the other one recently on cherry eye removal/replacement. Both had ophthalmologists giving very strong opinions based on their feelings of how cases should be managed and not good quality evidence. I realise often that evidence is lacking, but I do feel there is an element of self interest with some referral practioners. Imagine if removing cherry eyes was as good as replacing them with your operating microscope, imagine if a nylon lateral suture was as good as a TPLO.............[/quote]

Michael Woodhouse and David Mills, we have a problem here and I wonder whether you have any suggestions for a solution.

This is the problem. On the one hand, there's me running around trying to encourage more referral practitioners to come and share their experience, in addition to those that already give so much time and useful advice.

On the other hand, there are those people who feel that anything a referral practitioner says needs to be scrutinised and questioned to the nth degree, often in a style that can be read terribly negatively.

Saying some referral practitioners are just self-interested (in a discussion thread to which a referral practitioner is contributing) is a pretty negative starting point. Describing Vikki Halliday's thinking as arrogant was pretty, well, horrible.

I do understand your view that opinions and dogma need to be challenged. But there has to be some compromise here.

One possible compromise is for you to understand that those referral practitioners who come and give an opinion don't necessarily have the time to start referencing their every last word, and just accept what they have written for what it is: an opinion you can accept or discard, or seek to verify in other ways.

Another possible compromise is for you to start discussions from a perhaps more positive standpoint than 'all referral practitioners are giving opinions driven by self-interest'. In my experience, most vets, especially referral vets, have the wellbeing of the patient at the forefront of their mind, and it is pretty obnoxious to suggest otherwise. Particularly so in an online forum devoid of the niceties of a face-to-face discussion.

Of course, sensible discourse means opinions must be challenged and questioned.

But I don't think asking you to be polite when challenging people is asking for a compromise.

On the contrary, I find a Louis Theroux style of questioning so much more interesting and illuminating than a Donald Trump.

Be less Donald and more Louis!

RE: Non healing ulcer

Martin Atkinson — Thu, 29 Nov 2018 10:26:48 GMT

[quote user="Robert Lowe"]As to self interest - you know when you get cross about clients claiming vets are just in it for the money... Most referral practitioners are out there either teaching people who come to see practice, lecturing or publishing research that improves animal welfare. If the local practices want to come in and learn how to do a conjunctival graft then I teach them. We lose cases but more animals benefit. Maybe we get a few more referrals for cataract surgery but I have no idea if this happens in reality.[/quote]@Michael Woodhouse & David Mills: I have to concur with Rob on this. Having been to one of his CPD meetings to which he traveled a long way to talk to a handful of vets he was more than generous with dispensing his knowledge and I have changed my technique in some procedures as a result of this. As a result I may refer less but if he was closer he would be my default referral option. A win win situation maybe.

RE: Non healing ulcer

Robert Lowe — Wed, 28 Nov 2018 21:56:01 GMT

[quote user="robloxley"]

[quote user="Beats"]

[quote user="Liz Barton"]

[quote user="Robert Lowe"]Debridement is for under-run poorly adherent epithelium due to anterior stomal hyalinisation.[/quote]

In this scenario would you recommend grid keratectomy or cotton bud debridement? And do you tend to do them conscious under local or use sedation? TIA

[/quote]

What about option 3 of Algerbrush? - find this really helpful, can be done under local and good success rate.

[/quote]

For cases of spontaneous chronic corneal epithelial deficit (SCCED) then the Algerbrush is my treatment of choice. They are not expensive or complicated. There is less risk of deeper stromal injury than using a needle (if you are confident in using a needle then carry on). I do them under local and conscious. I place a human contact lens (trial lenses such as the Purevision 2) as they work better in my hands than the animal ones.

Algerbrush debridement has been shown to reduce anterior stromal hyalinisation significantly thereby effectively treating the underlying pathology.

Dawson, C. , Naranjo, C. , Sanchez‐Maldonado, B. , Fricker, G. V., Linn‐Pearl, R. N., Escanilla, N. , Kafarnik, C. , Gould, D. J., Sanchez, R. F. and Matas‐Riera, M. (2017), Immediate effects of diamond burr debridement in patients with spontaneous chronic corneal epithelial defects, light and electron microscopic evaluation. Vet Ophthalmol, 20: 11-15. doi:10.1111/vop.12337

There is no data out there to suggest pugs suffer from this particular pathology more than other breeds. My subjective assessment is that they suffer from this much less than Shih Tzu's who also have other eyelid and corneal pathology as well as SCCED.

RE: Non healing ulcer

Robert Lowe — Wed, 28 Nov 2018 21:47:18 GMT

[quote user="David Mills"]

See, to me, this seems like an oversimplification. It implies there is a population of pugs etc out there walking around with quite severe ophthalmic deformities that only become a problem when ulceration occurs (due to trauma, etc) - essentially on a knife edge? There may well be. But I suspect that population is miniscule, and probably the ones that end up at referral practices.

[/quote]

They really are on a knife edge. An example of the last pug I saw - seen for back pain and started on intense opiate pain relief elsewhere. Blink response reduced as a consequence. 3 days later right eye removed for gross corneal rupture and left eye extensive grafting for a deep melt.

Ok - seen at a referral practice, so what evidence do we have of poor eyelid conformation and corneal pathology in the general population. A BVA eye scheme assessment performed on a series of pugs at a group testing - pugs that are used for breeding and according to the owners had no ocular pathology. All had a degree of medial lower eyelid entropion and corneal pigmentation medially. The challenge is not to find pathology but to find a pug with no corneal pathology.

[quote user="Michael Woodhouse"]We have this thread and the other one recently on cherry eye removal/replacement. Both had ophthalmologists giving very strong opinions based on their feelings of how cases should be managed and not good quality evidence. I realise often that evidence is lacking, but I do feel there is an element of self interest with some referral practioners.[/quote]

Not good quality evidence! Those textbooks detailing corneal epithelial migration and the publications describing anterior stomal hyalinisation must be figments of my febrile imagination. These are not feelings, this is strong opinion is based on constant literature review, having to discuss daily with residents who question every thing we do. However, I am not going to be writing a fully referenced answer on the internet.

My point is that debriding corneas that do not have SCCED / stomal hyalinisation has no evidence to show it is effective and a base understanding of epithelial cell migration shows why epithelium does come off in other types of ulcer if derided had enough.

As to self interest - you know when you get cross about clients claiming vets are just in it for the money... Most referral practitioners are out there either teaching people who come to see practice, lecturing or publishing research that improves animal welfare. If the local practices want to come in and learn how to do a conjunctival graft then I teach them. We lose cases but more animals benefit. Maybe we get a few more referrals for cataract surgery but I have no idea if this happens in reality.

RE: Non healing ulcer

Michael Woodhouse — Wed, 28 Nov 2018 14:47:14 GMT

[quote user="David Mills"]I don't know why people (ophthalmologists?) get so defensive. Intelligent discourse requires opinions being questioned, debated and justified. To expect that people will take what you say at face value insults both parties' intelligence. It's nothing more than this.[/quote]

I think there ought to be more pressure on these referral practitioners to show us first opinion vets the quality evidence for these advanced procedures. Then we can come to a sensible conclusion with our clients how we treat their pet. Not just assume that more complex and expensive is better.

RE: Non healing ulcer

Beats — Wed, 28 Nov 2018 07:27:31 GMT

[quote user="robloxley"]What about option 3 of Algerbrush? - find this really helpful, can be done under local and good success rate.[/quote]

Never tried, but have some interdental brushes that didn't fit between my teeth from the dentists that I've got autoclaved for cytology brushings in deeper ulcers should I ever feel the need.

Do you think an Algerbrush is any better than a 23G needle?

RE: Non healing ulcer

Rob Loxley — Tue, 27 Nov 2018 23:09:51 GMT

[quote user="Beats"]

[quote user="Liz Barton"]

[quote user="Robert Lowe"]Debridement is for under-run poorly adherent epithelium due to anterior stomal hyalinisation.[/quote]

In this scenario would you recommend grid keratectomy or cotton bud debridement? And do you tend to do them conscious under local or use sedation? TIA

[/quote]

What about option 3 of Algerbrush? - find this really helpful, can be done under local and good success rate.

RE: Non healing ulcer

Beats — Tue, 27 Nov 2018 19:18:26 GMT

[quote user="Liz Barton"]

[quote user="Robert Lowe"]Debridement is for under-run poorly adherent epithelium due to anterior stomal hyalinisation.[/quote]

In this scenario would you recommend grid keratectomy or cotton bud debridement? And do you tend to do them conscious under local or use sedation? TIA

[/quote]

I know this wasn't a question for me! But an easy hook to hang my opinion on FWIW :-)

I would do both cotton-bud debridement and score it with a blue 23G 5/8inch needle after putting in a bit of proxymetacaine. I am right handed and rest the edge of my hand on the dog's head above and behind and to side of eye and use the needle in my thumb and finger of that same hand to score it - if the dog's head moves, then my hand moves. Takes less than a minute (after local taken effect - I put in fluroescein and then proxymetacaine to wash it out and seems to have worked by time I trek into scrub room for pack of sterile cotton buds). I can't remember the last one I sedated, but I have on occasions - the eyeball then goes down and have to pull it up again. I get the owner to stand in the position so that the dog looks at them to reveal the ulcer especially if ventromedially and/or make clicking noises to get attention. If the dog is wiggly, I get a staff member to help hold it.

If it's not healed in a week, then do it again, more vigorously.

I'm just a general practitioner, but I'm not aware of any dogs still running around with superficial ulcers through failure. Some, once debrided, cover almost whole cornea, but even these are healed in a fortnight if not sooner.

Obviously not suitable for other types of ulcers such as deep ulcers.

If I'm not sure if necessary, give it a week and see back again - if it's a superficial ulcer and not healed then needs debrided and scored in my opinion.

RE: Non healing ulcer

David Mills — Tue, 27 Nov 2018 11:58:44 GMT

[quote user="Arlo Guthrie"]And Rob's underlying point, that your description of the lecturer as 'apparently a little distant from primary practice' was an unfair criticism, seems valid to me. [/quote]

"Following graduation from the University of Melbourne in 1988, David spent 5 years in mixed practice throughout Australia, England, Scotland, and Wales. He then completed small animal and equine internships at Colorado State University, and a research fellowship and comparative ophthalmology residency at the University of Missouri. He joined the faculty at the University of California-Davis in 2000 where he is one of 8 ophthalmologists with 4 ophthalmology residents and an ophthalmic intern in training. He is the author of Slatter’s Fundamentals of Veterinary Ophthalmology (now in its 6th edition). David’s major interests are ocular surface disease and feline herpesvirus."

It's not that clear to me...

RE: Non healing ulcer

Arlo Guthrie — Tue, 27 Nov 2018 11:47:55 GMT

[quote user="David Mills"]rather tetchy[/quote]

Ok, I'll concede that, although for me it's a very long stretch from 'rather tetchy' to the hyperbolic 'bizarre'!

And Rob's underlying point, that your description of the lecturer as 'apparently a little distant from primary practice' was an unfair criticism, seems valid to me.

RE: Non healing ulcer

David Mills — Tue, 27 Nov 2018 11:27:57 GMT

[quote user="Arlo Guthrie"]My experience of those I've met (a fair few) has been almost entirely the absolute reverse of all of that. I've found them mostly very aware of their limitations, and certainly aware that their caseload is usually skewed to the unusual. [/quote]

I agree. I am dead against referral/specialist bashing, and my experience tallies with yours.

But that is not my point. With lecturing comes a certain responsibility. People are going to listen to you, and so they should, I mean who wouldn't want to learn from a specialist? However, sometimes the message that comes across is not clear in terms of what people are trying to say, or from where that opinion is formed. And when that opinion is controversial, and imparted to primary practitioners who then come away thinking we are missing this stuff, or doing things wrong, then it becomes quite dangerous in terms of dogma generation. The responsibility goes both ways - it is the primary practitioner's responsibility to question these things (which I suspect Neil was kind of doing here) if they don't tally with their experience, and perhaps ponder why people have given that opinion (and being divorced from primary practice is one such reason that is prevalent).

The rather tetchy response to pointing this out and questioning the opinion's provenance I find somewhat bizarre.

RE: Non healing ulcer

Arlo Guthrie — Tue, 27 Nov 2018 11:16:52 GMT

[quote user="David Mills"]I don't know why people (ophthalmologists?) get so defensive. Intelligent discourse requires opinions being questioned, debated and justified. [/quote]

David Mills Oh c'mon! I don't think there's any evidence that ophthalmologists are somehow more defensive than anyone else. If that's your take home message, it needs questioning!

Two things - as a breed, referral practitioners are, in my experience, sometimes accused of being 'ivory tower', 'removed from real life in general practice', perhaps a bit arrogant or know it all.

My experience of those I've met (a fair few) has been almost entirely the absolute reverse of all of that. I've found them mostly very aware of their limitations, and certainly aware that their caseload is usually skewed to the unusual.

That's by the by. The point really is that if you find people defensive, you might as ask yourself why, and try and make them feel a bit less defensive. Not to pander. Just because I think you'll get a better reply.

[quote user="David Mills"]Intelligent discourse requires opinions being questioned, debated and justified. [/quote]

Yes, of course. Absolutely agree with you. Who could disagree? But as I always bang on about, doing so online can appear hostile, aggressive, abrupt, rude etc etc., unless you compensate for the limitations of the written word by adding a certain amount of extra politeness.

[quote user="David Mills"]Now now. [/quote]

Is it me, or does this have a whiff of patronising about it? Face to face, I would suspect not. Online, I fear the worst!

RE: Non healing ulcer

Liz Barton — Tue, 27 Nov 2018 11:02:23 GMT

[quote user="Robert Lowe"]Debridement is for under-run poorly adherent epithelium due to anterior stomal hyalinisation.[/quote]

In this scenario would you recommend grid keratectomy or cotton bud debridement? And do you tend to do them conscious under local or use sedation? TIA

RE: Non healing ulcer

David Mills — Tue, 27 Nov 2018 10:40:08 GMT

[quote user="Robert Lowe"]The non-healers in pugs are nearly all as a consequence of poor corneal tear film health, lagophthalmos, medial lower eyelid entropion with more than the occasional ectopic cilia thrown in. Ulcers tend to occur due to trauma but then all these conditions affect the healing response. Ulcers complicated by ectopic cilia can heal despite the presence of the hair and may not immediately re-ulcerate so don't assume there are no ectopics if it does heal.[/quote]

[quote user="Robert Lowe"]Also the lecturer at LVS had been in first opinion practice almost as long as I have spent as a referral clinician. If you are going to play the man at least show some effort to see who you are playing against.[/quote]

Now now.

My point is this. I wasn't there, so have no idea what he said, but the issue is that Neil has come away with the above 'message'. If this is a faithful repetition of what was said, it deserves questioning, being as it is at odds with my (and several colleagues after asking them this morning) experience in primary practice. The lecturer obviously sees referrals alongside primary cases. His caseload will be skewed towards the unusual, which, whilst interesting, cannot be mapped onto the general population - indeed to do so is illogical. If this is not what he meant, then perhaps it should have been made clearer so that the take home message was not so extreme. In a slightly more negative note, these kinds of things imply people missing things - which I don't believe to be the case.

I don't know why people (ophthalmologists?) get so defensive. Intelligent discourse requires opinions being questioned, debated and justified. To expect that people will take what you say at face value insults both parties' intelligence. It's nothing more than this.

RE: Non healing ulcer

Robert Lowe — Tue, 27 Nov 2018 00:30:53 GMT

[quote user="David Mills"]I'm loathe to say it but the lecturer appears a little distanced from the swathes of these that are treated in primary practice. [/quote]

Also the lecturer at LVS had been in first opinion practice almost as long as I have spent as a referral clinician. If you are going to play the man at least show some effort to see who you are playing against.

RE: Non healing ulcer

Robert Lowe — Tue, 27 Nov 2018 00:20:42 GMT

Debridement is for under-run poorly adherent epithelium due to anterior stomal hyalinisation. Epithelium heals by migration of the entire epithelial sheet with cell division at the limbus and NOT division at the edge of the ulcer. Unsurprisingly then ulcers tend to have less adherent epithelium adjacent to the ulcer. If it is not poorly adherent due to stromal hyalinisation then the epithelium should be left alone instead of being bashed around the head with a cotton bud.

As a rule of thumb I would never debride a pug ulcer. Pugs are vastly under-represented in the breeds that get spontaneous chronic corneal epithelial deficit (SCCED).

The non-healers in pugs are nearly all as a consequence of poor corneal tear film health, lagophthalmos, medial lower eyelid entropion with more than the occasional ectopic cilia thrown in. Ulcers tend to occur due to trauma but then all these conditions affect the healing response. Ulcers complicated by ectopic cilia can heal despite the presence of the hair and may not immediately re-ulcerate so don't assume there are no ectopics if it does heal.

Pug ulcers then go wrong because they get an exuberant healing response with too many neutrophils leading to stromal breakdown and rapid worsening and deepening of the ulcer. Treat with antibiotics based on cytology, an anti-collaganase and tear replacement. And don't worry about systemic immunosuppressives even if they are present in the tear film.

RE: Non healing ulcer

David Mills — Mon, 26 Nov 2018 23:45:10 GMT

[quote user="Neil Wheadon"]if it is still there in a week then something is causing it. [/quote]

Compliance, wrong abx, dog rubbing etc all more common I think, otherwise

1. They wouldn't heal at all (I can't remember the last one) or would get worse (deeper) despite treatment.

2. Having healed they would return sharpish.

It just seems illogical to me.

[quote user="Neil Wheadon"]The lecturer was suggesting that dry eye was the commonest cause.[/quote]

Absolute nonsense. Dry eye presents very differently to a non healing ulcer.

I'm loathe to say it but the lecturer appears a little distanced from the swathes of these that are treated in primary practice.

[quote user="Neil Wheadon"]He went on to suggest that grids are never to be used in cats and are in fact a common cause of sequestrae.[/quote]

Agree to an extent, but never is a bold statement indeed.

RE: Non healing ulcer

Neil Wheadon — Mon, 26 Nov 2018 22:52:10 GMT

[quote user="David Mills"]I don't buy into pre-existing conditions more likely to be present after a week. Some are underrun, others compliance, but I can't remember the last ectopic cilia etc I saw. [/quote]

Well I was convinced

If the ulcer isn't underunning and so an indolent ulcer then as the cornea fixes in 4-5 days, if it is still there in a week then something is causing it. Much like a stone caught in your windscreen wiper. The lecturer was suggesting that dry eye was the commonest cause.

He went on to suggest that grids are never to be used in cats and are in fact a common cause of sequestrae.

Neil

RE: Non healing ulcer

Evelyn Barbour-Hill — Mon, 26 Nov 2018 22:41:55 GMT

[quote user="Neil Wheadon"]The cornea is avascular so how any non topical drug would affect the surface would be tricky?[/quote]

If the drug were present in the tears?