Benign neglect – when is doing nothing the best thing to do? - Veterinary Practice
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InFocus

Benign neglect – when is doing nothing the best thing to do?

Simply asking the owner if they believe their pet is bothered by the pathology we see during our clinical exam is perhaps the most important question we must ask

For the past five years I have spent my time studying various topics of veterinary medicine – anatomy, pathology, epidemiology, etc. But more recently, I have focused on what to do when things go wrong and when to give treatment. After all, this is the main reason owners bring their pet to the vet and how many of us make ends meet. But when is it time to stop? When is doing nothing the best thing to do? I have recently had the privilege of working alongside Dr David Williams, travelling around Cambridgeshire in a wonderfully bright yellow car to attend his many ophthalmology cases in the veterinary practices he visits on his ambulatory referral service. But a few days in I arrived at a question that many other students had asked before me: how do you know when to do nothing?

The first case that raised this question was a beautiful four-year-old mare. When we arrived, she was no longer the calm and friendly mare her owner had described. A much-used sub-palpebral lavage system hung from two plaits in her mane, and a tired and worried owner clung to her lead rope. A small whiff of sedation was needed before she would allow a gentle hello and a thorough examination of her eye. Despite persistent treatment from her loyal owner, the poor horse was suffering from recurrent uveitis in her right eye. Examination showed a hazy vitreous and corneal oedema, with poor vision and low intraocular pressure in the affected eye. Curiously, her owner reported no signs that the eye was bothering her horse; she did not rub at her face and seemed to frolic happily in the field despite her apparent poor vision. It was then and there that I discovered the first part of the answer to my question: look at the whole animal!

Alongside careful use of an ophthalmoscope and baffling owners with rebound tonometry […] deliberate consideration of the animal’s history and the owner’s opinion is needed

In some cases, the animal may be perfectly content despite the condition of its eyes. Alongside careful use of an ophthalmoscope and baffling owners with rebound tonometry (the lack of offensive air puff as used by opticians leads many owners to jealousy!), deliberate consideration of the animal’s history and the owner’s opinion is needed. At this point, David had a beautiful comment for the owner: “I may be the eye expert, but you are the expert when it comes to your beloved companion.” In this case, it was clear to the owner that the horse was becoming irate with the daily application of medications rather than any of the pain or discomfort from the eye. And there was the second part of the answer: consider the owner.

This horse’s owner had been battling to deliver medication to a stressed and somewhat dangerous animal for weeks, with minimal resolution of the clinical signs in the eye. The owner could no longer approach the stable without the horse becoming distressed in anticipation of more treatment, and the previously flourishing relationship between pet and owner had been stretched thin. So, the treatment of choice for this case: benign neglect. Continuing treatment was not resolving the ongoing inflammation in the eye and with concerns of more distress to both animal and client, benign neglect was the most appropriate course of action. The inflammation was in the back of the eye, causing vision problems but no pain or discomfort, and the animal was comfortable – that trumped returning the eye to clinically normal.

Particularly in ophthalmology, it can be argued that the owner is a key aspect of successful clinical resolution. The owner must feel able to apply topical medication often on a strict schedule and remain safe when doing so. Owner compliance, a phrase uttered by clinicians and vet students alike while they prescribe a multitude of treatments, is key, but it’s up to the vet to ensure that what we are asking the owner to do is possible. So frequently there is a look of dread on an owner’s face as they hear the words “four times a day” and a returning look of guilt when they inform the vet at the next consult that they have failed to apply the medication as they were asked.

Owner compliance […] is key, but it’s up to the vet to ensure that what we are asking the owner to do is possible

A few days after meeting the mare, we met a very friendly 13-year-old spaniel with diffuse mucoid deposits on his left eye. The dog had a previously reported vestibular episode that left him with a noticeable head tilt and an efferent pupillary deficit in his left eye. It was suspected that he had developed dry eye following this, so he was started on ciclosporin treatment in an attempt to improve tear production in the affected eye. Despite weeks of treatment, the tail-wagging spaniel had shown no improvement on repeated Schirmer tear testing and still greeted his owners every morning with a lick to the face and a gloopy eye.

As the owner recounted the past few weeks to us, one phrase continuously popped up – “he hates the drops”. It seemed that the dog’s tail only ceased wagging when the owner picked up the small white tube each morning, and it was always a battle to apply the prescribed blob of medication. Given the dog’s history, advanced age and wagging tail, it was decided to change the treatment the dog was on. You guessed it – the wriggly spaniel was prescribed a healthy dose of benign neglect. On exam, the mucoid discharge was actually the eye’s way of lubricating itself quite sufficiently and the dog did not appear to be in any discomfort. The owner was more than happy to monitor the dog for any sign of pain and simply clean the eye with a wet cloth when needed: anything to keep that tail wagging.

In many cases, benign neglect is the next scary but logical step. It is relief for a worried owner, peace for a stressed pet and, perhaps most importantly, a sign of a holistic clinical approach

As I approach my graduation, I find myself reflecting on the oath we all take. Our role as veterinarians is to ensure the health and welfare of the animals committed to our care; this is something we can all clearly identify as a feature of clinical practice. From the moment an animal is presented to us, we consider its health and welfare and discuss with clients how we can best maintain or improve this; however, on top of this we have a responsibility to the client. This is something that has become more apparent to me while working with David. That key question – simply asking the owner if they believe their pet is bothered by the pathology we see during our clinical exam – is perhaps the most important one we must ask in these cases. As I find myself on the cusp of becoming a new graduate, I believe I have discovered the answer to a very important question. In many cases, benign neglect is the next scary but logical step. It is relief for a worried owner, peace for a stressed pet and, perhaps most importantly, a sign of a holistic clinical approach.

I would like to extend a special thank you to David for allowing me to accompany him on his ambulatory referral visits as part of my final year elective. It has been an utterly amazing experience that has filled me with renewed passion for both the profession and the field of ophthalmology. It is not an experience I will soon forget, and I am so very thankful for the opportunity to meet an esteemed colleague and gain a friend.

Erín Courtney

Dr Erín Courtney originates from Ireland and qualified from the University of Liverpool in 2022. She has a special interest in veterinary ophthalmology, undertaking elective study at the University of Cambridge under Dr David Williams. Following graduation, Erín will be undertaking a small animal first opinion role in Northern Ireland.


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David Williams

Fellow and Director of Studies at St John's College, University of Cambridge

David Williams, MA, VetMB, PhD, CertVOphthal, CertWEL, FHEA, FRCVS, graduated from Cambridge in 1988 and has worked in veterinary ophthalmology at the Animal Health Trust. He gained his Certificate in Veterinary Ophthalmology before undertaking a PhD at the RVC. David now teaches at the vet school in Cambridge.


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