I do enjoy having students around with me on my ambulatory referral visits to various veterinary practices. It gives them a chance to see lots of ophthalmology cases and also how different clinics run, though one thing they often remark on at the end of a week is how often I do nothing.
Well, that’s not strictly true. Careful examination with an ophthalmoscope and slit lamp, and tonometry and ocular surface evaluations take time – the owner needs to know they are getting their money’s worth! And more often than not there’s phototherapy – every day there needs to be an image or two of an interesting case to put up on my Instagram feed after all! But quite often my recommendation is that therapeutically we do nothing: come off the topical medication that has been such a trial for the owner to apply numerous times each day – the medication that has stressed the owner, troubled the animal and quite possibly slowed the healing response of the eye as well.
More often than not the animal has been put on a commonly used topical antibiotic gel (no names, no pack drill as they used to say!) which kills the normal bacterial flora on the ocular surface. Now, we don’t know much about the role of the normal bacteria on the ocular surface, but if I told you that the most important thing to do for a vomiting dog with diarrhoea was to kill all of its normal gut flora, I do sincerely hope you’d stop reading at that point! Maybe maintaining a normal ocular surface flora is a good thing, so continuing topical antibiotic therapy may be less than useful.
Anyway, back to where we started – doing nothing. I often tell owners that everything is fine and nothing needs to be done. The dog with an eye that has gradually developed an intraocular pressure of 40mmHg but doesn’t seem to have any discomfort probably doesn’t need its eye removed. Your new all-singing, all-dancing tonometer – though it has to be said that even the best tonometers rarely sing or dance – might show you a ridiculously high pressure, but look at the animal itself. It might well be blind – pressure does that to an eye – but is it painful? Acute glaucoma might cause considerable discomfort with blepharospasm and guarding of the eye, but often chronic glaucoma doesn’t. If a human has a family history of glaucoma, they get a free annual ophthalmic examination with tonometry, as their pressure might be rising without them ever realising it. So, if the dog has a high pressure but isn’t blinking or squinting or off its food, it most probably doesn’t need frequent drops or an enucleation. Honest!
What is needed just about every day though is reassurance for the owner – what I like to call a worry-ectomy or a concern-oplasty. Just before Christmas, I was presented with a dog with bilateral conjunctivitis that just wouldn’t clear up no matter what antibiotics were used. A bacteriological culture and sensitivity had shown a really unusual bug, Pantoea aglomerans, that I hadn’t come across in all of the 30 years that I’ve been doing ophthalmology, but one that was sensitive to most antibiotics. So why hadn’t the conjunctivitis cleared up? The clue was found in an excessive tear overflow from each eye, revealing that the problem was a blockage of the nasolacrimal ducts. Easy!
Flushing the ducts was challenging, but possible, and for a couple of weeks the problem seemed sorted. Soon, though, the conjunctival redness and epiphora returned. I suggested that something more worrying might be going on, and as the practice had its own CT scanner, I recommended further diagnostic imaging. The resulting dacryocystorhinograms were beautiful but didn’t show any reason for the blockage, just normal but narrow ducts. I was disappointed not to find something there, but the owner was, perhaps not surprisingly, delighted. When I apologised for spending that amount of money without coming up with a clear diagnosis, she was just overjoyed that we hadn’t found some nasty tumour blocking the ducts. This experience led me to the subject of this article for the new year.
When we qualified, we all stood up in front of the president of our Royal College and declared that the welfare of the animals under our care would be our prime concern. Quite right, but we say nothing about a concern for the welfare of their owners. The guide to professional conduct tells us that we must be open and honest with clients and respect their needs and requirements, that we must provide independent and impartial advice and so on and so on. You could say that you’d expect the same of a garage servicing your car, but being a vet is much more than being a mechanic, isn’t it? It’s interesting that “care” for the owner isn’t mentioned anywhere that I can see in the RCVS website, yet that comes, in my book at least, as a very close second to care for the animals we deal with. So, my new year’s resolution will be to make that double care my aim for the whole of 2022.