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Blue Cross Veterinary clinic Blagoevgrad- Bulgaria
Canine transmissible venereal tumor(CTVT),also known as transmissible venereal tumor (TVT) or Stickers’s sarcoma, is a transmissible cancer, that affects dogs. CTVT is spread by the transfer of living cancer cells between dogs, usually during mating. It’s normally localized at the external genitalia of male and female dogs, also at the oral and nasal cavities. Immuno-compromised and generally unhealthy dogs are predispose of leishmaniasis associated to genital TVT, and especially in a dogs living in Mediterranean region. CTVT may also be transferred by licking, sniffing or parturition. Clinically, CTVT lesions are red to tan, friable, verrucous to multilobulated masses, predominantly affecting genital organs, and are usually ulcerated and inflamed. Metastasis is uncommon ,but is usually seen in regional lymphnodes. Other reported sites of metastasis include skin, subcutaneous, brain, eyes, spleen ,liver, musculature, lungs, anus, bones, kidneys ,testicles and mammary glands. Leishmaniasis is a vector-borne diseases with wide geographic distribution affecting humans, dogs and several wildlife species. Depending on the infecting Leishmania species and the immunocompetence of the host, the infection can result in visceral (CanVL), cutaneous or mucocutaneous disease. CTVT and CanVL can overlap epidemiologically particularly in regard to their geographical distribution. In recent study was found that Leishmania sp. has tropism for the canine male genital tract. CanVL has been previously identified concurrently with canine transmissible venereal tumor as well as Leishmania amastigotes within CTVT neoplastic cells.
CASE REPORT- A 10 yrs old mixed-breed female dog Lucky was presented in Blue Cross animal hospital in Blagoevgrad on 01.04.2019 in a state of prostration. The dog had been adopted from the street. On presentation Lucky was in a very bad body condition-cachectic with pale mucosa membranes , muscle atrophy, onychogryphosis and two large cauliflower-like, ulcerated, hemorrhagic vaginal tumor masses. (Figure 1). The skin examination showed generalized alopecia with lice infestation and diffuse seborrhea. There wasn’t any lymphadenomegaly detected. Abdominal ultrasound examination didn’t show abnormalities in the spleen and other organs.
Clinical diagnostic tests:
A complete blood(cell) count (CBC), serum biochemistry profile were performed along with a Snap 4Dx test to screen for vector borne disease agents Dirofilaria immitis (heartworm disease),Erlichia canis (ehrlichiosis) ,Anaplasma phagocytophilium (anaplasmosis) and Borrelia burgdorferi (Lyme disease) and test for Leishmania detecting antibodies. In addition, skin scrape of the few places on the skin and fine needle aspiration cytology of the vaginal mass was done. The CBC revealed anemia, haemoglobinemia, Leukocytosis (lymphocytosis, granulocytosis).The serum biochemistry profile revealed hyperglobulinemia, hypoalbuminemia, low A/G ratio, hypocalcemia. The dog was positive for E.canis, A.phagocytophilium and Leishmania Ab. The skin scrape was negative for demodicosis and scabies. A fine needle aspiration cytology of the vaginal mass revealed a neoplastic round and ovoid cell population with some inflammatory cells. Every cell is containing single ,large and round nuclei. The abundant cytoplasm was delicately granular and optically empty. The cells had an characteristic for transmissible venereal tumor (TVT).(Figure 2)
Treatment with doxycycline 10mg/kg,p.o. q12h for 30 days for ehrlichiosis and anaplasmosis was initiated. In addition Milteforan 2mg/kg,p.o. q24h for 28 days and Allopurinol 20mg/kg,p.o.,q12h for 6 to 9 months was initiated for treatment of Laishmaniasis. The dog get also every day, some supplement for the skin like omega 3 and omega 6 amino acids and every 3th day topical treatment with shampoo with ketoconazole and chlorhexidine. The dog spent 20 days in the clinic, during that time Lucky get really improved (figure 3 ).
For the TVT treatment with vinciristine sulfate 0.6 mg/kg/m2, I.V., q7d for a total 8 treatments was initiated. The dog was monitored with a CBC every week. Photographs of the vaginal tumors were taken at each follow up visit to monitor the progress. After the second vincristine treatment there was visible improvement. The mass had decreased in a size.(fig.4and 5)
By the f ourth week only a small remnant of the mass was visible(fig6).
During the all treatment there was no decreasing of the thrombocytes, CBC was completely normal. There was no side effects of the vincristine treatment.
The patient was fully recovered. The treatment with Allopurinol is stopped. Sixed months after the last vincristine treatment, Lucky was doing great, no TVT recurrence. Neutering of affected dogs can be beneficial to decrease distribution of the vaginal tumors.
2.Case report Leishmania sp. Amastigotes Identification in CTVT
3.Transmissible Cancer Group
Department of Veterinary Medicine
University of Cambridge
The alimentary secondary hyperparathyroidism is not so rare as many specialists think. For period of only 9 months we diagnosed in our clinics 17 cases and had serious observations in other 9 cases (the owners didn’t agree to prove 100 % in Laboklin) in different stages of the problem evaluating. We present below our treatment protocol and two concrete complicated cases – both with healed patients but one not operated – and our consequences experience in cases with or without surgery.
The hyperparathyroidism is primary and secondary. The secondary could be renal – complication of chronic renal insufficiency, it is more often seen even in comparison to the primary – and alimentary: rarest but for sure not exotic. The alimentary variant is seen in young dogs and especially cats fed only or almost only with meat. The low calcium levels and the inadequate calcium/phosphor ratio in meat starts a multi-vector pathological process evaluating for a couple of weeks to following clinical picture: unwilling for moving, lameness, stiff walking, spontaneous fractures, face edemas, easily teeth removing or teeth loosening, spontaneous neurological deficit in different levels. The standard hematological and biochemical blood panels usually do not give any diagnose direction. It is common the right diagnose to be reached with delay because often the colleagues miss during the anamnestic phase to become well informed about the alimentary regime of the patient, X-rays are rarely made in the very beginning and usually the therapy starts with NSAIDS and general strengthening protocol.
This disease not rarely causes hind legs function insufficiency and neurological deficit, paradoxally not corresponding to and many times exceeding the found through imaging diagnostic bone (including vertebral) changes. It is not exotic OCD (even in cats) to be diagnosed later due to cartilage underlying bone and bone vessels malformation.
Most directing is the anamneses especially the alimentary regime of the young patient. Absolutely enough for 90 % sure diagnose is combination of anamneses, estimation of the bone geometry and density due to X-rays covering flat bones, spinal cord, mandibula, maxilla and blood levels of macro elements especially P. For 100 % sure diagnose we send blood hormon sample to Laboklin Germany. The differential diagnoses are not many and include some genetic or metabolic disorders.
Our newest therapeutic protocol, product of enough clinical experience and leading to fastest and completest healing includes:
- Hospitalization of the patient in cage for maximal immobilization aiming to avoid pathological fractures and especially vertebral fractures.
- Diet change to P-poor and Ca-rich: the variants are so many, ii is important the diet to be diverse and with enough vitamins. In most of the cases we start with renal diet combined with additional food components;
- Calo-pet – zero P molecules and very adequate composition for this problem;
- NEO-K9: not only because of the demonstrative bone healing stimulation but also very adequate against all cases of hyperphosphatemia – and in cases of alimentary hyperparathyroidism we have severe hyperphosphatemia as well as serious bone demineralization and decrease of their potential for resistance to physical forces and for healing;
- Ipakitine – because of its ability to chelate and eliminate the phosphor
- HyalOral – because of its adequate to the therapy (especially against intra-joints complications) composition and especially because of the gamma-oryzanol inside
- NSAIDS – against pain and inflammation
- Calciferol (Vitamin D3) in dosage 2 ng/kg/24h– please be very careful when using it because increases the resorption of calcium but also of phosphor. Should be added to the protocol only after the phosphor is already in normal blood levels or very close to them;
- Sometimes after careful individual estimation – oral pure Ca human product for children or even injectable Ca vet product;
- Often repeated biochemical including P and Ca blood monitoring (a big Thank you! to our trusted lab VetDiaLab for the precise and reliable work during the last 15 years), every-day neurological monitoring and checking the ability for urination, every-day check for rib and long bone fractures and regular (minimum every 8-10 days) X-ray follow-up of the geometry and healing of all fissures and fractures;
- Therapy against the complications including the spontaneous fractures, eating difficulties because of jaw problems ets.
This algorithm leads to very fast and demonstrative health status improvement. Of course it is very important to estimate carefully when the patient is ready to get out of the cage. We recommend the bone fissues to be X-ray monitored every 5-10 days and all long-bone fractures to be operated especially those near the knee joints. The reason?: the long-bone fractures caused by SAHPT heal very often with malunion which is being well tolerated by young animals but many of them suffer when achieve adult/mature age. On the other hand we recommend vertebral fractures to be operated only in case of neurological deficit or pain. In all cases of eating difficulties esofageal probe and not manual assisted eating is recommendable.
Case 1: cat Darko, SAHPT complicated with two supracondylar femural fractures, operated with delay. We added Calciferol to the therapy protocol at the 7th day when the blood phosphor decreased to normal levels. The owners asked us not to operate and to wait but as usual despide the cage rest after a couple of days the fragments geometry get worse and the healing would lead to malunion and may be to patellar luxation. The owners agreed to operate, the surgeries with implants of Mikromed were fast and simple (peri-operatively: Clavaseptin) and the case result is 100% healthy and extremely mobil cat:
Case two: cat Pisi, SAHPT complicated with fissure and fracture, not operated. The X-ray fissure (left humerus) follow up showed no need to operate and healed without problems. Unfortunately we didn’t receive permission to operate the fracture and as usual the result is serious malunion:
Conclusion: strict cage rest, strict food and therapeutical protocol, strict clinical and paraclinical monitoring and careful surgery estimation = successful outcome.
This is the story of Josi. She is a female Pomeranian dog. She has a long history of epiphora, blepharospasm and ocular discomfort.
She has gone several treatments before including surgery of the eyelids with mixed success.
Josi is a well monitored patient with all his dewormings and vaccinations on time.
Josi was presented for second opinion for ocular exam and consultation.
With the direct ophtalmoscope I saw some hair in the right eye. Near the limbus there was a dermoid mass with very small size and 3 hairs growing on the cornea.
Then I did Jones test of the both eyes with some fluorescin stain and it was negative for more than 60 seconds. The STT time of the left eye was normal 20 mm / min.
Both eyes were negative for ulcers.
Meanwhile I did nasolacrimal flush of the ducts in the both eyes.
So the second dermoid was resected and removed with scalpel blade.
Than I did nasolacrimal flush with IV catheter.
So Josi was sent for home management with some local Tobramycin drops and some hyaluronic gel for the cornea to heal fast.
Recheck will be done after 5 days.
Bomed Veterinary Clinic, Sofia, Bulgaria
Abstract: Endometrial polyps from a 10 –year-old cat are described.The cat was presented in clinic due to vaginal bleeding. Few polypoid cystic masses pedunculated into the uterus lumen were found at the surgery. Sonographic, X-ray, cytology and histopathological examination revealed uterine polyp consisting mainly of endometrial fibrous tissue stroma and glands without invasive growth or atypical mitotic activity. Keywords: Endometrial polyp cats, Feline uterine polyps, Cystic uterine polyps in cat,Ultrasound endometrial polyps, Histology endometrial polyps, X-ray endometrial polyps
Endometrial polyps in cats are a rare disease condition. Much of the available evidence being anecdotal1. There are only three more detailed reports for this condition in cats. One from the archives of the International Registry of reproductive Pathology at the University of Illinois, US -14 cats1, one from Department of Obstetrics and Gynecology, Faculty of veterinary medicine, Kirikkale university, Kirikkale, Turkey-1 cat2 and one from School of Veterinary medicine, Azabu University, Kanagava, Japan -1 cat3.
A 10-year-old Persian cat was presented to Bomed Veterinary Clinic in Sofia, with history of acute vaginal hemorrhagic discharge. The cat was in good physical condition with normal temperature and behavior. Few bloody drops around the vulva. In middle to caudal abdomen was palpated some firm mases.
Under clinical differentials diagnoses of pyometra, uterine adenocarcinoma or alimentary lymphoma was performed abdominal ultrasound. Sonographic examination showed a few cavernous structures cranial to bladder and caudal to kidneys. The large one was about 4 cm in diameter. Caverns were dispersed in haphazard mosaic pattern. Doppler sonography showed good blood supply of masses. On the base of ultrasonography pyometra was excluded of differentials diagnoses list.
On the base of suspected uterine adenocarcinoma were performed two dimensional chest and abdominal X-ray. Lungs and chest X-ray did not show indication of metastases. Abdominal X-ray confirms sonographic findings about dispositions and dimensions of mases.
CBC and biochemistry was in normal limits. On the base of the clinic and tests an exploratory laparotomy under general anesthesia was performed. During surgery uterus with abnormal asymmetric horns was found. Few mobile firm – elastic mases were palpated in uterine lumen. Two and smaller in the right horn, and a bigger one in the left horn. Ovaries looked normal except one little cyst nearby to right ovary.
After OHE the uterus was dissected. Evidence for an inflammation was not found.
We found in left horn one big elongated egg-like structure pending on short narrow peduncle. It is about 5 cm long and 4 cm in diameter. The smallest one in the right horn was about 1 cm long and 0.6 cm in diameter starting nearby end of horn. The middle one was about 4cm long 2cm in diameter and partially entering in the cervix. Polyps had firmly –elastic consistency, easily bleeding, with small delicate cyst on the surface. Uterus wall had irregular thickening mostly because endometrial hyperplasia. On the luminal surface has similar small delicate cyst also. When we dissected one of the polyps many different sized caverns dispersed in haphazard mosaic pattern were found. They were full with translucent slightly mucinous secret. The stroma was tenacious.
Fig. 3 Morfology of uterine polyps. Polyps pedunculated from uterinw endometrium to uterine lumen. Many fine cysts are visualiseted on the surface of polyps. Uterine walls with irregular hyperplastic patern.
Many prints slides for cytolgy were made. We did not found inflamatory cells, evidance for adenocarcima or any proof for other malignasy. These polyps looked benign.
Fig.4 Cytology from uterine polyp. Left- stroma Ridht- cyst wall
Specimen for hystopatology was prepeared in 10% formalin and send to Pathology laboratory, at the same day.
Fig.5 Histology from uterine polyp. Up- Stroma and cysts. Down- Left -Hyperplastic proliferation of glandular epitelial cysts. Down-right- Atrophyc epitelial wall of large cyst.
Histology report: Protocol 107,108,109,110/05.04.2019
Hystological spesimen representing uterine wall with presence of polypoid tumor formations. Tumor origin is from endometrial surface, representing of stroma, built from mature fibroses tissue with glands structures in thinly pattern within. Many of these glands structures are cystic dilated. They are covered with one row cubic epithelium with primarily basal situated nuclei. No signs for epithelium proliferation activity, atypical mitotic activity or invasive proliferation regarding the stroma. An endometrium and myometrium has typical histological structure.
Histological diagnosis: Atrophic endometrial polypsOn the base of clinical examinations, Ultrasonography, X-ray, morphology, cytology and histology report our diagnosis is as follows: Endometrial Polyps. Discussion
A diagnosis endometrial polyp of this case is according to the nomenclature in the Histological Classification of Tumors of the Genital System of Domestic Animals4. Main differential diagnoses are between endometrial polyps and polypoid form of cystic endometrial hyperplasia. The more exact differences between true endometrial polyps and polypoid endometrial hyperplasia are defined as that endometrial polyp have a vascular connective tissue stalk5 or contain a substantial connective stroma in addition to glands, and are pedunculated6. Histology slides demonstrated changes in the different stages of cysts development. Focal cystic endometrial hyperplasia is the stimulus for formation of polyps. As hyperplasia progresses, out of synchrony with surrounding endometrium, the glands become larger and more numerous. If the cystic endometrial glands have no external opening, they start to accumulate fluid. When the fluid pressure in the cysts increases, the gland cells covering their walls are compressed and start atrophic process.1 On the base of reports no breed, age or other predispositions were found1.No evidence that endometrial polyps are preneoplastic changes of the feline uterus except one a 16-year-old cat with metastatic carcinoma and five endometrial polyps1, 2. This probably reflects the rarity of endometrial neoplasia in cats as compared to women1. On the base of this data prognosis in this concrete case is excellent. ConclusionEndometrial polyps in cats are very rare condition.It is difficult to classify this disease as gynecological, hormonal or oncological. On the base of the case studies OHE is choice of treatment with excellent prognosis.
Fig. 6 The lucky cat Dara.Acknowledgments:
The author would like to thank to team of Bomed Veterinary Clinic, Sofia, Dr. B. Rangelov, DVM for sonographic diagnostics, Dr. M. Lulcheva, DVM for anesthesia and Dr. J. Stojkov DM for histology report.
Hera, a 10 months old female Cane Corso, was presented on the 15th of October 2018 for a dental consultation. She had pink teeth, a strong halitosis, „wasn’t eating like she used to” and showed signs of pain (didn’t let anyone touch her mouth or look at her teeth).
X-rays showed a very large pulp cavity in all teeth, very thin dentin and enamel, crown fracture with pulp exposure in 304 and 404 (Image 2), but also an abnomal density of the cortical bone in the mandible (Image 1) . The owner reported that the deciduous teeth were pink too.
The dog previosly had 2 surgeries in both elbows in another clinic (bilateral elbow dysplasia). Hera is also blind with both eyes (there is no vascularization in the eyes).
Antibiotics (amoxicillin with clavulanic acid 20 mg/kg/12 h) and analgesia (meloxicam 0.1 mg/kg/day) were immediately started and the patient was scheduled for a dental procedure a week later. CBC and routine biochemistry were normal.
The dental examination under aneshesia revealed 6 crown fractures with pulp exposure (109, 110, 209, 210, 304, 404). We extracted these teeth and tried to seal with the remaining ones. The dental extractions were very difficult, but the healing was good (as you can see in the images from the second dental procedure).
At this first dental procedure (Images 4 – 11), we took a blood sample to see what were the vitamine D3, calcium and parathoyroid hormone levels. When results came, we found out that Hera had hypoparathyroidism (PTH level was 1.2 pg/ml, almost 16 times lower then the physiologic range) and recomanded a thyroid ultrasound, which is not availiable unfortunately.
Also Vitamine B12 was low, so the patient recieved treatment for that too.
After the first procedure, the recovery was fast, the dog started to eat the next day, but only very soft food.
The second dental procedure (Images 12 – 16) together with the ovariohysterectomy took place on the 23rd of February 2019, when we performed extractions of 208 and 209 retained roots and full 405 was extracted for histopathological examination (that will be performed at Histovet by Dr. Teodoru Soare). The recovery was even better than the first one. Hera received clindamycin 11 mg/kg/day, 7 days and meloxicam 0.1 mg/kg/day, 4 days. Unfortunatelly, because a second set of radiographs were not available for this dental intervention.
The dental pathology of this patient might be a very rare congenital dental condition called „shell teeth”, in which teeth have large pulp chambers and insufficient coronal dentin. The treatment of this dental disease is full mouth extractions, but given the very high level of difficulty of the extractions, we chose to extract only the fractured teeth. It may be a consequence of a congenital hypoparathyroidism, which would also explain the other pathological signs (blindness, bilateral elbow dysplasia).
Hera is a very interesting case with high didactic value. She remains supervised for evaluation of her clinical evolution.
Both interventions took place at QincyVet and were performed together with Dr. Raluca Zvorasteanu.
Veterinary clinic Bomed
A 6-year-old, neutered male domestic shorthair cat
was presented for dental cleaning due to “bed smell breath”.
No vaccinations history, irregular anthelmintic treatment.
No earlier dental care.
History of cystitis four years ago.
The cat was in good physical condition.
Normal temperature, auscultation, palpation.
Normal facial and eyes symmetry, no nose or eyes discharges.
No compression discomfort, no swollen regions, lymph nodes – normal, lips with black pigmented zones.
Conscious Oral exam:
The cat was cooperative.
Normal maxillomandibular joint mobility, without pain.
Normal buccal mucous membranes. Lingual, sub lingual, caudal mouth space and roof of the mouth was normal.
Moderate gingivitis, gingival recessions, missing all upper right premolars (106,107,108), left upper first premolar (206), first and third left mandibular premolars (307,308).
All canine teeth were with root exposure.
Many mobility teeth: 207,208,308,403, with root exposure and visual
root resorption and attachment loss.
Plaque index 2.
CBC, Biochemistry was in normal limits, except high globulins level.
Dental X-Ray was unavailable.
Oral exam and treatment under general anesthesia:
Missing all upper right premolars (106,107,108), left upper first premolar (206), first and third left mandibular premolars (307,308).
Moderate gingivitis (gingival index 2).
Gingival and alveolar recessions.
No periodontal pockets. Stage 3 furcation (307, 308, 309, 208)
All canine teeth were with root exposure due to tooth extrusion.
Mobility teeth: 207(M3), 208(M2), 308(M3), 303(M3), 309(M3), 403(M3), with root exposure, visual root resorption and attachment loss.
Idiopathic Tooth Resorption
Multi teeth simple extraction
Preoperative analgesia: Rheumocam
Chlorhexidine Rinse 0.12% solution
Simple extraction with elevator and extraction forceps.
Rheumocam 24h/3 days
Stomorgil 24h/8 days
Stomodine 12h/14 days
Dental and oral prophylaxis with Stomodine,
Regular examination every 3 months.
There are many theories about the etiology of Tooth resorption in domestic cats but main cause is still unknown.
Depends of the source, about 25–75% of domestic cats are affected.
There is an increasing prevalence of Tooth resorption as cats get older, with the first teeth becoming affected usually at four to six years of age.
Gender and neutering were not found to affect the prevalence of disease.
Cat owners may report halitosis, ptyalism, head shaking, dropping food
while eating, reluctance to eat hard food, excessive tongue movements,
repetitive lower jaw motions while eating, drinking or grooming,
sneezing, dysphagia, dehydration, anorexia, weight loss, and lethargy.
Clinical findings are various degrees of gingival inflammation, missing
or mobile teeth, gingival hyperplasia or recession, tooth extrusion, tooth
tissue destruction and others.
Earlier and most accurate diagnosis is made by dental X-Ray because
first changes are subgingival.
Depending on changes there are few classification based on severity
(stages 1–5) and radiographic appearance of the resorption (types 1–3).
Tooth resorption can develop with cementation and ankyloses or with
attachment loss and mobility of teeth. In case of attachment loss extraction
Tooth resorption is the most common progressive disease affecting the
dental tissues in domestic cats.
In every regular cat exam (with or without oral or dental abnormality)
Tooth resorption should be routinely suspected.
Choice of treatment – extraction of all affected teeth.
6th year veterinary student from Estonian University of Life Sciences
- Donskoy cat
- 6 years 10 months old
- Weight 3,66kg
Owners came to visit, because of halitosis and cats’ loss of appetite. Cat has also lost some weight in previous months. Cat lives mostly inside and was not vaccinated for any diseases over 2 years.
Gingiva was very red, inflammatory and gums were bleeding when the mouth was opened. Opening a mouth was painful for the cat and ulcers on the tongue were visualised (Figure1). Cat had also a lot of calculus and she was hypersalivating. Due to the fact that cat was not vaccinated, a FeLv/FIV snap test was done, and it was negative. Also hematology and biochemistry were evaluated. In biochemistry liver and kidney values were mostly within normal limits (WNL) Only UREA was a bit low (4,5mmol/L) but it might be due to the starvation. Electrolytes were also controlled and they were WNL. In hematology only mild leukocytosis was seen.
After the first visit, a dental appointment was planned. The cat got one subcutaneous injection of cefovencin (Convenia) 8mg/kg and went home with oral meloxicam 0,05mg/kg for 3 days. She came to tooth removal surgery in seven days. A cat was sedated with dexmedetomidine, butorphanol, and ketamine intramuscularly. TIVA with propofol was used during surgery. Cat got 5ml/kg/h of Ringer-Lactate during the procedure and free flow oxygen was given. Buprenorphine (0,01 mg/kg) intramuscularly and meloxicam (0,3 mg/kg) subcutaneously were given for analgesia and lidocaine was used for nerve blocks. Dental radiographs were made pre-and postoperatively (Figures 2). Figure 3 shows how important are dental radiographs. 301 was broken during the extractions but it was unclear if remnant got out or not. An x-ray was made and the root was visualised. Then the root remnant was removed and a new x-ray was taken.
During the procedure, clinical picture (gingivitis II-III in all dens, 204 had gingival pocket of 2mm. 404 had gingival hyperplasia and also pocket of 2mm) and full mouth radiographs were evaluated. All teeth except canines were extracted. A cat went home with oral meloxicam (0,05 mg/kg) for 5 days. A new checkup was in 7 days. Figure 5 shows that gingiva is not so inflamed anymore. Cat started eating with a good appetite already the next day after the extractions.
Figure 2. (a) 409 has a tooth resorption (TR). (b) 309 is missing. (c) and (d) are made after extractions.
Figure 4. was made right after the extractions.
Feline chronic gingivostomatitis (FCGS) is a common syndrome, but its’ aeitology is unclear. FCGS causes inflammation and proliferation for the gingiva and oral mucosa. Inflammation can be mild to severe and it worsens with time. Mucosal ulcers are commonly seen in cats with FCGS. Ulcers are the most commonly on gingiva, tongue, buccal mucosa, lips, palatoglossal folds, and the lateral pharyngeal walls.
Aetiology is unclear, but it might be due to bacteria (usually from plaque Pasteurella spp↑, Prevotella spp↑), viruses or immune-mediated. Feline calicivirus (FCV), feline herpesvirus (FHV-1), feline immunodeficy virus (FIV), feline leukemia virus (FeLV), feline coronavirus (FeCoV) may cause FCGS.
The most obvious clinical changes are bilateral focal or diffuse chronic gingival and oral mucosal inflammation, ulcers and hyperplasia. Cats with FCGS has halitosis, dysphagia, ptyalism, bloody saliva, anorexia, and bleeding gingiva. Caudal part of the oral cavity is also with lesions. There is no sex, age or breed predilection.
For diagnostics, laboratory examinations are mandatory. Complete blood count (CBC), biochemistry (glucose and kidney values) and serological assays (FeLV/FIV) should be done.
Since the aetiology of the disease is unclear then treatment is empirical. In some cases, conservative treatment may help. Administration of antibiotics (amoxicillin/clavulanate, clindamycin, metronidazole), corticosteroids (not a good choice, because of side effects) , megestrol acetate (was used widely in the past, but now it’s not recommended due to the side effect), sodium salicylate, gold salts, lactoferrin (in mild cases, inflammation and salivation↓), interferon (poor results without extractions), professional tooth cleaning 3-4 times per year, chlorhexidine mouth rinses (usually not tolerated by cats for a long time) and teeth cleaning have been reported. The best cure is still full-mouth extractions.
Holmstrom, S.E. Veterinary Dentistry: A Team Approach, 2nd edition. Elsevier 2012, 10:228- 230
Niemiec, B.A. Small Animal Dental, Oral & Maxillofacial Disease: A Colour Handbook. Manson Publishing 2012. 6:176-181
Correl C., Nind, F. Saunders Solutions in Veterinary Practice: Small Animal Dentistry. Saunders 2008. 12-15:79-97
Gorrel, C. Veterinary Dentistry for the General Practitioner 2nd Edition. Saunders, 2013
Tutt,C., Deeprose, J.& D.A. Crossley. BSAVA Manual of Canine and Feline Dentistry, 3rd edition. BSAVA. 2007.8:137-144
Provet clinic , Plovdiv, Bulgaria
Aprilcho’s story takes place in the centre of Plovdiv, Bulgaria. The kitten is a victim of a car accident. Our colleague
Nina is the only one, who noticed the helpless cat , squirming on the street with painful convulsions. Nina picked him
neurologic symptoms, acute mouth bleeding, and convulsions. It was visible that he had maxillofacial trauma and a
First we did shock therapy so we could stabilize the patient. After we had the shock under control, we performed the oral surgery.
The upper premolars and molars had to be extracted, then alveoloplasty and correction of the symphysiolysis.
We’ve inserted an esophagostomy tube, so we could deliver enteral nutrition during the recovery period.
The recovery was long, due to the vestibular syndrome. He had pus expulsion from the left nostril and forehead
edema. We gave him antibiotics (Synulox) , Nootropil (piracetam) diluted with Glucose per os, and he received for
- 6 weeks enteral feeding with *Recovery* Liquid (Royal Canine).
Indolent corneal ulcer
Faculty of Veterinary Medicine Bucharest
The fluorescein test is very important in diagnosis of corneal diseases. Is our best friend that accurately describes the size and the depth of the corneal lesions. If the fluorescein test is positive exclude primarily a foreign body (from the conjunctival fornix or from the internal surface of the third eyelid) and then examine using the loupe, the edges of corneal lesion. If is an area of loose of the epithelium at the periphery of the lesion, looking like an “opened book (Figure 1, Figure 2 and Figure 5) your patient has indolent corneal ulcer.
The first step in the treatment of indolent corneal ulcer is the debridement of the denude epithelium using a cotton-tipped applicators (Figure 2), scalpel blade or Alger Brush® (Figure 3). Local anesthesia of the cornea using Benoxi® will allow you to perform debridement.
Using cotton-tipped applicators, the loose epithelium is removed using gentle lateral and circular movements. Debridement using a surgical blade is easily performed doing lateral movements, holding the blade’s sharpen edge perpendicular on the corneal surface.
The burr of the Alger Brush® device is faced towards the edges of the corneal ulcer and debridement is performed in a circular movement, following the limit between the ulcer and the healthy cornea. The small burr of the device quickly removes the epithelium so that the surgeon’s hand is laid on the periorbital area for support, to avoid accidents. Throughout debridement the corneal surface is flushed continuously using saline.
After performing the debridement of the indolent ulcer, the lesion is significantly bigger than the initial one (Figure 6), and in some cases, the anterior epithelium is completely removed.
The fluorescein test is used to reveal the size of the lesion after debridement in order to choose a therapeutic approach:
- medical treatment – corneal healer eye drops and gels
- therapeutic contact lens and eye drops (Figure 7)
- VetShield® colagen contact lens and tarsorrhaphy
- only tarsorrhaphy
Indolent corneal ulcer after debridement can be healed ad integrum (Figure 8) in 5-10 days or, in some cases, we need to perform many debridements. That’s why rechecks should be performed each 5 days after debridement and fluorescein test and reexamination with the loupe is mandatory.
Alternative anesthesia protocols without use of the neuromuscular block for phacoemulsification in dogs and cats
Correspondence: Stroe Marina-Stefania, DVM, Marina-Stefania.Stroe-Giurca@uliege.be
Cataracts may occur at any age and in any location in the lens. Cataracts can block tapetal reflection and fundic examination partially or completely and are often classified by stage of maturation and cause.
Cataract surgery are facilitated by a central position of the eye ball within the palpebral fissure. A centrally positioned eye is normally achieved by using of neuromuscular blocking agents (NMBAs). NMBAs also decrease the ocular muscle tone and that is very useful because an increased tonus may cause ocular structures to become displaced and distorted and can also influence IOP. Use of these agents necessitates intermittent positive pressure ventilation (IPPV).
Objective: Offering alternatives for anesthesia to perform cataract surgery in dogs and cats without using the neuromuscular block.
The safety of anesthetic protocols consisting of midazolam, tramadol, lidocaine, propofol, fentanyl, ketamine, isoflurane without using the neuromuscular block was studied in 16 cataract surgeries in dogs and cats. The protocol’s safety was expressed by monitoring heart rate, oxygen saturation and pulse rate using pulse oximetry, respiratory rate, end-tidal carbon dioxide provided by capnography, arterial blood pressure using oscillometric method. Assessments were made for quality of induction, maintenance and recovery from anesthesia.
Animals: Sixteen animals, eleven dogs and five cats, all client-owned.
Methods: All animals were examined prior to premedication, were performed blood tests hemoleucogram and biochemistry and monitored during induction, surgery and recovery. Blood samples were analyzed for standard biochemistry panel including glucose, creatinine, ureea, hepatic transaminases and hemoleucogram. Before anesthesia, HR was measured using cardiac auscultation and MAP was measured using automated oscillometry, respectively. Protocols consisting of midazolam, tramadol, or lidocaine iv was performed. IV propofol was administered to abolish the palpebral reflex, produce jaw relaxation and facilitate ETI. Topical ocular administration of oxybuprocaine (Benoxicaine®) 0.4% drops to anesthetize cornea was performed before general anesthesia. All patients received topically sprayed laryngeal 2% lidocaine. The cough response at ETI was recorded.
After intubation, auscultation of heart and lung sounds was possible by means of an oesophageal stethoscope. Pulse oximetry was used to monitor oxygen saturation of hemoglobin in arterial blood and pulse rate. The patient was connected to the inhalational anesthesia machine. The maintenance of anesthesia was achieved using isoflurane like inhalant agent and fentanyl or mixture of fentanyl, lidocaine and ketamine. Respiratory rate and end-tidal carbon dioxide was provided by capnography. Assessments were made for quality of induction, maintenance and recovery from anesthesia by evaluation of the animal’s eye position, jaw tone, heart and respiratory rates and autonomic responses to surgical stimulation.
Results: The purpose of this work was to perform anesthesia protocols without use of the neuromuscular block for phacoemulsification in dogs and cats and make preliminary investigation into safety for patient and to record the advantages and disadvantages. Cataract surgery are facilitated by a central position of the globe within the palpebral fissure. A centrally positioned eye is normally achieved by using neuromuscular blocking agents (NMBAs). NMBAs also decrease the ocular muscle tone and that is very useful because an increased tonus may cause ocular structures to become displaced and distorted and can also influence IOP. But if there is no possibility of using NMBAs solutions must be found.
Conclusion: The aim of the project was to test several variants of anesthetic protocols to compare the various effects of molecules including lidocaine, ketamine, fentanyl, tramadol, propofol, isoflurane have on the organism.
The use of anesthetic drugs without using of neuromuscular block for cataract surgery may be challenging bringing both advantages and disadvantages. The recovery period after a classic anesthesia without neuromuscular block probably is much shorter than that achieved after a curarisation and the probability for hypotension is less likely. On the other hand, without neuromuscular blocking agents we can`t obtain the central position of the eye globe and that implicate make some compromises for the surgery.
Keywords: cataract, anesthesia, phacoemulsification, cat, dog,
Patients with ophthalmic disease, such as cataract, vary from young, healthy animals with congenital cataract to geriatric patients, which may have significant diseases like diabetus mellitus. When planning anesthesia for cataract surgery is important to consider the general health status because there are many patients with concurrent disease and that may present significant challenges for the anesthetist . It required investigations before anesthesia like blood tests and if there are changes ideally their condition should be stabilized before anesthesia. Also need to consider that animals that are blind are more likely to be stressed and fearful compared with patients that have vision, especially if the onset of blindness was acute .
A complete ophthalmic examination should be performed and should include examination of PLR and menace response, Schirmmer tear test, fluorescein stain test, intraocular pressure (IOP) and a fundic examination if possible. A complete physical examination is also pertinent, as cataracts may be related to extra-ocular disease.
Electroretinography and ocular ultrasonography are standard pre-operative screening tools to confirm an eye’s candidacy for cataract surgery. Although pre-operative preparation and postoperative management can be intensive, canine cataract surgery is often successful and rewarding. Risks, time commitment, and financial demands of phacoemulsification should be discussed with the pet owner.
Materials and methods
Eleven dogs and five cats presenting to the ophthalmology service with ophtalmological conditions that cause blindness. All patients received the cataract diagnosis after a full ophthalmic examination. Once a cataract forms, surgery is the only treatment method to restore vision. Phacoemulsification uses ultrasonic energy to fragment and extract cataractous lens material from its capsular bag. Exclusion criteria of the patients were concurrent diseases that could not be stabilized before anesthesia. Any pre-existing medical conditions and drugs administered were recorded.
Food and water were withheld from all patients for a minimum of 12 hours prior to surgery
Animals were gently restrained in a sitting or standing position for drug administration and data collection.
Mydriasis is obtained with topical mydriatic agents (Tropicamide) applied with 2-3 hours before intraocular surgery. Also, topical ocular administration of oxybupracaine (Benoxicaine®) 0.4% drops to anesthetized cornea was performed before general anesthesia. Topical local anesthetics are effective because of a direct action on the cornea and minimizing systemic side effects but their use is limited to diagnostic procedures and intra-operatively as they delay corneal healing, are epitheliotoxic and have a short duration of action .
The position of the animals during surgery was in lateral position for unilateral cataract and dorsal for bilateral cataract (Fig.1). HR was measured using cardiac auscultation and MAP was measured using automated oscillometry.
Anesthesia was maintained with isoflurane in a oxygen delivered via a rebreathing anesthetic circuit with the oxygen flow rate set at 60 ml/kg/min and vaporizer setting of 2%. Oxygen saturation as measured by pulse oximetry, pulse rate and respiratory rate were recorded every 5 minutes after anesthetic induction until the end of anesthesia (vaporizer turned off). Pulse quality was established by manual palpation of the femoral artery and respiratory rate was recorded by observation of the capnogram and chest movement.
Measurement of rectal and esophageal temperature was performed by use of 2 thermistor probes. Rectal temperatures were measured at initial hospital intake and after the end of anesthesia. Once each patient had been induced esophageal temperature was measured by placement of an esophageal thermistor probe and was removed at the end of anesthesia.
The premedication has been achieved with lidocaine 2 mg/kg iv or tramadol 2 mg/kg iv (Fig. 2). All the patients received the propofol-midazolam combination for anesthetic induction. The dose utilized for midazolam was 0,4 mg/kg iv.
The use of ketamine was accomplished in combination with lidocaine and fentanyl for dogs and for one cat was used the ketamine-propofol combination. There is significant interest in this combination of propofol and ketamine because has several benefits in the terms of hemodynamic stability, absence of respiratory depression, post-operative analgesia and recovery . The ketamine dose that was used was low at 0,6 mg/kg iv and was mixed in the same syringe with propofol 3 mg/kg.
Steroidal anti-inflammatory drug (Betametazone, Diprophos®) was administered intraconjuctival at the end of the surgery.
In total sixteen animals (eleven dogs and five cats) were enrolled in the project.
All patients were in good condition of general health just 2/11 dogs were stable diabetic patients and for they measurements have been taken to monitoring the blood glucose level before, during and after surgery.
Premedication with lidocaine 2 mg/kg was performed for 6 dogs and was made observation about cough during endotracheal intubation. IV lidocaine can decrease the incidence of cough during endotracheal intubation but does not appear to have a sparing effect on the dose of propofol required for endotracheal intubation.
Two patients receive tramadol 2 mg/kg iv in premedication, one in combination with lidocaine 2 mg/kg iv and the other just the tramadol. For the patient that receive just tramadol was not observed any changes in the propofol dose.
One dog received fentanyl in premedication and after induction was observed significant respiratory depression compared with the others. Two dogs and 6 cats did not receive anything for premedication.
The diabetic protocol for phacoemulsification consist in tramadol 2 mg/kg iv for premedication, induction with midazolam 0,4 mg/kg and propofol at effect. Maintenance of anesthesia has been achieved using isoflurane like inhalant agent and mixture of fentanyl, lidocaine and ketamine. The glucose level was measured before and every hour during anesthesia.
For all patients, cats and dogs, the induction was performed with propofol and midazolam 0,4 mg/kg and topical laryngeal lidocaine was used prior to intubation. One cat received the ketamine-propofol combination for induction.
The cough response at ETI was observed for 3 dogs, the patient that receive tramadol in premedication and the others that was not premedicated and 2 cats. In propofol anaesthetized dogs iv and topical laryngeal lidocaine attenuated the pressor response to ETI where iv lidocaine reduced the cough response.
Duration of the anesthesia from intubation to extubation was 80 min ±10 min depending of the surgical procedure, unilateral/bilateral cataract.
After induction, a rotation of the eyes towards the internal angle was observed. To achieve the phacoemulsification surgery, the eye was brought to the central position by means of the traction sutures.
Cardiovascular and respiratory parameters were well maintained during induction, maintenance and recovery periods for all patients. All patients receive Ringer Lactate infusion at 5 ml/kg/h. The anesthesia was maintained with isoflurane delivered via a rebreathing anesthetic circuit with the oxygen flow rate set at 60 ml/kg/min and vaporizer setting of 2%. This was completed by analgesia offered by combination of fentanyl-lidocaine-ketamine for dogs and fentanyl CRI for cats. The doses utilized for fentanyl was 4 μg/kg/h in combination with lidocaine 2 mg/kg/h and ketamine 0,6 mg/kg/h and when fentanyl was used alone, the dose was between 5-10 μg/kg/h.
Pulse oximetry was used to monitor oxygen saturation of hemoglobin in arterial blood and was maintained at >95%. MAP was measured using automated oscillometry and was stabilized at 80-110 mmHg.
Respiratory rate, end-tidal carbon dioxide was provided by capnography. The respiratory rate was maintained at 10 ± 5 rpm and the level of CO2 was 45-60 mmHg. All patients breathed themselves spontaneously, just one cat need the controlled ventilation because of the elevated level of EtCO2, up to 65 mmHg and the low respiratory rate.
For all patients the recovery from anesthesia was fast and without any complication. The temperature at the end of anesthesia was 37,2 ± 5ºC.
The ideal anesthetic protocol for cataract surgery should provide central position of the eye, decrease the ocular muscle tone, provide analgesia and narcosis for optimal operating conditions, be safe for the patient and comfortable for the surgeon  (Fig. 5).
Good communication with the surgeon before the procedure and an understanding of the surgeon’s requirements are essential when formulating an anesthesia plan. The patient position with the head lower than the heart should also be avoided and at 15 degrees head-up position during intraocular surgery has been recommended in humans.
Also, the position of the animal during surgery may influence the choice of breathing system and endotracheal tube (ETT). Related to intubation should be remembered that the mouth during tracheal intubation can increase IOP as the choroid process of the mandible moves into the orbit. Care must be taken when positioning patients for tracheal intubation, as pressure may be exerted on the globe while the maxilla is held; this is especially the case for brachycephalic breeds. An armored ETT is recommended to use.
The ability to influence IOP is very important part of anesthesia management. Is necessary to avoid increased IOP because in these circumstances may result in a globe rupture, risk for intraocular bleeding or retinal detachment.
The use of ketamine, a dissociative anesthetic, for ophthalmologic procedures is controversial. Ketamine used alone is likely to significantly increase IOP because it causes an increase in extraocular muscle tone . The good benefits of ketamine administration consist in increased of the amount of circulating norepinephrine, increase in peripheral arteriolar resistance and muscle activity and decrease the extent of redistribution hypothermia . The use of ketamine has beneficial effects on the blood pressure, cardiac output, corporal temperature and contributes to realization of a balanced anesthesia based on a multimodal analgesia. On the other hand, ketamine can increase IOP but considering that in the protocols used in this study was never used alone and the fact that the surgical procedure involves making a break through the incision of the cornea and penetrating the eye globe this pressure can be adjusted naturally without becoming hazardous for the structures of the eye.
Is mandatory to avoid coughing, sneezing, vomits when there is a risk of globe rupture because this can result in an increased central venous pressure . Therefore, drugs like morphine that causes vomiting should be avoided. On the other hand, the use of alpha 2 adrenergic agonist is not prohibited; although may induce vomiting especially in cats the alpha 2 adrenergic agonist can be very useful when we are dealing with uncooperative patients and the risk of globe rupture is bigger because of the stress and manipulation. In this study, for avoiding the coughing response was used lidocaine. Both iv and topical laryngeal lidocaine attenuated the pressor response to ETI and iv lidocaine 2 mg/kg reduced the cough response to ETI in propofol anaesthetized dogs  .
Intraocular blood volume is influenced by intraocular vascular tone (vasodilatation or vasoconstriction), arterial blood pressure (ABP) and outflow of the blood from the globe . Is well known that exist an inverse proportional relationship between arterial carbon dioxide tension (PaCO2) and vascular tone. Increased carbon dioxide tension causes choroidal vessel vasodilatation and an increase in IOP. Hypoxaemia can be detect using pulse oximetry and should be avoided by oxygen supplementation and ventilation. PaCO2 can be monitored by capnography or arterial blood gas analysis and controlled using IPPV. However, inappropriate use of IPPV can increase CVP by increasing intrathoracic pressure during inspiration, resulting in an increase in IOP.
Cataract phacoemulsification is not a very painful procedure except during the incision and suturing of the corneal limbus. Traditionally, most anesthetic molecules mildly decrease IOP by increasing the outflow of aqueous humor. The use of anesthetic induction agents such as propofol, alfaxalone, ketamine and etomidate may all increase IOP. All are ameliorated by co-induction agents like opioids, midazolam or diazepam .
One limitation to the present study was the small number of the patients (sixteen animals – eleven dogs and five cats) used.
In conclusion, if the realization of the neuromuscular block for phacoemulsification is not possible, we can perform anesthesia for this procedure using just the standard molecules like lidocaine, propofol, midazolam, fentanyl, ketamine and tramadol. The recovery period after a classic anesthesia without neuromuscular block is much shorter than that achieved after a curarisation and the probability for hypotension is less likely. On the other hand, after induction, a basculation of the eyes towards the internal angle was observed for all studied cases. In order to achieve the phacoemulsification surgery, the eye was brought to the central position by means of the traction sutures.
The great disadvantage is the fact that without neuromuscular blocking agents we can`t obtain the central position of the eye globe and that implicate make some compromises from the surgeon.