Entropion, the Feline Version. Why A Cream Can't Cure Everything.

Most examinations start the same way; Patient and clients escorted to an exam room by technician. Technician gets history, weight, temp and a summary of presenting need. This appointment was a little different from the get-go; cat on scale, parents waiting, and scribble in chart reads, "Client wants eye cream." I entered the room with an open mind and a blank exam chart page.

On the other side of the exam room door I was greeted with; "Doc, we are just here for a cream." Not much of a "hello," and straight to business.

But let me go back and set the stage. Sitting before me on the exam table was a cream colored rather tawdry looking fellow. Standing in front of him were his parents, an elderly coupe who also doubled as his muscle and protection. They were not here for a chat, they simply wanted an  eye cure cream,. They appeared to be on a tight schedule, and had no desire to meet me or start this relationship with a silly nicety like, "Pleasure to meet you Corky, I'm Dr. Magnifico. what brings you in to see me today?"

"OK, what kind of cream?" I replied. It is sometimes better to meet short and direct with the same and those routine examinations can get a bit mundane.

"Well, our friends had a dog with the same condition and their vet prescribed a cream which cleared it right up." Sit, sigh, fasten your seat belt. There is some mysterious illustrious miracle cream out there that never has a name,, yet people seek to find again,,perpetuate its elusive existence,  and the legend lives on. Much to the chagrin of every veterinarian there is not a cream that has magical powers. We treat a condition after it is diagnosed, then maybe after there is a cream. And, I promise we do not withhold the "miracle creams or pills" for the other clients.. After I explained this hey stepped away from the table and allowed me access to their cat, Corky.

"We saved the goop in the eye so you could see it." (For those of you out there who do this I would like to add a small polite humble side note; We know what goop looks like, and we believe you. And, personally, I am going to wipe it away becausse no one wants to sport goop in public. That's just embarrassing).

They rambled on for some time as I stood scribbling the important tidbits of information sprinkled between the miscellaneous stories of past veterinary experiences. It also seemed that they didn't see my white coat as bringing much to the proverbial treatment table..something about the "eye had been this way for years",,,"the goop gets bad and then a cream (still didn't know what cream we were referring to) gets it better,"  "Corky is an indoor only cat," and they "wanted the best for him." OK, common ground, I felt a bit more empowered and they took a pause.. (I think just to see if I was still present).

We are trained to start with a history. A good listener makes a good veterinarian. But the path to greatness is paved with good intentions and a thorough examination. 

This is what I saw..

Can you see Corky's problem?

 Maybe if you compare the top photo to this one?

Corky has entropion. His bottom eyelid rolls in and the hair on the lid brushes the cornea every time he blinks. This is painful and traumatic to the cornea. In an effort to reduce the irritation the eye produces excessive tears. The only way your eye knows how to get rid of an irritant is by flushing it out.

After a brief discussion and a tiny bit of  reinforcement that I was comfortable with both the diagnosis and treatment plan Corky's parents eagerly signed him up for his corrective surgery the following week. Turns out their initial gruff demeanor was just a case of over protective parents.. I have a very big place in my heart for people who adore their cats, and  they truly wanted nothing but the best for their Corky.

Corky left the exam with eye ointment to help heal the abraded cornea, updated vaccines and some pre-op blood work. His initial consult was $260.00. He was scheduled for surgery the next week, pending normal blood work.

Here he is on surgery day.

Entropion surgery entails correcting the eyelids so that they lay normally over the eye. This requires removing the slack or excessive skin so that it can open and close normally. This allows the tears to be evenly distributed, thereby keeping the eye clean, lubricated and protected. Corky had too much skin on the bottom lid. To tighten up this he needed an elliptical piece of skin removed.

 Corky also had an excessively long bottom lid so I shortened it.

Post-op Corky's right eye looks better already!

As with most patients with entropion, the condition is bilateral. Although Corky's left eye was not goopy it did roll in a little bit, and a little piece of lower lid was reoved to keep him squint free on the left side all of the rest of his days.

Post-op Corky has incisions under both eyes and an eyelid correction for the bottom lid on the right side outside (lateral).

Post-operatively Corky also needed an e-collar. Never over look this important medical device. A cat will lick or rub something that hurts. It is very important to keep the eyes protected from the paws rubbing, especially in light of needing to apply ophthalmic ointment every few hours. I know every pet hates an e-collar but they can save you both time (not needing to re-do the incisions), and money (again, not needing to re-do the surgery).  We place the e-collar on before they wake up completely as it can be difficult to do when they have all of their faculties and weapons on stand by.

Corky's surgery cost was $378.00. This included an i.v. catheter, i.v. fluids, anesthesia, entropion surgery bilaterally, pain medications post-op for three days, an e-collar, and ophthalmic antibiotics. 

Here is Corky at one week post-op, still a little bit of discharge but the cornea looks good, The eyelid is not red, swollen nor is it inverted and rubbing the eye.

The other important finding is that Corky holds his eyes open and they appear calm, quiet, and comfortable.

This is Corky at two weeks post-op. I do not charge for post-op re-checks. For me it is about encouraging compliance and monitoring, and assisting my clients and patients with an optimum outcome.

I spoke to Corky's parents today. It has been about a six weeks since his surgery. They reported that there has not been any eye discharge and that he is doing very well. Their only concern was that the hair we shaved for his i.v. catheter and around the eyes wasn't growing back as well or quickly as they had expected. I told them that sometimes this happens, we don't quite know why, but over time it should.

So, what I am most Thankful for this Thanksgiving? Having a job that I love, clients who love their pets, and a family to be surrounded by. Happy Thanksgiving Everyone!

If you have a pet question you can find a slew of helpful generous people at Pawbly.com. Pawbly is a free resource for pet people to ask questions, share advice, build relationships and we are always centered around how to provide better care and resources to pets. Pawbly is free for everyone.

If you would like to talk to me about my pet services at the clinic, Jarrettsville Vet, in Jarrettsville, Maryland, you can find information here. Or visit me on Twitter @FreePetAdvice.

Levi's Luck, and why we don't get a DVM degree online.

Levi’s story began very oddly.

Our first meeting.

I was called to the front desk one afternoon because, "There was an older gentleman in the reception area who had walked into the clinic and requested to talk with me."

I always get nervous when someone walks in off the street and asks for me by name. I knew I didn't have any appointments with anyone and he obviously was not a drug rep. (They, for reasons still not understood by me, always show up unannounced). I went out to the reception area and introduced myself with a hand shake, a smile, and a "hello." 

The man stood up, shook my hand and told me that we had already met and asked me if "I remembered this meeting?"

I slowly and quizzically said “No.” 

“I was here a few years ago with a friend who was here to euthanize his beagle.” (Still no recollection of any of this on my part). “You talked him out of euthanizing the dog because you believed he had a treatable medical condition and you said you would not euthanize the dog unless he was suffering and not treatable. I was so impressed by your compassion that I wanted to talk about my daughters dog with you.” (There was no dog with him. First red flag... Check).  

He went on to tell me that he had a 2 year old yellow lab that had had 2 seizures. He explained that his daughter was having some personal difficulties and that he and his wife were taking care of the dog, named Levi, for her. He went on to describe that Levi was a very active dog and they kept him outside in a chained enclosure. 

Somewhere in this discussion I asked him if he "was a client of ours?" 

“No, we bring our dogs to the clinic up the street.” (Red flag number 2. Check). He mentioned several times that he and his wife were “on a fixed income.” (I always secretly laugh at this. I mean, who isn't?) He went onto tell me that he had diagnosed Levi’s disease already. 

I asked "who had done this for him?" I expected he would tell me that the vet down the street had. 

Instead, I got “we found it on the internet.” (Red flag number 3. Check). Every vet in the world cringes inside when a client tells them that they have been doing their own vet school training online. 

When I asked him "What he based this diagnosis on?" 

He told me, that "Levi has had 2 seizures. The last one had lasted over 2 hours." And, that “it was really hard to watch him seizing for 2 hours, so he thought it would be better to euthanize him then let him suffer through another one of these.”

It was very clear that Levi needed a veterinarian to look at him. I told him that I would be happy to set up an appointment.

He asked "whether Levi’s presumed diagnosis was treatable?" 

I told him that "it certainly could be, but Levi needed an examination and work-up before anyone should diagnose him."

He then told me he was going to go back to the vet up the street and have him put down. He thought it would be cheaper than treating Levi.

I told him that "I believed this was immoral and unethical." I told him it was "$50 for a euthanasia here, which we would not do, and $45 for an examination." He once again repeated "that they were on a fixed income and he was sure that Levi was not treatable," and "he wouldn't put a penny out for him."

I had to take a deep breath and get out of the reception area. I was about to internally combust. 

"What the hell?" I thought. Did this man seriously just walk in here to tell me he was going to euthanize his dog? Was he asking for a professional opinion? Or a consent to his medical diagnosis? God help me not castrate him, or start screaming obscenities to him.  I asked him to follow me into the exam room. (Note to self, need to install sound proof walls in examination rooms). 

I realized that this dog, whom I had never met, owned by this man who wasn't a client, had no hope unless I agreed to do everything for free. I am happy to do pro bono work, but, I am indignant to provide it to people who can pay but would rather buy a new car, gun, cell phone, tattoo, or new replacement dog than help their companion when they need them most. 

I told him that he "could bring Levi in and sign him over to us and we would give him an examination, blood work, and come up with a treatment plan." He reiterated to me that he "would not pay for anything!" (I am not sure which part of free he was confused about?)


He left. I went to my office to settle my nerves. (Usually this means I take my dogs for a long walk). 

He came back the next day with Levi. I knew the minute I saw Levi that this was the right thing to do. Levi came bounding in the clinic door, tail wagging, tongue lashing out air kisses to everyone and everything he saw. I stopped thinking about how disappointed I was with this man and I reminded myself why I never choose the easy road. When I saw Levi I knew instantly that I loved this dog. He was all love but no manners. He looked like he had just escaped from dictatorship lead solitary confinement. Oh my goodness was he the worlds happiest dog!

As soon as the legal papers were signed we began performing every test we thought relevant, made up a treatment plan and observed him very closely. He had a seizure within the first few days with us. After a week I began calling clients to see if I could coerce someone into fostering him. I was very worried he might be having seizures at night that we weren't privy to. 

A seizure is a disorder at the level of the brain. In simplest terms it is what happens when the internal wiring and circuitry of your brain goes haywire. I remind my clients that it is always a life threatening event. I always make sure that my clients with pets that have seizures have an emergency plan. This includes emergency medications they can administer at home, and directions to the emergency facility if the medications don’t work.

Levi was tested for Lyme disease and was strongly positive for it. I was hoping that the seizures were a result of the Lyme disease. He also had a lot of discharge from his right eye. His right eye had what we call entropion. This means that the (lower eyelid in his case)rolls in and rubs the eye. If you have an eyelash, or other foreign body in your eye, you know it immediately and you try to remove it immediately. Think about having a whole bunch of hair rubbing your cornea (eyeball) every second of every day. You would do what he was doing, squint and tear, a lot!

Levi lived at the front desk for about three weeks. For every client who approached the front desk Levi would jump up, wag, and greet them. It was impossible to miss him, and impossible to dissuade him. He wanted to announce to the world that he was free and friendly. For one of our visiting clients Levi's hello caused her to fall in love with him even faster than I had. 

Within minutes of that smile she announced that she was "going home to tell her husband about him!" And, that she "was coming right back for him." She announced that she wasn't going home to ask permission, (the respectful thing to do in your marriage), but she loved Levi and needed to break it to her husband without the four legged bouncing boy breaking the news not-so- gently for her.  She came back a few hours later and took Levi home. I gave her a large supply of anti-seizure medications, explicit instructions, my cell phone number and an emergency plan. Levi did great in their home. He is still having seizures and is being treated for epilepsy (not the dreaded "untreatable" disease the internet had diagnosed him with). We also surgically corrected the eyelid deformity. His new family loves him immensely. He comes to visit often, tail wagging, kissing, and cuddling up to all of us. I am grateful everyday that he found a great home and that they love him in spite of his life-long disease. Levi has a great support system and medical team, dedicated to his well-being.

It has been about 6 months since Levi came to us. Last week the receptionists came to me, again, to say that there was "a man here to see me." This time I asked "whether or not I wanted to talk to him?" As soon as I saw him my heart sank. 

I trudged toward him and muttered a reluctant muffled “Hello.” 

“Do you remember me?” This time my answer was a definitive “Yes”.  

“I know I am not supposed to ask, and, you don’t have to tell me.” (the transfer of ownership papers he signed state very clearly that once JVC takes responsibility for a pet we do not give the former owners any further information on that pet). I took a deep breath again. I didn’t want to give him the satisfaction of relieving his guilt, (although now that I think about it, maybe he wanted to feel as if his medical diagnosis had been correct?). 

"He’s dead right? You had to euthanize him because he wasn't treatable. Right?”  

I confessed to him that Levi was doing very well. He had a wonderful family who loved him very much. After which he told me that he was going back to the breeder to buy a new puppy. 

I shed my professional composure suit. “You have no right to ever own another pet. You dumped Levi. A pet, just like every other living thing, requires time, care, AND, it might even  cost you a nickel if anything happens to them.” 

He stood up, said to me, “I knew you would be tough,” and left.

I am rethinking the walk in and request to see me thing.

If you would like to learn more about seizures, please see my blog on "Seizures What I Tell My Clients."

If you would like to learn more about entropion please see Corky's Story.


Meet Levi. This is pre-op for the eye. I will post post-op pictures in a few weeks, (after it has healed).

Happy Birthday Levi

"There is no such thing as too big to be a lap dog. Is there?"

Shotgun

Another grueling long day comes to an end.

Everybody needs a shoulder to lean on.

Pets With Santa

It has been over three years since I first met Levi. He is still a sweet, gentle, loving boy to a family who lost their son fighting overseas for our country a few years before Levi came into their lives. Levi remains at their side, helping to shoulder the grief of a loss that is deep and intensely painful. He has brought love, life, humor, joy, and levity into a family. His former family has no idea of what a wonder this boy is. To see one family purchase, chain, and then abandon and then another adopt, rescue, love, and honor the same dog is a true miracle and reminder of what the best of humanity looks like. 

There is always love to be found out there. Never give up on the power of second chances.

Update January 2016; I still see Levi every few months. I has been 5 years of watching him wag his way in the door. Many giggling visits with his family. Many tales of lab antics, silly dog capers, and he has remained the joy in a family who believes that the love he spreads far out weighs the condition he came with.

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Levi, January 2016.. he had a long day of playing in the snow.