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Technology Upgrade for Cataract Surgery at the AEC

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Cataract surgery in the dog is a highly successful procedure that many owners have chosen for their four-legged friends to regain or improve vision. Cataracts in general and a brief discussion of the preoperative workup and surgery is presented in a prior post that you can peruse if interested titled Cataracts in the Dog. (You can find this older post if you scroll to the bottom of this page and click on Older Entries.) Removal of an opaque, cataractous lens is an elective procedure that is chosen if we feel we can improve our dog’s quality of life by returning his or her vision. This surgery is rewarding for dog, owner and doctor as it can truly bring the “puppy” back in many dogs whose lifestyle had changed with a loss of sight. Nothing beats watching the joy on our client’s faces as their dog ambles back into their arms and makes eye contact after surgery!

The technical aspects of this surgery have evolved over the years with the goal to improve the ultimate success of the procedure. These improvements involve everything from patient selection and timing, pre- and post-operative medical management, surgical technique, quality and type of lens implants, instrumentation and last but not least the science of the cataract surgery machine itself. Veterinary medicine often trails human medicine when it comes to technical advances primarily due to the financial limitations of the very expensive equipment used for diagnosis and treament of many diseases. Here at the AEC, were are proud to introduce an upgrade to the most recent technology for cataract extraction in the dog in the form of a new cataract surgery machine, the Alcon Infiniti, and this post will focus on this machine.

Our new Alcon Infiniti Vision System

Our new Alcon Infiniti Vision System

Cataract removal is primarily achieved by what is called phacoemulsification. In general, a small, beveled needle is introduced into the eye through a 3mm incision. While concurrently irrigating with fluid and aspirating it out, the needle will vibrate with ultrasound power to break the cataract into small pieces that are ultimately sucked out through the tip. Very cool! As you can imagine, there are numerous factors that are involved to make this work. How fast do you introduce the fluid? How much suction do you need to suck the fluid and lens pieces out while keeping the eye inflated? How much ultrasound power do you safely use to break up the lens without disrupting the other structures? How do you create a handpiece to deliver this energy inside the eye? How do you minimize the heat and inflammation that is generated in the process? Lot’s of smart people have worked on these and many other issues to help create different machines to maximize success while miniimizing risk.

The main feature that makes the Infiniti and its Ozil handpiece better is the development of torsional or elliptical phaco. Standard phaco, used for the last 30-40 years, is in a longitudinal mode. The action of the needle is in an in-and-out motion that “jackhammers” the lens material into small pieces. The torsional movement this system features adds a side-to-side motion that shears the cataract as well. This combination creates two benefits. It reduces the heat that is created during the process which can affect inflammation and incision quality and it keeps the pieces stuck to the tip to allow faster breakdown and removal.

Other advances with the pump system help add a smoother delivery and removal of the fluid while protecting against “surge” of the fluid that disrupts the evenness of the procedure. I could go into this and other parameters in more detail here but the take home point for us and your pet is that the procedure becomes faster, easier and less traumatic with this new technology. The biggest difference between a human and a dog getting cataract surgery is that dogs generate more inflammation than people with similar ocular trauma. And inflammation after surgery is the linchpin of complication. Thus, if we can decrease our inflammation by utilizing the above upgrades we should see better success. Our pets are thus benefiting from these advances and possibly to a greater degree than people in respect to inflammation. We are excited to have this new machine in our clinic and maybe your dog will see the reason why!

Summertime Blues!

summertime blues

Summer is here in New England and hopefully all are out and about doing what they like to do when the weather is warm. If anyone complains of heat and humidity I am going to send them right back to February so they remember what cold feels like! I am a sun and fun lover so you won’t hear me complain…no summertime blues for me!

Blue shows up in veterinary medicine in a handful of different ways. We have blue-eyed dogs and Russian Blue cats, blue merle coloring and Blue Amazon parrots. When the eye is blue, that usually refers to the cornea which can get a bluish caste to it with many disease processes. What is going on when this occurs?

The cornea is clear window in the front of the eye that allows the light to pass through it on the way back to the retina. Clarity is essential here and many diseases processes will negatively affect the cornea and alter its appearance and function. A lecture I commonly give to general practitioners prompted by a good friend and mentor Dr. Chris Murphy boils down these changes to seven distinct corneal opacities. The one attributed to the blue color is called edema.

Normal clear cat cornea

Normal clear cat cornea

Edema is essentially fluid that gets into tissue which makes it swell. A strict definition would be “the accumulation of an excessive amount of watery fluid in cells, tissue or cavities”. As you can imagine, this occurs in many locations in the body such as your ankles if they swell up after a long day of hiking. This may or may not be associated with inflammation and many times is not uncomfortable. When referring to the cornea, this fluid can come from three locations.

First is from the tears. The cornea is in many ways a very fancy, clear skin. When in its normal state the tears moisturize and flow off just like water on skin. If there is a scratch or erosion on the surface, the protective outer barrier is breached and this fluid can now gain access to the deeper tissue. This will give the erosion a tint if not complicated by bacteria, vessels and other entities that will affect the clarity depending on the source of the erosion. Once the surface tissue heals, the edema will resolve.

Corneal ulcer (stains green) with perilesional edema (blue)

Corneal ulcer (stains green) with perilesional edema (blue)

Secondly, blood vessels can create edema. Vessels will enter into the cornea as a result of many issues, be it trauma, non-ulcerative inflammatory change, low-grade chronic irritation to name a few. As with vessels in any part of the body, elements from the blood stream can seep out of the vessels and into the local tissue if the integrity of the vessel is changed. Thus, a watery fraction of the blood can leak into the cornea creating a blue haze that surrounds the red vessels. This haze may resolve as the vessels regress when appropriately treated.

Extensive corneal inflammation with associated edema

Extensive corneal inflammation with associated edema

Lastly, fluid from inside the eye can leak into the cornea. Similar to the external surface, the internal surface of the cornea is a barrier to fluid migration. On the outer surface, the cornea is also exposed to air and we need to protect against drying by blinking to distribute the tears. We can also alter the amount of fluid present based on comfort, health and emotion. The internal surface, contrarily, is constantly bathed in fluid like the inside of a fish tank. This internal surface is built differently with a layer with pumps called the corneal endothelium that actively pulls fluid out of the cornea. If these pumps quit working properly more fluid will migrate in than gets pumped out. When this occurs, the cornea swells like a new sponge when it gets wet and, voila, it turns blue. Unfortunately, we only gets so many pumps at birth and can’t make new ones. So if these cells are not built right, become damaged, or start degenerating there is very little we can do in veterinary medicine.


Endothelial disease causing focal edema

Endothelial disease causing focal edema

Treatment of cornea edema then relates to the underlying cause. If associated with a surface defect, topical antibiotics or manipulation of the corneal surface as described in our post about indolent erosions may be warranted. If secondary to inflammation, a topical antiinflammatory like a cortisone or aspirin-based drug may be appropriate. And if the endothelial layer is faltering, we may need to treat for the intraocular disease that is creating it like glaucoma or uveitis. And if degenerative change or developmental anomaly is at the root of the problem we may be relegated to following for discomfort rather than trying to “remove” the fluid. In humans, a corneal transplant with a fresh, healthy, viable layer of pumps can be utilized to improve the clarity in patients with primary endothelial disease. This does not work in our patients to date due to the resultant inflammation from the procedure itself that will form a scar of the donor graft rather than maintaining clarity. This is truly unfortunate as lots of older dogs and predisposed breeds like the Boston Terrier will get dense edema that will ultimately affect the quality of their vision.

Where can discomfort come from? In cases of extensive edema, the fluid may start to accumulate under the external surface and form blisters rather than maintaining in the swollen sponge mode. Most are small but some can be quite impressive as shown in the image below. If these smaller blisters rupture a superficial erosion will now be present that can be a challenge to heal in such a soggy environment. In this situation, salt-based ointments may be used to try and locally dehydrate the blister to help it heal and may be needed as a maintenance drug to prevent blister formation. Sometimes surgery is necessary to stabilize the region if it is too wet to heal normally.

Large corneal bullae in a Boston Terrier

Large corneal bullae in a Boston Terrier

There’s more we could talk about but I will save that for another day. It’s nice outside so we are heading out to enjoy it! Have a great summer!

ACVO Diplomates Giving Back

I am always in awe of how animals enhance and improve our daily life. Whether it is the friendly greeting every day when I come downstairs in the morning or the benefit of the evening walk that I do even if I am not in the mood, to see that unrestrained, unconditional love regardless of the day or mood is priceless. The warm body on a lap during a cold day, the cat rubbing up on your legs awaiting some attention, the look of earnest when you are feeling down, pets of all types fill a very important niche in

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Those darned corneal erosions that won’t heal!

I frequently get asked “what is the most common problem you see?”. The long answer is “depends!” as different species get different diseases, different breeds get different problems, and some problems are seasonal and others are year round. So the allergic conjunctivitis may be absent in winter but cataracts occur at any time and at any age. But one of the problems that shows up on our doorstep on a regular basis is the non-healing corneal erosion in the dog. Your poor friend may be squinting and pawing for weeks in spite of repeated attempts to heal with various

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Losing an eye; it is not a bad as you think…

I was stunned to see the last posted picture on the front page here had snow all over the building and I was talking about our wonderful warm environment that is present year round. Now the warmth of summer is waning and we are all holding on to those last few days with green trees and sunny skies. A beautiful summer was our just reward after such a harsh winter! And September was equally nice!

Our pets have survived as well, and do through many adverse conditions and illnesses that would knock us for a loop. We can learn a lot

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A Warm Environment in the Cold Weather

Been cold enough for you out there? It sure has been for me. I like winter. I enjoy skiing, sledding with the kids, playing frisbee with my dog Tess after a fresh snow, the Winter Olympics this year. a warm fire, Christmas….but wait! I feel like it has been about 9 degrees all season long. Trust me, this is not a big complaint. I lived in Wisconsin for 7 years so this is nothing. And don’t get me started on snow days at school when it closes if it might snow! Alas, that’s one reason we live here is the

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What is the coolest animal you have seen?

This may be one of the more common cocktail party questions that veterinary ophthalmologists get asked! Not that eyes in any species are not cool, but a little exotic flavor can spice up the conversation. Fortunately for us veterinary ophthalmologists, the anatomy of the eye is very similar from species to species. There are significant changes when going from mammal to bird to fish since the anatomy is altered to maximize performance depending on the environment in which an animal lives, however, the main structures are present in most eyes. Disease states will also be different based on these living

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Put Another Lid on It!

Welcome back from the holidays! Hope everyone had a wonderful season full of family joy and giving. Our family here at the Animal Eye Clinic had no complaints as apparently all were on the “nice” list and the New Year rang in sweetly. And now that we have weathered the latest series of storms, I guess it means back to work for all full time!

We had last started a discussion about lid disease. We see lots of patients here with a variety of lid maladies that affect its position, function and appearance. Some are genetic in origin, many are acquired

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Merry Christmas!

From all of us at the Animal Eye Clinic to all of you, may you have a very Merry Christmas, a Happy Hanukkah and a Happy New Year! May your travels be safe and family be healthy and happy. We all hope and pray that the new year will fill us with peace and prosperity after such a trying 2012 especially here in the Northeast. Many thanks to all who visit us here in Wilton as we try our best in our little niche to help you and your furry friends at home stay comfortable and sighted!

Lisamarie, Katie, Christina,

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Put a lid on it!

The eyelid is involved in many diseases that we see and treat on a regular basis. Its function to protect the eye is an important one, whether it be to act as a barrier to prevent direct trauma, to limit bright light irritation or to distribute the tear over the corneal surface. Some species have an extra lid where others have no lids at all! I’ll take a couple of posts to address the lids and we will concentrate on congenital issues here. So take off your lid and stay awhile as we talk about the eyelid and some of

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