Wednesday, November 26, 2008

Horror-show Eyes

For some reason - perhaps because we're such a visual species, perhaps because it's a sensitive structure - eye things tend to freak people out. My own older sister told me, when I graduated vet school, "You know, I always wanted to be a vet when I was little."

I goggled at her. "Then why aren't you? You're more than smart enough."

"One day I was in the vet barn and I saw someone doing an operation on a cow's eye. I knew right then that this was not for me," she said.

Huh. What do you know. She's not a squeamish girl, my sis, and she's very accomplished in any number of areas, including taking care of the basics on her own livestock. But the eye thing got to her.

I've had the most hysterical phone calls on emergency regarding eye stuff. One time a woman called me in a complete weeping panic because her dog's eye was out of the socket. I admit this is a serious problem, but the owner was so panicky that I said, for the first time ever, "I need you to be REALLY careful when you drive in to the clinic."

"What does my driving have to do with anything?" she shrieked at me. "I just want you to come help my dog!"

"I'm on my way," I said, "but I'm concerned about you getting there safely. It's dark and the roads are icy. Ditching your vehicle isn't going to get your dog to the hospital faster."

"Fine!" she spat at me, hanging up. I drove in to the clinic and found the owner pulling in just ahead of me. Well, at least she got there in one piece. I did my intake quickly and sedated the dog, who indeed did have a big scary-looking proptosis, a condition in which the eye has been pushed out of the socket and is residing on the OUTSIDE of the eyelids, rather than behind them, where it belongs. I will grant you that this is a horrific-looking sight to most people; the eye is bulging and red and the normally-glossy cornea is often dried to a dull, sticky, dead-looking mess. The eye appears enormous, since we're not used to looking at the entire globe of the eye, just the relatively small portion normally visible through the open lids. It's common that the pupil is dilated, so the blue-green deer-in-the-headlights gleam of the tapetum (the reflective layer that glows when bright light illuminates an animal in the dark) is usually creepily visible, even through the gummy dead haze of the dessicated cornea. Often enough there is hair or dirt or other debris stuck to the surface; this is deeply distressing to many people, since we all know what it feels like to have even a single hair or a tiny speck of dust get in our eyes, let alone having gobs of the stuff plastered all over it.

Once the dog was asleep and safely intubated, the woman draws a deep breath and lets it out on a long, tremulous sigh. Her entire frame relaxes. Now that the dog is in my hands, and the responsibility is out of hers, the truthfully quite warm and pleasant person she actually is resurfaces abruptly. She smiles at me.

"I'm so glad you told me to be careful on the way in. You were right; even trying to be careful, I almost put the van in a ditch."

"Well, these kinds of eyes are pretty creepy-looking," I allow. "Nearly everyone freaks out when they see them."

I set to work trying to replace the eye in the socket. Unfortunately, our victim is a sturdy little cattle dog, a breed that typically has a normal to deep-set socket and a tight eyelid. That's unfortunate in the sense that it generally takes more trauma to proptose that kind of eye than it does to proptose the eye of, say, a Pekingese, who normally have large, prominent eyes in a shallow socket, and who can occasionally proptose their eyes all on their own, with no outside forces applied. Somewhat more unfortunate is the fact that the proptosis is of unknown duration, but probably at least a few hours old; the owner had been loading firewood with her family, the dogs running around in the dark as they did so. The owner had heard a short spat between the dogs, but thought nothing of it; the dogs were still running around, and there was no squealing or clinging other sign that there was a problem, and it was already too dark for the owner to get a good look without a concerted effort. Cattle dogs are stoic and tough, in general, so it probably didn't cross this dog's mind to complain about a little thing like having your eye hanging out of the socket.

Because there are a pair of small nicks in the eyelids, I assume that a face-bite during the dog squabble is the cause of the proptosis, though of course there's no knowing for sure. Unfortunately, that had occurred almost three hours previously, so there's bound to be significant swelling behind the eye now. Whee. My job just got more difficult.

Replacing a proptosed eye is deeply satisfying, in part because it's just wrong to have your eye hanging out on your face, and it is therefore very rewarding to put it back where it belongs. It's also satisfying because the procedure is kind of slick, and it just looks so cool when you pop it back into place.

Naturally I start by lavaging the eye with saline to get all the stuck-on gunk off it and to try to rehydrate the cornea as best I can, discovering in the process a broad but fortunately superficial corneal abrasion. That should heal without incident. There's a large and slightly bulging hematoma on this dog's sclera (the white of the eye), but no punctures. If the globe was not intact, this dog would be facing an enucleation, where we remove the ruptured eyeball. But so far, so good.

Now comes the tricky part, where I have to set some stay sutures in the lids. This involves setting a suture that passes from the lower lid to the upper, whist skipping over the protruding eyeball. This is a bit of a challenge, because the stay sutures should be set as close as possible to the edge of the lid, which is, quite naturally, deeply hidden behind the bulging curve of the eyeball. Since I don't want to poke the eyeball itself, this requires some careful manipulation. However, I soon have three stay sutures set, long ends trailing above and below the eye, the middles loosely arched above the globe. Under these arches I slip the well-lubricated and bladeless handle of a scalpel, pressed flat against the eyeball, while with the other hand I gather up all six of the ends of the stay sutures.

Now comes the fun part. Using the scalpel handle to push down on the globe, I pull on the stay sutures to draw the edges of the eyelids forward. The lid edges stretch to accommodate the girth of the eyeball - a larger stretch than they were ever intended to make, but one which, after all, they've already done once tonight, when they let the eyeball pop out - and presto, the eye is back in its socket.

It's still bulging, of course; there's swelling and maybe some bleeding behind the eye, making it press forward, and there may be some tearing of the quintet of muscles behind the eye. I'm concerned in this case about that, as well as damage to the optic nerve. I warn the owner that the dog may still be blind, and that if the muscles behind the eye - or the nerves that run them - were too badly damaged, the dog's eye set may never be strait, and that it might not be able to rotate the eye normally and synchronously with the other eye.

"I don't care," the owner says passionately. "I'm just happy the eye is back in the socket."

I slather on a large amount of antibiotic ointment, remove my stay sutures, and stitch the eyelids together over the dome of the bulging eye. This applies pressure to the eye to encourage it to go back to its normal anatomical position, as well as protecting the cornea; the dog won't be able to close her lids completely on her own until the eye sinks further back into its socket, and if she can't close the lids the cornea will dry out and be prone to further injury. The cornea is not fond of either circumstance, I assure you, so it will be much happier being smooshed behind a perfectly good pair of eyelids, even if they are sewn shut. I've used stents - made from sections cut from a piece of a red rubber French catheter - to prevent the sutures from pulling through the eyelid, so the dog has short hyphens of red decorating her upper and lower eyelids. She looks as if she is trying to signal us in Morse code (but all she can say is "O, O" - which may not be inappropriate, under the circumstances.)

I recover the dog from her anesthetic, advising the owner on medications to go home, timing for rechecks and sutures out, and the possible complications, such as secondary glaucoma and eye infections, reiterating the possibility that the dog may be blind in that eye. The owner absorbs all this happily, a rapt expression on her face, and asks intelligent questions. She takes her groggy but ambulatory dog out the door a short time later, pockets rattling with pill bottles and a with a wry promise to be careful on her drive home.

The dog did well in some respects; her corneal abrasion and scleral hematoma healed up completely. Unfortunately, she apparently had some optic nerve damage; while she seemed able to distinguish light and shadow on the injured side, she did not have normal vision. The retrobulbar muscles were damaged as well, so that her eye always tilted up about 30 degrees from true, although it could move laterally in concert with the other eye. But she never did develop glaucoma, and the eye remained comfortable and somewhat functional for the rest of her life. It wasn't a perfect outcome biologically, from the point of view (so to speak) of the eye; but both the owner and the dog were happy, so in the end I guess it was good enough. There was literally no more I could have done; trying to repair the retrobulbar muscles or the optic nerve would have been well beyond my skills and my training. I'm not sure even an ophthalmologist could have done more, given the time elapsed from the onset of injury to the onset of treatment, but in any case it was a moot point: there was at the time none available in the state of Alaska.

I became quite fond of that owner. It still makes me smile to remember how abrupt and complete her transformation was from frantic and strident to her true personality, which was uniformly kind, warm, pleasant, and generous. All it took to reveal that was the simple transfer of responsibility for the eye disaster from her hands to mine. No other emergency or extremity ever produced such a reaction in her, either; she had to have been stressed well beyond her normal limits that night.

Horror-show eyes will do that to you.


Anonymous said...

Wow what a story. Think I would be a mess if that happened to my dog.

AKDD said...

It's pretty freaky to look at, all right. Mostly they work out okay, though, amazingly enough.

Laura said...

That is exactly what happened to my Sophie Dawg. She popped her eye out with a kayak about six years ago. Like your patient, she lost some vision, and her eye is now tilted about 30 degrees "northeast." But the eye is healthy and she is happy. And like your client, I was a complete mess when it happened, and I am forever grateful to the wonderful vets at the Q Street Emergency Vet Clinic in Springfield, OR, for saving her eye. It's a good thing the vets don't get so freaked out by icky eye stuff!

AKDD said...

She popped it out with a KAYAK? Didn't anyone ever tell her you're not supposed to use a kayak on your eye? :D (And: YIKES!)

I will say that early on, when you're just starting out, there are any number of things that kind of freak you right out. You just learn to remain externally calm (so as not to panic the client) while your adrenal glands are doing the cha-cha on the inside. After a while, though, you've seen more stuff and you have a better idea of what you can do, so you freak a bit less. Even if you don't know what to do, you can usually figure out what to do NEXT, and that will lead you to the step after that and the step after that. Pretty soon, lo and behold, you're practially done. At least, that's how it worked for me.

Anonymous said...

I find eye stuff kind of interesting. I remember reading in some emergency medicine book or other (back when I was going to be JUST LIKE MY BIG SISTER AND BE A SURGEON AND ALL THAT) about how to get an eyeball back in the socket. I thought it was pretty cool that if you got it back quickly, there was usually no damage at all (barring what happened to get it out of the socket to start with).

MaskedMan said...

Eye injuries are definately yucky, but the whole business seems rather cool, too. I mean, I mentally wince at the description of the displaced orb, but at the same time, I'm figuring out the mechanics of the bite that could possibly have caused this (bad luck, a particularly curious angle, and a rather determined nip/bite) - I know cattle dogs well enough to guess how it might have gone down. Or maybe not - But I'm busily trying to figure it out. Then, I'm following along your very clear description of the process of restoration, and the whole thing seems... Well, cool.

As for maintaining a semblamce of calm in the face of dancing adrenal glands, well, all I can say is that the act of faking calm confidence often provides the discipline necessary to actually become calm - The need to behave in a certain way actually produces the real behavior that's being simulated. In short, 'faking it' causes you to actually 'make it.'
Yeah, I've been there a time or two.

It's kinda the same with the patient's owner - She undoubtably knew she was waaaaay out of her depth with the injury, but desperately needed the situation to be handled effectively. Once she was no longer responsible to taking effective action, she could back off and relax. Next time around, She already knew the drill, so didn't face the same pressures.

I doubt I'd have made a particularly good vet, but I can admire tallent when I see it.

Holly said...

I'm not squeamish about a lot, but a popped-out-eyeball might do it to me. As you said, it's just *wrong* to see it out of place. The thought of a partially blind dog does not bother me at all. In fact, I've often thought that as a training project I'd like either a blind or a deaf dog. Probably won't ever do it, but if one showed up at my house I am sure I would not turn it away.

Good Job on the patient handling and on the surgery to get that dog more comfortable.

elegy said...

Eyeballs squick me out. Even though I've been working in vet hospitals for over five years now, and even though I've assisted in enucleations, I still had to stay out of the back the day my own dog had his eye out (glaucoma).

On the other side of things, the tech student we had there on externship at the time took my dog's eye home in a jar. So. There are those people out there too.

Sheri said...

Thanks for sharing all of the stories -- I have been enjoying them very much ever since "finding" your blog from the 3 Woofs and a Woo blog. I grew up west of Denver so have been trying to figure out if I recognize anything when you talk about Colorado (don't think so so far unless you worked at the Arapahoe Park race track...). While I love animals, I am, I'm afraid, much too squeamish to have been a vet and so appreciate all my vet(s) have done over the years to help the various dogs, cats and horses that have been in my care. The eye story reminded me of a cat I had that would get in fights from time to time requiring all sorts of veterinary care (one time he had a surgical tube sewn into his side to allow a particularly nasty wound to drain). The one that reminded me, however, was when he came into the house one day with his eyelid swollen shut. My husband at the time was trying to open the lid to see if sometihng was wrong when it "popped". I still can't get over a 250 lb. man screaming "OMG his eye just popped!!" Fortunately, the cat's eye hadn't popped, just a cyst that had developed and all was well after that.

AKDD said...

Hedra, I had no idea you thought about being a vet. Mind you, you're doing much more hazardous duty, rearing 4 kids, but I'm sure you'd have been a fine dog doc, had you chosen to go that route. At least the eyes wouldn't have scared you off!

MM, thanks for saying it wsa a clear description (not to mention COOL!) :) - I try to convey these things without getting too technical (which generally just ends up being confusing). Glad to know I got the gist across.

BTW, I am a BIG proponant of "fake it til you make it". Seems like if you can invent the behavior somehow, it leads you to the doorway of where it really dwells within yourself, and eventually (if you practice) it becomes authentic.

Holly - thanks! I try to do a good job on these things (and all others, with varying success.) Elegy, I feel your pain... I felt a lot different about it when it was MY dog losing her eye (to cancer, when I was a freshman vet student.) I got over it, luckily. :D

Sheri, I'm glad you're enjoying the blog. It's fun to write. Hopefully you can all bear with me when I try to reply to comments during the migraine storms (etc) when I am likely to make peculiar mistakes that make no sense! :p Meanwhile, I did NOT work at Arapahoe, althugh I did once attend the races at Centennial, back in the dark ages when I was about 15 (BIL's older bro was a jockey, and we went to watch him race.) I don't even know if Centennial exists any more. I grew up in Ft. Collins, where the vet school is (and where I got two of my three degrees), but I lived in Denver (and associated suburbs) for a year or so before graduate school, and at various times for short stretches before that.