Adventures in Canine Dermatology

Once Humphrey's eye issues finally resolved, the next issue to tackle is his coat and skin.

About a year ago, Humphrey's coat began thinning, starting on the hind legs, and gradually affecting the tail, and the lower half of his body. Wearing the cone of shame also led to hair loss and skin damage on the back of his neck. Luckily, the front of his body remains fine (for now).

Despite alopecia, Humphrey is currently looking good and feeling great!

Extensive diagnostic testing revealed no medical explanation. Blood tests sought answers, especially thyroid/hormonal irregularities (such as Cushings) that are often associated with symmetric patterns of hair loss like Humphrey experienced. His blood tests have remained clear for a full year.

He was checked for parasites (such as dermodex mites), infections, and yeast/fungus. Scrapings and a lab culture revealed nothing wrong. Initially, an examination under a Woods Lamp revealed an excess of possible yeast. So, for  a year, he endured Nizoral baths, with the hope that the active ingredient (the antifungal ketokonazole) would eliminate any excess yeast. For periods of time, he was bathed every 2 days, otherwise weekly. He was also prescribed several courses of antibiotics to help with management. It made little difference.

This is a fantastic overview of dog hair loss by Dr. Karen Campbell, a veterinarian and Professor Emeritus at the University of Missouri, titled "The Bald Patient" - with photos and all!

With everything else ruled out, it appears that Humphrey may be suffering from an autoimmune disorder called sebaceous adenitis - but this is a tentative diagnosis of exclusion. Lucky for Humphrey, sebaceous adenitis does not pose any health risks, and the resulting alopecia and skin dryness is purely cosmetic.

Beginning this summer, Humphrey will undergo some interventions to see if the hair loss can be stopped, and perhaps even regrown! The best overviews of the affliction and its treatment, upon which the following is based, are:

• Smith & McKay's overview in the journal "Compendium"
• Rosenkrantz's "Topical and Systemic Therapy for Sebhorriec Disorders" which appears in the proceedings  

Treatment of sebaceous adenitis can be pharmacological/systemic (with cyclosporine, tetracycline, and oral retinoids), supplement-based (essential fatty acids, vitamin A, zinc, biotin), or topical (a combination of mineral oil, topical essential fatty acids, moisturizers, and salicylic acid cleansers). Research suggests that topical treatment can be as effective as pharmacological/systemic while avoiding the dire potential side-effects of immunosuppressants (oral cyclosoporine) or heavy-duty antibiotics and retinoids (tetracycline).

Here's an overview of the recommended, non-systemic treatments.

Supplements (should be monitored by a veterinarian)

• Melatonin has been shown to work on various alopecias (hair loss) in animals. The dose should be 1 mg for dogs under 10 lbs, and 2mg or 3mg for dogs 10 to 20 lbs (larger doses for larger dogs) for a period of 8 to 12 weeks. Melatonin is widely used to treat dogs with various anxiety disorders.  Melatonin can be applied topically - and topic treatment has been shown to be effective in humans.
• Biotin can improve alopecia in cases where a dog has a biotin deficiency. The recommended dose is 5mg per 10 kg of body weight for 4 to 6 weeks. In a study of 119 cases, all responded to some degree, but only about half achieved significant improvement.
• Vitamin A, 1000 IU per kg of weight, not to exceed 20,000 IU 
• Omega 3 essential fatty acids, 180mg per 5 kg of mody weightin in a formulation of EPA and DHA. Ascenta/NutraSea is a widely available,cost-effective option formulated for dogs. 
• In some cases, Zinc supplementation may be warranted, where the skin quality shows signs of possible Zinc deficiency (and Zinc also helps to keep Vitamin A in one's system). Dosing of Zinc depends on the type: Zinc sulfate: 10mg/kg; Zinc guconal/gluconate, 2mg/kg.

Topical Washes

• SALICYLIC ACID WASH. For at least 4 weeks, shampooing with a salicylic acid shampoo after a few hours of intense moisturization (mineral oil or baby oil) is recommended. The salicylic acid removes excess topical oil, but also de-scales and exfoliates dead and dry skin that can block hair growth. Widely available options include Sebcur and Neutrogena T/Sal.

Topical Ointments and Oils (all are recommended, to work together to heal the skin)

• MINERAL OIL. A first line of defense is a weekly, 2 hour soak with baby oil or another mineral oil. The purpose of this is to moisturize the top layer of the skin, which is typically dried out  in cases of sebaceous adenitis. After applying oil to the whole body (which is sometimes recommended in a 50% water dilution), the excess can be washed away. Upon results in 4 to 8 weeks, the frequency of this step can be decreased.
• ESSENTIAL FATTY ACIDS (EFAs). In between the intense baby oil soaks, less oily but constant moisturization is recommended. First is using topical essential fatty acids (EFAs), which are widely available in beauty products in the form of botanical oils. For instance, sunflower oil, chia oil, and others are effective EFAs. Many are available at low cost. The Ordinary offers a pure chia oil for under $8 Canadian. Peas in a Pod offers Bottoms Up "bum spray" for babies that contains various EFAs and other moisturizing agents. Finally, Verb Ghost Dry Oil and Briogeo Farewell Frizz (a leave-in conditioner) both provide spray-on formulations that contain EFAs without too much mess. Studies published in medical journals on humans as well as on rats reveal that EFAs have benefits for healing and preventing lesions that far exceed mineral oil (e.g., those prone to pressure ulcers). For those with sebaceous adenitis, EFAs provide moisture to heal the skin and possibly hair follicles.
• MOISTURE-LOCKING TOPICALS. The research on sebaceous adenitis also recommends applying a moisture-locking preparation daily - usually a propylene glycol spray. This does not replace EFAs (which moisturize), but rather locks the moisture into skin and hair. Commercially, Naked Manicure Hydrating Hand and Body Serum is a non-greasy, propylene glycol solution. Alternately, there may be value in using a hyaluronic acid preparation to lock moisture into the skin and hair, such as The Ordinary's Hyaluronic Acid 2%.
• ANTI-INFLAMMATORY TOPICALS (E.G., PHYTOSPHINGOSINE). Research suggests value in applying phytosphingosine, which has anti-inflammatory properties and is part of the skin's natural lipd layer. It often appears in ceramide-based cosmetic creams for humans (since phytosphingosine is part of the ceramide structure) which can be used. It is a main ingredient in the Douxo Calm line for dogs (e.g., the Douxo Calm Mousse). A multi-tasking product from The Ordinary called Natural Moisturizing Factors + HA contains ceramides as well as hyaluronic acid may be a good substitute for the much more costly Douxo products (though may be more difficult to apply than the Douxo spray or mousse)
• MELATONIN is sometimes applied topically.

Other interventions may contribute to managing sebaceous adenitis that should be further explored. These include:

• Red light therapy, that is effective in human dermatology and hair loss.
• Microneedling (AKA, the Kim Kardashian Vampire Facial) has been effective in treating dogs with alopecia X that are resistant to other treatments. In addition to a study published in a veterinary journal, it is now practiced at Colorado State University's veterinary school (check out the dramatic before-and-after photos on their site). Nobody in Canada is currently practicing microneedling on dogs.  
• Urea-based creams that moisturize and may contribute to gentle exfoliation and de-scaling.
• Vitamin A topicals that could assist with  exfoliation and skin quality, such as Mad Hippie Vitamin A Serum (it is all natural and contains EFAs) or The Ordinary's Retinol 1% in Squaline (a bargain at $6!). Vitamin A is harsh on the skin - so must be used in small quantities and definitely not more than once weekly to start. However, since topical Vitamin A (Retinol) cause skin renewal, it might be beneficial for the exfoliation process, and avoids the dangers of oral retinoids which are sometimes prescribed to dogs. One caution is that topical Vitamin A causes sun sensitivity, so the skin to which it is applied should be covered when outdoors.
• Various essential fatty acid (EFA) masks and leave in treatments, such as Kiehl's Ginger Leaf and Hibiscus Firming Mask, or Weleda's Skin Food, could enhance the skin's moisure. These are rich oil-based pastes, so may pose some challenge in application on a dog with a dense coat.
• Omega 6 promotes dermal healing, both topically and orally (see Silva et al., 2018). While the earlier research emphasizes Omega 3 supplementation, it may be beneficial to also supplement Omega 6 (topically, sunflower oil is perhaps the best source of Omega 6). 
• Peppermint and rosemary essential oils (diluted in a carrier base of sesame and sweet almond oils) stimulate hair follicles and deliver moisture when massaged.

So now, we apply lotions and potions, and wait a month or two. Fingers crossed that these work!

UPDATE: 4 months later, Humphrey is experiencing some hair regrowth! The regrowth remains patchy, but the vet and the groomer commented on it without prompting.  It seems that his progress may be related to the following:
- 0.25 mg melatonin, orally, every night. This is about 1/12 the recommended dose for a dog his size experiencing Alopecia X, but it seems to work. Biotin supplements had no effect and were tried for about 6 weeks before melatonin.
- Oral Omega 3 supplement for dogs daily as directed on packaging.
- Weekly shampooing with Nizorol and a salicylic shampoo (a good option is LaRoche-Posay), and if necessary a wipe down with Clean & Clear's lemon exfoliating wipes.
- Weekly serum treatment with Elizabeth Arden ceramide pods on the affected areas right after bathing. The Elizabeth Arden pods (even when used mid-week) seem to cause immediate exfoliation of any dark spots that materialize. They also seem to deliver more sustained moisture to the skin than other products (perhaps this has to do with ceramides which purport to be identical to the skin).
- Daily moisturizing with a rotation of  Avene Cicalfate (it contains zinc, moisturizes without being gooey, and is a good barrier cream for bare skin in harsh weather), the sesame oil tincture containing peppermint essential oil, and an EFA treatment with Yves Rocher creme riche. It seems that Humphrey's skin's needs changed based on the weather, so his treatments are adjusted from day to day with this group of products.
- Occasional red light therapy using the now-defunct Tanda Luxe device (other options remain on the market). Humphrey does not love sitting still long enough to do a proper treatment, but it's a harmless process that probably yields some benefit to the skin if not hair follicles. The vet wondered if this wasn't the deal-maker in his progress.

On a related note, we have spoken with the vet about microneedling, and he is fascinated but (not surprisingly) unwilling to try. Presently, no local vets in Canada nor US locations surrounding Humphrey's home offer it. Depending on Humphrey's progress, we may attempt a DIY with the help of women who are skilled at doing their own (human) microneedling at home and swear it is not uncomfortable.

Treating dry eye - a work in progress

Humphrey's ophthalmologist has initiated some treatment for dry eyes. Keratoconjunctivitis sicca (or keratitis sicca) is chronic, bilateral desiccation of the conjunctiva and cornea due to an inadequate tear film. Humphrey has typically shown low-normal tear production on the Schirmer tear test (STT), but his values were never quite low enough to warrant formal treatment. Even after his recent corneal ulcers, his STT is unclear.

Humphrey's delighted expression the moment he learned his ulcer was healed and the cone was off for good!

Nonetheless, his STT history suggests he may benefit from attempting to increase tear production, as well as adding artificial lubrication. For the past 10 days, he has received OptixCare with hyaluron lubricating gel in his eyes multiple times a day, and it gives him immediate relief. In fact, he signals discomfort every so often by trying to paw at his face, and immediately stops when the gel is administered.

The next intervention recommended is the introduction of topical cyclosporine or tacrolimus. Often taken orally or intravenously, cyclosporine is an immunosuppressant used to treat rheumatoid arthritis, psoriasis, Crohn's disease, nephrotic syndrome, and in organ transplants to prevent rejection. But in ophthalmology, it is used topically in drops or gel to stimulate tear production.  Fun fact: ophthalmologic cyclosporine was originally developed for use in dogs, then adapted for humans as Restasis. Tacrolimus is typically also used as an anti-rejection medication when prescribed orally, but in veterinary ophthalmology it is applied topically to stimulate tear production.

In humans, a preparation of 0.05% cyclosporine is sufficient to stimulate tear production for people who suffer from dry eyes, but the proportion is different for dogs. veterinary A product called Optimmune® is widely available (and inexpensive compared to the human preparation!) at 0.2%, but Humphrey's ophthalmologist is considering up to a 2% preparation. However, Humphrey discovered that small dogs who received 2% experienced suppression of systemic lymphoblastogenesis, but not with 0.2%, suggesting that a lower concentration might be safer for a fellow his size.

Humphrey's opthalmologist prescribed tacrolimus 0.02% in an olive oil suspension - and it has worked extremely effectively. Upon his first dose, his scleritis (inflammation/redness of the sclera or whites of the eye) resolved! He will continue on EDTA as well, to manage mineral deposits that arrive in his eyes.

By the middle of July, as predicted, Humphrey's corneal lesions seem to have resolved - the scar tissue seems to be mostly gone, and his vision is restored, even in the bright sun!

This is a fantastic resolution to a very long and difficult healthcare journey!

Plasma for the eyes

Humphrey has benefited from ophthalmologic plasma drops in his eyes. He's decided to do a little further research to understand why, and if he might benefit from longer-term use of plasma.

Plasma has been used in ophthalmology for about 20 years, because plasma allows for a variety of therapeutic benefits based on its composition. An outstanding summary in Acta Ophthalmologica provides a comprehensive description of components, but  highlights include:

• epidermal growth factor (EGF) and transforming growth factor‐β (TGF‐β) which promotes tissue growth 
• fibromectin and fibroblas growth factor B (BFGF), which promote healing
• albumin
• a high concentration of vitamin A that reduces degradation of cytokines and growth factors
• nerve growth factor (NGF) that helps to restore the function of injured neurons

Plasma is are used to treat corneal problems and substitute for natural tears in some cases where the body cannot sufficiently produce tears according to he Review of Ophthalmology., as well as for lesions and healing after LASIK surgery.

In humans, autologous plasma (meaning the patient's own) is used, as well as donor plasma where the source is a blood bank. The UK's Queen Victoria Hospital produced an excellent informational document on the collection, preparation and use of autologous plasma for corneal disease, including dry eye.

According to the Review of Ophthalmology, ophthalmologic plasma can be pure, or diluted with sterile saline to contain 20%, 25% or 50% plasma serum to saline. In that article, a physician interviewed estimates about half of patients who try plasma receive sufficient benefit to continue with the costly drops.

So far, Humphrey has benefited from plasma obtained from the animal blood donor clinic, but his vet is able to create autologous serum for him for a cost of around $100. The latter, as far as he knows, would not be diluted.

2021 UPDATE: Humphrey needed plasma for his eyes in 2021, but could not get an appointment with an ophthalmologist in time to get sufficient plasma for every-two-hour instillation! No vets in the area carried it. So, he put his crack research skills to work and determined that it could indeed be ordered (by a vet) from the Canadian Animal Blood Bank in Alberta. For ophthalmologic use, the product is Canine Neonate Plasma, 5 ml for $20 in 2021 plus shipping. It shipped in 24 hours frozen, and each 5ml vial was sufficient for 2 or 3 days of drops instilled every 2 hours. We used fine-tipped glass eyedropper which we sterilized every day. Once unfrozen, the plasma is good for about 3 days (though one ophthalmologist told us it can be used for up to 5 days). If kept in the freezer, the vials are good indefinitely.

Humphrey's angelic look-a-like

A friend of Humphrey's remarked that he bore an uncanny resemblance to actor Michael Sheen in "The Good Fight." True enough (with the defiant grin, on a day he refused to come inside), but perhaps he resembles Sheen's angelic incarnation in "Good Omens" even more closely? You be the judge...

An at-home ophthalmology diagnostic lab? You bet!

Poor Humphrey suffered 3 corneal lesions in a matter of about 4 weeks. Odds are that he'll need a lot more corneal testing for suspected (or real) lesions in the future. Anytime he gets to squinting, or if his eyes are teary, or look a little cloudy, he'll need a fluorescien stain (or slit lamp evaluation) to be sure. This is going to get expensive!

Next stop: Shark Tank. Eat your heart out ,Mark Cuban!

Consider that to identify a corneal lesion or matter in the eye is pricey (about $85 in Toronto for a fluorescien stain)! PLUS the cost of a consultation bring it to a grand total of about $160! That's just with a general practitioner vet - add another $300 for a referral consultation with a veterinary ophthalmologist, and you're up to $500. Yet, you can purchase all the materials to do the test at home (as often as needed) for a fraction of the price.

Humphrey is considering setting up an amateur ophthalmology diagnostic lab in his basement. Here's his research so far (and this may be updated as he gathers more information!)...

The main test that will most certainly repeated on him in the near future is the fluorescein stain to determine if he has an actual lesion when he displays possible symptoms (squinting, teary eyes, or  clouds). This is the least expensive set of equipment and supplies.

First, you need a light to illuminate the dye you'll use. The  Fluoro-Dot™ Specialty Light is about $30 plus shipping to order. However, a 2015 study published in the medical Journal of the American Academy of Dermatology revealed that an LED black light was as effective as a specialty Wood's lamp or opthalmologic light, and can be obtained for as little as $5. The researchers in the study found that the Black Light Master, a 9-LED flashlight-style device, was as effective as specialty equipment ($3.55 with free shipping at the time of writing!). However, the sleek Bluminator (at $80) is the option for stylish armchair ophthalmologists who have the disposable income.

Then you need fluorescien dye or stain, which is about $15 to $30 for 100 strips (for example, this vendor has them for $12, this one for $15 - however in Canada they were reclassified in 2018 as medical equipment so are not as easy to obtain as they were before). And finally, you'll need some sterile eye wash, which is about $5. This video demonstrates the process of applying the stain. Basically the most an untrained eye can detect is lesion/no lesion/ulcer, but not the depth of a deep lesion or ulcer.

That means that the total supplies to do 100 fluorescien tests is between $25 and $45, depending on the deals you can find on the equipment and supplies (more expensive if you go for sleek design). Comparably, the retail cost of 100 tests at a Toronto veterinarian's office would be $8500 not including the consultation fee, which would double that.

Similarly, the Shirmer Tear Test (STT) can be done with strips that cost only $15 for 100. This is a very easy test - the papers are held to they eye, and produce a value. The general STT reference range 15 to 20 mm/min for a normal reading, but other factors can affect what the value actually means. For example, older dogs frequently have STT values lower than 15 mm/min but have no clinical signs of keratoconjunctivitis sicca (KCS).

Humphrey envisions that any at-home testing would be a prelude to a veterinary visit for treatment where necessary. Now that he has successfully conquered 3-ish corneal ulcers, he knows the protocol, and would just require professional confirmation of the diagnosis, and a script for antibiotic drops and plasma.

Ideally, a slit lamp would allow for more advanced diagnostics - a portable one is quite costly, but a smaller, handheld version is more affordable ranging from about $300 to $600 and can do the same types of things (magnification and lighting that allow you to see beneath the surface of the eye). Humphrey's highly trained ophthalmologist is able to determine the presence of a lesion using a handheld slit lamp without fluorescien dye (though in the past 6 weeks, he experienced at least 4 fluorescein stains at relatively great expense). Interestingly, the ER hospital he visited after hours a few weeks back did not have a slit lamp on site, much to the disappointment of the attending veterinarian! If Humphrey had brought his own, Dr. Chan could have provided him with a more complete examination and diagnosis.

A hand-held slit lamp can accompany Humphrey to the ER where they don't have one!

This offers an overview of using a slit lamp with photographs of human eyes.

A final piece of diagnostic equipment Humphrey is eyeing (no pun intended!) is a blood pressure monitor. He recently learned that blood pressure can cause certain eye problems, and was quite shocked to be charged $50 US for a simple reading. And for anyone concerned: his blood pressure was within the normal range in the vet's office, which is a stressful situation that often causes "white coat syndrome" even in dogs!

Though blood pressure reading is $50 at the veterinary hospital, an at-home blood pressure monitor for animals (with an appropriate cuff for a dog) is about $60 US on ebay - so basically, he could have had his own monitor for the cost of one reading + a fancy latte or two!

It appears that the more sophisticated monitors from veterinary supply companies are far more expensive, but they have features and parts unnecessary or at-home use (continuous monitoring features, a wide assortment of cuffs for animals of different sizes that one would need in a clinical setting but not for single-dog use).

In the coming days, Humphrey will be making some big purchase decisions, and hopes that a small investment (maybe as little as $25!) will save him thousands as he inevitably experiences weird ocular phenomena that can't be identified with the naked eye.

Contemplating the options, and daydreaming about an amateur lab.

Corneal Ulcers: Lessons Learned in Their Financialization, Treatment and Recovery

Does successful healing of 3 corneal ulcers involving treatment by 3 different board-certified ophthalmologists in two countries amount to expertise? Probably a little bit.

Humphrey wishes to share his experience, and hopes he won't have to go for a fourth round (but you never know - and we'll do better next time). Here, he rounds up lessons learned in terms of treatment and recovery, as well as the financialization of them.

If you're new to corneal lesions, be cautious, but don't panic! While they can be dangerous, if the ulcer is not too deep, there's a pretty good chance of full recovery. Once the ulcer heals, it can take a while (even months) for the scar tissue  to resolve. But usually, sight is eventually fully restored.

1. When to go to the vet for a suspected corneal ulcer
Squinting can indicate the first signs of an ulcer - squinting often implies eye pain. Humphrey was squinting, but also a cloudy, gray "dot" appeared on his eye - which is really bad! Excessive tears or discharge can be another sign. That usually suggests an infection. If these symptoms are present, it's not a bad time to take a dog to the vet!

To determine if the cornea is damaged, the vet will have to do a fluoroscien stain - where fluorescent dye is put on the eye to show a lesion or wound, because they normally aren't visible to the naked eye. It the tear is bad (see below), a vet may make a referral to an ophthalmologist.

2. Types of corneal ulcers: the not-good, the bad, and the ugly
Humphrey has noticed that ulcers are assessed along a couple of axes: depth, and infection.

First, there's the depth of the ulcer. The cornea is a transparent surface covering the eye - but it is made up of 4 layers (which I also described in a previous post), which you can see in the image below (source).



Humphrey has had 2 stromal ulcers (one in each eye) in the past 4 weeks, meaning that the depth was beyond the epithelium and Bowman's membrane. The deeper the ulcer the more dangerous it is - and the longer it takes to heal. His superficial ulcer (which was only the epithelium) healed in about a week, his first stromal ulcer took a little less than 3 weeks to fully heal. The second stromal ulcer is a work in progress, but has shown signs of very good healing without CXL (but with more frequent drops) within 2 days. To Humphrey's untrained eye, this one is healing much faster than the first one, and with a lot less discomfort.

In addition to the depth of the ulcer, an ophthalmologist will note if the ulcer is infected - the problem with an infection is that it eats away at the corneal tissue and prevents healing. This is called a melting corneal ulcer.  Humphrey has had 2 of these! The ophthalmomogist might use terms like "malacia" or "actively dying tissue" (which appeared in Humphrey's documentation). The danger is permanent loss of corneal tissue, and the worst case scenario is corneal perforation - where the infection eats away the entire cornea!  This can happen quickly with a bad infection (some reports say as quickly as a day or two). So far Humphrey has managed to catch his melting corneal ulcers in time, and prevented tissue loss deeper than the stroma.

3. Triage: Initial treatment
Different ophthalmologists have different approaches to triage and early treatment of corneal ulcers.

In Humphrey's first experience, Corneal Crosslinking (CXL) was strongly advised to kick-start healing. The problem with CXL (which is used in humans and dogs) is that how much the eye benefits is not truly known. It will definitely not harm the eye - because all it involves is adding a lot  of collagen in the form of riboflavin to the eye surface over about 20 minutes, then shining a special light on the eye. CXL is an emergency-type triage treatment and is followed by more conventional drop therapies to promote healing and stop infection. The other problem with CXL: it is (perplexingly - since it's so simple and done by vet techs) very expensive: $1200 in Toronto.

For Humphrey's second stromal ulcer, he saw a different ophthalmologist, who said she does not do CXL at all, because the evidence to support it is insufficient. "It's an adjunct therapy," she said. So the first course of treatment was drops every 2 hours.

That wink looks adorable, but it's actually Humphrey's discomfort when he had his first corneal ulcer!

4. Managing healing to recovery

All three of Humphrey's ophthalmologists put him on therapy with drops, with very slight variations in content, and different schedules. The first ophthalmologist had Humphrey  on atropine drops for pain once daily, and two antibiotics (Tobrex, Vigamox) plus plasma every 6 hours for 3 weeks. Healing was noted in a week, and the drops were continued for a total of 3 weeks.

The second ophthalmologist had Humphrey taking one antibiotic (Vigamox) and plasma every 2 hours for 3 days, then every 4 to 6 hours thereafter. The frequency was reduced only after a fluoroscien stain indicated improvement. Instead of a topical pain reliever (atropine), this vet prescribed an oral pain killer (tramadol) as needed. That second vet also recommended Opixcare eye lubricant, which seems to make a big difference in his comfort (Humphrey asked about a lubricant from the first vet because his eyes are always on the dry side, but was told it was not necessary).

Even in human medicine, the frequency of drops recommended by ophthalmologists seems to vary. Some reports suggest hourly plasma for the first couple of days, others every 2 hours, and others every 4 hours.

Antibiotics are important to eradicate the infection, and plasma promotes healing. For Humphrey, the plasma serum (which is actually plasma ophthalmologic serum that probably contains saline) comes from an animal blood bank. Plasma has been used in human and veterinary ophthalmology for about 20 years with great results - it contains enzymes that promote healing, tends to reduce inflammation and has no side effects in most users. Humphrey was told he can use it  as often as he wishes.

The order of drops matters: plasma first, then antibiotics, then lubricant. As well, all the  vets Humphrey consulted ordered at least 5 minutes between drops. And all ordered that the area around the eyes be kept free of debris (which means very, very gentle wiping with a cotton pad or compress).

Humphrey experienced a bit of confusion on how long to use thawed plasma serum (it is dispensed frozen). One vet said 2 to 3 days, another said up to a week. Extensive online research suggests that older advice was 2 to 3 days, but more recent studies on the degradation of plasma claim that so long as it's always kept refrigerated, it can have therapeutic benefits for about a week (though YMMV!).

Be sure to get an appropriate cone that will prevent rubbing against  the cone itself, as well as protect the eyes from debris. Two of Humphrey's three vets also said RexSpecs (see below!) are appropriate, but not Doggles. RexSpecs take a little getting used to, so it's not a bad idea to train a dog to wear them when they are young and healthy.

If corneal ulcers do not heal on their own, or if they are very deep (deeper than Humphrey's), surgical options exist, and apparently have high degrees of success. Solutions include corneal grafts and transplants. If a problem with the eye area (for example, inward-turning lashes) causes repeated ulcers, some can be surgically corrected to prevent further injury.

5. How to save a few bucks in buying supplies and selecting treatment
The best advice Humphrey can offer is to get multiple ophthalmologic opinions if you can afford it, and ask a LOT of questions. Sadly, sometimes you get no answer to a question, or competing advice (as with CXL). Then you have to make a choice.

Given that Humphrey's second ulcer healed fairly rapidly without CXL, he would not repeat this procedure, which would save $1200. The 2-hour frequency of drops worked well for him, though obviously poses a burden on caregivers.

Always price check medications! Humphrey could have saved hundreds of dollars by taking prescriptions to his local pharmacy. For example:

• Humphrey was charged $77 for compounded atropine, which was $17 at Shopper's drug mart
• Humphrey was charged $40 for generic Tobrex, $25 at the human pharmacy, and only $14 at the Toronto veterinary pharmacy!
• Humphrey was charged a whopping $70 US for generic Vigamox, which was $25 CD or $29 US at the pharmacy. Twice!
• Humphrey was charged $40 US for Optixcare eye lubricant which is $14 at the Toronto pet pharmacy without a prescription
• The cost of plasma serum varied between $50 US and $75 CD. The $50 amount was greater volume, but in a single dispenser which had to be discarded, whereas the $75 set was 5 loaded syringes that could be defrosted as needed and reduced  waste. This cannot be filled in a conventional pharmacy!

Hundreds of dollars of drops, and syringes filled with plasma serum!

Obviously, having to fill prescriptions at the pharmacy means extra trips, and delays the start of drops until picked up. But veterinarians in Ontario cannot deny a written prescription request (the Veterinarians Act RSO 1990 states this), so patients have every right to request this approach, bearing in mind some veterinary preparations need to be filled from a veterinary pharmacy and cannot be obtained at the human pharmacy, and vice versa for some of the antibiotics.

6. Possible Underlying Causes of Chronic Corneal Lesions
While corneal lesions and ulcers can occur through trauma (scratching the eye while sniffing around a bush with many branches), some dogs have underlying conditions that lead to frequent lesions and ulcers. Dr. John Sapienza created a thorough and easy to follow explanation of corneal ulcers and some of the underlying causes. They include:

• Defects in the basement membrane of the cornea, which can either be treated with plasma or surgically
• Chronic dry eyes (Keratoconjunctivitis Sicca), which can be treated with topical cyclosporine (Restasis)
• Chronic superficial keratitis (or CSK) in which the cornea is inflamed, and can be treated with topical steroids or topical cyclosporine
• Corneal degeneration, which can be treated with lubricants that improve the tear film, cyclosporine (to improve the tear film and to provide immunomodulatory function), EDTA (to bind to the calcific material), and topical antibiotics to fight infection. Surgical options include a superficial keratectomy to remove degenerative material, conjunctival grafts to provide support, excimer laser ablation of the lesions, corneal cyanoacrylate application, and donor corneal transplants. Note that EDTA is a non-invasive choice in people and dogs, and has been used for many years with good results 
• Episcleritis, or the inflammation of the tissue underlying the conjunctiva and overlying the sclera
• Corneal neoplasia, or tumours

Ophthalmologic Adventures Round 3: Humphrey Versus Stomal Ulcer!

It's a smakdown, a thrilla with malacia! Round three in veterinary ophthalmology has commenced, this time with a cross-border twist.

Oh the new vocabulary Humphrey has acquired in the past week: sclera, hyphema,stromal, malacia.

Humphrey's right eye corneal ulcer - the bad one - remains fully healed. However, that eye has an existing cataract (which we knew) and has hyphema: evidence of previous bleeding, which seems to be new. Perhaps he had trauma to the eye last Friday or something? But for now, therapeutic focus is totally on the left eye.

Recall a week ago the superficial ulcer on the left eye had fully healed (in fact, it had been healed for 3 or 4 weeks). Somehow, Humphrey managed to get another quite terrible lesion on that good cornea! The diagnosis is "moderately severe deep corneal ulcer with actively dying tissue" (in other words, a melting ulcer). Did  you know  that the cornea has four layers? It does! The outermost layer is called the epithelium, followed by basement membrane, then the stroma, then the Decemet's membrane. So, when the diagnosis is a stromal ulcer, you know how deep it goes. The seemingly simplest things can cause a corneal ulcer: an eyelash or rubbing the carpet the wrong way.

That means that the awful treatment resumes: a cone, drops every two hours, and some pain medication to help things along. Recheck in two to three days (it will be two based on appointment availability!).

Because this was a second ophthalmologist, Humphrey noted a difference in treatment styles. He asked, "Do I need another corneal crosslinking (CXL)?" Recall that CXL is an "adjunct" therapy in which riboflavin (a type of collagen) drops are applied every 5 minutes for 20 minutes, then UV light is directed to the area. The idea is that this should accelerate healing. Humphrey had this procedure at a very steep costs ($1,200) in Toronto by Dr. Hockeypuck's veterinary technicians.

Interestingly, in Toronto Humphrey asked questions about CXL's efficacy, how much it helps, risks, and the proportion of success. Dr. Hockeypuck's staff acted insulted to be questioned, and could not offer  any data on efficacy. Humphrey's own research revealed that as an adjunct therapy, it appears promising to speed healing but there is no clear data on its actual results. The new ophthalmologist, Dr. Yankee, said she does not use CXL because (just as Humphrey determined in his research) it's an adjunct therapy and she is not convinced it has any real or significant benefit.

Whereas Dr. Hockeypuck prescribed 5 drops every 4 hours, Dr. Yankee prescribed 2 drops (plasma, and Vigamox) every 2 hours. The latter is consistent with most published protocols for dealing with corneal ulcers, so Dr. Hockeypuck's approach is puzzling (but - anecdotally - it was quite effective 4 weeks ago). She also incorporated lubricating drops into the mix, which Humphrey suspected were in order based on previous eye exams (even brought it up to Dr. Hockeypuck who said no way).

While Dr. Yankee had a slightly better bedside manner than Dr. Hockeypuck, she was nonetheless hurried, curt and came across as adverse to questions, as though it was an inconvenience (though to her credit she answered them). Yet, for the steep fees, the consultation with the actual ophthalmologist was minutes. This is a very different experience compared to the doctors in ER, cardiology and surgery at the very same clinic that Humphrey consulted in the past.

Humphrey's continued concern with costs resulted in some interesting developments - and despite his best efforts he got ripped off again!! Recall (here and here) that he has the retail pharmacy costs of many different ophthalmology remedies and ointments committed to memory (especially after being charged $77 for a $17 bottle of Atropine!). At Dr. Yankee's office, he indicated that he needed another bottle of Vigamox antibiotic drops, which Dr. Yankee's assistant offered to fill. Humphrey inquired about the price, stating it is $25 at his pharmacy. The assistant said, "Oh, it's about $30 I think, maybe $40."

"If that's what it is, then I'll just get it here to save me a trip to the pharmacy." The assistant said she would double check, so when she handed him the bottle he assumed that it was not more than the estimate.

In the chaos of "checkout," (there were several dogs present and everyone was spunky), Humphrey paid his bill without looking at the itemized list. When he got home, he realized he was charged $70 US for a $25 CDN bottle of drops! He called Dr. Yankee's clinic - no returns once it has left the building.

When it comes to obtaining veterinary pharmaceuticals, these clinics are Lucy holding a football to Humphrey's Charlie Brown. Despite his best efforts, they somehow manage to pull the football out of the way before he gets to kick it.

In terms of consultation fees, Dr. Yankee charges $185 for the first consult including tests, compared to Dr. Hockeypuck's $300 plus tests. But  a big difference exists in follow up visits. Dr. Hockeypuck charges $85 for a follow up, and t Dr. Yankee's follow-up visit is $150. Humphrey also had to pay $50 to  have his blood pressure checked!

Caveat emptor, people and dogs!

Meanwhile, Humphrey expects to win this battle eventually - but how to win the war when a cornea seems so vulnerable to tearing? Perhaps he will have to wear goggles all the time (wouldn't be the first time, right?)? Stay tuned to find out....

And for anyone who wants to know more about the cornea, this is a fantastic article.

Humphrey buys gifts (or, "Oh Consumerism, how I missed thee!"): A photo essay

While Humphrey tries to be a critical consumer, sometimes one just needs to shop! Especially after being cooped up indoors for four weeks with a cone of shame, only to emerge healthy, energetic, and with the weather in the throes of spring!

Lucky for Humphrey, he has various chauffeurs and companions to show him a good time. And with several pack-member birthdays forthcoming, he was successful in his ability to identify (and afford!) gifts that will express his appreciation to several pack members in financialized terms. Or in his words, "I love you $$*this*$$ much!"

Humphrey arrived at what appeared to be a very civilized outdoor shopping centre,
with an impressive, modernist outdoor sculpture. It took every ounce of self-restraint not to mark that thing!

The shopping centre was *mostly* civilized! Humphrey
shopped indoors in his Bendel carrier.
First stop: Kate Spade New York, with lovely wallpaper and
upholstery that were very much to Humphrey's liking.

Humphrey spotted these fine Kate Spade shoes, and spent a great deal of time staring at the
Boston terrier faces. Were they real animals? Toys? Who cares! They make a perfect gift!
That was his first purchase - and if the gift recipient didn't like them, well,
Humphrey was prepared to add them to his art collection. Or toy collection. Whatever.
Did he mention 80% off regular price? WOW!

Next stop was Cole Haan. Humphrey was actually dressed to match these
silhouette portraits of the label's founders!
(details below)

Humphrey left with a bag bigger than he is! The result: lovely boots for his grandmother's birthday gift.
He could not believe the price! Only $60 for a $400 pair in her size! Fingers crossed she likes them.
Humphrey's expression signals that by this point he was quite pleased with himself.
Notice the sporty stripes that match the Cole Haan portraits!

After much effort expended to find the perfect gifts, Humphrey needed some "me time."

And then you have to enjoy the last bit of your outing.

You know what the humans say (especially for a shopping trip like this one):

"If the shoe fits....."

(...buy it!)

Compassion Burnout & Help For Dogs In Need

This morning, Humphrey's guardian had a conversation with a non-practicing veterinarian who followed up on the "adverse effects" report of one of Humphrey's eye medications.

"Help dogs in need!"

In the course of that conversation, the vet described how compassion burnout (also called compassion fatigue and vicarious trauma) led to his leaving private practice to work for a corporation. According to the American Veterinary Association, it's a problem in the profession - with "moral stress" being the number one trigger for veterinarians.

The vet described how he would encounter very simple problems - for instance, a dog who swallowed a sock, causing an obstruction. The solution is a straightfoward procedure to remove the sock - but as Humphrey often reports, the financial cost of such veterinary procedures (see here, here and here) can be high! The vet said that many neither have the means, nor health insurance, so a very simple problem like a swallowed sock becomes fatal. 

It's sad to lose excellent, compassionate veterinarians to compassion fatigue. What can be done to help animals get the help they need? Humphrey is never short of ideas. Here are a few:

• Tax Deductions. Allow tax deductions for some or all veterinary services. After all, many veterinary services (like vaccinations!) are a matter of public health since they prevent the spread of infectious diseases that humans can get (rabies, west Nile). While the province and feds don't love giving tax deductions, professional associations and individuals should advocate for this simple policy change. In the public interest, it would make sense for some of the more infectious disease vaccinations to be subsidized.
• HST Break. Eliminate HST on veterinary services and pharmaceuticals. This is modest, but 13% (in Ontario) can make a profound difference in affordability. The same prescription a human gets (HST-free), filled at the very same human pharmacy, is taxed it is for animals!
• Employer-sponsored Insurance. Encourage employers to include pet insurance in employee benefits (Fortune magazine declared it the "hottest employee benefit" in 2016, but Humphrey has yet to see it offered in Canada).
• Stronger Awareness for Charitable Organizations Linked to Vets. Humphrey became aware of the Farley Foundation, a charity that provides relief to low-income pets for non-elective procedures, when his regular veterinarian had posters up in the office. Fun fact: the Foundation is named for Farley the dog in Lynn Johnston's "For Better or Worse" ® comic strip. 

The ophthalmologic adventures continue: A critical analysis

Eyes as darling as these need to be protected!

Since Humphrey's corneal ulcer was detected, the veterinary bills have soared to almost the equivalent of a kitchen renovation!

As Humphrey noted in a recent post, the costs of veterinary ophthalmology in Toronto are outrageous when compared to equivalent human healthcare and procedures. He has had several follow-up examinations with his ophthalmologist, none longer than 3 minutes with the doctor. The wonderful news is that his corneal ulcers were declared healed, and that means no more cone! He will not miss the nicknames he endured while wearing that contraption: Coney Island, Coney Dog, Conehead, and of course Director James (Jim) Coney.

While four of Humphrey's five eyedrops (atropine, plasma, Tobrex, and Vigamox) were discontinued, he was instructed to continue Disodium Edatate (EDTA) for chelation of calcium deposits in or around the cornea. In addition, on Thursday the ophthalmologist also prescribed something called Isathal, which is an antifungal containing fusidic acid. Humphrey's guardian asked a lot of questions about it, much to the visible annoyance of veterinary staff, and was told it is a benign antibiotic for longer-term use.

After  Humphrey's first application of Isathal, he showed signs of great discomfort and scleral redness. His guardian emailed the ophthalmologist, only to receive a response at closing time saying the individual was away from the office, and to contact them on Monday if problems persist.

After his Friday evening Isathal application, Humphrey rapidly lost his vision! To the point that he was totally blind.

Lack of Continuum of Care in the System
Clearly, Humphrey needed immediate medical attention. Humphrey's humans called every single emergency clinic within 40 km to determine who might have an ophthalmologist on call. Not one facility did. The three of them got in the car and made haste to get to one of the 24-hour clinics, and were able to complete the paperwork by phone on the way there so they could be seen immediately.

After various tests (that further confirmed the corneal ulcers were healed from a fluoroscien stain), and pressure tests to ensure the eye was mostly OK, the veterinarian on duty concluded "suspected uveitis" and instructed Humphrey to discontinue Isathal, and to administer Voltarin drops as an anti-inflammatory, and Tobrex as an antibiotic. She also recommended continuing EDTA, though the humans were skeptical since EDTA seems to irritate Humphrey's eyes.

The veterinarian on duty said  that the facility does not have specialized ophthalmologic equipment for other sorts of tests, so she could not determine the state of the retina or iris. She also confirmed that to the best of her knowledge, no ophthalmologists were on-call after hours in the city.

The lack of on-call specialists appears to be a real problem, and one that would be easy to remedy.
By comparison, in Southfield, MI, Blue Pearl Pet Hospital has an ophthalmologist on-call at all times for emergencies like Humphrey's.

UPDATE: As readers know, on Friday the ophthalmologist was not in to take a call before the emergency. On Monday, he would not answer questions by phone or email because it was "surgery day," and on Tuesday and Wednesday, he simply did not bother responding.

On Thursday (almost a week later), Humphrey's guardians called in with questions, and being the last day before a long weekend, that ophthalmologist was not in! So after some largely not useful information from the person who answered the phone, they made an appointment in the United States.


Fee Disparities: By Species and By Country
As Humphrey detailed in his recent post, the costs of dog ophthalmology services are many times the costs of similar services for Humans. Similarly, costs of identical medications are at least double in most cases when purchased from a veterinarian versus at the local (human) pharmacy. The example he cited previously was Atropine, which is $17 at Shoppers Drug Mart, but he paid $77 for an identical compounded bottle. This trip, Humphrey was able to price-compare for a new bottle of Tobrex antibiotic drops. At the clinic, he would have paid $40 plus tax, but at the pharmacy on the way home, he obtained the identical drops for $25 including tax.

The consult fees are much more reasonable for dogs in the US! Recall for a Toronto ophthalmologist, the fee is $300 plus the costs of tests. At Southfield, MI's Blue Pearl, the cost is $185 US and three major ophthalmology tests are included in that fee. That represents significant cost savings even with exchange, and the assurance that an ophthalmologist could weigh in on an emergency like the one Humphrey just experienced.

Luckily, All's Well That Ends Well....
Despite some terrifying moments and hours when Humphrey experienced total vision loss, everyone was relieved when his vision began to return about 4 hours later before any treatment commenced. While it may be a coincidence, the veterinarian who saw him said that it's quite possible Humphrey has a hypersensitivity to fusidic acid, and that may have caused temporary blindness.

As he approaches the 24-hour mark, his vision continues to improve. Fingers crossed!

UPDATE: No more blindness occurred as of a week later! However, they were unable to get any meaningful help from the veterinary community in Toronto.

Humphrey also did a bit of additional reading about the latest round of drops now that the emergency was over and there was more time available. Turns out the NSAID he was prescribed (Voltaren) can impede healing, and can compromise the cornea in otherwise healthy eyes with prolonged use! Not one of the  three vets consulted mentioned this! (He sent emails to his regular vet and to the ophthalmologist inquiring about their opinions on the new treatment immediately after the emergency - not one response!). This is highly questionable practice, since using an NSAID could do more harm than good!

Finally, Humphrey filled out an online form for the pharmaceutical company that manufactures Isathal to report an adverse effect. He could not believe that he received a call back in less than an hour by an actual veterinarian to follow up! The vet was very inquisitive, and took additional information to submit to Health Canada to record this as a side effect. The vet noted that he believes most veterinarians fail to report such things to the manufacturer.

Humphrey's epic April Fools 2019 prank!

How can a little dog get payback for the indignity of  having to wear a cone?  Can a little dog prank two Human beings with advanced educations? Read on and find out!

It didn't take long for Humphrey to hatch a plan for the dog prank of the century.

As readers know, Humphrey is subjected to 4 rounds of 5 eyedrops each day for his recent corneal mishap. After finishing the final drop, he is rewarded with a little portion of sugar-free, cherry Jello.

He tucked a little bit of that cherry Jello in his cone last night without any Human noticing.  Then, he went to his bed and subtly rolled around to spread the clandestine Jello around the base of his cone. Once he was satisfied with the result, he innocently approached his Human to have a look.

She thought he was bleeding profusely at the base of the cone! Ripping off the cone from Humphrey's neck in a panic, a strong cherry aroma filled the room. She didn't see any cut, and the staining didn't wash off. Humphrey giggled. And the 2 Humans realized they'd been outwitted by their little genius.

This will continue to terrify for weeks to come, since Jello dye is very permanent.

Happy April Fools, everyone!

Adventures in Vet-Ophthalmology

An eye chart for dogs hanging in the specialist's office

The past week ushered in a surprise adventure in veterinary ophthalmology. Readers know that Humphrey is not entirely new to this type of adventure: several years ago, he developed a puzzling condition that was initially misdiagnosed as pink eye. When his regular veterinarian made a referral to Toronto’s veterinary ophthalmologist, Dr. Wolfer, Humphrey investigated fees. Just to get “in the door,” Humphrey would have to be re-tested for diagnostics, because the specialist would not accept the results furnished by the regular vet, and was subject to a steep specialist consultation. The total fee was estimated at $1,000.00. Humphrey did a little research and decided he would go to Blue Pearl veterinary hospital in Southfield, Michigan, since he was travelling to Detroit later that week. His diagnosis (blepharitis) and treatment (oral cyclosporine) totalled about $110.00 and the problem resolved.

Given that history, it’s no surprise that Humphrey is wary of veterinary fees to this day. He is reeling from the sticker shock of on day of veterinary procedures and drops: $3,000.00.

But, in an emergency situation, there’s no option for comparison shopping! This past week, Humphrey had his regular consultation because his right eye was read and sensitive. He had an immediate referral to that same ophthalmologist Dr. Wolfer, who accommodated him on a cancellation. The diagnosis this time was melting corneal ulcer, and Humphrey had to make a quick decision whether to attempt to save the eye with the recommended procedure called corneal crosslinking or CXL. That procedure involves putting riboflavin drops into the affected eye at 5 minute intervals, then shining a UVA light into the eye. The riboflavin promotes collagen production, which can speed healing. The estimate for the procedure was $1,100 for the process, $90.00 for the riboflavin, and another $300.00 for various drops to be used post-operatively. And about $700 worth of tests from his regular vet earlier that day. Plus HST.
UPDATE: Four and five days later, Humphrey didn't know whether the appearance of his eyes were normal, so he called Dr. Wolfer's office and got little insight. Upon their advice (which included "Why don't you photograph it and send that?", he sent and email and got a response from the specialist. Then, he went to his regular vet to inquire if the eye required immediate attention. The regular vet was unsure, so the vet took photos and Humphrey sent those to the specialist. The response he got was appalling. The Doctor "read your email and reviewed the photographs you so kindly included. Unfortunately photos are rarely (if ever) truly diagnostic. If you feel Humphrey's left eye is deteriorating you may want to consider having him seen prior to your scheduled progress exam." Humphrey did not respond but wondered why they would instruct him to send photos, when they are not useful. And he wondered why, given the prose description, the "specialist" would not offer specific advice beyond "suit yourself."

The moment Humphrey was out of the procedure, looking very glam-rock with tousled hair and
asymmetrical streaks of  riboflavin on his temple, cheek and ear

Humphrey is hoping for the best and that his right eye will survive. While he heals, his is satisfying his curiosity about late capitalism and healthcare costs, and the difference in costs for the same or similar procedures for dogs versus humans.  

The psychological trauma of the "cone of shame" exceeds any physical discomfort.

Let’s take a moment to contrast fees billed for Ontario humans versus dogs. In the province, OHIP (the universal, single-payer medical system) dictates maximum fees physicians and other health professionals can charge. For humans, a regular appointment with a family physician is $77.20 (though a comprehensive assessment is $144.75 for 50 minutes or $217.15 for 75 minutes. The veterinary equivalent is an appointment with a generalist or “regular” vet, and the base fee is comparable (Humphrey’s vet charges $77.90 for an “office examination and consultation” plus $156.30 for an “advanced wellness check” (the equivalent of a physical). While a human emergency room (ER) exam is $76.90, a veterinary ER exam is substantially more expensive, varying by hospital though at least double that fee in Humphrey’s experience.

Human specialist fees vary. For instance, a “normal neurology consultation” (one of the more expensive ones) is $176.35 with subsequent visits in the following six months capped at $31.00, but a special consultation of 75 minutes or longer is $300.70. The cost for similar “normal” veterinary specialist consultations (as is the case with Humphrey’s internal medicine doctor, and the ophthalmologist) are double those of humans (the going rate in Toronto is about $300.00 for a normal consultation – something Humphrey has paid to several specialists in different practices over the past year). Additional diagnostics are paid for individually, on top of the specialist consultation fee. Follow-up visits have never been less than $85 for Humphrey. Two years ago, he was urged to have a cardiac workup. In Toronto, the consultation and tests were estimated at about $1000 and with a lengthy wait (6 weeks to 3 months). At Blue Pearl in Michigan, the same workup was about $230 and could be done within days.

Frances Wolley’s October 21, 2011 Globe & Mail article, “Visit to vet an eye-opening adventure in private care,” described the ten-fold difference in the price of identical cataract surgery for dogs versus humans. In the 8 years since that article was published, little has changed. Consider the following ophthalmology fees:

Procedure	Current OHIP billing fee	Approximate veterinary fee for same or similar service in Toronto
Major eye examination and/or ocular assessment in office	$48.90 to $51.10	$300.00 for first visit, $85 for subsequent
Corneal testing (pachymetry, keratometry, etc.)	$5.00 per test	Within consult
Local anasthetic for ophtho	153.00	Within procedure fee
General anaesthetic for ophtho	150.00	Within procedure fee
Human chelation of band keratopathy with EDTA VS canine CXL for keratosis with riboflavin and EDTA	$496.00 plus anaesthetic (approximately $650)	$1,350.00
Cataract (with no complications) including retrobulbar injection administered by surgeon and including insertion of intraocular lens	$397.75 Plus $50.00 per post-op visit	$5,000.00 Plus approximately $3,000.00 for post-op follow up

No wonder the veterinary staff are grinning! That's Humphrey being brought out from his initial tests.

One other important financial consideration for health care professionals is who profits (and how much) from pharmacological dispensing. While perhaps some physicians have a stake in a pharmacy, veterinarians often dispense on their own medications – and often with steep mark-ups beyond those applied to humans for the same medications (the CBC reported on this). Humphrey usually performs price-comparisons with local pharmacies and compounding pharmacies, and has been successful in negotiating reduced medication prices from veterinarians. For instance, the cost of Caninsulin varies between $85 per case from most veterinary pharmacies, to upwards of $200 at some veterinary clinics. Accompanying needles vary in price between $19 and $50 per carton for identical or nearly identical products. Pain medications are often half (or less) the price at a human pharmacy (they accept veterinary prescriptions).

This time around, price comparisons were impossible since Humphrey had to begin medications immediately. However, it appears that at least some of the drops (most of which were $75 to $80 per bottle from the specialist) cost only about $25 from a human pharmacy based on a cursory investigation.
UPDATE: a price check before refills revealed that the  most staggering difference was Atropine 1% which is $77 from the vet, but $17 from the local pharmacy. Wow.

Humphrey in his protective "Doggles" from last year.
The ophthalmologist recommended Rex Specs (since they are a single unit) over these,
so Humphrey went ahead and ordered himself a pair. 

To be clear: Humphrey is grateful for the competent veterinary care he receives, and he strongly supports living wages for all workers (not just in health care!). He recognizes that operating a clinic is costly, and veterinarians must be fairly compensated for their education, expertise, and skill. But undoubtedly some of the fees he has experienced seem to be unjustly inflated. The College of Veterinarians of Ontario considers charging fees that are excessive in relation to what is normally charged professional misconduct, but since fees are high across the board, the examples here would not be problematic under Reg. 1093 of the Veterinarians Act.

AND ONE MORE UPDATE: The seven-day follow up revealed healing! The eye is saved, but drops and protective gear will continue for 2 more weeks and then be re-assessed.

Sources:

OHIP Physician Billing

OHIP Lab Services Billing