Immune mediated intrasclera conjunctivitis

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Immune mediated intrasclera conjunctivitis

Postby maxs_mommy » Fri Aug 08, 2014 3:21 pm

Eye doc was today. Max did well and didn't do more than whine a bit at the stain and tests. The doc was really good with him and super excited to explain what was going on to us. :rofl:

The diagnosis was immune mediated intrasclera conjunctivitis. The other word thrown around was Keratoconjunctivitis Sicca, so dry eye. All that to mean that his sclera layers are pissed, blood vessels have started to grow into his cornea and everything is inflamed. The conjunctivitis is between the two sclera layers which is why nothing we've tried touches the issue. He will be on an immunosuppressant ocular drop, first in a load-up dose and then maintenance, for life. Tacrolimus is the drug, which is we're told, proprietary to this clinic (sigh). Google says otherwise though. If untreated, this will eventually blind a dog. We're not remotely close to that yet, thankfully. It is common in Cockers. We went with ocular drops b/c the vet didn't want to go systematic without having to. I'm ok with that. We report back in a week via phone and recheck in a month to see what progress is being made. He also has mineral deposits in one eye but those are not worrisome unless they start causing discomfort.

So here are my questions. The drops are suppressing his immune system as it relates to his eye. What care do we need to take because of that? Also, he hates eye drops but will deal. Any tricks if I'm going to do this for another 7-10 years (hopefully)?
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Re: Immune mediated intrasclera conjunctivitis

Postby connie » Fri Aug 08, 2014 3:34 pm

So, you know my little Charlie Bear? He is blind because he has KCS and it was never treated. He has corneal ulcers that have healed, but he is at risk to develop more of them, and did in fact just do that. The treatment for that was triple abx ointment and Atropine drops, which are also what they gave my brother when the retina in his non-seeing eye (he was a preemie in 1960 and blind in one eye from birth) detatched a few years ago. Both corneal ulcers and detatched retinas are very painful and atropine is a wizard painkiller. Charlie is going back for a re-check next week but seems to be back to his old self and the ulcer is healing, knock wood. So that's what *untreated* KCS can present as, in the dog's senior years. :(

Tacro isn't proprietary to any clinic that I know of, that confuses me a bit. Charlie came to me with Tacrolimus drops from one of the rescue vets. Another rescue vet provided Optimmune, but my own vet says Tacro is the drug of choice for this condition now. Tacro drops are expensive and there isn't a generic equivalent, maybe that's what your vet meant?

The condition is also common in Pomeranians, which is probably how Charlie Bear got it.

I'm very sorry to hear that Max got this diagnosis, but I do know the condition is very manageable if the owners are aggressive about treatment and use the daily drops. And since you have Max on such a good regimen of diet and no unnecessary vax, etc., I think you have an excellent reason to consider this just a daily eye-drop routine and nothing worse than that. :thumbup:

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Re: Immune mediated intrasclera conjunctivitis

Postby maxs_mommy » Fri Aug 08, 2014 3:41 pm

I don't know if that's what they meant, I asked the tech. The drops were $40 and we're also on a neomycin/polymyxin b slufates and dexamethasone suspension we'll use too, at the optho's request and wean off that to the Tacro.

As an aside, I know I posted this in the wrong place and have asked for it to be moved. I'm just dumb today.
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Re: Immune mediated intrasclera conjunctivitis

Postby UpwardDog » Fri Aug 08, 2014 4:27 pm

Poor Max (and Charlie) that sounds uncomfortable. I'm glad there are drops to improve things.
How old is Max?
Tacrolimus is not propriety to any clinic--I wonder what she really meant?

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Re: Immune mediated intrasclera conjunctivitis

Postby JudyL » Fri Aug 08, 2014 4:44 pm

I'm so glad you have that new vet that made the referral! Chi also has immune mediated dry eye, but chihuahuas and other small breeds are prone to it, and chis have the added benefit of having those eyes that bulge and bump into things as their vision fails. You already know my story so I won't repeat it. I've been using compounded optimmune and vit a. Right now she is on abx drops called Tobramycin .3% and the anti-inflammatory drops are Ketorolac .5%. So you can see with you, Connie and I all having some different meds for the similar conditions, if one isn't well tolerated, don't hesitate to call and ask if you should switch to something else.

It's interesting that Connie made mention of Poms being prone to it. We don't know what Chi and Dixie's mix is. Dad was supposed to be a chi, and I met their mom that looked like a chi-sized rough coat JRT. I think she was a sweet chi-terrier-whoknowswhatelseWVmutt. lol

Chi has always been good about the ointments and drops. The biggest thing is to let him know it's coming, establish a routine, and don't mess around and take a long time getting them in. Chi always got a small treat afterward, so she associated it with the treat as much as anything else. Connie said that C Bear wasn't good about it at first, and I suspect that's because he couldn't see it coming, didn't know something was going to hit is eye, and his eye's were painful at that time too. Because he was already blind, he had to learn her routine. I bet he is a lot better about it now. How about it Connie, is that right?

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Re: Immune mediated intrasclera conjunctivitis

Postby connie » Fri Aug 08, 2014 4:47 pm

Oh, he's a doll about it now. He has grown very fond of me, which helps. I hold his collar under his chin and he knows what's coming. I have soaked his eyes in gauze pads with colloidal silver on them; I have put ointment on both eyes and gently distributed it with my fingertip; and I have put drops in both eyes. Yes, his eyes are much better than when he arrived, so the discomfort is probably much less, I'm sure that's a factor too. I would be surprised if Max objected to the drops once it got to be a routine daily thing.

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Re: Immune mediated intrasclera conjunctivitis

Postby Sabine » Fri Aug 08, 2014 4:49 pm

I'm sorry poor Max is affected by this, but glad you have a diagnosis and a treatment plan. :)
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Re: Immune mediated intrasclera conjunctivitis

Postby maxs_mommy » Fri Aug 08, 2014 5:33 pm

Heather, Max is 8 so some of this is just age, some of it is a brachycephalic breed issue with big eyes/small heads, some of it is his puppymill breeding I'm sure. The amount of shih's and pugs that came in through the door was kind of a shock to me, though I suppose it shouldn't have been. lol We'll get a routine for him, treats are always forthcoming so I'm sure that will help too. He'll get used to it. Connie, does your Tacro get refrigerated? The ophthalmologist is also going to talk to the new vet to keep her up to date and fax over records. We go back for a recheck in a month, they call for a progress report in a week. The docs work out of the e-vet office we go to anyway and, handily, have a 24 hour on-call line if disaster strikes.
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Re: Immune mediated intrasclera conjunctivitis

Postby SherriA » Fri Aug 08, 2014 5:51 pm

Not a dx you want, but it does sound like you got it relatively early and have a good treatment plan. That makes me feel better.

FWIW, Oliver hated anyone messing around with anywhere near his face - eyes, teeth, etc. After the first time or two, he was OK with the ointment I had to put in them for a couple of weeks. He never loved it, but he tolerated it more than many other things. I'm sure Max will get into a routine and it will be NBD for him.
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Re: Immune mediated intrasclera conjunctivitis

Postby maxs_mommy » Fri Aug 08, 2014 6:01 pm

Here's another layer to the onion. Max is due for Rabies (actually overdue). The vet has a thermosol free version but what will this do to his immune system with the eye drops? Should I ask for an exemption? No vax until we're on a maintenance dose, that's for sure so at least a month or two.
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Re: Immune mediated intrasclera conjunctivitis

Postby SherriA » Fri Aug 08, 2014 6:04 pm

I would definitely ask for an exemption. he has an immune disorder; I wouldn't vax for anything.
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Re: Immune mediated intrasclera conjunctivitis

Postby connie » Fri Aug 08, 2014 7:35 pm

He should have an exemption, that should be a no-brainer. No dog with a sub-par immune system (which by definition is any dog with an auto-immune condition) should be vaccinated. You can titer to establish that he has protective immunity from previous vax, if that's a concern. I've never had a rabies titer come back below protective levels, and I've titered NINE years after the last vax, in Miss Pip's case.

Besides, a rabies titer will run you $200 and you haven't spent enough money on veterinary care lately! :rofl:

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Re: Immune mediated intrasclera conjunctivitis

Postby maxs_mommy » Fri Aug 08, 2014 7:47 pm

Lovely, I'll have to convince S to add it to the budget...not that it's not tight enough already :tongue: as if I have $400 extra a each week. I can always console myself that I'm being "proactive" I suppose.
I thought last I read Hemopet would do it for 100 before blood draw/office visit and postage. His last vax were in 2009, he'd had 5 sets in his three years up to then including rabies. I don't know if KCMO will give me a license on exemption and I'd like to have him licensed if he's on exemption.
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Re: Immune mediated intrasclera conjunctivitis

Postby connie » Fri Aug 08, 2014 7:55 pm

Yes, there may be less pricey options for the rabies titer. You have time to shop around, I would think; you can wait a few months to make that call on the titer, since you're getting him set on his meds for the eye condition right now. As far as licensing, everything I know indicates that the license is issued as usual, only with the exemption/waiver in place of the rabies vaccination cert. I've never heard of a municipality withholding a license for a vax-exempt dog, I wouldn't expect that. :wink:

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Re: Immune mediated intrasclera conjunctivitis

Postby JudyL » Fri Aug 08, 2014 8:11 pm

The licensing here is as Connie described. I didn't even have to have rabies titers done. All I did was present the letters from the veterinarian stating why the dogs won't be revaxed along with my renewal apps and fees. I have a tag and license for each of the exempted girls. Of course, if they did bite someone or another pet, the rabies vax is the important part that is missing and that would mean automatic quarantine. DE is using PetData, a national database service, that sends out a reminder bill when the license expires. If the dog is vaccinated, the owner can file online or by mail. Because I have the exemptions letters, I have to take those in person to our county office where the clerk keeps a copy of the letter and the spay/neuter certificates.

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Re: Immune mediated intrasclera conjunctivitis

Postby LisaT_II » Sat Aug 09, 2014 3:41 am

Dodds charges $98 for rabies titer test:
https://labordatenbank.com/cake/hemopet ... mopet_form

I had an exemption for indy the last many years of her life. Titers were never run and not required, since vax status cannot be legally based on titers, but health status is based on the vet and the letter they write. Titers though might make a hesitant vet more willing to write a letter. Some states/counties have barbaric exemption policies, if any, so you need to call your local animal control for their procedures. If your vet has not done this before, don't ask them about the rules, they won't know them and often they make up stuff that isn't right.

IIRC, all tacrolimous is compounded. If you are getting a tube for $40, that sounds pretty good, compared to what I used to pay for my Max's (I guess depending on the size). The eye place probably works with a compounding pharmacy to have stock on hand, and the eye vet may also tell the compounders what oils her prefers it mixed in, etc. I'm betting that's why they said it's proprietary, but you definitely could get a verion of it elsewhere. It's the carrier oils, etc, that often determine whether the drops sting or not.

It is am immune suppressant, so watch for changes in the eye. I found tacrolimous much more effective than the cyclosporine for my max, but he had infection problems, and later we had to stop it. When he was on long term abx, he didn't need the eye meds so strong.
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Re: Immune mediated intrasclera conjunctivitis

Postby connie » Sat Aug 09, 2014 5:08 am

Yes, I just looked at Charlie Bear's Tacro -- it is from Wedgewood Pharmacy, which is a compounding pharmacy. (I used them for Mike's tetracycline in years past.) Prices at compounding pharmacies can be all over the place, you can do a bit of shopping for that, and your vet clinic will supply the scrip. And no, my Tacro is not required to be refrigerated.

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Re: Immune mediated intrasclera conjunctivitis

Postby maxs_mommy » Sat Aug 09, 2014 4:52 pm

That may be the difference. My doc said there were few preservatives so maybe the carriers are the proprietary-ness in the drops and also the reason for the refrigeration. He seems to like the drops cold so maybe that's soothing to the inflammation, dunno. So far so good, though he's started running away when I pull out the bottle from the fridge. He runs back when I pull out the pickles though. lol I'll take what I can get. His eyes do seem less squinty and goopy.

I checked K-state's labs since a lot of the vets here are alums and use them and the fee for rabies titer is $45 for animal version, $65 for human/animal, both are non-export, which is fine. Antech does them but does not list a price online.
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Re: Immune mediated intrasclera conjunctivitis

Postby connie » Sat Aug 09, 2014 4:57 pm

Pickles?! :wow: :wtf:

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Re: Immune mediated intrasclera conjunctivitis

Postby JudyL » Sat Aug 09, 2014 5:37 pm

Maybe he'll learn to associate the drops with relief from the pain. If not, pickles work too. lol

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Re: Immune mediated intrasclera conjunctivitis

Postby maxs_mommy » Sat Aug 09, 2014 8:22 pm

Connie, Max is a galloping gourmet of the highest order, donchaknow? The only foods he actively won't eat are black olives and raw mushrooms. (He prefers shiitake over button, sauteed in butter and garlic, tyvm.) :sgrin: We told the new vet about pickles and she just shrugged and said cucumbers were cooling and vinegar was good for digestion. :rofl: He can't do potatoes of any sort, we don't do grains, fish or chicken. Everything else is fair game for taste testing. His palate is the whole reason we had to move our garden to the front yard and I rarely get any strawberries out of the back yard. :thumbup: Hard to believe when he came home we didn't think he was food motivated, turns out he just hated the milkbones the shelter used. It's good to be Max, even with eye drops.
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Re: Immune mediated intrasclera conjunctivitis

Postby connie » Sun Aug 10, 2014 5:15 am

Cucumbers are cooling and all my dogs love them -- Sundance ate them off the vines, the two summers I planted them -- but I think vinegar would be a deal-breaker for them. I'll have to check that! But obviously it has some benefits for Max, since he goes for pickles in a big way. What a funny dog!

In Nosework we are told to bring very high-value treats to give our dogs when they locate the hides. I brought sweet potato chips for Alex: that boy will do ANYTHING for a sweet potato in any form. All my dogs like s/p but Alex is a s/p pig!

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Re: Immune mediated intrasclera conjunctivitis

Postby LisaT_II » Sun Aug 10, 2014 12:25 pm

I checked K-state's labs since a lot of the vets here are alums and use them and the fee for rabies titer is $45 for animal version, $65 for human/animal, both are non-export, which is fine. Antech does them but does not list a price online.
That's an even better deal and good to know, as long as they will accept shipment from owners and not only through vets. If it's through the vets only, most vets will double that charge.
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Re: Immune mediated intrasclera conjunctivitis

Postby connie » Sun Aug 10, 2014 1:36 pm

Yes, what Lisa said. My vet sends rabies titers to the Rabies Lab (at Kansas State), and that $45 might be what my vet clinic pays, but I pay a multiple of that.

I don't care, actually: I know my vet clinic is expensive; I know they have high costs (and just built an addition on); and I only do one rabies titer a year, since I rotate my vaccine-eligible dogs in that. This year Rowley, next year Alex, etc. Half of my crew is legally exempt now due to chronic or terminal health conditions, so I won't bother titering them. If this were something I did more than once a year, I'd look for a cheaper way to do it, probably.

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Re: Immune mediated intrasclera conjunctivitis

Postby maxs_mommy » Sun Aug 10, 2014 5:24 pm

I totally realize there are office fees but since I'm not going to be doing the blood draw myself, I'd still have to pay it and K-state is 1/2 of what Dr. Dodds charges. It's easier to let them interface and just get copies of the results. I don't know if owners can request tests or not. Our vet is on the higher end of the scale in the city but they try to keep prices down so usually I can go in for a blood draw or HW test without an exam fee. It's not like he's never seen for exams so usually they don't worry about it.
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Re: Immune mediated intrasclera conjunctivitis

Postby LisaT_II » Sat Aug 16, 2014 1:57 pm

But, just to clarify, the vet may charge for a blood draw in either case (my vets do nowadays). The markup may be over 100%, so $45 may well be over $100 if done through the vet's office. Dodds sends the results directly to your email and also the vet.

Generally I like to support my vet clinic when I can and let them make an appropriate amount of money, because they do run a business. But that can depend on how much I've already been spending on my dog's health issues (I do have another million dollar dog), and sometimes it depends on the amount of control I want. For example, when I send off tick titers, I want that control of what boxes to check, and that's also true when I do the thryoid and other checks. I've had vets check the wrong boxes before and order the wrong test, and I've not once have them offer to correct their error and pay. It's not just a money issue, but I usually want things for a particular reason.

Oh, and since one vet practice has been bought and sold a couple of times (now a VCA clinic), one vet has me send in stuff because now their markup and restrictions are crazy.

I think I'm basically just venting here. Sounds like you have a good relationship and communication with your vets and the above doesn't apply!
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Re: Immune mediated intrasclera conjunctivitis

Postby connie » Sun Aug 17, 2014 5:26 am

Yeah, it all has to do with what kind of relationship the person has with the vet clinic, and how much leeway the clinic has on certain things. If the Rabies Lab will take owner requests directly, that's great, and will probably turn out to be the least pricey way to get a rabies titer done. :thumbup:

The subject of costs can be a touchy one for client and clinic alike. I ended up taking Charlie Bear to a rescue vet this summer for his bladder-stone surgery, because the estimate from my vet clinic was one I felt was unnecessarily high -- and because the rescue really should have dealt with the stones before it adopted CB out. (However, the rescue was in a turmoil over the sudden death of its director, so I'm not blaming, just noting.)

My clinic's prices are on the higher end, and I know it. The tradeoff is that they never, ever argue with me or lecture me on the way I do things; they are willing to let me forego things like rabies vax in favor of titers; they always back me up on things; and this weekend when Beau laid his leg open to the tendon, they said 'bring him in now' when I called, they rearranged the doc's schedule for the next few hours so he could get Beau into surgery, and they spent A LOT of time and care on him at a time when I was completely freaked out. (The surgery was $500, BTW, which I thought was a pretty reasonable cost.) Add to that: my vet calls me to follow up after every visit that is not routine -- to see how Pip is doing, or how Charlie's eye is, etc. We know each other, I inquire after his dogs and his wife, we are both White Sox fans, we have a nice business-friendship going.

I know this is OT, I just am thinking out loud about how the costs are only one element in a relationship, and trusting skilled people to look after my dogs does create a relationship. I would love to pay less than $100 for a rabies titer test, but I am not able to do my own blood draws, etc., so that will probably never be an option for me, nor will I break down my clinic's services into each component. Because I don't want them to say, when I am looking at my dog's flexor tendon and gagging, 'we can get him in next Tuesday at 3 p.m.' -- and yes, I do know clinics that would do that!! :thumbdown:

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Re: Immune mediated intrasclera conjunctivitis

Postby LisaT_II » Sun Aug 17, 2014 1:05 pm

...I know this is OT, I just am thinking out loud about how the costs are only one element in a relationship, and trusting skilled people to look after my dogs does create a relationship.
I think this is a really important point. I've been trying for the last many years to develop the right kind of relationship with a new general vet (since my old one is semi-retired), and 1) it's not easy finding the right vet, and 2) it just takes time for that to develop, even with the right vet.
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Re: Immune mediated intrasclera conjunctivitis

Postby connie » Sun Aug 17, 2014 1:34 pm

I agree, Lisa. And then you have to hope that the clinic doesn't get taken over by Banfield or VCA or some other corporation. I am not able to have relationships with corporations. :tongue:

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Re: Immune mediated intrasclera conjunctivitis

Postby LisaT_II » Sun Aug 17, 2014 1:37 pm

corporations are people too, you know :rolleyes:
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