Sheba, elderly diabetic needing eye enucleation

[carocats]

Sheba is an elderly rescued himalayan, age unknown but at least 14, possibly older. She had some weight loss in the summer and bloodwork showed everything within normal range except slight blood glucose elevation which could have simply been stress from vet visit so vet said recheck at home (I run a rescue and have had quite a number of diabetic cats over the years). Recheck was normal. She was a bit dehydrated and slightly constipated so we medicated for that and she improved and seemed OK for a while. About October she developed a slight corneal ulcer (she came to us years ago with a scar on that eye, so was probably a herpes carrier but until then had not had any symptoms). I treated the ulcer right away and on day two it looked better already. On day 3 her eye appeared to have suddenly ruptured. Vet said too far gone, would have to enucleate. Then she saw the previous bloodwork in the file and said oh, let's check her glucose first - and she was high. She then said she could not operate and only real option was euthanasia. I wasn't willing to give up on Sheba that easily and took her home. Started her on glargine, one unit, but she remained high. Eventually increased to two units and she was doing OK. On buprenorphine to control pain from the eye situation, plus ocuflox drops in the eye itself. After a couple of weeks the eye actually looked a lot better and I was hopeful that maybe it wasn't fully ruptured and might even be saved, and glucose was reasonably controlled (still high before 2nd shot of day, but within range at nadir). Vet was surprised eye was doing so well and didn't say anything further about removing it. A couple more weeks went by, and then the day before Thanksgiving Sheba's eye suddenly blew again and this time, despite trying everything, it is completely ruptured. Since regular vet had not been supportive of continued treatment for her, we decided to consult opthalmologist. She said she could do it, although there would be slightly higher risk than normal, which of course is understandable. She redid the bloodwork. Unfortunately, Sheba's glucose was suddenly low, so she said that needed to be worked on - too risky to proceed with surgery. She had been a little off food for a couple of days, probably due to the discomfort from the eye situation, therefore causing the sudden low reading. That evening she was high again and I gave the usual 2 units. By following a.m. she was very hypo and I had to give karo syrup and work on her for a couple of hours. Got her up to 67 and she spent the rest of the day at vets, ostensibly for a dextrose bolus, but I was charged only for a glucose test - no catheter or IV, so I don't think they did it - I think they just observed and since her level was going up and she was eating there they weren't worried. Reduced insulin to 1 unit, put her on zithro, and had no more really low lows so we scheduled the enucleation for yesterday. Withheld food and buprenorphine from midnight per vet's instructions, gave slightly under 1 unit to be on safe side as her reading was 300. It was 87 before we set off to the specialists. Unfortunately she developed some diarrhea overnight - I think this is due to the zithro. Her glucose levels continued to go down during the morning and after consulting the internist they decided not safe to anesthetize her and didn't do the surgery. Their readings were in the 60's - so I am confused. I thought this was an acceptable number, but apparently they were afraid she would go down further before she could get back to a point of being able to eat again and get insulin again. They wanted us to either hospitalize her at emergency/internist for IV dextrose and antibiotic ($1500-$2500), or at our regular vet (would be considerably less there), or to euthanize her. Said can't go on with her eye like that (she does have purulent discharge from the eye, but does not have an elevated white count). Sheba ate a large handful of Whisker Lickins on the way home (and she hadn't had buprenorphine since midnight and this was at 4 pm in the afternoon, so presumably not too much in pain not to eat), and for the first time in her life actually ate canned a/d (I have never ever before been able to get her to eat even one bite of anything other than dry food or soft Whisker Lickins - not even real baked chicken, tuna, or any other delicacies cats normally kill for. Sheba has unfortunately been a dry-food-only cat all her life). Last night she was 339 so I again gave her slightly under 1 unit. She ate more during the night and at midday today was 241. I obviously don't want her to have to continue too much longer with the discomfort from the eye situation, but am somewhat at a loss to know what these vets need with the diabetes situation in order to take care of the eye. Considering consulting the regular vet again today and maybe letting her be there in the daytime for IV antibiotic, but not convinced she really needs it since she is eating well - seems to me a cat needing IV antibiotics for supposed systemic infection would not be wanting to eat. Anyone have any input that might be helpful at this point?

 

[Melanie and Smokey]

As far as dealing with her eye, It seems to me like it would work best to skip her shot the morning of the surgery. She may run high, but better running high for that day than risking running low. 60 is a fantastic number, but not a comfortable number with insulin on board going into anesthesia (can lower) and a day without eating.

Glargine isn't the best insulin for shooting the preshot numbers (ie, she's high now, I'll shoot 1U, she's lower, I'll shoot under, etc), it works best with consistancy, the same dose every 12 hours. If 1U seems to be bringing her to low at times, maybe you need to try 0.75U twice a day and see if that gives you good numbers to work with.

Sounds like she's got a lot of things going on and you are managing them as best you can. Sometimes we need to put the treatment of diabetes in the backseat while we treat something more urgent. If lowering the dose and keeping her safe, but maybe not quite as low and tightly regulated as we'd like to see allows her to get the eye surgery done, then in the long run her diabetes may be better off too.

 

[carocats]

Thanks Melanie. She's been fine ever since she came home - eating fairly well and consistently - even ate some canned again. She was a bit high last night but I had so much going on I couldn't remember at midday if I gave her insulin or not and didn't want to risk a double dose. Just did the 1 unit last night after doing .75 the previous night and she was 120 or so this morning. She was much perkier than the day she went for the surgery. I have reduced the amount of buprenorphine as the eye was better today - very little discharge and she had it open and was up and about more. We went to the regular vet this afternoon to remove the IV catheter and get her heart rate checked since the specialist had found it to be a bit slow - we believe that was due to the dehydration and possibly to the amount of buprenorphine also, and all that was probably due to the discomfort from the eye at that time. My regular vet now says she could do the surgery if we ultimately decide it is still necessary, but she would not withhold food. Interestingly, she has never told us to withhold food before any surgery and I hadn't thought to ask why that is OK with her and not with any other vet we've ever used, so I will ask her next time I go. She can't do the surgery before Christmas as her father is dying and she needs some time with him, so we hope we can keep Sheba comfortable and regulated for another couple of weeks, and hopefully during that time the eye will no longer be causing her such problems. I think 1 unit or slightly under may be right for her - it was 2U that was apparently too much. If the specialist would have said don't give any insulin the night before surgery I would not have - what she said was if she was under 300 I could withhold it, and since she was right around 300 I thought 1 unit would be OK - now I wish I had not given it, but perhaps it was meant to be as she seems to have turned a corner with the eye problem now. It's so strange - she has been really good about letting me clean the eye and the surrounding facial and nose area (as gently as I can), yet she got really testy about having the catheter removed - she hates having her feet and legs touched (her previous owners declawed her front paws, but she even hates the back ones being touched!). My neighbor used to foster her and christened her "Granny Grump" and we also sometimes refer to her as the real "Grumpy Cat" (since the famous Grumpy Cat isn't Grumpy, but Sheba is!). But all in all the old girl has really been a trooper through what must have been at best a very uncomfortable medical problem, so I'm not going to give up on her unless she tells me she's ready to go, and she's not doing that so far.