Clinical findings and progression of 10 cases of equine ulcerative keratomycosis (2004–2007)

Ulcerative keratomycosis is a serious sight‐threatening disease of horses and the veterinary literature is replete with cases of poor visual outcome following this condition. During a 3 year period, 10 horses were treated for confirmed keratomycosis at the Veterinary Teaching Hospital (VTH) of the University of Cordoba (Spain). Ulcerative keratomycosis accounted for an average of 8.62% of the total equine ophthalmic admissions during this time and an average of 33.3% of horses were diagnosed with infectious keratitis. Fungi were diagnosed using cytology (n = 4) and/or culture (n = 8) and histopathology (n = 1). Aspergillus sp. was the most commonly isolated fungus. Medical therapy alone or combined medical and surgical treatment was utilised for therapy depending on the clinical condition. Miconazole 1% was the most common topical antifungal therapy employed. Median duration of treatment was 73.12 days. Records were evaluated to determine visual outcome and globe survival.     

Equine keratomycoses in California from 1987 to 2010 (47 cases)

Reasons for performing study: Equine keratomycosis in the western USA has received little study, probably owing to its low prevalence. Objectives: To determine clinical features, predominant fungal isolates, treatment modalities and outcomes of horses with keratomycosis in California and compare these with results from different geographic regions. Methods: Records of horses presented to the University of California‐Davis Veterinary Medical Teaching Hospital (UCD‐VMTH) with confirmed keratomycosis between 1987 and 2010 were reviewed for this retrospective study. Information retrieved from the record included background, ophthalmic examination findings, treatment prior to and following presentation, visual outcome, and ocular survival. Results: A total of 48 eyes in 47 horses met the inclusion criteria and comprised 2% of cases presented to the UCD‐VMTH ophthalmology service. Prior to presentation, 20 horses (43%) received at least one topically administered anti‐inflammatory medication. Keratomycosis was confirmed by fungal culture in 38 horses (81%), by histopathology in 2 horses (4%) and by cytology in 7 horses (15%). Forty‐four isolates were identified in the 38 horses cultured; Aspergillus was the most common isolate (64%) and a novel isolate, Papulospora, was identified in 2 horses. Treatment consisted of medication only (73%), medical and surgical treatment (25%), or immediate enucleation (2%). Globe retention was 77% and vision retention was 53%. Corneal perforation was significantly associated with loss of vision (P<0.001). Conclusions: Keratomycosis is relatively uncommon in horses presented for ophthalmic conditions at UCD‐VMTH. Corneal perforation was a negative prognostic indicator for vision in this population of northern Californian horses.     

Equine keratomycosis in Japan

Objective To describe the incidence, clinical progress, visual outcome, and laboratory findings of equine keratomycosis in Japan. Procedure Retrospective study of the medical records of horses clinically and mycologically diagnosed with keratomycosis at the Equine Hospitals of the Japan Racing Association from 2005 to 2011. Results The diagnosis of keratomycosis was confirmed in eight horses (40.0% of the 20 horses with infectious keratitis from which fungi and/or bacteria were isolated). Fungi recovered from corneal swabs were identified as Aspergillus flavus (4), Aspergillus niger (1), Fusarium solani (1), and Mortierella wolfii (2). All horses were treated medically with topical antifungals, and one horse was also treated surgically. The median of treatment period was 40 days. Two horses were rendered blind in the affected eye and the others retained vision. Conclusions Equine keratomycosis comprises a considerable portion of infectious keratitis in Japan, and the causative fungi that we isolated had been isolated previously from horses with keratomycosis in other regions with the exception of M. wolfii. Culture and cytological examination of corneal lesions should be immediately performed on eyes with signs of keratitis, particularly on those not improving with antibacterial medication, as early initiation of aggressive antifungal treatment tended to result in better outcome and shorter treatment period.     

Prevalence of equine ulcerative keratomycosis in Colorado and association of environmental factors: A retrospective and descriptive study (2002–2017)

Equine ulcerative keratomycosis is relatively commonly presented to teaching hospitals in North America, with a prevalence from 24 to 86%. Horses in Colorado may have lower risk due to the dry mountain climate, but data are lacking. This study aimed to determine the prevalence of ulcerative keratomycosis amongst horses with ulcerative keratitis presented to Colorado State University Veterinary Teaching Hospital (CSU-VTH) ophthalmology service and to evaluate environmental factors (season, temperature, humidity, wind speed and elevation) associated with ulcerative keratomycosis in Colorado. A database search identified horses with ulcerative keratitis presented to the ophthalmology service at CSU-VTH from January 2002 to August 2017. Sixty-one horses met the inclusion criteria of a corneal cytology and/or culture or histopathology at the time of diagnosis; cases lacking that were excluded. Environmental factors at the boarding sites, including season, temperature, humidity, wind speed and elevation and clinical outcomes for fungal cases, were recorded. Prevalence of fungal infection amongst equine ulcerative keratitis was 16.4% (10/61), suggesting that CSU-VTH has considerably fewer ulcerative keratomycosis cases than other veterinary teaching hospitals in North America. Spring (50%, 5/10) and fall (40%, 4/10) had the highest prevalence of fungal ulcerative keratitis in Colorado. Only one case was reported in summer (10%, 1/10); no horses were positive (0%, 0/10) in winter. Only wind speed seemed to influence the development of ulcerative keratomycosis with higher wind speeds associated with greater rates of fungal involvement (P = 0.047). Other environmental factors did not show a detectable association (all P-values >0.05). Outcomes were variable. It was concluded that horses from the area of CSU-VTH appear to be at lower risk for ulcerative keratomycosis than from the areas around other North American veterinary teaching hospitals that have reported data. Most horses with keratomycosis in this area present in the spring and fall.     

Clinical features and outcomes of severe ulcerative keratitis with medical and surgical management in 41 horses (2000–2006)

The clinical features and outcomes of equine ulcerative keratitis with and without conjunctival graft surgery were assessed using a retrospective study. Medical records of horses hospitalised from July 2000-January 2006 for ulcerative keratitis were included if a diagnosis of melting ulcer, descemetocele or iris prolapse was made, or if surgery was recommended due to severity of corneal disease, and aggressive medical therapy using a subpalpebral catheter was instituted. Treatment and outcome variables were evaluated with and without conjunctival graft surgery. Forty-one horses, 21 that had surgery and 20 for whom surgery was recommended but not performed, were included. Horses were hospitalised for an average of 24 days, with 37/41 melting ulcers, 17/41 descemetoceles and 3/41 iris prolapses, with no statistical difference in frequencies between groups. Bacterial or fungal organisms were cultured from 22/39 cases, with 10 Aspergillus spp. and 8 Pseudomonas spp. Infectious organisms were seen on corneal cytology in 23/30 cases. Surgical cases were hospitalised for an average of 4.9 days prior to surgery. Abdominal discomfort was observed in 8/41 hospitalised horses, with 5/8 operated horses developing caecal impactions. Thirty-five horses retained an intact globe, including 18/20 treated medically and 17/21 that had surgery. Hospitalisation cost was 24% more for cases that had surgery than for medical cases. It was concluded that there was no statistical difference in length or cost of hospitalisation between surgical and nonsurgical groups. Outcomes from both groups were similar, with a high frequency of globe retention.     

In vivo confocal microscopy of equine fungal keratitis

Objective To describe in vivo corneal confocal microscopy of horses with fungal keratitis and correlate findings with clinical, histopathological, and microbiological evaluations of clinical cases and an ex vivo experimental equine fungal keratitis model. Animals studied A total of 12 horses with naturally‐acquired fungal keratitis and ex vivo equine corneas experimentally infected with clinical fungal isolates. Procedures Horses with naturally‐acquired fungal keratitis were examined with a modified Heidelberg Retina Tomograph II and Rostock Cornea Module. Confocal microscopy images of clinical isolates of Aspergillus fumigatus, Fusarium solani, and Candida albicans were obtained by examination of in vitro cultures and experimentally infected ex vivo equine corneas. Results Non‐specific in vivo corneal confocal microscopic findings in horses with fungal keratitis included leukocyte infiltrates, activated keratocytes, anterior stromal dendritic cell infiltrates, and vascularization. Linear, branching, hyper‐reflective structures that were 2–6 μm in width and 200 to >400 μm in length were detected in all horses with filamentous fungal keratitis. Round to oval hyper‐reflective structures that were 2–8 μm in diameter were detected in a horse with yeast fungal keratitis. The in vivo confocal microscopic appearance of the organisms was consistent with fungal morphologies observed during examination of in vitro cultures and infected ex vivo equine corneas. Conclusions In vivo corneal confocal microscopy is a rapid and non‐invasive method of diagnosing fungal keratitis in the horse. This imaging technique is useful for both ulcerative and non‐ulcerative fungal keratitis, and is particularly advantageous for confirming the presence of fungi in deep corneal stromal lesions.     

Isolation of obligate anaerobic bacteria from ulcerative keratitis in domestic animals

Objective To determine the frequency of obligate anaerobic bacterial isolation from corneal samples of domestic animals with ulcerative keratitis and to characterize the historical, clinical, cytological, and microbiological features of culture‐positive cases. Animals studied Three hundred and thirty domestic animals with ulcerative keratitis. Procedures Anaerobic bacteriologic culture and Gram stain were performed on corneal samples from consecutive animals examined with suspect septic ulcerative keratitis. Additional corneal diagnostics included: aerobic bacteriologic culture for all species; fungal culture for ungulates; Mycoplasma culture and virus isolation or feline herpesvirus‐1 (FHV‐1) polymerase chain reaction (PCR) for cats. Historical, clinical, and cytological findings were correlated with microbiologic data. Results Anaerobic bacteria were isolated from 13.0% of corneal samples (dogs: 14.0%; horses: 12.9%; cats: 7.9%; alpacas: 18.8%). The most frequent isolates were Clostridium, Peptostreptococcus, Actinomyces, Fusobacterium, and Bacteroides species. The majority of these infections were mixed anaerobic and aerobic bacteria, unless antimicrobial therapy had been administered prior to presentation. The clinical appearance of anaerobic bacterial culture‐positive cases was highly variable. Ocular trauma, pre‐existing corneal disease, previous corneal surgery, and chronic dermatological disease were significantly (P ≤ 0.05) correlated with positive anaerobic cultures in one or more species. Conclusions The results of the present study demonstrate that obligate anaerobic bacteria are present within the intralesional flora of ulcerative keratitis in domestic animals. In most species evaluated, these bacteria were identified infrequently. Anaerobic bacterial infection of the cornea most frequently occurs in association with other ocular pathogens and previous corneal abnormalities.     

Rose bengal positive epithelial microerosions as a manifestation of equine keratomycosis

Purpose To describe the clinical appearance of corneal epithelial cell microerosions associated with keratomycosis in the horse. METHODS: Retrospective clinical study. RESULTS: Multifocal, punctate, superficial corneal opacities with positive rose bengal retention were noted in six horses with presumed 'viral keratitis'. Faint fluorescein staining was also present in three cases. Equine herpesvirus tissue culture inoculation was negative for a cytopathic effect in three cases. Aspergillus (n = 3), Curvularia (n = 1), and an unidentified fungus (n = 1) were cultured in five horses, and hyphae found on corneal cytology from the sixth. Mixed bacterial infections were present in three eyes. The eyes of two horses with Aspergillus progressed to deep melting corneal ulcers that required surgical therapy. The microerosions remained superficial, but persistent in the other four eyes. Natamycin was utilized topically in all six horses. Transmission electron microscopy from case 6 revealed mucin layer disruption, an intact corneal epithelial cell layer, and fungal attachment to degenerating epithelial cells. The visual outcome was positive in all six horses, although healing was prolonged (48.5 +/- 14.5 days on average in the horses with no surgery; 62 days on average in the two horses that required surgery). CONCLUSIONS: Complete removal or full-thickness penetration of the corneal epithelial cell barrier may not be necessary to allow fungal adherence and initiation of keratomycosis in the horse. Prior to colonization and invasion of the horse cornea, fungi may induce changes in the mucin layer of the tear film that result in or are associated with rose bengal positive microerosions of the superficial corneal epithelium. Horses with painful eyes, and eyes with superficial, multifocal corneal opacities should have their corneas stained with both fluorescein and rose bengal as fungal microerosions may stain weakly, or not at all, with fluorescein, and may thus be mistaken for presumed 'viral keratitis' of the horse.     

Scedosporium apiospermum keratomycosis in a dog

A 6‐year‐old male castrated Norfolk Terrier dog was examined following a 21‐day history of an increasingly painful eye. Examination revealed marked blepharospasm and purulent ocular discharge associated with an ulcerative keratitis. There was panstromal corneal opacity with raised gray to white lesions. Corneal cytology demonstrated branching septate fungal hyphae identified by polymerase chain reaction as Scedosporium apiospermum. Treatment with topical 1% voriconazole solution was successful in resolving the keratomycosis.     

In vitro susceptibility patterns of fungi associated with keratomycosis in horses of the northeastern United States: 68 cases (1987-2006)

OBJECTIVE: To determine in vitro susceptibility patterns of fungi associated with keratomycosis in horses in the northeastern United States and compare those patterns with results of studies from other geographic regions. DESIGN: Retrospective case series. ANIMALS: 68 horses with keratomycosis. PROCEDURES: Medical records of horses with a clinical diagnosis of keratomycosis, positive results of corneal fungal cultures, and susceptibility data were reviewed from the years 1987 to 2006. Fungal identification and in vitro antifungal susceptibility test results were recorded. The percentage of susceptible isolates was compared among antifungals for all isolates together and for the most common genera individually. RESULTS: 74 fungal isolates from 68 horses that met inclusion criteria were identified. Aspergillus, Candida, and Fusarium spp were the most frequent isolates. Grouped isolates had the highest percentage of susceptibility to nystatin (87.7%), natamycin (87.5%), and clotrimazole (80.6%). Grouped isolates had the lowest percentage of susceptibility to fluconazole (15.8%) and miconazole (27.5%). Aspergillus spp (> or = 81.0%) were most susceptible to nystatin, clotrimazole, itraconazole, and natamycin. Candida spp (100%) were most susceptible to ketaconazole, natamycin, and nystatin. Fusarium spp (100%) were only consistently susceptible to natamycin. CONCLUSIONS AND CLINICAL RELEVANCE: On the basis of in vitro susceptibility testing, nystatin, natamycin, or clotrimazole is recommended for initial topical treatment of keratomycosis in horses from the northeastern United States. Contrary to results of studies of ocular fungal isolates of horses from other regions, Candida spp were identified more frequently and miconazole had lower in vitro efficacy in the present study.     

Ulcerative keratitis in thoroughbred racehorses in Japan from 1997 to 2008

Objective To describe the number of cases, etiologies, healing times, and results of microbial culture and susceptibility testing of corneal ulcers in thoroughbred racehorses in Japan. Procedure Retrospective study of the medical records of racehorses belonging to the Japan Racing Association (JRA) from 1997 to 2008. Results A total of 2846 horses suffered ulcerative keratitis. These horses accounted for 90.5% of all the corneal problems and 54.9% of the entire number of horses with ocular diseases. Running in races was the cause in 64.3% of the cases. The mean healing time of the ulcers developed in races was 5.5 ± 9.6 days, which was shorter than that of the ulcers unrelated to racing (8.6 ± 11.7 days). In horses presented for examination by the next day after the race, healing was even more rapid (4.1 ± 7.5 days) than in horses presented later (12.4 ± 14.7 days). Microbial culture was performed on 74 samples of 58 horses. Forty‐four bacterial and four fungal organisms were isolated from 35 samples of 29 horses. Pseudomonas aeruginosa (10) and Streptococcus equi subspecies zooepidemicus (5) were the bacteria most frequently isolated. There was no tendency of increasing antibiotic resistance of these organisms. Conclusions Ulcerative keratitis is the most frequent corneal and ocular disease of the racehorse in Japan. Careful observation of the eyes after racing is necessary as early diagnosis and treatment of corneal ulcers speeds healing. Many antibiotic have efficacy against the bacterial isolates, however, potent antibiotics should be reserved for the most severe corneal ulcers.     

Mortierella wolfii keratomycosis in a horse

Purpose To describe a case of superficial keratomycosis caused by Mortierella wolfii (M. wolfii) in a horse. Methods A thoroughbred filly was presented with painful right eye of 2 days’ duration. A superficial corneal ulcer was observed ventrally together with multifocal punctuate opacities axially. Samples were collected by swabbing and scraping the ulcerated lesion and submitted for microbiologic and cytologic examination. Results Microscopic evaluation of debrided corneal tissue revealed the presence of nonseptate fungal hyphae, and culture of a corneal swab yielded fungal growth. Medical treatment with topical antifungal, antibiotic and autogenous serum and systemic anti‐inflammatory resolved the problem within 2 weeks. Conclusions Cytologic evaluation of a corneal scraping was useful to make a clinical diagnosis of keratomycosis. Based on the mycological characteristics, the fungus isolated from the corneal lesion was identified as M. wolfii. To the authors’ knowledge, this is the first case report of equine keratomycosis associated with this fungus, although the organism is known to infect various organs of cattle.     

Nonulcerative bullous keratitis associated with Pseudomonas alcaligenes infection in a Thoroughbred mare

A 5‐year‐old Thoroughbred mare presented with an intermittently mildly painful right eye with a nonulcerative corneal opacity of several weeks' duration that had improved with topical steroids but recurred when steroids were withdrawn. Ophthalmic examination demonstrated a focal region of moderate corneal oedema and midstromal corneal infiltrate centrally but no other significant ocular abnormalities, and suggested a diagnosis of immune‐mediated keratitis. Empirical courses of both topical and systemic anti‐inflammatory drugs, both nonsteroidal and steroidal, led to initial improvement but bullous keratopathy developed when corneal oedema became profound. Due to the rapidly progressive nature of the bullous keratopathy combined with poor response to medical therapy, a keratectomy and conjunctival graft were performed under general anaesthesia. Intraoperative corneal culture of the keratectomy site grew Pseudomonas alcaligenes, a common soil and water contaminant. Histopathology of the keratectomy specimen revealed neutrophilic inflammation. Keratectomy and conjunctival graft led to resolution of ocular pain and inflammation, with an acceptable cosmetic and visual outcome. This report describes an unusual case of a nonulcerative Pseudomonas keratitis that responded well to surgical therapy, and underscores the complicated nature of nonulcerative keratitis in horses.     

Pseudallescheria boydii keratomycosis in a horse

The fungal organism Pseudallescheria boydii was isolated from the cornea of a Quarter Horse with ulcerative keratitis. Despite aggressive hourly medication through a subpalpebral lavage system, with drugs including miconazole and natamycin, the cornea developed a stromal abscess. Orbital exenteration was performed after 3 weeks. The fungal isolate was later determined to be resistant to all 8 antifungal drugs tested. Microscopic examination of the cornea revealed fungal hyphae throughout the corneal stroma and penetrating the Descemet membrane. Pseudallescheria boydii has not been implicated previously as a cause of keratomycosis in horses or in other domestic animals, although cases in human beings have been described.     

CASE REPORT: Keratomycosis in a dog treated with topical 1% voriconazole solution

A 2‐year‐old Jack Russell Terrier was presented for treatment of a worsening corneal ulcer and keratomalacia following removal of a vegetative foreign body. The keratomalacia responded to topical gentamicin therapy; however, the eye became suddenly painful and at examination two areas of increased opacity had developed. Fungal keratitis was demonstrated by corneal scrape showing branching, septate fungal hyphae. Treatment with 1% voriconazole was effective in resolving the keratomycosis.     

Conjunctival bacterial and fungal flora in healthy horses in the UK

Objectives To describe the bacterial and fungal flora of the normal conjunctiva of horses in the UK; to determine the effect of horse age, sex, geographic location, and housing on this flora; and to determine the most appropriate antimicrobial drug(s) for prophylactic treatment of corneal ulcers. Animal studied A total of 60 adult healthy horses were studied. Procedure Swabs of the conjunctiva were obtained from 60 horses housed in two locations within the UK. Specimens were cultured for aerobic bacteria and fungi, and sensitivity against six ophthalmic antimicrobials assessed. The effect of age, sex, location and housing on the frequency of microbial isolation was evaluated. Results Fifty‐four bacterial isolates, representing thirteen genera of bacteria were cultured from 31 (52%) horses. The most frequently isolated bacterial species was Acinetobacter sp (17/32 horses). The majority of isolates (28/54: 52%) were gram‐positive. Three genera of fungi (Mucor, Absidia and Aspergillus spp) were isolated from eight (13%) horses. There was no significant effect of geographic location, sex, age or housing on frequency of microbial isolation. Horses from which gram‐negative bacteria were isolated were significantly older than horses from which gram‐positive bacteria were isolated. High efficacy (greater than 90% of isolates sensitive in vitro) was displayed by chloramphenicol, gentamicin and tetracycline. Conclusions The microbial species isolated are comparable with studies performed in other countries, although the frequency of Acinetobacter isolation was higher which may reflect a geographic difference. The topical antimicrobials gentamicin and chloramphenicol are appropriate first line antimicrobials for empirical treatment of corneal ulcers in the UK.     

Immunohistochemical study of matrix metalloproteinases‐2 and ‐9, macrophage inflammatory protein‐2 and tissue inhibitors of matrix metalloproteinases‐1 and ‐2 in normal,purulonecrotic and fungal infected equine corneas

Objective Determine the effects of matrix metalloproteinases (MMPs)‐2, ‐9, macrophage inflammatory protein‐2 (MIP‐2), tissue inhibitors of matrix metalloproteinase (TIMP)‐1 and ‐2 by immunohistochemical expression in fungal affected and purulonecrotic corneas. Procedure Paraffin‐embedded equine corneal samples; normal (n = 9), fungal affected (FA; n = 26), and purulonecrotic without fungi (PN; n = 41) were evaluated immunohistochemically for MMP‐2, ‐9, MIP‐2, TIMP‐1 and ‐2. The number of immunoreactive inflammatory cells was counted and statistics analyzed. Western blot was performed to detect MMP‐2, MMP‐9, TIMP‐1 and TIMP‐2 proteins. Results Matrix metalloproteinases‐2, ‐9, MIP‐2, TIMP‐1 and ‐2 immunoreactivity was identified in corneal epithelium of normal corneas, and in corneal epithelium, inflammatory cells, keratocytes, and vascular endothelial cells of both FA and PN samples. Inflammatory cell immunoreactivity was significantly higher in FA and PN samples than in the normal corneas. There was positive correlation between MMP‐2 and MIP‐2, MMP‐9 and MIP‐2, and MMP‐9 and TIMP‐1 in inflammatory cell immunoreactivity in FA samples. There was positive correlation between MMP‐9 and MIP‐2, MMP‐9 and TIMP‐2, MIP‐2 and TIMP‐1, and MIP‐2 and TIMP‐2 in inflammatory cell immunoreactivity in PN samples. Western blot confirmed the presence of all four proteins in equine corneal samples. Conclusion Increased immunoreactivity of MMP‐2 and ‐9 in FA and PN samples is indirectly related to MIP‐2 through its role in neutrophil chemo‐attraction. Tissue inhibitors of matrix metalloproteinase‐1 and TIMP‐2 are up‐regulated in equine purulonecrotic and fungal keratitis secondary to MMP‐2 and MMP‐9 expression. The correlation between MMPs ‐2 and ‐9, MIP‐2, TIMPs ‐1 and ‐2 suggests that these proteins play a specific role in the pathogenesis of equine fungal keratitis.     

Surgical Repair of Mid‐body Proximal Sesamoid Bone Fractures in 25 Horses

Objective— To describe the characteristics of unilateral mid‐body proximal sesamoid bone (PSB) fractures, to determine factors associated with the outcome of horses after surgical repair, and to describe a technique for arthroscopically assisted screw fixation in lag fashion. Study Design— Retrospective case series. Animals— Horses (n=25) with unilateral mid‐body PSB fracture. Methods— Medical records (1996–2006), radiographs, and arthroscopic videos of horses with surgically repaired unilateral mid‐body PSB fractures were reviewed. Retrieved data included signalment, affected limb and PSB, fracture characteristics, and surgical technique. Outcome was established by radiographic assessment of healing and race records; categorical data were analyzed using Fisher's Exact test. Results— Medial forelimb PSBs were most commonly affected (80%). Surgical technique and degree of reduction were significantly associated with outcome; 44% of horses with screw repair and none of the horses with wire fixation raced (P=.047). Factors that may have influenced this outcome were differences in fracture reduction (improved reduction in 22% wire repairs and 88% screw repairs, P=.002) and use of external coaptation (22% wire repair and 88% lag screw repair, P=.002). None of the horses with unimproved reduction raced after surgery. Conclusions— Only 28% of horses with mid‐body PSB fractures raced after surgery. Compared with wire fixation, screw fixation in lag fashion resulted in good reduction and is seemingly a superior repair technique. Clinical Relevance— For mid‐body PSB fractures, arthroscopically assisted screw fixation in lag fashion and external coaptation for anesthesia recovery and initial support provides the best likelihood of return to athletic use.