Respiratory muscle perfusion in ponies during prolonged submaximal exercise in thermoneutral environment.

Distribution of blood flow among various respiratory muscles was examined in 8 healthy ponies during submaximal exercise lasting 30 minutes, using radionuclide labeled 15-microns diameter microspheres injected into the left ventricle. From the resting values (40 +/- 2 beats/min; 37.3 +/- 0.2 C), heart rate and pulmonary arterial blood temperature increased significantly at 5 (152 +/- 8 beats/min; 38.6 +/- 0.2 C), 15 (169 +/- 6 beats/min; 39.8 +/- 0.2 C), and 26 (186 +/- 8 beats/min; 40.8 +/- 0.2 C) minutes of exertion, and the ponies sweated profusely. Mean aortic pressure also increased progressively as exercise duration increased. Blood flow increased significantly with exercise in all respiratory muscles. Among inspiratory muscles, perfusion was greatest in the diaphragm and ventral serratus, compared with external intercostal, dorsal serratus, and scalenus muscles. Among expiratory muscles, blood flow in the internal abdominal oblique muscle was greatest, followed by that in internal intercostal and transverse thoracic muscles, in which the flow values remained similar. The remaining 3 abdominal muscles had similar blood flow, but these values were less than that in the internal intercostal, transverse thoracic, and internal abdominal oblique muscles. Blood flow values for all inspiratory and expiratory muscles remained similar for the 5 and 15 minutes of exertion. However, at 26 minutes, blood flow had increased further in the diaphragm, external intercostal, internal intercostal, transverse thoracic, and the external abdominal oblique muscle as vascular resistance decreased. On the basis of our findings, all respiratory muscles were activated during submaximal exercise and their perfusion had marked heterogeneity.(ABSTRACT TRUNCATED AT 250 WORDS)     

Electromyographic activity of the stylopharyngeus muscle in exercising horses

REASONS FOR PERFORMING STUDY: There is a need to understand the process which leads to failure of recruitment of the stylopharyngeus muscle in clinical cases of nasopharygeal collapse. We therefore studied the timing and intensity of stylopharyngeus muscle activity during exercise in horses. OBJECTIVE: To measure the electromyographic (EMG) activity of the stylopharyngeus muscle in exercising horses and correlate it with the breathing pattern. METHODS: Five horses were equipped with a bipolar fine wire electrode placed on the stylopharyngeus muscle and a pharyngeal catheter. The horses exercised on a treadmill at speeds corresponding to 50 (HRmax50), 75 and 100% of maximum heart rate, and EMG activity of the stylopharyngeus muscle and upper airway pressures were recorded. The EMG activity of the stylopharyngeus muscle was then correlated to the breathing pattern and the activity quantified and reported as a percentage of the baseline activity measured at HRmax50. RESULTS: There was ongoing activity of the stylopharyngeus muscle throughout the breathing cycle; however, activity increased towards the end of expiration and peaked early during inspiration. Tonic activity was present during expiration. Peak, mean electrical and tonic EMG activity increased significantly (P<0.05) with exercise intensity. CONCLUSION: The stylopharyngeus muscle has inspiratory-related activity and tonic activity that increases with speed. POTENTIAL RELEVANCE: The stylopharyngeus muscle is one of a group of upper airway muscles that function to support and maintain the patency of the nasopharynx during inspiration. Failure of recruitment of the stylopharyngeus muscle during exercise is a potential explanation for clinical cases of dorsal pharyngeal collapse, but further work investigating the activity of the stylopharyngeus muscle in horses affected by this disease is needed.     

Cardiovascular effects recorded in horses during anaesthesia after treatment with trichlorfon

Five horses were anaesthetised twice with thiopentone sodium, guaifenesin and halothane. The second anaesthesia was 16 days after the first and two days following oral administration of trichlorfon. Heart rate, carotid arterial, pulmonary arterial and right atrial pressures, cardiac output and blood temperature were measured every 15 minutes for 120 minutes. Heart rate, carotid arterial pressure and cardiac output were similar on both occasions. Pulmonary arterial and right atrial pressures were highest during anaesthesia after treatment with trichlorfon when compared with values obtained before treatment. Pulmonary vascular resistance was significantly decreased at four measurement times during anaesthesia after treatment with trichlorfon. All cardiovascular measurements were within ranges accepted as normal for halothane anaesthesia in horses. In a second experiment, four ponies were anaesthetised with xylazine and ketamine on two occasions one week apart. Two ponies received trichlorfon two days before the second anaesthesia. Heart rate, arterial pressure and respiratory rate recorded during anaesthesia were not different in ponies after organophosphate treatment. The time to standing after the second anaesthesia was significantly increased in all ponies.     

Electromyographic activity of cubital joint muscles in horses during locomotion

Electromyographic (EMG) activity of 4 muscles of the cubital joint and the strain of forelimb hooves were recorded telemetrically in 4 Thoroughbreds (with and without a rider) standing, walking, trotting, and cantering. Bipolar fine wire electrodes were inserted into the muscles, and strain gauges were attached to the hoof wall. Motion pictures (16 mm), synchronized with EMG tracings, were taken to obtain kinematic data. When horses were standing, the biceps brachii had tonic activity, but the brachialis and the caput longum and the caput laterale of the triceps brachii had no EMG activity. The biceps brachii had EMG activity during the stance phase. The brachialis had EMG activity from the end of the stance phase to the middle of the swing phase. Unlike the biceps brachii, the brachialis acted as a flexor muscle of the cubital joint during locomotion. The EMG activity of the caput longum of the triceps brachii was detected from midswing phase to early stance phase. The EMG activity of the caput laterale of the triceps brachii began in midswing or late-swing phase and ceased in early stance or midstance phase. During locomotion, caput longum EMG activity always preceded caput laterale activity. When horses were cantering, the brachialis and the caput longum (acting mainly in the swing phase) had an EMG activity phase different from those in leading and trailing forelimbs. These 4 muscles had similar EMG activity patterns during locomotion in horses with and without a rider.     

The effect of breed of sire and age at feeding on muscle tenderness in the beef chuck

Steers (n = 59) produced from the mating of Braford, Simbrah, Senepol, and Simmental bulls to Brahman- and Romana Red-sired cows and Brahman bulls to Angus cows were used in this study. Effects of sire breed and age at feeding on muscle tenderness in the major muscles of the chuck when steers were fed to 1.0 cm 12th rib fat were determined. There were no muscle tenderness effects due to sire breed group, with the exception of the serratus ventralis muscle, which was more tender in Brahman- and Braford-sired steers than in Simmental-sired steers. Additionally, the supraspinatus muscle from the yearlings was lower in shear value than that from the calves. The Brahman-sired steers had serratus ventralis muscles with higher percentages (P less than .05) of intramuscular fat than those of Braford-, Simbrah-, and Simmental-sired steers. Fat deposited within the muscle or between muscles in the chuck was not related to muscle tenderness as measured by Warner-Bratzler shear values. Also, percentages of intramuscular fat of the triceps brachii, serratus ventralis, or supraspinatus muscles were not influenced (P greater than .05) by age at feeding.     

Ultrasound-guided superficial serratus plane block in dog cadavers: an anatomical evaluation and volume dispersion study

ObjectiveTo evaluate the anatomy of the serratus plane in dogs to establish the optimal landmarks for a superficial serratus plane (SSP) block and evaluate ropivacaine–methylene blue solution dispersion with three volumes of injection.Study designProspective experimental cadaveric study.AnimalsA formaldehyde solution-preserved dog cadaver and 15 frozen/thawed adult dog cadavers.MethodsThe thoracic wall of the formaldehyde-preserved cadaver was dissected. An SSP injection was performed on each hemithorax of the cadavers, with the ultrasound transducer placed over the fourth and fifth ribs, at the level of the shoulder joint. A needle was inserted in-plane in a caudocranial direction until it could be visualized between the serratus ventralis thoracis and latissimus dorsi muscles. Dog cadavers were injected with a ropivacaine–methylene blue solution at 0.3, 0.6 and 1.0 mL kg^–1 and were dissected to determine the spread of the dye.ResultsThe thoracic wall muscles identified in the formalinized cadaver were the cutaneous trunci, latissimus dorsi, external abdominal oblique, serratus ventralis thoracis, scalenus, serratus dorsalis cranialis and external intercostal. The nerves identified in the SSP included the lateral cutaneous branches of intercostal nerves, intercostobrachial nerves and long thoracic nerve. The solution was successfully injected at the SSP in 26 of 29 (89.7%) attempts. Dermatomal dye spread, median (range), was 4 (3–6), 4 (2–5) and 5 (4–8) for 0.3, 0.6 and 1.0 mL kg^–1, respectively, with no significant difference among them.Conclusions and clinical relevanceInjections for an SSP block were easily performed under ultrasound guidance, using the fourth and fifth ribs at the level of the shoulder joint as reference landmarks. An injected volume of 0.3 mL kg^–1 may be sufficient for hemithorax analgesia in dogs. Further studies in dogs are required to determine the utility of this technique.     

Type,diameter and distribution of fibres in some respiratory and abdominal muscles of the goat

This study was designed to determine the histochemical properties, size and composition of fibres in the diaphragm, intercostal and abdominal muscles of goats to clarify whether reported similarities in respiratory muscle physiology between goats and humans have a structural basis. Serial sections (10 µm) of muscular tissue from adult female goats were stained for myosin adenosine triphosphatase and reduced nicotinamide adenine dinucleotide dehydrogenase-tetrazolium reductase activities; the fibres were classified into types I, IIA and IIB; and their mean diameter and composition were determined. Abdominal and intercostal muscles contained types I, IIA and IIB fibres in the ratio 1:1:1, and the mean diameter of the fibres ranged from 49.2 to 62.2 µm. In contrast, the diaphragm contained 58.9% type I and 41.1% type II fibres, and the latter could not be differentiated into types IIA and IIB. Diaphragmatic fibres were also smaller (36.9 – 40.9 µm). These findings contrast with those in humans, where the diaphragm, intercostal and abdominal muscles contain >50% type I fibres and have fibres of identical diameter. The differences in fibre characteristics between the diaphragm, intercostal and abdominal muscles of goats and the differences between goats and humans need to be taken into consideration in interpreting the results from studies in respiratory muscle physiology.Abbreviations mATPase myosin adenosine triphosphatase - NADH-TR nicotinamide adenine dinucleotide dehydrogenase-tetrazolium reductase     

Anatomy of the dorsoscapular ligament of horses

Thoracic limbs from 8 horses were dissected. The dorsoscapular ligament was determined to consist of a collagenous part that fused to the surface of the thoracolumbar fascia and of an elastic part that extended laterally from the collagenous part to attach to the medial surface of the scapula and interdigitate with fibers of the serratus ventralis thoracis muscle.     

蒙古马全身主要骨骼肌表型谱的构建及比较研究

为探究蒙古马骨骼肌在运动和肉质方面的特点，本研究选取2匹5岁健康未调教的成年公马全身主要骨骼肌52块(2匹×26块)作为研究对象。试验采用石蜡切片、免疫组化、HE染色的方法得到26个部位骨骼肌形态、快慢肌纤维分布情况、肌纤维横截面积。因不同部位骨骼肌存在差异，本研究将肌肉组织分为5组(头颈部、前肢、躯干部、腹壁侧、后肢)分别进行统计。将其中对应的24个部位与前期得到的纯血马骨骼肌快慢肌纤维比例进行分组比对。结果得到蒙古马全身主要骨骼肌的表型谱，其中颈锯肌、冈上肌、臂二头肌、腕桡侧屈肌、腓肠肌、菱形肌、胸腹侧锯肌的慢肌纤维占比较低；腕桡侧伸肌、臂三头肌、背最长肌、臀中肌慢肌纤维占比达70%以上；且慢肌纤维占比与肌纤维横截面积呈负相关。蒙古马骨骼肌慢肌纤维占比基本高于纯血马，前肢、躯干部差异极显著(P<0.01),后肢、腹壁侧差异显著(P<0.05)。其中蒙古马与纯血马在臂三头肌、臀中肌、半膜肌和背最长肌慢肌纤维的差值大于50%。结果表明，蒙古马颈锯肌、冈上肌、臂二头肌、腕桡侧屈肌、腓肠肌、菱形肌、胸腹侧锯肌具有耐力训练的潜力；腕桡侧伸肌、臂三头肌、背最长肌、臀中肌品质好，可为...     

Standing Lateral Thoracotomy in Horses: Indications,Complications, and Outcomes

Objective: To describe the indications for, complications arising from, and outcome of horses that had standing lateral thoracotomy for pleural or pericardial disease. Study Design: Case series. Animals: Horses (n=16). Methods: Medical records (January 1990–December 2008) of sedated standing horses that had lateral thoracotomy were reviewed. Clinical and surgical findings, perioperative and short‐term complications were recorded. Long‐term (>6 months) outcome was determined through telephone conversations with owners and veterinarians. Results: Mean (±SD) horse age was 6.6±5.3 years (range, 1–15 years). Thoracotomy was most commonly for treatment of recurrent or chronic pleural infection (94%). Anaerobic bacteria were frequently isolated from pleural effusion associated with pleuropneumonia (63%). Right lateral intercostal thoracotomy was performed in 13 horses (82%); intercostal muscle myectomy in 5 horses; and rib resection in 1. Perioperative complications were hemipneumothorax (2 horses) and short‐term complications included cellulitis and abscessation of the thoracotomy site (6 horses). Fourteen (88%) horses survived to discharge and 46% of horses that survived returned to their previous level of athletic activity. Conclusions: Lateral thoracotomy is well tolerated by standing sedated horses with minimal perioperative and short‐term complications. Clinical Relevance: Standing lateral thoracotomy should be considered for the treatment of complicated pleuropneumonia in horses.     

Comparative pulmonary mechanics in the horse and the cow

Pulmonary mechanics and lung volumes were measured in horses and cows to determine if differences in breathing pattern between the two species were due to differences in the mechanical properties of the lungs. Tidal volume (VT) was larger in the horses, while the respiratory rate (fR) and minute ventilation (VE) were higher in the cows. The horses often had a double peak in airflow during inspiration and, or, expiration, while the cows had a single peak during expiration. Measured lung volumes were larger in the horses and they had a higher dynamic lung compliance (Cdyn,L), although the static compliance of the lung, chest wall and respiratory system (Cst,L,Cst,w and Cst,rs respectively) did not appear to differ between the two species. The cows had a greater change in maximum transpulmonary pressure (delta PLmax) and an increased nonelastic work of breathing (Wb). However, the pulmonary resistance (RL) did not differ between the two species, thus the higher delta PLmax and Wb in the cows were most likely a function of their higher flow rates. Calculations of the rate of work of breathing (W) indicate that both species breathed at an fR above the minimum W. The fR in the horses was close to the fR predicted for the average minimum muscle force, but the fR in the cows was higher. As the differences in the mechanical properties of the lung do not explain the differences in flow pattern, nor adequately account for the higher fR in the cows, it is suggested that the differences in breathing pattern between the two species is due to differences in the chest wall, particularly the size and shape of the abdomen.     

Muscle perfusion in the horse

Muscle perfusion was studied in conscious and anaesthetised horses by monitoring the clearance of a locally injected bolus of saline containing radioactive xenon (¹³³Xe). The mean of all the measurements made from the brachiocephalicus and semimembranosus muscles in conscious subjects was 1.29 ml/min/100 g while in anaesthetised subjects it was 0.40 ml/min/100 g. The significance of these results is discussed in relation to the clinical occurrence of post anaesthetic myositis.     

Controlled mechanical ventilation in equine anaesthesia: Physiological background and basic considerations (Part 1)

Controlled mechanical ventilation (CMV) is routinely used in equine anaesthesia, with many different options available to mechanically deliver breaths. The complexity of respiratory pathophysiology in anaesthetised horses and the wide range of devices available is described in this scoping review. The first part of the review outlines basic equine respiratory physiology and pathophysiology during anaesthesia to illustrate what makes horses prone to inefficient gas exchange and ventilation when they are recumbent. The difference between spontaneous ventilation and CMV is reviewed and basic considerations of CMV are explored in more detail.     

Electromyographic activity of the hyoepiglotticus muscle and control of epiglottis position in horses

OBJECTIVE: To determine whether the hyoepiglotticus muscle has respiratory-related electromyographic activity and whether electrical stimulation of this muscle changes the position and conformation of the epiglottis, thereby altering dimensions of the aditus laryngis. ANIMAL: 6 Standardbred horses. PROCEDURE: Horses were anesthetized, and a bipolar fine-wire electrode was placed in the hyoepiglotticus muscle of each horse. Endoscopic images of the nasopharynx and larynx were recorded during electrical stimulation of the hyoepiglotticus muscle in standing, unsedated horses. Dorsoventral length and area of the aditus laryngis were measured on images obtained before and during electrical stimulation. Electromyographic activity of the hyoepiglotticus muscle and nasopharyngeal pressures were measured while horses exercised on a treadmill at 50, 75, 90, and 100% of the speed that produced maximum heart rate. RESULTS: Electrical stimulation of the hyoepiglotticus muscle changed the shape of the epiglottis, displaced it ventrally, and significantly increased the dorsoventral length and area of the aditus laryngis. The hyoepiglotticus muscle had inspiratory activity that increased significantly with treadmill speed as a result of an increase in phasic and tonic activity. Expiratory activity of the hyoepiglotticus muscle did not change with treadmill speed in 4 of 6 horses. CONCLUSIONS AND CLINICAL RELEVANCE: Findings reported here suggest that contraction of the hyoepiglotticus muscle increases dimensions of the airway in horses by depressing the epiglottis ventrally during intense breathing efforts. The hyoepiglotticus muscle may be an important muscle for dilating the airway in horses, and contraction of the hyoepiglotticus muscle may induce conformational changes in the epiglottis.     

Abnormal regulation of muscle contraction in horses with recurrent exertional rhabdomyolysis.

OBJECTIVE: To determine whether abnormal regulation of muscle contraction similar to that associated with malignant hyperthermia (MH) was evident in intact external intercostal muscle cells from Thoroughbreds with recurrent exertional rhabdomyolysis (RER). ANIMALS: 5 adult Thoroughbred horses with RER and 7 clinically normal adult Thoroughbred or mixed-breed horses. PROCEDURES: Twitch time course variables and contracture responses to various concentrations of potassium, caffeine, and halothane were measured in small bundles of intact external intercostal muscle cells from clinically normal horses and horses with RER. RESULTS: Threshold for significant contracture induced by potassium depolarization was lower for RER-affected muscles, compared with normal muscles, although the relationship between potassium concentration and membrane potential were not different. Thresholds for contracture induced by caffeine and halothane were also lower for RER-affected muscles, compared with normal muscles. Lower thresholds for caffeine- and halothane-induced contractures, as well as depolarization-elicited contractures, in RER-affected muscles suggest a defect in myoplasmic calcium regulation. CONCLUSIONS AND CLINICAL RELEVANCE: Regulation of muscle contraction is abnormal in Thoroughbreds with RER. The specific defect may be attributable to abnormal intracellular calcium regulation. Knowledge of the specific defect involved in RER may lead to improved prevention and treatment of RER-affected horses.     

Activity of selected rostral and caudal hyoid muscles in clinically normal horses during strenuous exercise

OBJECTIVE: To determine the phase and quantitate the electromyographic (EMG) activity of the genioglossus, geniohyoideus, hyoepiglotticus, omohyoideus, sternohyoideus, sternothyroideus, and thyrohyoideus muscles of clinically normal horses during strenuous exercise. ANIMALS: 7 clinically normal adult horses (2 Thoroughbreds and 5 Standardbreds). PROCEDURES: Bipolar electrodes were surgically implanted in the aforementioned muscles, and horses were subjected to an incremental exercise test on a high-speed treadmill. The EMG, heart rate, respiratory rate, and static pharyngeal airway pressures were measured during exercise. The EMG was measured as mean electrical activity (MEA). The MEA values for maximal exercise intensity (13 or 14 m/s) were expressed as a percentage of the MEA measured at an exercise intensity of 6 m/s. RESULTS: MEA was detected during expiration in the genioglossus, geniohyoideus, sternohyoideus, and thyrohyoideus muscles and during inspiration in the hyoepiglotticus and sternothyroideus muscles. Intensity of the MEA increased significantly with exercise intensity in the genioglossus, geniohyoideus, and hyoepiglotticus muscles. Intensity of the MEA increased significantly in relation to expiratory pharyngeal pressure in the geniohyoideus and hyoepiglotticus muscles. CONCLUSIONS AND CLINICAL RELEVANCE: Once exercise intensity reached 6 m/s, no quantifiable additional increase in muscular activity was detected in the omohyoideus, sternohyoideus, sternothyroideus, and thyrohyoideus muscles. However, muscles that may affect the diameter of the oropharynx (genioglossus and geniohyoideus muscles) or rima glottis (hyoepiglotticus muscle) had activity correlated with the intensity of exercise or expiratory pharyngeal pressures. Activity of the muscles affecting the geometry of the oropharynx may be important in the pathophysiologic processes associated with nasopharyngeal patency.     

Incidence of sarcocysts in skeletal muscles of horses.

The incidence of sarcocysts was examined in postural, propulsive and respiratory muscles from 74 horses ranging in age from mid-gestation to 14 years post-natal. Cryostat sections were stained for myosin adenosine triphosphatase (ATPase) at pH 9.5 and the type of muscle fibre containing sarcocysts was identified. Sarcocysts were found in muscles from three animals, all aged 1 year or more. Counts showed that they displayed no preference for any particular muscle. However, fibres with a high activity for myosin ATPase were preferentially colonized. Transverse sectional profiles of sarcocysts showed a wide variation in size, shape and wall thickness. Both the proportion of horses infected and the intensity of infection per animal were considerably lower than those reported in other studies.     

Prolonging dissociative anaesthesia in horses with a repeated bolus injection

The effects of prolonging romifidine/ketamine anaesthesia in horses with a second injection of ketamine alone or both romifidine/ketamine compared with only induction injection of romifidine and tiletamine/zolazepam were studied in 6 horses anaesthetised in lateral recumbency on 3 random occasions. All horses were sedated with romifidine 0.1 mg/kg bwt iv and, on 2 occasions, anaesthesia was induced by iv injection of ketamine 2.2 mg/kg bwt. To prolong the ketamine-induced anaesthesia, either ketamine (I.1 mg/kg bwt iv) or ketamine and romifidine (I.1 mg/kg bwt and 0.04 mg/kg bwt iv, respectively) were given 18–20 min after the start of the ketamine injection for induction. On the third occasion, anaesthesia was induced by iv injection of 1.4 mg/kg bwt Zoletil (0.7 mg/kg bwt tiletamhe + 0.7 mg/kg bwt zolazepam). No statistically significant differences in the measured cardiorespiratory function were found between the 3 groups. Heart rate was decreased significantly after sedation but increased during anaesthesia. Arterial blood pressure increased after sedation and remained high during anaesthesia. A significant decrease in arterial oxygen tension was observed in all groups during anaesthesia. The muscle relaxation induced by romifidine was, in most cases, not sufficient to abolish the catalepsy following a repeated injection of ketamine alone. Zoletil or a repeated injection of ketaminehornifidine resulted in smoother anaesthesia. When additional time is required to complete surgery during field anaesthesia, it is advisable to prolong romifidine/ketamine anaesthesia with an injection of both romifidine and ketamine in healthy horses. When a longer procedure is anticipated from the start Zoletil is an alternative for induction of anaesthesia. The mean time to response to noxious stimuli and mean time spent in lateral recumbency was 28 and 38 min for the anaesthesia prolonged with ketamine, 3.5 and 43 rnin for the anaesthesia prolonged with ketaminehornifidine and 33 and 45 min for the anaesthesia with Zoletil. All horses reached a standing position at the first attempt.     

Complications associated with anaesthesia for ocular surgery: a retrospective study 1989-1996

This retrospective study was initiated to identify complications of anaesthesia occurring during ocular surgery. Records of 74 horses anaesthetised for eye enucleation, 65 horses anaesthetised for surgery of the eye and adnexa, and 51 horses anaesthetised for splint bone excision were reviewed. Fifty-three percent of the horses anaesthetised for eye enucleation moved during surgery which was significantly more frequent than in the other groups (P = 0.001). The incidence of moving was significantly reduced by use of an anaesthetic gas analyser for monitoring (P = 0.001). Transient hypertension was measured in 6 horses during removal of the eye. One horse experienced a momentary decrease in heart rate from 36 to 26 beats/min at the start of surgery involving a mass on the third eyelid. The incidence of unsatisfactory recovery from anaesthesia involving multiple attempts to stand was significantly greater after ocular surgery than after splint bone excision (P = 0.036). Our conclusions were 1) the oculocardiac reflex was not active in these horses undergoing ocular surgery, 2) increased attention must be paid to provision of analgesia and adequate depth of anaesthesia, which may be facilitated by use of an anaesthetic gas analyser and 3) horses were at greater risk for unsatisfactory recoveries from anaesthesia after ocular surgery.