Otitis -- continuing GI problems

Question
QUESTION: One of our 4 house buns is about to enter his 6th week of otitis treatment (though for the first 2 he was treated only for head tilt -- I saw the other symptoms early on, but neither I nor our rabbit vet realized they were anything other than head-tilt complications until they persisted after the head tilt was cleared up).

He's been on oral Baytril for about 5.5 weeks now, to treat the systemic infection, and on a variety of other meds to treat the side effects (e.g. the corneal lesion, which seems now to be mostly gone).


The persistent problem seems to be his continued tendency to verge toward dehydration and stasis. I'm having a lot of trouble getting him to start eating normally again -- he doesn't want to drink much or eat his hay. (In fact, we wound up with a bloating problem when all he'd eat for a bit was kale -- which apparently got him bloated. Simethicone dealt with that.)

For the past nearly 2 weeks, I've been giving him daily (or 2x every 3 days) sub-q fluids [which, having a needle phobia, I hate doing] -- 75 ml of 0.9% saline for a 3.5 lb mini-lop. His energy and appetite invariably perk up after getting his fluids... only to slowly die off again over the next day or day and a half.

I've also been giving him 8-10 ml a day of a homemade "motility mix" -- pineapple juice, simethicone, vitamin & electrolyte supplements and a tiny bit of baking soda -- to try to ensure GI hydration. I've tried to match the suggested dosages in the back of the "Five-minute veterinary consult: ferret & rabbit" book for the simethicone and bicarbonate. He's also been on a daily Metacam dose from the vet (which just ran out today... we have a checkup appointment in 3 days).

He has fresh timothy hay, fresh greens (parsley is a favorite), a bit of alfalfa haycube, timothy-hay pellets [Oxbow's], water (both bottle and bowl) and very-dilute pineapple juice available in his "med bay", where he spends nights and part of each day (allowing me to monitor his food intake and pellet production).

Fecal pellets of late have been the alarming small hard "peppercorn" type (rather than the larger & more frangible I'm-eating-my-hay type)... but they do continue to appear. I have not seen any unconsumed cecals lately.


One possible cause -- in addition to they systemic effect of the otitis -- for his inappetite may be discomfort from facial muscles: the left side of his face is contorted into a permanent "sneer" (presumably from neurological trauma caused by the otitis complications), to the point where it now is even pulling his lips - and the "line" between middle of top lip and nose -- off center. Despite the ongoing Baytril treatment, this contortion seems to, very slowly but steadily, be getting worse. Our vet says this is a natural result of fibrosis developing as a response to the infection, but I wonder if maybe it makes eating or drinking uncomfortable?


Is there anything else I should be doing to try to encourage him to resume normal eating and activity habits? Is there some other med he should be on to address the otitis? Are there other signs/symptoms I should be looking out for?

I'd very much like to be able to get him eating normally -- and stop having to stab him with a needle every day (shudder) -- but everything we've done for the past month still hasn't gotten him back to normal. (Though I know, with bad otitis cases, that the antibiotic regimen regularly runs over 2 months and can be lifelong...)

Thanks!
Laurence (and Hickory the minilop)


ANSWER: Hi Laurence and Hickory,

Ear infections are very difficult to treat...especially in lops.   Keep in mind that I am not a vet but I have treated very sick rabbits for many years and have the support of numerous exotics specialists...some that are actually using protocols I developed.  And tilt (technically called torticollis) is one of specialties.

Has a culture been done on this infection?  At one time, we could pretty much assume pasteurella multocida as a primary pathogen especially in the middle and/or inner ear.  That is no longer true.  If it is a bacterial infection and is sensitive to Baytril, it should have cleared the infection by now.  That doesn't mean the tilt will correct.

Baytril has fallen from favor from most exotics specialists.  I haven't use Baytril in quite some time....and was actually the one that pointed out the problems with using that drug mainly since I deal with so many infections.  That drug has been so overused that many of the bacteria have become or are becoming resistant.  Baytril is more effective when given by injection.  It's also less stressful to the rabbit....but there are much better choices.  Baytril (like all drugs) does have some side effects when used long term.  I am also concerned that the long term use of an antibiotic might be causing some yeast concerns in those ears.  The corneal lesion...I am thinking ulcer here....leads me to some concerns.  I would really like to know more about that....exactly what it was and how it was treated.

I would continue with the sub-q fluids.  In this case, I might would opt for Lactated Ringers since it seems to pack more of a punch due to the electrolytes it contains.  I suspect there is something else going on here.  Has a blood panel been performed to check kidney and liver values?  Keep this thought in mind as it will come up a couple of more times.

I am very concerned about the "motility" mix.  I do use pineapple juice here for some issues...no clinical proof it works in stasis...but it sure seems to.  This has to be fresh juice squeezed directly from the fruit itself.  It can't be canned, bottled or frozen.  Those forms have too much sugar which leads to GI issues.  DO NOT GIVE BICARBONATE OF SODA!!!  That is old information from a time when a rabbit and a cat were thought to be alike.  Doing it on ferrets is one thing as they are carnivores.....a rabbit is an obligate herbivore.  Totally different type of digestion with totally different dynamics.  Bicarbonate is an antacid....to get a good gut the pH has to be acidid.  When you combine the gut issues caused by the oral Baytril and the loss of beneficial bacteria due to the change pH, that is most likely most of your digestive system problems.  Once that balance is upset, it takes a while to get things back into balance and it's even more difficult with a sick rabbit.  An adult rabbit's gut pH should be 1-2 and that allows a good climate for beneficial bacteria to populate the cecum.  I use a probiotic....specifically I like Bene-Bac powder.  It contains acidifying components.  It also contains strains of L Casei and Enterococcus bacteria which are essential to a ready gut.  I use this stuff like crazy with weaning wild rabbits.

The paresis on the side of the face is an indication the infection has invaded the brain stem.  Many rabbits will present with positional nystagmus with a brain stem issue.  I have one that flat spins.  She is also nearly blind and deaf....all from an improperly treated ear infection.

I am concerned too with the long term use of Metacam.  NSAIDs are very stressful to the liver and kidneys....especially when used long term or used when there is any signs of dehydration.  Remember I mentioned kidney and liver values?

If you keep getting infections....there is a protozoan infection known as E Cuniculi.  It is generally blamed for head tilt but fact is, it doesn't cause the tilt directly.  This parasite can lead to "roving" infections or very stubborn infections because it all but destroys the immune system  Diagnosing and treatment are difficult.  Most vets have never seen an actual case of E Cuniculi.  It can cause some severe kidney damage due to scarring from the spores shedding.  We have had EC positive rabbits have continuous infections....including one ear infection with tilt that took over 7 months to contain.

The longer this condition lingers, the less likely you can correct the tilt.  We have two tilters (one ear infection not treated and the other was misdiagnosed) and they live good lives despite their condition.  It does take some husbandry modification but it's a doable thing.

This is a summary of how I treat ear infections.  Again, keep in mind that I am not a vet.  I use some treatment that are "outside the box" but they are effective and under the supervision of licensed vets.

>Get at least a cytology from the ears.  Check for bacteria and/or yeast.  If bacteria is found, perform a full culture and sensitivity.  Knowing the most common pathogens, my usual drug choice is at least one of the following....Zithromax, Penicillin or Chlorampehicol.  I have also recently been working with a cephalosporin called Convenia.  I have to stress the fact that these drugs can lead to death if not properly dosed either in the dosing amount or by administration methods.  Properly used, they are fantastic.
>Ear infections are painful.  I think maybe your bun needs a break from the Metaccm (I'm sure his liver would appreciate it anyway).  Something to consider are some narcotics...buprenorphine or tramadol are good choices.  Buprenorphine is a controlled drug and some vets are hesitant about sending that out of the clinic...but Tramadol is certainly worth a look.  It's not expensive, not controlled (but requires a RX) and very effective in rabbits.
>Have a blood panel performed.  Look closely at the kidney and liver values.  A slightly elevated liver value may be related to the stress of the trip or procedure.  Have a titer for EC performed during the lab.
>Toss the bicarbonate and use a probiotic to stabilize and maintain proper GI pH.
>Keep the fluids going...preferably Lactated Ringers for a while.  You might also ask your vet about an injection of B Comp.  It's a vitamin shot we use often in sick or rehabbing animals.
>I would at least consider an x-ray of the skull and take a close look at the molar roots.  They can become impacted and abscess...and that can cause numerous problems in the head area.
>Offer some high calorie greens such as dandelions (in moderation of course).  Carrot tops are also a good choice.
>One of the few Oxbow products I use is Critical Care.  It is a great product.  It is a hand feeding formula for sick herbivores.  Our little fellow that we treated tilt for 7 months....he lived off this stuff.
>Keep the "down" eye flushed and lubricated.  I use basic saline to flush and basic tears to lubricate.  I now use the gel tears since it stays in the eye better.  The "down" eye tends to dry out and that results in corneal issues.  Rough bedding such as shavings can also scratch and irritate the cornea.  And a side note...the down side is the side of the worst infection.

This is a lot of info.  It will take you several reading to get thru it.  I have more but I don't want to overload your circuits right now.  Read this over and get back to me....I'm sure you will have many questions.

---------- FOLLOW-UP ----------

QUESTION: Thanks for a thorough and timely answer. Here's the follow up info you asked for:


1. HEAD TILT: The head tilt is gone (or almost entirely - there may still be about a 5 degree tilt; it's hard to tell given the issues with the facial mucles). It was caused, we think, by a buildup of wax and pus in the left ear. Initially, that's all the vet thought the problem was, and it was only once it cleared up that we realized more (otitis) was going on.


2. CULTURING: Because the treatment was initially just on the ears (both oral & topical Baytril), by the time we recognized otitis, the bunny was already under an antibacterial regimine. The vet said he'd have to be off the topicals for 3 days before a meaningful culture could be done and we opted just to keep treating him. When we see her for a checkup on monday, he'll have been off for 3 days and so we could do one then.


3. CORNEA: The corneal lesion occured -- or so I guess -- because of the problems with the facial muscles. His blink reflex on that side seemed absent, and the nictitating membrane started to come up more. From what I read when doing more research, this is characteristic of otitis and can lead to lesions as the eye isn't getting enough moisture. We put him on a topical application of Vetro-Gen (gentamicin sulfate) 3x a day for 2 weeks and it seems to have cleared up (at least as far as I can tell w/o veterinary instruments... it's one of the things I want our vet to check on Monday).

As the blink reflex isn't totally back, I've recently started using the vetrogen once a day to keep things lubricated. (I figured this could be a temporary measure until the vet visit).

You mention "gel tears" -- what brand do you recommend? When I first saw the eye problem, before his next vet visit, I looked through the eye med section at the supermarket but had no idea what would be safe or appropriate for him. But if the facial contortions he's developed are life-long, he may have permanent problems with blinking that eye and I'll need something preventative to keep it moisturized.


4. BICARBONATE: I'll toss it directly. Thankfully, he's gotten that in his mix for less than a day -- it was something I added after reading it online repeatedly (and checking it in the "5 minute vet consult") only yesterday as I mixed up a new batch... this posting was part of that same research process. It doesn't seem to have done anything terminal -- he ate greens and produced fecals overnight, though he's still not drinking very much.

What's my best chance of finding Bene Bac? Is it something most pet stores or vets will carry, or should I order it online?


5. PINEAPPLE -- I've been using it as a "base" both because the papain is said to help motility and because he likes the juice. But, without a juicer in the kitchen, bottled/canned juice is the only option (though I try to get brands with no added sugar).

I read one breeder's site which recommended adding a bit of meat tenderizer (which contains papain) to the meds given to a rabbit with ileus issues - do you have any experience with that?


6. BAYTRIL -- The vet wondered about e cuniculi and put him on baytril and panacur (dewormer) as her best guess -- in the absence of a culture -- to treat the most likely causes of a systemic infection. The topical application, at least, does seem to have dealt with the head tilt -- on a follow up visit (after, I think, 1.5 weeks of the topical Baytril in the ears) the amount of pus in the ears was way down and the only bacteria she saw, looking at a swab from the ears under the microscope, were inside the white blood cells, suggesting that his system was fighting off the infection (at least in the ears).


7. BRAIN STEM -- this has been my personal biggest worry since I first figured out he must have otitis, but my vet keeps gently telling me I worry too much. But given that the paresis has been getting steadily (albeit very slowly) worse over the last 6 weeks, I can't help but think that it reflects a reaction to _something_ that isn't being treated... and I know that Baytril doesn't cross the blood/brain barrier.

On the other hand, the "5 minute vet consult" suggests that for paresis/paralysis it's best to let the animal fight off the infection on his own unless the exact cause is specifically known.

On the facial issue -- he's showing contraction of muscles, not looseness from inability -- the book (under otitis media/internal) describes: "with chronic facial nerve paralysis, contracture of the affected side of the face caused by fibrosis of the denervated muscles."


8. CRITICAL CARE -- I've used it before. Hickory is very resistant to taking meds: usually if you try to give him more than 3 syringes, he starts holding the stuff in his mouth and spitting it out. In the past, it's proved almost impossible to get him to eat CritC -- another reason I'm eager to get him back to eating & drinking normally on his own (even if I am still giving him meds).


I hope that helps flesh out the details of this particular case. Thanks again for such a detailed & thoughtful answer!


LP & Hickory


ANSWER: Hi Guys,

It sounds as if your vet is doing things by the book.  I do have some responses to each of your points.  Just remember I am not a vet.  I treat the sickest of the animals so many times what I do is not strictly by the book.

1. Have you flushed those ears regularly?  Once a rabbit gets an ear infection, we have found that regular flushing is needed.  I generally use something like Epi-Otic for regular cleanings and a product called Cerulytic for more difficult flushings.

2.  Your vet is correct in normal protocol of not culturing for at least 3 after after cessation of antibiotics.  This is one of the rules I don't always follow.  I am seeing a lot of resistant bacteria.  The thing is that if the drug isn't working (resistant bacteria) then the culture is still going to grow that particular pathogen.  In one of my worst case tilts, we cultured on a rabbit that had been on Baytril and Sulfatrim for nearly a month....and grew pasteurella in three days.  That was my first true encounter with resistant bacteria.  And since it was literally do or die, that is when I started working on some of the other drugs I use.  In his case, Zithromax was the winning move.

3. The "down" eye is always a problem since it can be easily damaged.  I generally use the "Refresh" brand eye gel because it was the very first one available....but there are several brands out there now.

4. The bicarbonate is an old and incorrect idea.  We still have people giving Pepto to rabbits and that is an antacid.  Not good for the beneficial bacteria in the gut.  They need that acidic pH.  Bene-Bac can be purchased at most pet stores and vet clinics.  I prefer the powder.  I buy a huge canister from a wildlife supply (specializing in squirrels).  Their address is www.squirrelsandmore.com.  I don't know if they ship outside the US.  I think in the UK there is something called Pro Lapis or something like that.  I can do some research on that if needed.

5. It has to be fresh juice from the fruit.  All of the canned, bottled, etc has excessive sugar no matter what the label says.  It can result in a very upset GI.  I squeeze my pineapple by hand....it's not very difficult to do.....just expensive.  The meat tenderizer stuff if based again on old breeder infomation (no flaming intended to breeders) that just doesn't hold up to the facts.  Papain is very beneficial...but the other stuff in meat tenderizer is not.  Papaya is the source of papain.  You can feed them small amounts of fresh papaya or find papaya extract tablets.  We find them at health food stores...we have even found them at Wal-Mart. Oxbow offers the best ones.

6. My experiences with E Cuniculi (far too many of them) has shown that the relationship between E Cuniculi and head tilt is the depressed immune system allowing bacterial infections.  EC itself doesn't appear to be primarily responsible.  I still would get a blood titer to check for EC antibodies since EC may be present and contributing to the bacterial infections via the stressed immune system.  And as I mentioned about Baytril, unless I get in some specific turtles or birds, my bottle of Baytril are being used as paperweights.

7. Another reason I don't use Baytril.  It could also be from a progressing EC issue...that is why I would really like to see a blood panel with EC titer.  Ask your vet about using a NSAID (most likely Metacam) for about three days.  See if any improvement is noted.  Can you send me a like to this "5 minute vet consult"?  I would really like to check that one out....from what you have told me, it's scary.  I am concerned that there isn't a lot of rabbit knowledge here.  Rabbit's have the most fragile immune systems and can rarely fight off serious infections themselves.  It's hard enough using appropriate drugs.

8.  I know all too well the challenges of syringe feeding CC.  So I developed something to not only get in the CC but to offer some physical therapy for the tilter as well as some one-on-one TLC.  Make the CC into a paste and spread in on a leaf of romaine lettuce (or any wide leafed green he will eat).  Roll the leaf of lettuce up into something like a burrito....and hand feed it.  This gets the nutrition of the CC and the hydration of the greens.  Move it around, starting in small amounts, an let him come to the food.  It helps with their reorientation from the ear infection.  As he gets better at tracking the food, move it more and let him come get it.  And while he is eating, it gives you an excellent opportunity to give a light massage to those stretched neck muscles...a little extra TLC.  I fed my EC positive, confirmed by culture ear infection rabbit for months...he lived off of CC, romaine and lactated ringers for months.....took about 7 months in all to clear the infections.

Keep at it and keep me posted.  Hickory sounds like a very special rabbit.


---------- FOLLOW-UP ----------

QUESTION: Thanks for another quick & helpful reply. I'll reply again w/ more follow up info -- both to get more feedback and to get more information/treatment/suggestions out there on the web for the next person w/ a distressed rabbit googling this condition! :-)

---

1. EAR FLUSHING -- No, we haven't done this. The rather serious infection seemed to clear up over the course of treatment with topical Baytril. He'll have been off that for about 85 hours or so when the vet sees him tomorrow -- if there's buildup starting again (as I suspect there may be -- a slight bit of disorientation has started appearing in his motion in the last 24 hours or so), I'll get her to show me that technique and add it to my growing list of rabbit medical skills.


2. CULTURING -- though off the topical Baytril, he's remained on the oral. But if a buildup is recurring in the ears, I'll insist on culturing this time. The only reason we didn't do it before is that he was on antibiotics (oral Baytril and a weaker topical for the ears) for 2 weeks before we identified the otitis, and was still doing poorly enough that I didn't dare take him off them for 3 days.


3. EYE GEL -- When I first noticed the problem, I checked the drug store for moisturizers, but all of them had various polysyllabic chemicals in them. Knowing how sensitive rabbits are, I didn't dare experiment. Our vet advised against using such things and gave us the aforementioned ointment instead.

Doing a websearch on "Refresh PM" I see it's largely chemical free -- Bausch & Lomb "Dry Eye" looks even more so, consisting of only white petrolatum and mineral oil.

In your experience, are these safe for the bunny?

NB -- this is NOT a "down" eye... the head tilt has gone away. It is, rather, the side of the face afflicted with the contortion (presumably from fibroses of the denervated muscles) which is inhibiting his blink reflex. This means the primary danger is from drying out, not from contact with the floor/carpet. At least at the moment.


4. BENE-BAC -- I drove into town today to hunt it down. Found the gel (not the powder) at PetSmart. Based on all of one attempt, the gel is a nuisance to administer (has to be put directly into the mouth) -- Hickory informs me that "it's a yucky"... but, then again, he resents being force fed anything.


5a. PINEAPPLE JUICE -- I'm currently trying dissolving his electrolytes, vitamins & simethicone in a 50/50 mix of juice and water, and he's spitting out more of it. The sweetness in the pineapple really was helping him take in his meds. I, too, worried over the sugar issue (especially since this is given to him when his appetite is down)... we're talking only about 9ml a day (less, really, given the % he dribbles) -- in your experience, is that too much?


5b. PAPAIN/TENDERIZER -- I looked over the ingredients yesterday & today at various stores and they all had salt & sugar in them. Ick. Didn't buy them. Today I went to the high-end health food store and looked at supplements. All of them had lots of other stuff forming capsules, tablets, etc -- I couldn't find a straight dosage of either papain or bromelain. I do recall seeing those tablets at Oxbow -- I'll add them to my next order if I can (I hear they still take phoned-in orders, though they have -- irritatingly -- ceased selling on their website). In the meantime, I"ve still got dried no-sugar-added papaya as a special treat, and I bought some fresh organic papaya for him today (expensive!!!).


6. E CUNICULI -- From what I've read (doubtless of varying quality & reliability), the E.C. test is problematic because the presence of antibodies only shows exposure at some point -- and, at least so I've read, many rabbits are exposed to it at some time in their lives -- and doesn't prove that an EC infection is the cause of the current problems. The "5 minute vet consult" book I cited earlier [more on it shortly] says "Encephalitozoon cuniculi - this is a diagnosis of exclusion. Every attempt should be made to rule out otic disease prior to assuming E. cuniculi infection in rabbits with vestibular signs... usefulness is extremely limited since a positive titer indicates only exposure and does not confirm E. cuniculi as the cause of neurologic signs. E. cuniculi can only be definitively diagnosed by finding organisms and resultant lesions on histopatheologic examination in areas that anatomically correlate with observed clinical signs."

Still, since after 6 weeks on Baytril Hickory still isn't "well" (though we keep fighting off all the secondary issues -- like head tilt, corneal lesions, periodic ileus), I think I'm going to ask the vet to do the full battery of tests -- culturing, blood panel, xray -- so that we can confirm otitis as the cause and find a more effective antibiotic regimen. (By the way, the _Vet Consult_ recommends many of the things you do -- including the culturing to pick the proper antibiotics.)


7a. NSAID -- He was on Metacam for about 2 weeks. His prescription expired 2 days ago, and yesterday he was more "sullen", "moody" and "aggressive" than usual. Last night I added asprin to his oral treatments (it has been 36 hours since the last Metacam dose) and his mood & behavior both improved. This suggests to me that there must be on-going low-level discomfort, which is probably also responsible for his reduced eating. I hate to think what another 2 or 3 weeks of NSAIDS would do to his liver, though -- another reason to try to target the underlying systemic infection more aggressively.


7b. The "5 Minute Veterinary Consult" series has several volumes: Cats & Dogs, Horses, Ferret & Rabbit. Our vet speaks highly of the Cats & Dogs one and -- when I came in with a printout of a sample page from books.google.com of the otitis section from the Ferret & Rabbit volume (pub. 2006), she was excited to hear about it and is getting a copy. I currently have one -- on my lap right now -- I got from an interlibrary loan as part of my effort to get more educated & be able to care for Hickory more effectively.

Here's the link -- you can see some sample pages on google which perhaps will let you, with all your field experience, evaluate its quality:

http://www.amazon.com/5-Minute-Veterinary-Consult-Ferret-Ruminant/dp/0781793998/


8. I shall try the CC burrito trick... though it's tough to get Hickory to eat even that way (though, with patience, I can sometimes get parsley into him that way but getting him to bite at the stalk that I tease his whiskers with). I'm out of CC at the moment (well, what I've still got is stale) but I know I can make up my own -- a bit of water added to timothy hay pellets and then microwaved effectively reduces the pellets to a powder, which can then be supplemented into a paste. I bought some organic baby-food applesauce today for just that purpose.

But, yeah, I'm figuring I'm in this for the long haul and will have to not make any travel plans for the next several months until I can get him over this. I will never hear the end of it from my mother. ("You couldn't leave your stupid rabbit for one week to come visit the family?!!...")  :->


> Keep at it and keep me posted.  Hickory sounds like a very special rabbit.

We lost our first bunny, about 2.5 years ago -- the world's sweetest, friendliest black polish (named "Rabsputin")... if I'd known more how to spot ileus early on -- and had the materials and knowhow to administer sub-qs -- he might have made it. It was less than 36 hours between first outward signs of distress and death... if only I could have sub-qed him perhaps he could have hung on long enough for the vet to treat him.

Which is an experience which has gotten me rather aggressive about trying to learn as much as I can to keep our remaining 4 rabbits healthy.

Once they, ultimately, cross the rainbow bridge, my wife wants us to get Flemmies... I'm sure there'll be a whole new set of "big bunny" skills & issues I'll have to learn about when *THAT* happens!!!


Thanks again for all the feedback & advice!

LP & Hickory


Answer
You are like a breath of fresh air....you truly "get it".  If everyone would do their research like you do, we would have much healthier animals.

I did see where Oxbow was changing their distribution network.  I only use Critical Care and Papaya tabs from them so it's not a really big deal for me.  The bottom line of this change is basically money.  Oxbow has been placed on a pedastal by many (not saying their products are good, but there are other sources that are just as good or better).  The whole thing with the distribution thing is to become more exclusive (meaning they can charge more).  Ever noticed that vets really push Oxbow when there are other products at least equal?  Know why?  There is a huge mark-up in Oxbow products at the clinics so it's a huge profit center for exotic clinics.

We have a rescued Polish named Jasper....he is a licker.  He is so tiny but has such personality.  And we have two Flemmies.  Chyna....aka "The Big Show" is a 4 year old fawn colored rescue...from an abuse situation out of West Virginia.  Andre "The Giant" is a steel colored 3 year old and was a gift from some friends that we helped get set up in rescue.  They are both well into the 20 pound range.  Flemmies are really no different that other breeds except for the space required for them.  They do tend to pack on extra weight so we closely monitor their pellets and people are shocked at just how few pellets they get.

As far as the eye gel....any of the "basic" version will work.  I don't use any that is medicated.  Eyes are eyes no matter the species and from a truly technical stand point....a human opthalmologist can do the same thing to rabbit eyes that is done to human eyes.

The titer for EC is open to interpretation.  The key is to look at the entire picture as the titer is only one part.  If you have a high EC titer along with unexplained and/or roving infections, eye issues (cataracts, unexplained corneal issues or "snow" inside the pupil) or what appears to be a urinary infection....things point to EC.  We have also documented that most cases of active EC also involves some type of paresis of the hind quarter...and in every case here it started with a very slight dragging of the left rear leg.  The vet that is one of my volunteers has recently discovered her rabbit has active EC. And you are so correct, most domestic rabbits will titer positive.  That is why you can't totally rely on the titer...but a high titer with other clinical indications usually means EC is doing something.  I have seen it so much that I don't really need to titer...I know the signs.  In fact, my vet friend titered only after we discussed her rabbit's other issues and I brought up some points I have seen with EC.

You might ask your vet about using Tramadol for a while to see what reaction you get.  It's great at pain control when dosed 2X daily and can be used to sedate at 3X.  It does have to be compounded but it has similar effects of NSAIDs without all the side effects.  It is a narcotic but we haven't had any issues with it.

If you would like, send me a response with your e-mail and we can talk off forum.  I routinely consult with vets about EC and related issues.  As long as they know I am not a licensed vet things are good.  They usually realized quickly that I come from a very clinical background.  I can give them some very detailed info about treating infections in EC positive rabbits.  At one of my vets, I am an "honorary doctor"  and I work quite a bit with rotating vet students to give them exposure to real world rabbit (and other exotics and wildlife) that have real world issues that they are likely to see in residency.

And your experiences are the same as mine for getting into rescue.  Since EC and it's baggage took my Sabrina....it's a personal thing.  And that is why I do so much research on treating this condition.  Having vet school professors on my team really helps too.

Talk with you soon...and do keep me posted.