Practice to Practice

Bringing Ophthalmology in General Practice into Focus

Bringing Ophthalmology in General Practice into Focus
  •  
  •  
  •  
  •  
  •  
  •  
  •  

pdf_button


Elizabeth Barfield Laminack, DVM

Our Practice to Practice column gives veterinary professionals a forum to share their personal experiences with our readers—their peers. This column brings you narratives about how clinical medicine and practice development concepts became a reality for veterinary team members and their patients and clients. Whether you’re inspired, cautioned, or educated—our goal is to provide a column that brings peers and practices together.

Like many in our profession, I grew up spending all my free time around animals. Once in college, the top three career choices I wanted to pursue were veterinary medicine, optometry, or medical ophthalmology. I now spend my days in small animal private practice but combine my interests by pursuing additional education in veterinary ophthalmology.

Integrating the desire to follow an interest in ophthalmology as well as taking the time to correctly diagnose and manage an eye case in private practice can be a challenge. Seeing a myriad of different ophthalmic cases can feel like a daunting task and makes many practitioners want to shy away from the prospect of ophthalmic pursuits. There are several practical ways to help provide the best possible outcome for your patients and also increase your ophthalmic knowledge.

THE OPHTHALMIC EXAMINATION

In an animal presenting as an ocular case, I begin an ophthalmic examination by viewing both eyes with minimal restraint of the animal’s head, illuminating the good eye first if signs are unilateral. I use a strong penlight or transilluminator to check the pupillary light reflexes. I assess the palpebral reflexes bilaterally.1

In order to facilitate accurate testing, our technicians support the caudal end of the animal against the technician’s body, tip the chin up with minimal pressure on the head, and use the opposite hand to gently restrain the legs of the animal (Figure 1).

1_Fl stain and restraint

Figure 1. Proper, gentle restraint of a cat to facilitate administration of fluorescein stain to the cornea

If the client can afford the services, I like to perform the following ophthalmic tests:

  1. The Schirmer tear test (STT) provides an accurate representation of true tear production before any other liquids are placed in the eye; it also requires maximal patience from the animal.
  2. The fluorescein stain test can be used to evaluate tear breakup time as well as the surface of the cornea, serving as a way to assess precorneal tear film (see Why Assess Precorneal Tear Film?).
    • After applying the stain, allow the animal to blink once, hold the eye open, use a blue light to view the cornea, and count the seconds it takes for dark spots (drying in the tear film) or areas of drying to appear on the cornea.
    • Afterwards, rinse the excess stain and evaluate the cornea for ulcers.1,2
  3. Lastly, proparacaine is applied prior to intraocular pressure measurement with a Tono-Pen.
    • A tip for success is to know how to calibrate your Tono-Pen accurately. We keep a card with calibration directions in the case for quick reference.

Tonometry is incorporated into the cost of the practice’s senior wellness examinations and blood analyses. All animals 7 years and older receive an intraocular pressure check automatically.

Why Assess Precorneal Tear Film?

Disorders of the precorneal tear film are related to keratoconjuctivitis sicca; drying is secondary to decrease in mucus or lipids and exposure. Exposure may be due to lagophthalmos, buphthalmos, and/or exophthalmos. The aforementioned may result from glaucoma, neoplasia, and/or neurologic dysfunction.

For ophthalmoscopy, we often use a Direct Pan-Optic ophthalmoscope (welchallyn.com).

  • Panophthalmoscopy provides a wider field of view with lower magnification than many other direct ophthalmoscopy techniques and is easy to use in the examination room (Figure 2). Dim the lights prior to routine ophthalmoscopy.
  • Indirect ophthalmoscopy is often necessary to obtain a better view of the retina with a wider field of view (image inverted). A 20-diopter condensing lens with a penlight or transilluminator works well in general practice.1,2
3_Dr. Weaver and pan ophth

Figure 2. Gentle restraint with minimal pressure on the dog’s head to facilitate panophthalmoscopy examination

Regarding pupil dilation, make sure topical tropicamide is stored at room temperature. Sometimes it is accidentally refrigerated with proparacaine, which decreases the efficacy and slows the time it takes to dilate pupils. Also, if the pupils are not dilated but part of the fundus is visualized during the examination, note in the chart that the fundus was not fully examined. Do not write that the retina or fundus was within normal limits.

050612 p2p opth normals

FOCUSING ON THE DETAILS

Ocular Cytology

  • When performing ocular cytology, take care to avoid disturbing healthy cornea by brushing the area of the conjunctivae of the upper eyelid adjacent to the cornea (when determining therapy for conjunctivitis) or gently over the lesion itself (in cases of corneal ulceration).
  • Provided it is kept clean and free of debris, Diff-Quick stain is appropriate for ocular cytology in general practice. Be sure to allow slides to dry adequately before staining.
  • A gentle cytology brush called a microbrush with a disposable micro-applicator can be used as an alternative to the back of a scalpel blade or spatula.3

Ocular Prescriptions

  • When prescribing different drops for home care, encourage clients to keep an Excel spreadsheet for ease in tracking drops administered (or provide one for your clients to use). This is especially helpful if a patient returns to the clinic for additional treatment or boarding.
  • Triple BNP (bacitracin/neomycin/polymyxin B) ointment is a mainstay of antibiotic therapy of the eye; however, it has become more expensive.
  • An alternative is ofloxacin (Ocuflox, allergan.com), 3 mg/mL in 5-mL solution, which provides better corneal penetration.
  • An ocular solution created with cefazolin has been described, but its use is off label.4

OPHTHALMIC SURGERY IN GENERAL PRACTICE

Surgical repair of a prolapsed gland of the third eyelid is an excellent surgical skill to improve the ocular health of patients and practice income (Figures 3 through 5).

4_pgte prior to pocket technique

Figure 3. Prolapsed gland of the third eyelid in a 5-month-old English bulldog prior to surgical intervention

5_pocket technique complete

Figure 4. The appearance inside the third eyelid after repair using a modified Morgan technique with double-layer closure

6_post-op recovery

Figure 5. The appearance of the eye after surgical intervention. Note: The third eyelid may have a more swollen appearance after surgery than what is shown in this figure; it is important to educate the owner that swelling will decrease within a few weeks and that the dog should wear an E-collar during the recovery time when unsupervised.

  • The procedure only requires 6-0 PDS (polydioxanone suture) and a simple ophthalmology pack.
  • This surgery does not usually present as a medical emergency, allowing institution of topical antibiotic and anti-inflammatory therapy for 7 to 10 days prior to the procedure.
  • We are able to charge for our services appropriately because clients appreciate the treatment of a bright red cherry eye and the avoidance of keratoconjunctivitis sicca (KCS).
  • The use of a pocket (embrication) or anchoring (tacking) technique to replace the gland instead of removal (excision) preserves the form and function of the third eyelid gland. This gland provides 35% of tear secretion.5
  • In a study by Morgan, et al, 42% of dogs studied developed KCS if left untreated (75% in high-risk breeds), 48% treated with excision of the gland developed KCS (59% in high-risk breeds), and only 14% developed KCS if the gland was replaced (17% in high-risk breeds).6
  • The level of anesthetic risk with this procedure is variable because most affected patients are young and healthy but many are brachycephalic breeds.

Other in-house ocular surgeries that help to facilitate expedient resolution of disease or injury are:

  • Eyelid mass removal
  • Eyelid laceration repair
  • Temporary tarsorrhaphy
  • Third eyelid flap removal
  • Grid keratotomy (to promote healing of corneal ulcers).

FOUR EYES

Sometimes the management, expertise, and specialized equipment required to address an eye case exceed the time and cost available in general practice. In this case, another pair of eyes—a specialist—is needed. The patient’s veterinarian plays a vital role in educating the client and discussing cost or expectations regarding a referral.

Client Education

For example, when I evaluate a lens that has grey/blue hazing or a dense opacification, I tell the client what I am visualizing and let them stand close by so they can view it as well. If the diagnosis is nuclear sclerosis, I explain this normal aging change in the lens while describing or enabling the client to see the tapetal reflection and as much of the fundus as possible. I had one new client become a “regular” simply because I was the only veterinarian that both showed and illustrated to her the difference between various types of cataracts and nuclear sclerosis.

The Referral Process

If the diagnosis is a cataract, I talk with the client prior to referral about what blood chemistry and urinalysis may show regarding glucose levels and diabetes mellitus. Depending on the dog’s age and examination results, we discuss referral for cataract evaluation as well as further staging, re-checks, and/or surgery.

When discussing referrals with clients, our local College of Veterinary Medicine appreciates it when we let our clients know beforehand the:

  • Associated costs, such as the cost of specialist evaluation and cost per eye for surgical intervention
  • Possibility that they may need to administer an extensive list of ocular medications 5 minutes apart multiple times daily
  • General systemic status of the patient based on physical examination, CBC/serum biochemical profile, and urinalysis.

For practices not located within driving distance of a veterinary university or for other options, locate a specialist at acvo.org. Select ACVO Purpose; then Referral Process to locate a veterinary ophthalmologist.

CONTINUING EDUCATION

Many of the latest ocular diagnostic, treatment, and surgical recommendations are best presented by a specialist. A great venue for continuing education in ophthalmology is the ACVO Annual Conference, which offers a general practitioner’s course that provides 8 hours of CE. After attending the 2011 conference, I can attest that the board-certified instructors provide helpful visuals and practical advice. The ratio of attendees to speakers fosters discussion with other practitioners and provides time to ask the presenters specific questions.

You can also combine the ACVO general practitioner’s course with general registration. The resident’s workshops, research presentations, and exhibit hall provide additional opportunities to pursue your interest in veterinary ophthalmology. The 2012 conference will be held October 17 to 20 in Portland, Oregon (acvoconferance.org).

Finally, another great way to obtain ophthalmic CE is to see what courses your local veterinary school offers. You can also visit the American Veterinary Medical Association’s Meetings and CE Calendar (avma.org/meetings/calendar/default.asp), which provides a complete list of CE opportunities across the country and is searchable by keyword.

BNP = bacitracin/neomycin/polymyxin B; KCS = keratoconjunctivitis sicca; PDS = polydioxanone suture; STT = Schirmer tear test

References

  1. Moore PA. Examination techniques and interpretation of ophthalmic findings. Clin Tech Small Anim Pract 2001; 16(1):1-11.
  2. Ollivier FJ, Plummer CE, Barrie KP. The eye examination and diagnostic procedures. In Gelatt KN (ed): Veterinary Ophthalmology, 4th ed. Ames. IA: Blackwell Publishing, 2007, pp 438-483.
  3. Willis M, Bounous DI, Hirsh S, et al. Conjunctival brush cytology: Evaluation of a new cytological collection technique in dogs and cats with a comparison to conjunctival scraping. Vet Comp Ophthalmol 1997; 7:74-81.
  4. Weigt A. General practitioners course: ocular pharmacology. ACVO Conf Proc, 2011.
  5. Martin CL. Prolapse of third eyelid gland (cherry eye). Ophthalmic Disease in Veterinary Medicine. London: Manson Publishing, 2005, pp 206-209.
  6. Morgan R, Duddy JM, McClurg K. Prolapse of the gland of the third eyelid in dogs: A retrospective study of 89 cases (1980 to 1990). JAAHA 1993; 29:56-60.

Elizabeth Barfield LaminackElizabeth Barfield Laminack, DVM, practices at Companion Animal Hospital in Athens, Georgia. She received her DVM from University of Georgia and her undergraduate degree in biology from Reinhardt University. Dr. Laminack continues to study small animal ophthalmology at the UGA Veterinary Teaching Hospital and recently presented an abstract on canine glaucoma at the Association for Research in Vision and Ophthalmology (ARVO) Annual Meeting. She wishes to thank Drs. Denise Weaver and Troy Pickerel and the practice team of Companion Animal Hospital for their support of her ophthalmic pursuits; she also extends gratitude to her mentors, Drs. Anthony Moore and Kate Myrna of UGA-VTH.

DMCA.com Protection Status
[gravityform id="6" title="false" description="false"]
<div class='gf_browser_unknown gform_wrapper' id='gform_wrapper_6' style='display:none'><form method='post' enctype='multipart/form-data' id='gform_6' action='/practice-to-practice-bringing-ophthalmology-in-general-practice-into-focus/'> <div class='gform_body'><ul id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below'><li id='field_6_1' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' >Name<span class='gfield_required'>*</span></label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_6_1'> <span id='input_6_1_3_container' class='name_first' > <input type='text' name='input_1.3' id='input_6_1_3' value='' aria-label='First name' aria-required="true" aria-invalid="false" /> <label for='input_6_1_3' >First</label> </span> <span id='input_6_1_6_container' class='name_last' > <input type='text' name='input_1.6' id='input_6_1_6' value='' aria-label='Last name' aria-required="true" aria-invalid="false" /> <label for='input_6_1_6' >Last</label> </span> </div></li><li id='field_6_2' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_2' >Email<span class='gfield_required'>*</span></label><div class='ginput_container ginput_container_email'> <input name='input_2' id='input_6_2' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id='field_6_7' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_7' >Profession / Role<span class='gfield_required'>*</span></label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_6_7' class='medium gfield_select' aria-required="true" aria-invalid="false"><option value='Veterinarian' >Veterinarian</option><option value='Veterinary Nurse / Technician' >Veterinary Nurse / Technician</option><option value='Practice Manager / Veterinary Assistant / Support Staff' >Practice Manager / Veterinary Assistant / Support Staff</option><option value='Student (Veterinarian or Veterinary Nurse)' >Student (Veterinarian or Veterinary Nurse)</option><option value='Other' >Other</option></select></div></li><li id='field_6_20' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><br></li><li id='field_6_15' class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' >Inbox Preferences</label><div class='gfield_description' id='gfield_description_6_15'>Customize your inbox by selecting the areas you are most interested in. </div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_15'><li class='gchoice_6_15_1'> <input name='input_15.1' type='checkbox' value='NAVC Better Care Weekly&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;A weekly roundup of the new and noteworthy innovations and educational opportunities in the veterinary industry.&lt;/div&gt;' checked='checked' id='choice_6_15_1' /> <label for='choice_6_15_1' id='label_6_15_1'>NAVC Better Care Weekly<br><div style="font-size: 12px; color: #808080;">A weekly roundup of the new and noteworthy innovations and educational opportunities in the veterinary industry.</div></label> </li><li class='gchoice_6_15_2'> <input name='input_15.2' type='checkbox' value='Today&#039;s Veterinary Business eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Covers topics relating to practice management, financial metrics, marketing, retailing and merchandising, and industry news.&lt;/div&gt;' id='choice_6_15_2' /> <label for='choice_6_15_2' id='label_6_15_2'>Today's Veterinary Business eNewsletter<br><div style="font-size: 12px; color: #808080;">Covers topics relating to practice management, financial metrics, marketing, retailing and merchandising, and industry news.</div></label> </li><li class='gchoice_6_15_3'> <input name='input_15.3' type='checkbox' value='Today&#039;s Veterinary Nurse eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Provides practical, peer-reviewed companion animal educational CE for veterinary nurses, technicians and assistants.&lt;/div&gt;' id='choice_6_15_3' /> <label for='choice_6_15_3' id='label_6_15_3'>Today's Veterinary Nurse eNewsletter<br><div style="font-size: 12px; color: #808080;">Provides practical, peer-reviewed companion animal educational CE for veterinary nurses, technicians and assistants.</div></label> </li><li class='gchoice_6_15_4'> <input name='input_15.4' type='checkbox' value='Today&#039;s Veterinary Practice eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Provides practical, peer-reviewed articles focused on the latest diagnostic and treatment techniques to enhance your knowledge and confidence.&lt;/div&gt;' id='choice_6_15_4' /> <label for='choice_6_15_4' id='label_6_15_4'>Today's Veterinary Practice eNewsletter<br><div style="font-size: 12px; color: #808080;">Provides practical, peer-reviewed articles focused on the latest diagnostic and treatment techniques to enhance your knowledge and confidence.</div></label> </li><li class='gchoice_6_15_5'> <input name='input_15.5' type='checkbox' value='VetFolio eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Discover online CE resources offered in a variety of formats including videos, podcasts, webinars and more.&lt;/div&gt;' id='choice_6_15_5' /> <label for='choice_6_15_5' id='label_6_15_5'>VetFolio eNewsletter<br><div style="font-size: 12px; color: #808080;">Discover online CE resources offered in a variety of formats including videos, podcasts, webinars and more.</div></label> </li><li class='gchoice_6_15_6'> <input name='input_15.6' type='checkbox' value='Partner Emails&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Exclusive deals and information from our partners.&lt;/div&gt;' id='choice_6_15_6' /> <label for='choice_6_15_6' id='label_6_15_6'>Partner Emails<br><div style="font-size: 12px; color: #808080;">Exclusive deals and information from our partners.</div></label> </li></ul></div></li><li id='field_6_19' class='gfield gfield_html gfield_html_formatted field_sublabel_below field_description_below gfield_visibility_visible' ><br></li><li id='field_6_22' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' >Do you want to be added to our postal mailing list?</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_22'><li class='gchoice_6_22_1'> <input name='input_22.1' type='checkbox' value='Yes, I love mail!' id='choice_6_22_1' /> <label for='choice_6_22_1' id='label_6_22_1'>Yes, I love mail!</label> </li><li class='gchoice_6_22_2'> <input name='input_22.2' type='checkbox' value='No thank you.' id='choice_6_22_2' /> <label for='choice_6_22_2' id='label_6_22_2'>No thank you.</label> </li></ul></div></li><li id='field_6_10' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' >Please provide your mailing address below.<span class='gfield_required'>*</span></label> <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_6_10' > <span class='ginput_full address_line_1' id='input_6_10_1_container' > <input type='text' name='input_10.1' id='input_6_10_1' value='' aria-required="true"/> <label for='input_6_10_1' id='input_6_10_1_label' >Street Address</label> </span><span class='ginput_full address_line_2' id='input_6_10_2_container' > <input type='text' name='input_10.2' id='input_6_10_2' value='' /> <label for='input_6_10_2' id='input_6_10_2_label' >Address Line 2</label> </span><span class='ginput_left address_city' id='input_6_10_3_container' > <input type='text' name='input_10.3' id='input_6_10_3' value='' aria-required="true"/> <label for='input_6_10_3' id='input_6_10_3_label' >City</label> </span><span class='ginput_right address_state' id='input_6_10_4_container' > <input type='text' name='input_10.4' id='input_6_10_4' value='' aria-required="true"/> <label for='input_6_10_4' id='input_6_10_4_label' >State / Province / Region</label> </span><span class='ginput_left address_zip' id='input_6_10_5_container' > <input type='text' name='input_10.5' id='input_6_10_5' value='' aria-required="true"/> <label for='input_6_10_5' id='input_6_10_5_label' >ZIP / Postal Code</label> </span><span class='ginput_right address_country' id='input_6_10_6_container' > <select name='input_10.6' id='input_6_10_6' aria-required="true"><option value='' selected='selected'></option><option value='Afghanistan' >Afghanistan</option><option value='Åland Islands' >Åland Islands</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Congo, Republic of the' >Congo, Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Côte d&#039;Ivoire' >Côte d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Curaçao' >Curaçao</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard and McDonald Islands' >Heard and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macau' >Macau</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Korea' >North Korea</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Réunion' >Réunion</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Barthélemy' >Saint Barthélemy</option><option value='Saint Helena' >Saint Helena</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia' >South Georgia</option><option value='South Korea' >South Korea</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' >United States</option><option value='Uruguay' >Uruguay</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select> <label for='input_6_10_6' id='input_6_10_6_label' >Country</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li> </ul></div> <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_6' class='gform_button button' value='Sign Up' onclick='if(window["gf_submitting_6"]){return false;} window["gf_submitting_6"]=true; ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_6"]){return false;} window["gf_submitting_6"]=true; jQuery("#gform_6").trigger("submit",[true]); }' /> <input type='hidden' class='gform_hidden' name='is_submit_6' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='6' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_6' value='WyJbXSIsIjNkNTNhNjhlOThlOGY4N2JlZWZiNTRmZDhlZDQ5OWI3Il0=' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_6' id='gform_target_page_number_6' value='0' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_6' id='gform_source_page_number_6' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> </form> </div><script type='text/javascript'> jQuery(document).bind('gform_post_render', function(event, formId, currentPage){if(formId == 6) {gf_global["number_formats"][6] = {"1":{"price":false,"value":false},"2":{"price":false,"value":false},"7":{"price":false,"value":false},"20":{"price":false,"value":false},"15":{"price":false,"value":false},"19":{"price":false,"value":false},"22":{"price":false,"value":false},"10":{"price":false,"value":false}};if(window['jQuery']){if(!window['gf_form_conditional_logic'])window['gf_form_conditional_logic'] = new Array();window['gf_form_conditional_logic'][6] = { logic: { 10: {"field":{"actionType":"show","logicType":"any","rules":[{"fieldId":"22","operator":"is","value":"Yes, I love mail!"}]},"nextButton":null,"section":null} }, dependents: { 10: [10] }, animation: 1, defaults: {"1":{"1.2":"","1.3":"","1.4":"","1.6":"","1.8":""},"15":["choice_6_15_1"],"10":{"10.1":"","10.2":"","10.3":"","10.4":"","10.5":"","10.6":""}}, fields: {"1":[],"2":[],"7":[],"20":[],"15":[],"19":[],"22":[10],"10":[]} }; if(!window['gf_number_format'])window['gf_number_format'] = 'decimal_dot';jQuery(document).ready(function(){gf_apply_rules(6, [10], true);jQuery('#gform_wrapper_6').show();jQuery(document).trigger('gform_post_conditional_logic', [6, null, true]);} );} gformInitChosenFields('#input_6_7','No results matched');} } );jQuery(document).bind('gform_post_conditional_logic', function(event, formId, fields, isInit){gformInitChosenFields('#input_6_7','No results matched');} );</script><script type='text/javascript'> jQuery(document).ready(function(){jQuery(document).trigger('gform_post_render', [6, 1]) } ); </script>
MENU