Glaucoma severity at first presentation to an ophthalmologist and risk factors for late presentation in rural Australia: the S1P study.

CLINICAL RELEVANCE: Well-targeted referrals and timely commencement of treatment are essential to limiting vision loss in glaucoma. Optometrists, primary care providers, and public health policymakers can utilise predictors of late to identify and target at-risk populations. BACKGROUND: This study, which aimed to evaluate glaucoma severity at first presentation to an ophthalmologist in a rural Australian population, is the first of its kind in an Australian population. METHODS: Patient records from a large ophthalmology clinic in Port Macquarie, NSW were retrospectively reviewed using the Fight Glaucoma Blindness registry to identify patients who were first diagnosed with glaucoma at an ophthalmology practice in 2020 or 2021. Associations with glaucoma severity at presentation, measured with visual field index (VFI), were analysed using a beta-regression model. Retinal nerve fibre layer measurements were evaluated as a secondary outcome measure using linear regression. RESULTS: From 3548 new patients seen, 110 cases of glaucoma were diagnosed, 95 of whom met inclusion criteria. These comprised 41.8% primary open-angle glaucoma, 32.7% normal-tension glaucoma, 11.8% secondary open-angle glaucoma, 12.7% primary angle closure glaucoma, and 0.9% secondary angle closure glaucoma. The median VFI at presentation was 94.5%, and 71.9% of patients had a VFI ≥ 90%. However, 6.3% of patients presented with a VFI below 50%. Older age, higher intraocular pressure, and worse visual acuity were significantly associated with severity at presentation. No associations were found for remoteness, sex, family history, or glaucoma type. CONCLUSIONS: Glaucoma appears to be diagnosed relatively early in this population. Severity at presentation was associated with age, intraocular pressure, and visual acuity, but not influenced by the social determinants assessed. These findings underscore the importance of frequent comprehensive eye examinations in older patients. Replication in other Australian populations is recommended as the generalisability of these findings is limited.

Lateral canthal fixation using an oblique vertically orientated asymmetric periosteal transposition flap.

Herein a modification of the highly useful lateral tarsal strip procedure is presented. The refinement of the technique uses an oblique, vertically orientated, asymmetric, periosteal transposition (OVAPT) flap from the lateral orbital rim to fix the tarsal strip. From a consecutive series of 53 patients, A cohort of 49 procedures on 41 patients with a minimum of 3-month follow up is described. The procedure had a high rate of success in terms of canthal fixation over the median 14-month follow up. There was only one case of late stretching of the canthal repair in an anophthalmic orbit, one case of recurrent cicatricial ectropion due to an inadequate skin graft, and finally a case of early recurrent tarsal ectropion. The OVAPT flap further enhances the stability of the tarsal strip procedure, and allows greater control of lid position and tension. The pull is in a superior and lateral direction, mimicking that of the lateral canthal tendon.

Mycosis fungoides causing severe lower eyelid ulceration.

Mycosis fungoides is a form of cutaneous malignant T-cell lymphoma initially confined to the skin. A range of ophthalmic manifestations has been described; these usually appear in advanced disease. Lid involvement is most common and ranges from ectropion, usually cicatricial, to diffuse thickening and placoid tumours. A case of a 72-year-old man presenting with progressive, full thickness, lower eyelid ulceration is presented. The patient had a long history of placoid skin lesions, previously diagnosed as discoid lupus. Repeat biopsies of these lesions including the eyelid eventually revealed mycosis fungoides. The ulceration progressed to destroy most of the lower lid before the correct diagnosis was made. This type of eyelid involvement has not previously been reported in mycosis fungoides. This case also highlights the diagnostic difficulties encountered in the early phases of mycosis fungoides. If suspected, multiple biopsies are essential to establish the diagnosis.