Cysts and tumours of the iris: Diagnostic tools and key management considerations-A review.

The iris is a unique structure, with exquisite variations in colour and form. Pathological changes, specifically including iris cysts and tumours are relatively uncommon, difficult to diagnose, and yet potentially blinding or life-threatening. Based on a comprehensive literature review, with highly illustrated key case examples, this report aims to guide the clinician in filtering the differential diagnoses of iris cysts and tumours. Evaluation is in the context of key diagnostic clinical tools and management considerations. Diagnostic imaging techniques include serial anterior segment photography, ultrasound, anterior segment optical coherence tomography, and iris fluorescein angiography, however, the roles of computerised topography and magnetic resonance imaging are also considered in this review. Management includes categorisation in terms of solid iris tumours (melanocytic vs. non-melanocytic), or iris cysts (primary vs. secondary) that may be usefully differentiated by clinical assessment, avoiding more invasive interventions. Cystic lesions are generally benign, although implantation cysts in particular cause significant complications and surgical challenges. Most solid tumours are melanocytic and also typically benign. However, in larger lesions, rapid growth, symptoms and complications more likely indicate malignancy, requiring further investigation.

Changing Trends in Corneal Transplantation in Aotearoa/New Zealand, 1991 to 2020: Effects of Population Growth, Cataract Surgery, Endothelial Keratoplasty, and Corneal Cross-Linking for Keratoconus.

PURPOSE: The purpose of this study was to identify trends in the primary indication for keratoplasty in New Zealand/Aotearoa (NZ) after significant population growth, increase in the number of cataract surgeries per population, widespread adoption of endothelial keratoplasty, and introduction of corneal cross-linking for keratoconus. METHODS: Statistical analysis of the New Zealand National Eye Bank's prospective database of all keratoplasties was performed between January 1991 and January 2020. Indications for keratoplasty were isolated for the primary diagnosis. RESULTS: In total, 6840 corneas were transplanted with mean 236 ± 57.5 transplants/year, increasing from 2.55 to 6.06 per 100,000 NZ population/year. Over the past decade, the number of transplant recipients aged 60 years or older has increased and recipients aged 20 to 39 years have plateaued. In 2019, for the first time, regraft became the most common indication (30.9%), followed by keratoconus (27.9%) and corneal dystrophy (18.8%), with a steady decline in bullous keratopathy. Proportions of the keratoplasty technique changed dramatically: penetrating keratoplasty fell from 91.4% in 2006 to 55.0% in 2019, Descemet's stripping endothelial keratoplasty increased from 0% to 29.5%, anterior lamellar keratoplasty increased from 2.5% to 5.7%, and Descemet membrane endothelial keratoplasty increased from 0% to 9.1%. CONCLUSIONS: Keratoplasty trends in Aotearoa/NZ have changed considerably because of the evolution of phacoemulsification and keratoplasty techniques. Unlike proportions observed overseas, NZ still performs penetrating keratoplasties in over half of all transplants. Corneal cross-linking may be having an early effect of reducing keratoplasty rates for keratoconus.

Auckland Cataract Study IV: Practical application of NZCRS cataract risk stratification to reduce phacoemulsification complications.

IMPORTANCE: Reduction of intraoperative complications in phacoemulsification cataract surgery. BACKGROUND: To assess practicability of a risk stratification system, the New Zealand Cataract Risk Stratification (NZCRS) system, in a major teaching hospital service, without investigator oversight, to ascertain whether benefits identified in research studies are maintained in busy clinical practice. DESIGN: Prospective cohort study in a major public teaching hospital. PARTICIPANTS: Five hundred cases of phacoemulsification cataract surgery. METHODS: NZCRS system inserted into 621 consecutive preoperative cataract patient files. Recommendation to allocate higher-risk cases to experienced surgeons. MAIN OUTCOME MEASURES: NZCRS system uptake and adherence, appropriate identification of high risk cases and intraoperative complication rates. RESULTS: NZCRS scores calculated in 500 of 621 (80.5%) cases and 98 (19.6%) scored as "high risk." Cataract surgery (N = 500) performed by: 12 Registrars (20%), 4 Fellows (7.2%), 26 Consultants (72.8%). Risk scores adhered to in 99%. Overall intraoperative complications (3.0%) included iris prolapse 1.6% and posterior capsule tear 0.8%. No statistical difference in complication rates identified between surgeon grades. Mean best-corrected visual acuity was 6/10 (20/32). Postoperatively, cystoid macular oedema occurred in 3.2%. Rescoring by an experienced investigator noted a greater number of "high risk scores" (31.6% vs 19.6%) related to differences in subjective scoring of anterior chamber depth and cataract density. CONCLUSIONS AND RELEVANCE: Practical uptake of cataract risk stratification was promising in this study with NZCRS calculated in 80.5% with 99% adherence to scoring recommendations. Compared to baseline studies, in the day-to-day clinical setting, a continued, decreasing trend in frequency and severity of intraoperative complications was noted. Subjective variability of risk scoring may be further improved by better, objective, standardization.

Auckland Cataract Study III: Refining Preoperative Assessment With Cataract Risk Stratification to Reduce Intraoperative Complications.

PURPOSE: To assess intraoperative complications of phacoemulsification surgery in public teaching hospital settings using modified preoperative risk stratification systems. DESIGN: Prospective cohort study. METHODS: Preoperative risk stratification of 500 consecutive cataract cases using the New Zealand Cataract Risk Stratification (NZCRS) scoring system. Recommended allocation of higher-risk phacoemulsification procedures to experienced surgeons in public teaching hospital setting. MAIN OUTCOME MEASURE: Intraoperative complications relative to adherence to stratification recommendations. RESULTS: NZCRS classified 192 cases (38%) as high-risk, recommended for fellows or consultants (attendings). Primary surgeons were residents (n = 142, 28%), fellows (n = 88, 18%), and consultants (n = 270, 54%). Overall rate (N = 500) of any intraoperative complication was 5.0%. Where NZCRS scoring recommendations were observed (n = 448) the intraoperative complication rate was 4.5% but in "nonadherence" cases (n = 52 residents operating on higher-risk cases) this nearly doubled (9.6%). Postoperative complications occurred in 5.2%, primarily cystoid macular edema (3.7%). Postoperatively, mean unaided visual acuity was 6/12 (20/40) and best-corrected visual acuity improved from 6/20 (20/63) preoperatively to 6/10 (20/32) postoperatively (P < .05). CONCLUSIONS: The NZCRS system aids identification of higher-risk cataract cases and appropriate case-to-surgeon allocation and may increase surgeon awareness of risk factors. Compared to 2 previous studies under similar conditions in the same institution, the NZCRS system was associated with a 40% reduction in intraoperative complications (8.4% to 5%). The rate of posterior capsular tear was 0.6% (P = .035) compared to 2.6% in baseline phase and 1.4% in a prior risk stratification phase. Risk stratification seems to reduce intraoperative phacoemulsification complications in public teaching hospital settings.

The Auckland Cataract Study II: Reducing Complications by Preoperative Risk Stratification and Case Allocation in a Teaching Hospital.

PURPOSE: To assess the effect of preoperative risk stratification for phacoemulsification surgery on intraoperative complications in a teaching hospital. DESIGN: Prospective cohort study. METHODS: Prospective assessment of consecutive phacoemulsification cases (N = 500) enabled calculation of a risk score (M-score of 0-8) using a risk stratification system. M-scores of >3 were allocated to senior surgeons. All surgeries were performed in a public teaching hospital setting, Auckland, New Zealand, in early 2016. Postoperatively, data were reviewed for complications and corrected distance visual acuity (CDVA). Results were compared to a prospective study (N = 500, phase 1) performed prior to formal introduction of risk stratification. RESULTS: Intraoperative complications increased with increasing M-scores (P = .044). Median M-score for complicated cases was higher (P = .022). Odds ratio (OR) for a complication increased 1.269 per unit increase in M-score (95% confidence interval [CI] 1.007-1.599, P = .043). Overall rate of any intraoperative complication was 5.0%. Intraoperative complication rates decreased from 8.4% to 5.0% (OR = 0.576, P = .043) comparing phase 1 and phase 2 (formal introduction of risk stratification). The severity of complications also reduced. A significant decrease in complications for M = 0 (ie, minimal risk cases) was also identified comparing the current study (3.1%) to phase 1 (7.2%), P = .034. There was no change in postoperative complication risks (OR 0.812, P = .434) or in mean postoperative CDVA (20/30, P = .484) comparing current with phase 1 outcomes. CONCLUSION: A simple preoperative risk stratification system, based on standard patient information gathered at preoperative consultation, appears to reduce intraoperative complications and support safer surgical training by appropriate allocation of higher-risk cases.

Postoperative rotation of supplementary sulcus-supported toric intraocular lenses.

We describe 7 cases in which supplementary sulcus-based toric intraocular lenses (IOLs) rotated postoperatively, requiring surgical realignment. The initial rotation was identified clinically between 3 months and 36 months postoperatively. All eyes had keratoconus, with and without prior keratoplasty, and 6 had longer than average axial lengths. No preceding trauma could be identified for 5 of the eyes. One eye had 3 episodes of postoperative IOL rotation, eventually requiring suture fixation to stabilize the IOL. This series indicates that postoperative rotation of a supplementary sulcus-based toric IOL may occur in eyes with or without preceding trauma. Eyes with keratoconus are at risk for postoperative rotation of the IOL, and suture fixation may be required to obtain stability.

Long-term survival following diabetic vitrectomy.

AIM: To update long-term survival data on patients with proliferative diabetic retinopathy undergoing vitrectomy and to identify associated risk factors. METHODS: Retrospective clinical record review at a single New Zealand tertiary referral centre. A total of 182 eyes that underwent a vitrectomy for a diabetic vitreous haemorrhage and/or tractional retinal detachment between March 2000 and December 2010 were included. Kaplan-Meier survival curves and Cox-regression analyses were performed for survival rates and associated risk factors. RESULTS: The mean age of patients was 55 years (range 22 to 85) at time of surgery. The three-year survival rate following diabetic vitrectomy was 83.5%, and the five-year survival rate (N=154) was 70.1%. Increasing age, dialysis and high serum creatinine were associated with poorer survival on multivariate Cox regression analyses (hazard ratio of 1.035, 4.216 and 1.930 respectively with p-values of 0.018, <0.001 and 0.046). CONCLUSION: Survival rates after diabetic vitrectomy remain relatively poor but comparable to earlier New Zealand and international reports. However, there remain significant differences between ethnic groups within New Zealand that need to be addressed in addition to renal disease, which appears to be a major risk factor for poor survival. Overall, the contemporary survival outcomes observed in this study may influence decision making by patients and clinicians as well as encourage a review of current healthcare resource allocation in diabetes care.

Auckland cataract study 2: clinical outcomes of phacoemulsification cataract surgery in a public teaching hospital.

IMPORTANCE: A contemporary benchmark for the most common ophthalmic surgery. BACKGROUND: To assess patient characteristics and outcomes of contemporary phacoemulsification cataract surgery in a New Zealand public teaching hospital setting. DESIGN: Prospective observational study. PARTICIPANTS: Consecutive cases (n = 500) of phacoemulsification surgery between April and June 2015. METHODS: An independent observer assessed clinical and surgical data preoperatively and 4-6 weeks postoperatively. MAIN OUTCOME MEASURES: Visual acuity, intraoperative and postoperative complications. RESULTS: Mean age was 72.3 ± 11.9 years and 57% female. Mean preoperative best-measured visual acuity was 6/30. Ocular comorbidity was present in 45.8% of eyes, most commonly glaucoma (10%), age-related macular degeneration (8%) and diabetic retinopathy (8%). Systemically, hypertension (59%) and diabetes mellitus (31%) were prevalent. Mean contralateral best-measured visual acuity was 6/12 (n = 495) with 62% being phakic. The rate of posterior capsular tear was 2.6% and cystoid macular oedema 3.5%. Intraoperative complication rates were not significantly different between surgeon levels (P = 0.234). However, registrars had fewer postoperative complications than fellows (2.2% vs. 11.9%, P = 0.012). Postoperatively, mean unaided and best-measured visual acuity were 6/12 and 6/9. CONCLUSIONS AND RELEVANCE: This study reports current phacoemulsification surgery outcomes in a major public teaching institution. A large proportion of patients exhibited systemic and ocular comorbidities, relatively dense cataracts and poor presenting visual acuity. However, visual outcomes and intraoperative complication rates were not statistically different between trainees and senior surgeons. Generally, outcomes reflect international standards and have improved since the last comparable study in this region.

New Zealand trends in corneal transplantation over the 25†years 1991-2015.

AIMS: To report the 25-year longitudinal trends in indications and corneal transplantation techniques in New Zealand. METHODS: Statistical analysis of prospectively acquired New Zealand National Eye Bank (NZNEB) electronic database from 1991 to 2015 inclusive. Subjects were recipients of corneal transplants in 62 centres supplied by the NZNEB. Main outcome measures were indications, recipient age and transplantation techniques. RESULTS: From January 1991 to December 2015, NZNEB supplied tissue for 5574 corneal transplants, increasing annually from 89 (1991) to 290 (2015). Penetrating keratoplasty remained the most commonly performed technique throughout the 25-year period, although it decreased from 98.9% of all transplants in 1991 to 60.3% in 2015. There was a corresponding increase in deep anterior lamellar and endothelial keratoplasty over the most recent decade from 2.5% to 7.2% and 4.9% to 31.4%, respectively. Keratoconus remained the leading indication for keratoplasty through to 2015 (34.5%). Regrafts (23.1%) and Fuchs endothelial corneal dystrophy (17.0%) have become more common indications, while bullous keratopathy has become less common (10.8%). There was a bimodal distribution in age with peaks at 20-29 and 60-79 years. There was a reduction in recipients under age 40 and corresponding increase in the percentage of recipients aged 40-69. CONCLUSION: Changing indications and increasing uptake of lamellar keratoplasty have been significant international trends over the last 25 years. However, New Zealand's corneal disease and population characteristics create unique longitudinal trends, with keratoconus remaining the leading indication and penetrating keratoplasty the leading technique from 1991 to 2015.

The Auckland Cataract Study: Assessing Preoperative Risk Stratification Systems for Phacoemulsification Surgery in a Teaching Hospital.

PURPOSE: To evaluate 2 preoperative risk stratification systems for assessing the risk of complications in phacoemulsification cataract surgery, performed by residents, fellows, and attending physicians in a public teaching hospital. DESIGN: Cohort study. METHODS: One observer assessed the clinical data of 500 consecutive cases, prior to phacoemulsification cataract surgery performed between April and June 2015 at Greenlane Clinical Centre, Auckland, New Zealand. Preoperatively 2 risk scores were calculated for each case using the Muhtaseb and Buckinghamshire risk stratification systems. Complications, intraoperative and postoperative, and visual outcomes were analyzed in relation to these risk scores. RESULTS: Intraoperative complication rates increased with higher risk scores using the Muhtaseb or Buckinghamshire stratification system (P = .001 and P = .003, respectively, n = 500). The odds ratios for residents and fellows were not significantly different from attending physicians after case-mix adjustment according to risk scores (P > .05). Postoperative complication rates increased with higher Buckinghamshire risk scores but not with Muhtaseb scores (P = .014 and P = .094, respectively, n = 476). Postoperative corrected-distance visual acuity was poorer with higher risk scores (P < .001 for both, n = 476). CONCLUSION: This study confirms that the risk of intraoperative complications increases with higher preoperative risk scores. Furthermore, higher risk scores correlate with poorer postoperative visual acuity and the Buckinghamshire risk score also correlates with postoperative complications. Therefore, preoperative assessment using such risk stratification systems could assist individual informed consent, preoperative surgical planning, safe allocation of cases to trainees, and more meaningful analyses of outcomes for individual surgeons and institutions.

Natural history of corneal haze after corneal collagen crosslinking in keratoconus using Scheimpflug analysis.

PURPOSE: To analyze corneal haze after corneal collagen crosslinking (CXL) for progressive keratoconus using Scheimpflug densitometry. SETTING: Auckland District Health Board, Auckland, New Zealand. DESIGN: Prospective randomized controlled study. METHODS: Both eyes of all patients were examined preoperatively and 1, 3, 6, and 12 months postoperatively. One eye of each patient was treated with corneal CXL, with the contralateral eye serving as the control. Examinations included uncorrected distance visual acuity and corrected distance visual acuity (CDVA), slitlamp biomicroscopy, and Scheimpflug tomography (Pentacam). RESULTS: Thirty-six eyes of 36 patients were enrolled. The mean preoperative corneal densitometry was 19.0 ± 3.2 (SD). Postoperatively, the mean densitometry peaked at 1 month, decreasing to baseline level after 6 months without application of topical corticosteroids. The development of haze was significant compared with the contralateral untreated eyes (P < .01). The anterior (120 µm) and inner (central 0.0 to 2.0 mm) zones of the cornea had the highest densitometry after treatment. Lower preoperative central corneal thickness (CCT) was significantly correlated with higher corneal densitometry (P = .03). However, the preoperative CCT, keratometry, and astigmatism did not influence the difference in densitometry between the treated eyes and untreated eyes. There was no evidence of a relationship between densitometry and CDVA (P = .30). CONCLUSIONS: After corneal CXL, patients with keratoconus developed transient corneal haze in the anterior central cornea that might not require specific treatment. Thin corneas were associated with higher densitometry; thus, there might be a greater expectancy of corneal haze in patients with advanced keratoconus. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Annular Salzmann degeneration: Avoiding perturbations and pitfalls in phacoemulsification surgery.

UNLABELLED: We highlight potential problems and pitfalls in cases of Salzmann nodular degeneration by reporting the case of an 84-year-old man with reduced visual acuity due to particularly extensive bilateral Salzmann nodules and moderate cataracts. Large annular Salzmann lesions were removed by superficial keratectomy in each eye. The reproducibility and accuracy of keratometry and biometry improved significantly, and uneventful phacoemulsification cataract surgery was performed 4 weeks after the keratectomy. The phacoemulsification procedures were routine other than the development of pronounced epithelial bullae in the area of Salzmann nodule excision. At final review, the uncorrected distance visual acuity was 20/20 in the right eye and 20/25 in the left eye. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Contemporary Treatment Paradigms in Keratoconus.

The past 20 years have witnessed an explosion in our knowledge of keratoconus, accompanied by a radical transformation of management options. A 2-hit hypothesis proposes an underlying genetic predisposition coupled with external environmental factors, including eye rubbing and atopy. The variable prevalence and natural history have been better defined including significant cone progression in middle age. Therefore, current management must include early diagnosis, regular monitoring, and treatment of environmental cofactors. Spectacles and contact lenses remain fundamental to the optical management of keratoconus. Intrastromal corneal ring segments have been increasingly used, providing improvement in the corneal shape, corrected visual acuity, and contact lens wear. However, like contact lenses, intrastromal corneal ring segments do not treat the underlying disease process. Therefore, current approaches must also consider treatments to minimize keratoconus progression. Fortunately, there is increasing evidence that corneal collagen crosslinking will halt or slow progression in most cases. Until relatively recently, penetrating keratoplasty was the preferred intervention for advanced keratoconus, with long-term success in the region of 90%; however, the greatest risk of failure remains endothelial allograft rejection. Deep anterior lamellar keratoplasty has emerged in the new millennium as a preferred approach to conserve the host endothelium and avoid rejection. Nonetheless, the overall superiority of deep anterior lamellar keratoplasty compared with penetrating keratoplasty, in terms of optical and survival benefits, is still debated. This perspective provides an overview of our current knowledge of keratoconus and current management options. A step-ladder approach to managing keratoconus is outlined to provide the practitioner with a contemporary management paradigm.