Iris melanocytic tumours in New Zealand/Aotearoa: presentation, management and outcome in a high UV exposure environment.

BACKGROUND/OBJECTIVES: Iris melanoma, a rare intraocular malignancy, represents the smallest subgroup of uveal melanoma. This first, comprehensive study of iris melanocytic lesions in the high ultraviolet environment in New Zealand/ Aotearoa (NZ) examines diagnosis, management and outcomes. SUBJECTS/METHODS: Retrospective study of iris melanocytic tumours referred to tertiary referral centres in Auckland, NZ, over 20 years (1999-2018). Data analysed include demographics, tumour characteristics, histology, genetic analyses, treatment modalities, recurrence, metastasis, 5-year and overall survival. RESULTS: Cohort (N = 51) was predominantly NZ European (98.0%) with no indigenous Maori, or Pasifika. Median age at presentation was 58 years. Tumours involved a median of two clock hours of iris. The posterior tumour margin extended to the anterior chamber angle in 22 patients (45.8%). Management included initial observation 54.9%, iridectomy/excision biopsy 29.4%, irido-cyclectomy 7.8%, plaque radiotherapy 7.8%, proton beam radiotherapy 7.8%, and ultimately enucleation 17.6%. Histology was performed in 19 cases (37%) with 16 confirmed melanomas (84%). Mean follow-up 4.2 years with median visual acuity of 6/7.5 two years post intervention. Melanoma-related metastasis and mortality occurred in two cases with five-year melanoma-related mortality of 2.0%. CONCLUSION: In a climate with high ultraviolet exposure iris melanocytic tumours occurred almost exclusively in NZ Europeans, however, the majority of cases were category T1, possibly reflecting early diagnosis in the NZ health system. Nonetheless, >50% underwent surgery or radiotherapy, often utilising more than one modality. A high index of suspicion and early referral of iris melanocytic lesions should be considered in regions with high UV exposure.

Microdroplet and spatter contamination during phacoemulsification cataract surgery in the era of COVID-19.

IMPORTANCE: Determine phacoemulsification cataract surgery risk in a Covid-19 era. BACKGROUND: SARS-CoV-2 (Covid-19) transmission via microdroplet and aerosol-generating procedures presents risk to medical professionals. As the most common elective surgical procedure performed globally; determining contamination risk from phacoemulsification cataract surgery may guide personal protection equipment use. DESIGN: Pilot study involving phacoemulsification cataract surgery on enucleated porcine eyes by experienced ophthalmologists in an ophthalmic operating theatre. PARTICIPANTS: Two ophthalmic surgical teams. METHODS: Standardized phacoemulsification of porcine eyes by two ophthalmologists accompanied by an assistant. Fluorescein incorporated into phacoemulsification irrigation fluid identifying microdroplets and spatter. Contamination documented using a single-lens reflex camera with a 532 nm narrow bandpass (fluorescein) filter, in-conjunction with a wide-field blue light and flat horizontal laser beam (wavelength 532 nm). Quantitative image analysis using Image-J software. MAIN OUTCOME MEASURES: Microdroplet and spatter contamination from cataract phacoemulsification. RESULTS: With phacoemulsification instruments fully within the eye, spatter contamination was limited to <10 cm. Insertion and removal of the phacoemulsification needle and bimanual irrigation/aspiration, with irrigation active generated spatter on the surgeons' gloves and gown extending to >16 cm below the neckline in surgeon 1 and > 5.5 cm below the neckline of surgeon 2. A small tear in the phacoemulsification irrigation sleeve, presented a worse-case scenario the greatest spatter. No contamination above the surgeons' neckline nor contamination of assistant occurred. CONCLUSIONS AND RELEVANCE: Cataract phacoemulsification generates microdroplets and spatter. Until further studies on SARS-CoV-2 transmission via microdroplets or aerosolisation of ocular fluid are reported, this pilot study only supports standard personal protective equipment.

Characteristics of Platelet Lysate Compared to Autologous and Allogeneic Serum Eye Drops.

Purpose: Platelet lysate produced from platelet apheresis components has been proposed as an alternative to serum eye drops in the treatment of ocular surface disease. This study compared the effects of platelet lysate and serum on growth factor, cytokine and nanoparticle concentrations, and corneal epithelial cell proliferation. Methods: The concentration of growth factors, cytokines, and nanoparticles in platelet lysates manufactured from either fresh or expired platelet apheresis concentrations collected with Trima or Haemonetics technology was characterized and compared with those of allogeneic, autologous, and fetal calf serum. The ability to promote corneal epithelial cell proliferation and wound healing was tested in vitro. Results: Platelet lysate enriched the amount of transforming growth factor ß1, platelet-derived growth factor -AB and -BB, fibroblast growth factor, and epidermal growth factor compared with the two sera groups. The concentrations of insulin-like growth factor 1, hepatocyte growth factor, and fibronectin were significantly lower than in sera. There were no differences in nanoparticle concentrations. There was no significant difference in corneal epithelial cell proliferation. Platelet lysates were comparable to fetal calf serum in accelerating corneal epithelial wound healing in vitro. Conclusions: Fresh and expired platelet lysates from the Trima and Haemonetics systems had higher growth factor concentrations than sera. The ability of platelet lysates to promote corneal epithelial cell proliferation and wound healing was equivalent to sera. Translational Relevance: Platelet lysates may serve as an efficient and reliable source of human growth factors for the treatment of ocular surface diseases.

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.

The Rapid Transformation of Transplantation for Corneal Endothelial Diseases: An Evolution From Penetrating to Lamellar to Cellular Transplants.

The cornea is the major focusing structure of the human eye and the corneal endothelium maintains the relatively dehydrated state of the cornea required for clarity. The endothelial cells respond to disease or injury by migration and cellular enlargement. Our current understanding is that there is a very limited degree of proliferative or regenerative capacity in the human corneal endothelium. Thus, corneal endothelial diseases may result in corneal edema, significantly impact vision and quality of life. Contemporary surgical transplantation options for treating moderate to advanced endothelial dysfunction include penetrating keratoplasty (PK), Descemet stripping endothelial keratoplasty (DSEK), and Descemet membrane endothelial keratoplasty. Advances in surgical techniques aim to bring faster visual recovery and improve visual outcomes; however, there is still a significant donor cornea shortage worldwide and alternative methods for treatment for corneal endothelial disease are rapidly evolving. Indeed, we are at a pivotal point in corneal transplantation for endothelial disease and novel surgical strategies include using 1 donor for multiple recipients, a minimally attached endothelial graft, and Descemet membrane stripping only. Crucially, forthcoming approaches include the use of Rho-Kinase (ROCK) inhibitors, endothelial cell therapy, tissue engineered grafts, and consideration of stem cell techniques. Ultimately, the choice of technique will be dependent on recipient factors such as age, type of endothelial disease, extent of the disease, and associated ocular disorders. The safety and efficacy of these rapidly developing treatments warrant further investigations. In time, some or all of these alternatives for corneal transplantation will alleviate the reliance on limited corneal donor tissue.

Repeat corneal transplantation in Auckland, New Zealand: Indications, visual outcomes and risk factors for repeat keratoplasty failure.

IMPORTANCE: In New Zealand, repeat keratoplasty has become the second leading indication for corneal transplantation. BACKGROUND: To report the indications, outcomes and survival of repeat keratoplasty and evaluate the risk factors for graft failure. DESIGN: Retrospective study in a public corneal service. PARTICIPANTS: Two hundred nineteen patients undergoing 279 repeat keratoplasty procedures during 1991-2017. METHODS: The New Zealand National Eye Bank prospectively collects data on all corneal transplants. This was utilized to identify patients undergoing repeat keratoplasty in Auckland. Clinical records were retrospectively reviewed. MAIN OUTCOME MEASURES: Graft survival and visual outcome. RESULTS: The repeat keratoplasty technique was penetrating keratoplasty (PK) in 242 cases (86.7%) and endothelial keratoplasty in 37 (13.3%). The most common primary indication was keratoconus (46.6%). The most common indication for repeat keratoplasty was endothelial decompensation (37.6%). For PK performed as a repeat keratoplasty, the median survival in years was 12.0 for first, 3.5 for second and 2.3 for third repeat keratoplasty. Keratoconus had the longest graft survival (median 13.0 years). In surviving grafts, median visual acuity was 6/15 at 1 year and 6/12 at 2 years. On multivariate analysis, regraft number (P = .022), non-European ethnicity (P = .007), concurrent surgical procedure (P < .0005), lower donor endothelial density (P = .028), previous glaucoma surgery (P < .0005), postoperative raised intraocular pressure (P = .001) and graft rejection (P = .032) were associated with keratoplasty failure. CONCLUSIONS AND RELEVANCE: Repeat keratoplasty survival is affected by multiple interacting factors and prognosis worsens with each subsequent regraft. These results will help guide clinicians in addressing patients' individual risk factors when embarking on repeat corneal transplant surgery.

Cystoid macular oedema following cataract surgery: A review.

Pseudophakic cystoid macular oedema (PCMO) remains a significant cause of compromised postoperative vision in contemporary cataract surgery. Well-established risk factors include intraoperative complications such as posterior capsule rupture and preoperative factors including: diabetes mellitus, uveitis, retinal vein occlusion, epiretinal membrane. The role of topical glaucoma medications in PCMO continues to be debated. Current treatment strategies largely target suppression of inflammation. Topical NSAIDs remain the mainstay in prophylaxis and treatment of PCMO. Topical corticosteroids are commonly used as monotherapy or in combination with NSAIDs. Unfortunately, high-quality trials are notably lacking for other PCMO treatment modalities such as: periocular corticosteroids, orbital floor triamcinolone, intravitreal triamcinolone, corticosteroid implants, intravitreal bevacizumab and pars-plana vitrectomy. A lack of consistency in defining PCMO and resolution of PCMO explains why even large systematic reviews may come to contradictory conclusions. This review explores the varied contemporary evidence-base in relation to the aetiology, diagnosis, prophylaxis and treatment of PCMO.

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 rising tide of Acanthamoeba keratitis in Auckland, New Zealand: a 7-year review of presentation, diagnosis and outcomes (2009-2016).

IMPORTANCE: Acanthamoeba is an increasingly prevalent cause of vision-threatening microbial keratitis. BACKGROUND: To assess the incidence, clinical presentation, diagnosis and outcomes of patients with Acanthamoeba keratitis (AK) in Auckland, New Zealand over a 7-year period. DESIGN: Retrospective observational consecutive case series. PARTICIPANTS: Fifty-eight eyes of 52 patients diagnosed with AK. METHODS: All cases of AK were identified using a cross-referenced search of clinical, laboratory and pharmacy records from March 2009 to May 2016. MAIN OUTCOME MEASURES: Demographic and clinical data were collected including age, gender, risk factors, clinical manifestations, initial diagnosis, diagnostic investigations, treatment, presenting and final visual acuity and surgical interventions. RESULTS: Contact lens (CL) use was noted in 96% of unilateral and 100% of bilateral cases. The mean duration of symptoms at presentation was 21 days and the mean duration from presentation to definitive diagnosis was 14 days. Initial diagnosis was recorded as CL-related keratitis in 70.6%, viral keratitis in 15.5% and AK in 12.0%. The diagnosis was confirmed with In vivo confocal microscopy (IVCM) in 67.2%, corneal scrape in 22.4%, corneal biopsy in 1.7% and clinically in 8.6%. IVCM sensitivity was 83.0%. Surgical intervention was required in four patients, all with delayed diagnosis (range 63-125 days). The incidence of AK has more than doubled when compared with the preceding 7-year period. CONCLUSIONS AND RELEVANCE: AK is a rare vision-threatening protozoal infection with rapidly-increasing incidence in New Zealand, predominantly affecting CL users. Diagnosis is often challenging and when delayed is associated with worse outcomes. IVCM offers rapid diagnosis with high sensitivity.

Corneal Transplantation in New Zealand 2000 to 2009.

PURPOSE: To quantify all minor/major adverse events in a large cohort of consecutive corneal transplants, particularly in respect to penetrating keratoplasty (PKP). METHODS: All corneal transplants in the Auckland region over a 10-year period (2000-2009) were identified through the New Zealand National Eye Bank. Relevant clinical records were assessed for this period and 2 years after. All intraoperative or postoperative adverse events/complications, visual acuity, and graft outcomes were recorded. RESULTS: Detailed data were available for 941 (94.5%) of 996 procedures in the study period, including 834 PKPs, 73 deep anterior lamellar keratoplasties, 28 Descemet stripping endothelial keratoplasties, and 6 tectonic keratoplasties. Intraoperative adverse events occurred in 117 (12.4%) procedures, most commonly positive vitreous pressure (6.3%). Postoperative adverse events included elevated intraocular pressure (21.3%, >30 mm Hg), graft rejection (29.8%), suture-related complications (30.1%), dry eye (15.9%), epithelial defect (9.8%), wound compromise (3.4%), microbial keratitis (3.2%), and endophthalmitis (0.6%). At 2 years, 58.7% of eyes achieved best-corrected visual acuity of ≥6/12 (20/40) and 69.6% achieved ≥6/18 (20/60). Graft survival at 2 years was 87.9%, 92.3%, and 100% for PKP, deep anterior lamellar keratoplasty, and Descemet stripping endothelial keratoplasty, respectively. CONCLUSIONS: In this study of 941 consecutive, principally penetrating, corneal transplants, adverse events were found to be more common than typically reported. In an era in which PKP is increasingly substituted by lamellar surgery, this provides useful insight into operative and postoperative adverse events in penetrating surgery.

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.

Corneal Transplantation in Auckland, New Zealand, 1999-2009: Indications, Patient Characteristics, Ethnicity, Social Deprivation, and Access to Services.

PURPOSE: To analyze characteristics and indications for corneal transplantation in patients undergoing penetrating, lamellar, and endothelial keratoplasty in Auckland, New Zealand (NZ). METHODS: Corneal transplantation data from the NZ National Eye Bank and hospital records of corneal transplant recipients in the Auckland region from January 1, 2000, to December 31, 2009, were collated. Patient demographics, preoperative diagnosis, indication, ocular and medical history, visual acuity, deprivation index, and access to transplantation surgery were analyzed. RESULTS: A total of 941 corneal transplants involving 770 patients were included for analysis. Mean age was 46 years. Age and ethnicity varied according to the transplant indication. A male preponderance and disproportionally high rates of Maori and Pacific ethnicity with a mean age of 30 years were observed in transplants for keratoconus. A total of 67.2% of corneal transplants were completed in the public health system and were associated with higher levels of deprivation than those completed in private facilities. Preoperative visual acuity varied according to the transplant type and indication. The most common clinical indication for corneal transplantation was keratoconus (41.3%), followed by repeat transplantation (21.0%). There was no significant change in the relative proportion of transplant indications in any year over the duration of this study (P = 0.41). A contralateral corneal transplant was present in 24.4% and glaucoma in 12.8% of penetrating keratoplasty recipients. CONCLUSIONS: Keratoconus is the leading indication for corneal transplantation in Auckland, NZ, and involves a disproportionately high rate of Maori and Pacific transplant recipients with a male preponderance and comparatively low mean age at the time of surgery.

Umbilical cord stem cells in the treatment of corneal disease.

Stem cells are capable of giving rise to progenies with specific functional and morphological traits and, in recent years, extraordinary scientific advances have initiated an era of hope for clinical regenerative strategies and tissue engineering applications. We appraise the potential benefits of human umbilical cord-derived stem cell therapy and consider current approaches to utilize these stem cells in corneal epithelial, stromal, and endothelial disorders.

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.

The natural history of corneal topographic progression of keratoconus after age 30†years in non-contact lens wearers.

BACKGROUND/AIMS: To determine if significant progression of disease occurs in older, non-contact lens wearing, subjects with keratoconus and to identify potential predictive factors. METHODS: Clinical and computerised corneal topography records of subjects with keratoconus attending a specialist optometry practice were retrospectively analysed to identify those aged ≥30 years, with ≥2 consultations ≥12 months apart, no contact lens wear and no corneal scarring, surgery or corneal hydrops. Topographic parameters assessed included: maximum keratometry (Kmax), steep keratometry (Ksteep), flat keratometry (Kflat), inferior-superior (I-S) ratio and the surface asymmetry and regularity (surface asymmetry index and surface regularity index) indices. RESULTS: Of the 449 subjects with keratoconus assessed, 43 eyes of 27 patients (6.01%) met inclusion criteria, with median age 38.45 (12.86) years at baseline and median follow-up 4.36 (8.68) years. There was a significant increase in Kmax (0.30 (1.21) D), Ksteep (0.27 (0.90) D), Kflat (0.34 (1.12) D) and I-S (0.26 (0.82) D) between baseline and final review, p<0.05. Notably, 18.6%-25.6% of eyes demonstrated ≥1.00 D increase in one or more of four principal topographic parameters (Kmax, Ksteep, Kflat, I-S ratio), while 18.5%-37.0% of subjects had ≥1.00 D increase in the aforementioned parameters in at least one eye over the study period. However, <10% of eyes exhibited ≥1.00 D increase/year in all topographic parameters. The only significant predictor of progression was follow-up time. CONCLUSIONS: This study confirms that keratoconus may continue to progress beyond age 30. Older subjects with keratoconus should be monitored for progression, particularly with respect to possible corneal collagen cross-linking or astigmatic correction in cataract surgery.

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.

Dr John Nottingham's 1854 Landmark Treatise on Conical Cornea Considered in the Context of the Current Knowledge of Keratoconus.

John Nottingham has been widely credited with the first accurate description of keratoconus in his treatise on conical cornea, published in 1854. Contained within the 270-page treatise are accounts and theories of keratoconus postulated by authors such as Scarpa, von Carion, von Ammon, and Mackenzie, synthesized by Nottingham in a treatise containing his own original observations. Nottingham's work delves deeply into keratoconus, with coverage reminiscent of a modern review, albeit in a far less succinct manner. He extensively describes the epidemiology, clinical presentation, underlying cause, and treatment of keratoconus. However, the concepts put forth are limited largely by the contemporary lack of understanding of the underlying anatomy and physiology of the eye, and the observations, by technological limitations. He postulates a similar treatment algorithm to that used today; optical devices being the management option of choice in the mild stages with surgery being a last resort. None of the surgical methods discussed are used in the modern era, but he does make reference to the possible efficacy of corneal transplantation. Nottingham's treatise was published over 160 years ago, yet his ideas and observations are surprisingly accurate. It is very possible that he was the first person to publish an accurate, comprehensive description of keratoconus.