Accuracy of diagnosis of pterygium by optometrists and general practitioners in Australia.

BACKGROUND: It was the author's (LWH) observation that pterygium was frequently misdiagnosed by general practitioners that led to this study. The aim was to identify the rate of misdiagnosis of pterygium by optometrists and general practitioners based upon assessing referral accuracy to a single ophthalmologist (LWH). METHODS: This study involved a prospective case series from 25 March 2015 to 18 December 2018 in a tertiary referral practice specialising in pterygium. The accuracy of diagnosis of pterygium, based upon the content of the clinical referral, was undertaken for optometrists and general practitioners. The benchmark for diagnostic accuracy was the diagnosis made by the author (LWH) during a consultation in person by the author (LWH) using a hand-light examination and confirmed by slitlamp examination. RESULTS: A total of 1,511 consecutive patients were included in the study with 90/549 incorrectly diagnosed (16 per cent) by general practitioners and 14/962 (1.4 per cent) by optometrists. General practitioners were 13.28 times more likely to incorrectly diagnose a pterygium than optometrists (95% CI 7.48-23.57). Almost exclusively, the incorrect diagnosis made by general practitioners was naming a pinguecula, a pterygium. The same misdiagnosis was made by optometrists but far less frequently. CONCLUSION: General practitioners misdiagnosed pterygium far more often than optometrists which may reflect a reduction in training in eye health.

Eight-year trends in the Australian surgical approach to pterygium removal.

IMPORTANCE: Pterygium is a very common disease in Australia but the statistical data on the provision of pterygium surgical services is poorly understood. BACKGROUND: This study evaluated the trends in the types of surgeries performed for pterygium in Australia over an eight period. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: All surgeries performed for pterygium in Australia from 2005 to 2010 in the Medicare system. METHODS: Eight years of Medicare data were analysed for services performed with pterygium removal. MAIN OUTCOME MEASURES: Concurrently used MBS item numbers 42 686 (pterygium removal) with 42 641 (conjunctival autograft) and also 42 686 with any other ophthalmic item number. RESULTS: Pterygium removal was undertaken together with conjunctival autografting in 73% of patients in 2005 rising to 88% in 2010. Five other non-related surgical procedures were performed simultaneously with pterygium removal in 10% of patients in 2005 decreasing to 5.9% in 2012. CONCLUSIONS AND RELEVANCE: About 12% of pterygium surgeries are not combined with a conjunctival autograft. It is possible that these may have been used with an adjuvant such as mitomycin or radiotherapy, or performed as simple excision. Allowing for the possibility that billing errors may have occurred it is still likely that in 5.9% of patients, other procedures that would normally not be performed with pterygium surgery, are undertaken simultaneously and may have an adverse outcome on the inappropriate concurrent surgery and on the recurrence rate of the pterygium. The surgeon should carefully review billing codes before submitting them to Medicare.

Double-Headed Pterygia Treated With P.E.R.F.E.C.T for PTERYGIUM.

PURPOSE: There are very few studies that describe the technique and results of double-headed pterygium removal and most of these have recurrence rates higher than those described for single pterygium removal. P.E.R.F.E.C.T for PTERYGIUM has a very low recurrence rate, and this study describes the recurrence rate and cosmesis when used on double-headed pterygia. METHODS: A prospective intervention series was performed on 20 eyes with a follow-up of 1 year or more with examination for recurrence and cosmetic appearance. RESULTS: There were no recurrences. Cosmetic appearance in 20 eyes was normal or excellent, and the conjunctival donor site was normal in appearance in 19 eyes. CONCLUSIONS: P.E.R.F.E.C.T for PTERYGIUM provides excellent cosmetic results and no recurrences, and slit-lamp examination of the superior bulbar conjunctiva is normal in most cases after 2 graft retrievals from the same site.

Evaluation of the AlgerBrush II rotating burr as a tool for inducing ocular surface failure in the New Zealand White rabbit.

The New Zealand White rabbit has been widely used as a model of limbal stem cell deficiency (LSCD). Current techniques for experimental induction of LSCD utilize caustic chemicals, or organic solvents applied in conjunction with a surgical limbectomy. While generally successful in depleting epithelial progenitors, the depth and severity of injury is difficult to control using chemical-based methods. Moreover, the anterior chamber can be easily perforated while surgically excising the corneal limbus. In the interest of creating a safer and more defined LSCD model, we have therefore evaluated a mechanical debridement technique based upon use of the AlgerBrush II rotating burr. An initial comparison of debridement techniques was conducted in situ using 24 eyes in freshly acquired New Zealand White rabbit cadavers. Techniques for comparison (4 eyes each) included: (1) non-wounded control, (2) surgical limbectomy followed by treatment with 100% (v/v) n-heptanol to remove the corneal epithelium (1-2 min), (3) treatment of both limbus and cornea with n-heptanol alone, (4) treatment of both limbus and cornea with 20% (v/v) ethanol (2-3 min), (5) a 2.5-mm rounded burr applied to both the limbus and cornea, and (6) a 1-mm pointed burr applied to the limbus, followed by the 2.5-mm rounded burr applied to the cornea. All corneas were excised and processed for histology immediately following debridement. A panel of four assessors subsequently scored the degree of epithelial debridement within the cornea and limbus using masked slides. The 2.5-mm burr most consistently removed the corneal and limbal epithelia. Islands of limbal epithelial cells were occasionally retained following surgical limbectomy/heptanol treatment, or use of the 1-mm burr. Limbal epithelial cells were consistently retained following treatment with either ethanol or n-heptanol alone, with ethanol being the least effective treatment overall. The 2.5-mm burr method was subsequently evaluated in the right eye of 3 live rabbits by weekly clinical assessments (photography and slit lamp examination) for up to 5 weeks, followed by histological analyses (hematoxylin & eosin stain, periodic acid-Schiff stain and immunohistochemistry for keratin 3 and 13). All 3 eyes that had been completely debrided using the 2.5-mm burr displayed symptoms of ocular surface failure as defined by retention of a prominent epithelial defect (∼40% of corneal surface at 5 weeks), corneal neovascularization (2-3 quadrants), reduced corneal transparency and conjunctivalization of the corneal surface (demonstrated by the presence of goblet cells and/or staining for keratin 13). In conclusion, our findings indicate that the AlgerBrush II rotating burr is an effective method for the establishment of ocular surface failure in New Zealand White rabbits. In particular, we recommend use of the 2.5-mm rotating burr for improved efficiency of epithelial debridement and safety compared to surgical limbectomy.

Nontraumatic paecilomyces anterior segment infection: a pathognomonic clinical appearance.

PURPOSE: The aim of this study was to review a series of consecutive cases of corneal and scleral infection by Paecilomyces spp. and to identify features of clinical presentation and assess treatment modalities. METHODS: This retrospective review of a case series included 22 patients with nontraumatic Paecilomyces anterior segment infections who were seen in a tertiary referral practice. Outcome measures were the number of eyes that were lost and visual acuity in eyes that were saved. RESULTS: Twenty-two patients with Paecilomyces corneal or scleral infection with no significant history of trauma or surgery were identified over a 20-year period. Two distinct clinical presentations were noted with 17 presenting with corneal infection and 5 initially presenting with scleral infection, and all demonstrated a classical endothelial plaque and deep stromal infiltrate. Almost all required single or multiple anterior segment reconstructive surgeries together with systemic and topical antifungal agents. The first 10 patients were treated with amphotericin B, whereas the remaining 12 patients were treated with voriconazole and 21 of 22 patients underwent surgery. Paecilomyces spp. was identified from most intraocular specimens although corneal fungal growth was noted only from deep corneal biopsies or corneal buttons removed during corneal transplantation. Outcomes were better in the last 12 patients treated with voriconazole. CONCLUSIONS: Nontraumatic Paecilomyces anterior segment infection presents with a pathognomonic clinical picture when the cornea is the initial site of infection and later in scleral infections. Early identification and aggressive treatment with extirpative surgery and voriconazole may result in retention of the eye with useful vision.

Risk factors for ocular surface squamous neoplasia recurrence after treatment with topical mitomycin C and interferon alpha-2b.

PURPOSE: To determine the rate of recurrence and associated risk factors after the use of mitomycin C (MMC), interferon alpha-2b, or both for management of noninvasive ocular surface squamous neoplasia (OSSN). DESIGN: Retrospective, noncomparative, interventional case series. METHODS: Clinical practice setting of 135 patients treated consecutively with topical MMC (0.4 mg/mL), interferon alpha-2b (1 million units/mL), or both for OSSN observed for clinical recurrence. RESULTS: Clinical recurrences were diagnosed in 19 (14.1%) of 135 eyes after topical treatment. The mean time to recurrence was 17.2 months (range, 4 to 61 months), with 14 eyes (73.7%) recurring within a 2-year period. There was no greater risk of recurrence identified for variables including lesion size, lesion location, gender, age, treatment type, or treatment duration. Post hoc log-rank pairwise comparisons revealed that lesions initially treated using surgery alone had significantly reduced time to recurrence (21.1 ± 5.6 months) compared with previous topical treatment with MMC (with or without surgery; 29.6 ± 4.7 months; P = .04) and primary OSSN (23.2 ± 1.8 months; P = .09). CONCLUSIONS: Topical MMC and interferon alpha-2b are an effective treatment method for a wide range of noninvasive OSSNs. Topical therapy avoids the morbidity of excisional surgery with equivalent or reduced recurrence rates and should be considered as primary therapy.

Pterygium removal using a polyethylene glycol hydrogel adherent ocular bandage.

PURPOSE: To describe the result of using a polyethylene glycol hydrogel contact lens (ReSure; Ocular Therapeutix, Inc, Bedford, MA) as a protective bandage over denuded areas of Tenons after pterygium removal. METHODS: Five sequential patients underwent pterygium removal with a conjunctival autograft and painting of bare Tenons in the area of the graft retrieval with a biodegradable polymer, and these patients were followed for 1 year for immediate postoperative pain, epithelial healing, and long-term conjunctival scarring. RESULTS: All patients showed prolonged persistence of the polymer for up to 8 to 10 weeks with resultant increased conjunctival inflammation and scarring with no evidence of decreased postoperative pain. CONCLUSIONS: This hydrogel polymer seems to cause prolonged inflammation and resultant scarring when used over extended areas of Tenons, and it has no role in reducing pain after pterygium surgery.

Pterygium extended removal followed by extended conjunctival transplant: but on which eye?

PURPOSE: To assess the cosmetic result after pterygium extended removal followed by extended conjunctival transplant. METHODS: A web-based program was used by graders to select from a series of pairs of photographic images which eye of each pair had had pterygium surgery and which eye had the better appearance. A total of 395 pairs of eyes in which 1 eye had had pterygium surgery with the opposite eye acting as the control were assessed. Graders were asked the question "which eye has had surgery?" in sections 1 and 2, and then asked which "was the better looking eye?" for each pair, first at real-life size and then with magnified images in sections 3 and 4. Analysis was undertaken on the correlation of the selection of the eye that was thought to have had surgery with the eye that had actually had the surgery, and correlation between the eyes selected for the better appearance with the eyes that had had surgery. RESULTS: Thirteen graders completed the study and most graders correctly selected the operative eye in fewer than 50% of the pairs of eyes in sections 1 and 2. In addition, the operated eye was selected as the "better looking eye" in almost 40% of the pairs of eyes in sections 3 and 4. CONCLUSIONS: Pterygium extended removal followed by extended conjunctival transplant results in an appearance that is indistinguishable from a normal eye.

Recurrence and complications after 1,000 surgeries using pterygium extended removal followed by extended conjunctival transplant.

OBJECTIVE: To document the recurrence rate and complication rate of pterygium extended removal followed by extended conjunctival transplant. DESIGN: An open, prospective study of consecutive pterygium patients undergoing pterygium extended removal followed by extended conjunctival transplant. PARTICIPANTS AND CONTROLS: The study included 1000 consecutive patients undergoing pterygium surgery between August 2001 and September 2009. INTERVENTIONS: All patients underwent pterygium extended removal followed by extended conjunctival transplant by the author with attempted follow-up for 1 year. MAIN OUTCOME MEASURES: Recurrence and complication rates. RESULTS: Follow-up of >1 year was obtained in 99% of patients. There was 1 recurrence in the 1000 surgeries (0.1%) with 95% confidence intervals of 0.003%-0.56% (Fischer exact test). Seven patients required further surgery: 3 had graft replacements, and 1 each for recurrence, strabismus, inclusion cyst, and granuloma. One patient lost 4 lines of vision from a corneal ulcer. CONCLUSIONS: Pterygium extended removal followed by extended conjunctival transplant results in one of the lowest recurrence rates reported in the world's literature and an acceptable complication rate.

Visual outcomes and complications of scleral-fixated posterior chamber intraocular lenses.

PURPOSE: To report the long-term visual outcomes and complications after implantation of scleral-fixated posterior chamber intraocular lenses (PC IOLs). SETTING: Princess Alexandra Hospital, Mater Hospital, and Queensland Eye Institute, Brisbane, Australia. DESIGN: Case series. METHODS: This study reviewed the records of patients who had anterior vitrectomy and scleral-fixated PC IOL implantation between 1993 and 2008 and had a minimum follow-up of 6 months. RESULTS: The study comprised 82 eyes of 72 patients (47 men). The mean follow-up was 83.3 months (range 6.7 to 166.5 months) and the mean age at surgery, 62 years (range 15 to 97 years). The mean improvement in corrected distance visual acuity (CDVA) was 1.6 Snellen chart lines of vision, which was statistically significant; 59 eyes (72%) had an improved or unchanged CDVA, and 23 eyes (28%) had a reduced CDVA. The most common postoperative complication was ocular hypertension (25 eyes [30.5%]). Suture breakage occurred in 5 eyes (6%) after a mean of 4.9 years; 4 of these patients were younger than 40 years. Overall, 44 eyes (53.7%) had at least 1 complication, 36.4% within 1 week postoperatively and 63.6% after 1 week. Thirteen eyes (15.8%) required at least 1 further operation. CONCLUSIONS: Scleral-fixated PC IOL insertion provided favorable visual outcomes in many cases. Complications were common, and suture rupture is an important long-term complication, particularly in young patients. These issues affect IOL choice for the surgical treatment of aphakia and should be discussed with patients during the consent process. FINANCIAL DISCLOSURE: Neither author has a financial or proprietary interest in any material or method mentioned.

Cosmesis after pterygium extended removal followed by extended conjunctival transplant as assessed by a new, web-based grading system.

OBJECTIVE: To design a web-based system to grade the cosmetic results after pterygium surgery and to use this to assess the aesthetic results of pterygium extended removal followed by extended conjunctival transplant. DESIGN: A standardized grading system with gradings of normal, excellent, good, fair, poor, and ungradeable was designed and tested by the author (standard gradings). This was then installed on a website where ophthalmologists and lay people could undertake grading and anatomy tutorials, and subsequently grade randomly assigned images in a masked fashion, of eyes after pterygium surgery and control eyes. PARTICIPANTS AND CONTROLS: A sample of 119 postoperative eyes were randomly selected from 279 consecutive surgeries together with 119 control eyes from the contralateral eyes of these patients supplemented with otherwise normal eyes. INTERVENTIONS: The author was tested twice on a sample of 40 images and then the full set, with 24 images repeated giving a total of 288 images using the proposed grading system, resulting in an intraobserver reliability score of 0.98. These images were then randomly presented to the graders, of whom 6 were postpterygium patients and 6 were corneal specialist ophthalmologists after they had completed the tutorials and passed a trial grading test. MAIN OUTCOME MEASURES: The percentage of images of postoperative and controls that were graded in each grading category were obtained and compared with the only existent study of post pterygium cosmetic results. RESULTS: Six lay people and 6 corneal specialists successfully passed the trial grading test of 40 images with weighted kappa of 0.70 to 0.85 and intraobserver reliability scores of 0.86 to 0.95 for lay graders and 0.90 to 0.92 for ophthalmic graders. Ninety-four percent of all pterygium surgery eyes were graded as acceptable; both ophthalmic and lay graders were unable to distinguish between postoperative and control eyes. CONCLUSIONS: This grading system is robust and user friendly, and pterygium extended removal followed by extended conjunctival transplant provides a very pleasing aesthetic result in most patients.

Recurrent pterygium surgery using pterygium extended removal followed by extended conjunctival transplant: recurrence rate and cosmesis.

OBJECTIVE: To assess the rate of recurrence, complications, and cosmesis after recurrent pterygium removal with P.E.R.F.E.C.T. for PTERYGIUM (Pterygium Extended Removal Followed by Extended Conjunctival Transplant). DESIGN: A case series study of P.E.R.F.E.C.T. for PTERYGIUM was conducted by 1 surgeon with a 1-year follow-up to assess the recurrence, complication rate, and cosmesis. PARTICIPANTS: A total of 111 consecutive patients with recurrent pterygium removals. INTERVENTION: A major modification of conjunctival autograft surgery was used to treat recurrent pterygia. MAIN OUTCOME MEASURES: The recurrence rate, complications, and cosmesis after excision of recurrent pterygia using P.E.R.F.E.C.T. for PTERYGIUM. RESULTS: There were no patients with recurrence in 111 consecutive patients, and all but 2 patients were followed for at least 1 year. One patient developed an exotropia that required no treatment, and 1 patient lost 4 lines of vision as a result of a corneal ulcer. CONCLUSIONS: In this series, P.E.R.F.E.C.T. for PTERYGIUM resulted in a zero recurrence rate (2 patients lost to follow-up) with few complications and a good cosmetic appearance.

Localised peripheral primitive neuroectodermal tumour (PNET) of the conjunctiva.

A 16-year-old male presented with a 3-month history of an asymptomatic, enlarging conjunctival lesion. An excisional biopsy was performed and histologic and immunohistochemical examination showed characteristic features of a peripheral primitive neuroectodermal tumour (PNET) adjacent to a benign compound naevus. FISH analysis, demonstrating a split-signal at 22q12, confirmed the diagnosis. Staging investigations were negative confirming the primary nature of the lesion. The patient was treated with local wide re-excision and chemotherapy. He remains alive and well 29 months after initial resection.

Pterygium and associated ocular surface squamous neoplasia.

OBJECTIVE: To measure the rate of histopathologically identified ocular surface squamous neoplasia (OSSN) in pterygium specimens. METHODS: All pterygium specimens collected from consecutive patients between April 8, 2003, and February 6, 2008, were submitted for histopathologic examination, and the rate of OSSN was calculated. RESULTS: The rate of OSSN was 9.8% (52 of 533) insequential pterygium specimens. CONCLUSIONS: This rate of unsuspected OSSN suggests that all specimens of pterygium should be submitted for histopathologic examination and that patients in whom OSSN is noted should be examined at more frequent intervals so any clinical OSSN that develops can be identified at an early stage.

Potential effect of excluding variant Creutzfeldt-Jakob disease on the eye donor pool in Australia.

PURPOSE: To quantitate the likely effect on the available eye donor pool by excluding potential donors who may have had exposure to variant Creutzfeldt-Jakob disease by virtue of spending time in countries where bovine spongiform encephalopathy (BSE) is endemic. METHODS: A telephone survey by systematic sampling from the Brisbane phone directory was undertaken to ascertain the number of potential donors who had resided in the United Kingdom and in other countries. RESULTS: Between 19% of potential donors would have had to have been excluded by virtue of residing in the United Kingdom for >6 months between 1980 and 1996 and 29% for those who had traveled to any other country in which BSE was identified. CONCLUSIONS: This study suggests that adopting an eye bank policy of excluding donors potentially exposed to BSE would have a significant effect on donor numbers. Health departments and eye banks will need to weigh the small additional protection from such policy decisions against the likely effect on corneal tissue supply.