Choroidal Rupture in the Setting of Multi-Trauma.

Herein the authors call attention to the importance of ophthalmic evaluation in the setting of multi-trauma, particularly with facial and orbital fractures. In institutions such as ours, a tertiary general hospital, where such fractures are initially managed by a non-ophthalmic team such as trauma or maxillofacial surgeons, we would advocate for prompt referral to the ophthalmology team for assessment as described by our case of a choroidal rupture in the setting of multi-trauma.

Total Traumatic Expulsive Iridodialysis with an Orbital-Floor Fracture.

The objective of this report was to describe a case of total traumatic iridodialysis in the context of blunt trauma with an orbital-floor fracture. A 76-year-old female presented post-fall with right-eye blunt trauma. She underwent canthotomy and cantholysis due to concern of orbital compartment syndrome in a regional hospital with emergency physicians clearing dark tissue near the lateral canthus at the time of canthotomy cantholysis. She had a traumatic expulsive iridodialysis with 360° loss of iris through the previous phacoemulsification wound in the clear cornea. The patient also had an orbital-floor fracture, which together with internal decompression through the previous phacoemulsification wound possibly prevented further damage to intraocular structures. There was good visual recovery. Herein, we propose that the combination of the orbital-floor fracture in tandem with the reopening of the previous phaco wound served as a decompressing mechanism to prevent further intraocular injury above that of total iridodialysis.

The Aotearoa Research Into Keratoconus Study: Geographic Distribution, Demographics, and Clinical Characteristics of Keratoconus in New Zealand.

PURPOSE: To investigate the epidemiologic, demographic, and basic clinical characteristics of individuals with keratoconus managed by optometrists in New Zealand (NZ)/Aotearoa. METHODS: A prospective, longitudinal, nationwide, survey protocol was completed for every patient with keratoconus who underwent a consultation with participating optometrists in a 2-year period. Data for each patient included date of birth, sex, self-reported ethnicity, new or previous diagnosis, uncorrected (UCVA) and best-corrected visual acuity (BCVA), type of refractive correction required to obtain BCVA and keratometric readings obtained using keratometry or computerized topography. RESULTS: One thousand eight hundred sixty-nine cases were identified, with a mean age of 41.0 ± 15.7 years, 56.4% being men, and 87.3% with previous diagnosis. The distribution of cases was skewed toward Auckland (41.6%), Waikato (21.3%), Wellington (16.8%), and Bay of Plenty (13.3%). Self-reported ethnicities were predominantly NZ European (54.4%), Maori (24.7%), and Pacific Peoples (15.5%), disproportionate to the general population profile (74.0%, 14.9%, and 7.4% respectively). Most eyes (64.3%) were managed with rigid contact lenses (corneal lens in 34.2%). The mean K-mean was 49.0 ± 5.7 D. The mean UCVA was 6/42 and BCVA was 6/9. Maori and Pacific Peoples had both the highest K-mean and proportions of eyes graded stage IV on the Amsler-Krumeich scale. CONCLUSIONS: The results indicate that keratoconus is relatively common in NZ with at least 1869 patients managed by optometrists in 2 years. Most eyes had mild to moderate disease; however, Maori and Pacific Peoples seem to have greater disease severity. An ethnic predilection is apparent, with Maori and Pacific Peoples overrepresented relative to their population proportions, reinforcing a long-held clinical suspicion.

Cataract surgery in New Zealand: access to surgery, surgical intervention rates and visual acuity.

AIMS: To analyse the surgical intervention rate (SIR), best spectacle-corrected visual acuity (BSCVA) and disparities in access to public-funded cataract surgery in New Zealand. The New Zealand Ministry of Health uses the National Prioritisation Web Service (NPWS) to prioritise all patients for public-funded cataract surgery. BSCVA at prioritisation, ethnic, demographic and geographic disparities have not previously been assessed. METHODS: A retrospective cohort study. Between November 2014 and March 2019, 61,095 prioritisation events for 44,403 unique patients were identified. Cataract prioritisation events extracted from the NPWS were merged with date of birth and ethnicity extracted from the National Health Index database. All data were de-identified prior to statistical analysis. RESULTS: Mean age at prioritisation was 74.4 years, with female preponderance (56%). Overall ethnicity was 'European' in 69.8% and 'New Zealand Maori' in 9.6%. Mean Snellen BSCVA was 6/30-2 (prioritised eye), and 6/12-1 (binocular). Maori and Pasifika presented on average 10 years earlier than other ethnic groups with significantly worse BSCVA. Surgery was approved in 74.4% of prioritisation events with mean Snellen BSCVA of 6/38-2. Only 34.9% of New Zealand patients had Snellen BSCVA of 6/12 or better in the prioritised eye, compared to 58.4% in the European Union. Cataract SIR varied by region. CONCLUSIONS: New Zealand's cataract SIR is lower than most Organisation for Economic Co-operation and Development countries and patients have significantly worse BSCVA at prioritisation. Access to cataract surgery in New Zealand varies according to region. Maori and Pasifika present younger with worse BSCVA, suggesting potential barriers in accessing timely referral and prioritisation.

Clinical management and patient persistence with antibiotic course in suspected group A streptococcal pharyngitis for primary prevention of rheumatic fever: the perspective from a New Zealand emergency department.

AIM: Rates of acute rheumatic fever in the Northland region are historically among the highest in New Zealand, impacting disproportionately on Maori children and youth. The primary aim of this study was to determine patient persistence to antibiotic treatment for group A streptococcus (GAS) pharyngitis in patients presenting with sore throat to the Whangarei Hospital Emergency Department. Secondarily, this study sought to determine prescriber adherence to the national antibiotic guideline for sore throat management. METHOD: A retrospective audit of patients presenting to ED with presumed GAS pharyngitis between 1 May 2016 and 31 August 2016 was carried out. Data on patient demographics, clinical examination findings, investigations and antibiotic prescription were extracted from electronic medical records. Patients were contacted and after obtaining consent, were asked about their antibiotic treatment using a standardised telephone interview script. RESULTS: The patient population audited reflects those at high risk for acute rheumatic fever. All patients were discharged on the recommended medication, but only 82.7% (62/75) received the correct length (10 days) of oral antibiotics. Of the total of 75 patients audited, 61 (81%) had a swab taken and 41% (25/61) of these were confirmed positive for GAS. Patients were either advised to commence medication without waiting for a swab result (96%, 72/75) or delay treatment and commence only if no improvement in symptoms (4%, 3/75). Of those advised to commence medication immediately, 94% (67/72) obtained their medication from a community pharmacy. Three patients were advised to stop treatment after confirmation of a negative result. Of those patients assessable for medication persistence (n=65), 73.8% (48/65) of patients were compliant in completing the full course of antibiotic therapy. CONCLUSION: This is the first study to assess patient persistence to an antibiotic course for GAS after presentation at an emergency department in Northland and possibly New Zealand. The results indicate a relatively high persistence rate with oral antibiotic treatment by patients treated for suspected GAS pharyngitis. An important finding is that community pharmacy dispensing does not appear to be a major barrier to patients acquiring medications. Additionally, the study shows low levels of follow up of patients with negative throat swab results, resulting in these patients completing the course of antibiotics unnecessarily.

Implantation of Human Peripheral Corneal Spheres into Cadaveric Human Corneal Tissue.

Stem and progenitor cells isolated from human limbal tissue can be cultured in vitro as spheres. These spheres have potential for use as transplantable elements for the repopulation of corneal tissue ( Mathan et al., 2016 ). Herein we describe the detailed protocol for the implantation of human corneal spheres into cadaveric human corneal tissue. This protocol describes the procedure for sphere formation and culture, preparation of tissue for sphere implantation, corneal limbus microsurgery and sphere implantation.

Sphere-forming cells from peripheral cornea demonstrate the ability to repopulate the ocular surface.

BACKGROUND: The limbus forms the outer rim of the cornea at the corneoscleral junction and harbours a population of stem cells for corneal maintenance. Injuries to the limbus, through disease or accidents such as chemical injuries or burns, may lead to significant visual impairment due to depletion of the native stem cells of the tissue. METHODS: Sphere-forming cells were isolated from peripheral cornea for potential use as transplantable elements for limbal stem cell repopulation and limbal reconstruction. Immunocytochemistry, live cell imaging and quantitative PCR were used to characterize spheres and elucidate activity post implantation into human cadaveric corneal tissue. RESULTS: Spheres stained positively for stem cell markers ∆NP63α, ABCG2 and ABCB5 as well as the basal limbal marker and putative niche marker, notch 1. In addition, spheres also stained positively for markers of corneal cells, vimentin, keratin 3, keratocan and laminin, indicating a heterogeneous mix of stromal and epithelial-origin cells. Upon implantation into decellularized corneoscleral tissue, 3D, polarized and radially orientated cell migration with cell proliferation was observed. Cells migrated out from the spheres and repopulated the entire corneal surface over 14 days. Post-implantation analysis revealed qualitative evidence of stem, stromal and epithelial cell markers while quantitative PCR showed a quantitative reduction in keratocan and laminin expression indicative of an enhanced progenitor cell response. Proliferation, quantified by PCNA expression, significantly increased at 4 days subsequently followed by a decrease at day 7 post implantation. CONCLUSION: These observations suggest great promise for the potential of peripheral corneal spheres as transplantable units for corneal repair, targeting ocular surface regeneration and stem cell repopulation.

Analysis of Glaucoma Subtypes and Corresponding Demographics in a New Zealand Population.

PURPOSE: The aim of this paper was to determine the diagnosis distribution and demographic characteristics of glaucoma in a New Zealand population. METHODS: The clinical records of all patients presenting consecutively to the Auckland District Health Board Glaucoma Service over a 6-month period were reviewed. Demographic parameters including ethnicity, age at presentation, and gender were collected along with all clinical data. RESULTS: The case records of 857 patients were reviewed. Primary open-angle glaucoma (POAG) was the most common diagnosis (39.0%, n = 235), followed by primary-angle closure (PAC) diagnoses (24.8%, n = 149). This group was formed by the combination of narrow angle 18.1% (n = 109), narrow-angle glaucoma 0.3% (n = 2), PAC 2.1% (n = 13), and PAC glaucoma 4.2% (n = 25). Normal-tension glaucoma (NTG; 17.4%, n = 105), secondary glaucoma (SG; 11.5%, n = 69), ocular hypertension (5.0%, n = 30), and mixed mechanism (2.3%, n = 14) were also found. There was a significant difference in the ethnic distribution in the study population compared to the catchment population (p < 0.001). Caucasian and Indian ethnicities were overrepresented, whereas the Pacific Island Nation ethnicity was underrepresented in all groups except SG. The Maori ethnicity was underrepresented in all groups except PAC. The underrepresentation was most prominent in POAG (only 2 patients of Pacific origin and 1 Maori patient with POAG). Significant differences were identified in gender distribution including a higher preponderance of females in NTG and PAC. Significant differences in age at presentation were also identified between different glaucoma subtypes and ethnicities. Markers of glaucoma severity did not vary with respect to demographic characteristics. CONCLUSION: In a tertiary glaucoma service in New Zealand, Maori, Pacific peoples, and, to a lesser extent, Asians are underrepresented, while Caucasians and Indians are overrepresented in the glaucoma population.