Chemical eye injuries: a 10 year retrospective review of acute presentations and clinical outcomes in Auckland, New Zealand.

To assess the aetiologies, clinical characteristics, treatment regimens, and outcomes of acute chemical injuries treated at an emergency eye clinic. Retrospective, observational study of all cases of chemical eye injury that presented acutely to the Greenlane Clinical Centre in Auckland, New Zealand from 1 January 2012 through 31 December 2021. Patient demographics, activity at the time of injury, causative chemical, clinical characteristics of injury at presentation, severity (Dua) classification, admission and discharge best corrected visual acuity (BCVA), treatment regimen, time to epithelisation and number of follow-up appointments were recorded. In total, 1522 cases involving 1919 eyes were studied. The mean age was 40.6 ± 18.8 years and 65% were male. The majority of cases occurred at home (62%) and cleaning was the most common activity (38%). There were 1490 Grade I (98%), 22 Grade II (1.5%), 5 Grade III (0.3%), 1 Grade IV (0.07%), 0 Grade V, and 4 Grade VI (0.3%) cases. An epithelial defect was noted in 409 cases (26.9%), of which re-epithelialisation occurred within one week for 378 cases (92%) and within 30 days for 384 cases (94%). Moderate vision loss (BCVA ≤ 6/12) attributed to the injury occurred in 152 (10%), while severe vision loss (BCVA ≤ 6/60) occurred in 30 (2%). Lack of irrigation at the scene was associated with an increased risk of severe injury and longstanding visual impairment (p = 0.0001). Most acute chemical injuries are mild with good clinical outcomes. Although rare, severe injuries are associated with a lack of irrigation at the scene and worse visual outcomes.

Tumor Profiles of Late Presentation Uveal Ring Melanoma With Novel Characteristics - A Case Series.

Purpose: The purpose of this study was to investigate the clinical features, tumor characteristics, including histopathology and cytogenetic analysis, and management of patients with uveal ring melanoma in New Zealand. Methods: A retrospective review was conducted on all uveal melanoma cases treated in a single national oncology center in New Zealand. The study period was from January 1, 2013 to December 31, 2022 (10 years). Written consent was obtained from all patients included in this case series. Results: Uveal ring melanoma of ciliary body origin (n = 4) comprised 0.7% of all uveal melanomas (n = 571). Ethnicity distribution was three patients of New Zealand European ancestry and one patient of Chinese/Pasifika ancestry. Three patients (75%) were symptomatic at presentation (spontaneous hyphema, glaucoma, and cataract), whereas one was asymptomatic but subsequently developed painful refractory glaucoma. All eyes underwent enucleation. Three eyes had primary iris biopsies with subsequent enucleation for refractory glaucoma and pain and one eye underwent primary enucleation. All cases demonstrated malignant tumor characteristics including diffuse 270 to 360-degree ciliary body ring growth pattern, epithelioid-cell type and presence of either BAP-1 expression loss or gain of MYC gene. Two cases (50%) developed distant organ metastasis - liver, parotid gland, and breast. Of those, one patient was deceased at the time of follow-up whereas one had completed treatment for metastases. Conclusions: Uveal ring melanoma is a rare tumor that is highly invasive and malignant. When detected, prompt definitive treatment should be advocated, and patient counselling should be given regarding the high risk of developing a painful, blind eye with increased risk of metastasis in the absence of treatment.

Endocapsular artificial iris implantation for iris defects: Reducing symptoms, restoring visual function and improving cosmesis.

BACKGROUND: To investigate repair of iris defects by endocapsular implantation of an artificial iris, in relation to visual outcomes, safety profile and patient satisfaction. METHODS: Retrospective, consecutive case series from Greenlane tertiary teaching hospital and Eye Institute, Auckland, New Zealand. Medical records of patients implanted with an endocapsular artificial iris were reviewed and followed for minimum 3 months. Patient characteristics, surgical management, clinical outcomes and subjective responses were recorded. RESULTS: Nineteen artificial irises were implanted in 18 patients. Etiologies were iris melanotic lesion excision (73.7%), trauma (10.5%), congenital aniridia (10.5%) and Urrets-Zavalia syndrome (5.3%). During postoperative follow-up [14.1 ± 12.4 months (range: 3 to 59 months)], best corrected visual acuity (BCVA) and intraocular pressure (IOP) did not change significantly [BCVA, 0.23 logarithm of the minimum angle of resolution (logMAR) (20/32 Snellen) preoperatively vs. 0.18 logMAR postoperatively (20/25 Snellen) (Z = -0.222, p = 0.824); IOP, 15 mmHg preoperatively vs. 17 mmHg postoperatively (Z = 1.377, p = 0.1447)]. Mild or self-limiting complications included: elevated IOP (42.1%), cystoid macular oedema (15.8%); persisting postoperative uveitis (15.8%) and minor vaulting of the prosthesis (15.7%). Moderate or severe complications included significant vaulting of prosthesis requiring surgical revision (5.3%) and a single eye (5.3%) with trabeculectomy and corneal graft failure. 94.4% of patients were very satisfied with the cosmesis and would be highly likely to have the procedure again. CONCLUSIONS: This study confirms that endocapsular insertion of an artificial iris is typically associated with good functional and cosmetic results and a relatively low risk of significant complications.

Case Series: Different Presentations of Iris Melanoma-Potential Masquerade of Benign and Malignant.

SIGNIFICANCE: Iris melanoma and iris nevi can be challenging to distinguish clinically. This case series provides unique insight into the rare condition and variable clinical presentations of iris melanoma. PURPOSE: This study aimed to highlight the varying clinical presentations of iris melanoma and to demonstrate the overlapping features of melanoma and nevi. CASE REPORTS: This case series includes five patients of varying age and sex who presented to clinic with pigmented iris lesions. These five patients have differing timeline to presentation and very different clinical presentations of their lesions. Clinical evaluation was based around the established "ABDCEF" guide for the assessment of malignant risk in iris lesions. The presentation of each lesion is discussed in relation to this guide and the experienced clinician's clinical suspicion of malignancy. When comparing the clinical suspicion with histological analysis, after biopsy, the result may be unexpected. Notably, initially benign nevi may transform into melanoma over time. These five cases were managed on an individual basis because the management and prognosis of iris melanomas vary significantly. Importantly, iris melanotic lesions have variable metastatic risk based on cytology and genetic predisposition. Informed consent was obtained from all the patients, institutional approval was obtained, and no identifiable health information is included in this case series. CONCLUSIONS: When presented with a pigmented iris lesion, clinicians must be vigilant with regular monitoring and have a low threshold for biopsy in pigmented lesions of high clinical suspicion.

The Enigma of Environmental Factors in Keratoconus.

Keratoconus is an ectatic disorder with highly complex and varied causes including genetic variations and environmental factors. Its prevalence varies widely between regions and countries. Many environmental factors have been proposed to be associated with keratoconus, but the interpretation of their individual contributions is difficult due to the presence of many confounding variables. The current literature was reviewed to evaluate the strength of the associations and the causative effects of environmental factors on keratoconus. Ethnicity and consanguinity have been revealed as important determinants for geographical variations in keratoconus prevalence. Eye rubbing, atopy, floppy eyelid syndrome, contact lens wear, pregnancy, and thyroid hormone disturbances are likely associated with keratoconus. The first 4 factors can induce ocular surface inflammation, matrix metalloproteinase release, and keratocyte apoptosis, consistent with the postulated etiology of keratoconus. The associations of keratoconus with UV exposure, cigarette smoking, personality, and sex were less convincing once confounding factors were considered. Future studies powered for multivariate analysis of factors discussed will hopefully shed light on what is truly important in the development and progression of keratoconus.

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.

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.

Penetrating Keratoplasty for Keratoconus With and Without Resolved Corneal Hydrops: Long-term Results.

PURPOSE: To evaluate the long-term risk of endothelial rejection, graft survival, and associated factors following penetrating keratoplasty (PK) for keratoconus, with and without prior resolved corneal hydrops. DESIGN: Retrospective cohort study. METHODS: Primary outcome measures were endothelial rejection-free survival and failure-free survival. Secondary outcome measures were corneal neovascularization following hydrops and complications following PK. RESULTS: A total of 245 eyes underwent PK for keratoconus with mean follow-up of 5.6 ± 3.6 years. Eyes with prior hydrops (n = 74) had lower endothelial rejection-free survival rates compared with eyes without prior hydrops: 86.5% ± 4.0% vs 86.5% ± 2.6% at 1 year, 61.0% ± 6.2% vs 76.9% ± 3.3% at 5 years, and 45.8% ± 10.1% vs 70.9% ± 4.3% at 10 years, respectively (P = .023). Multivariate analysis identified factors associated with endothelial rejection as age ≤25 years (P = .017), corneal neovascularization (P = .001), donor trephination size >8 mm (P = .017), and poor clinic attendance (P = .015). There was no difference in the failure-free survival rates with and without prior hydrops: 98.6% ± 1.3% vs 97.1% ± 1.3% at 1 year, 97.3% ± 1.9% vs 95.1% ± 1.9% at 5 years, and 97.3% ± 1.9% vs 92.2% ± 2.7% at 10 years, respectively (P = .42). Corneal neovascularization was present at the time of PK in 44.6% of eyes with prior hydrops and 7.6% without prior hydrops (P < .001). CONCLUSIONS: Corneal neovascularization, a frequent complication of corneal hydrops, was associated with increased risk of endothelial rejection following PK. However, allograft survival was similar in eyes with and without prior hydrops.

Treatment adherence after penetrating corneal transplant in a New Zealand population from 2000 to 2009.

PURPOSE: The aim of this study was to evaluate the extent of nonadherence after penetrating keratoplasty in Auckland, New Zealand, over a 10-year period and to identify predictive variables. METHODS: The New Zealand National Eye Bank records were analyzed for the decade January 1, 2000, to December 31, 2009, inclusive. Variables evaluated included age, gender, ethnicity, proximity to treatment center, level of deprivation, indication for surgery, previous ocular surgery. The number of scheduled appointments offered and attended by each patient was recorded. Outcome measures were appointment compliance and 2-year follow-up completion. RESULTS: Over the study period, 1055 corneal transplant procedures were identified. After applying exclusion criteria, data from 695 penetrating keratoplasty procedures were included in the study. Two-year follow-up information was available for 91.4%, of which 87.8% survived and 77 (12.1%) failed. Over the study period, 1065 (10.5%) appointments were not attended by patients. Appointment compliance was good in 68.5%, moderate in 26.3%, and poor in 4.9%. Maori and Pacific Island ethnicities were observed to be associated with the lowest level of attendance, whereas European and Indian ethnicities were the most likely to complete follow-up. Rates of appointment compliance were greater at private treatment centers (P = 0.009) and inversely associated with proximity to treatment center (P < 0.0001). CONCLUSIONS: The rate of nonattendance reported in this study is considerably higher than that observed in other forms of organ transplantation. Both ethnic and socioeconomic factors seem to have a significant influence on attendance compliance. Strategies to improve adherence should take these factors into account.

Comparison and repeatability of keratometric and corneal power measurements obtained by Orbscan II, Pentacam, and Galilei corneal tomography systems.

PURPOSE: To assess the repeatability and comparability of corneal power and central corneal thickness (CCT) measurements obtained using Orbscan II (Bausch & Lomb), Pentacam (Oculus), and Galilei (Ziemer) tomographers. DESIGN: Prospective, comparative study. METHODS: setting: Departments of Ophthalmology, University of Auckland and Auckland District Health Board, Auckland, New Zealand. study population: Thirty eyes of 30 healthy participants. observations. CCT and corneal power measured using Orbscan II, Pentacam, and Galilei tomography. main outcome measures: Degree of agreement in and repeatability of CCT and corneal power measures. RESULTS: Orbscan II measured significantly lower CCT compared with Pentacam (20 µm; P < .0005) and Galilei (18 µm; P < .0005). The Orbscan II had wide limits of agreement when compared with both the Galilei (-11 to 47 µm) and Pentacam (-88 to 47 µm). For each device, the intraclass correlation coefficient for CCT was higher than 0.9. The coefficient of variation ranged from 0.33% to 0.93%. There was no significant difference in mean steep keratometry or mean flat keratometry between instrument pairs. However, there was poor agreement in flat keratometry and steep keratometry obtained by Orbscan II compared with those obtained by the Galilei and Pentacam. CONCLUSIONS: The keratometry and pachymetry measurements obtained by Orbscan II, Pentcam, and Galilei tomographers were sufficiently disparate that the 3 devices could not be considered equivalent. All 3 devices demonstrated a high level of repeatability, although the Galilei exhibited the best repeatability.

A brief history of corneal transplantation: From ancient to modern.

This review highlights many of the fundamental concepts and events in the development of corneal transplantation - from ancient times to modern. Tales of eye, limb, and even heart transplantation appear in ancient and medieval texts; however, in the scientific sense, the original concepts of corneal surgery date back to the Greek physician Galen (130-200 AD). Although proposals to provide improved corneal clarity by surgical interventions, including keratoprostheses, were better developed by the 17(th) and 18(th) centuries, true scientific and surgical experimentation in this field did not begin until the 19(th) century. Indeed, the success of contemporary corneal transplantation is largely the result of a culmination of pivotal ideas, experimentation, and perseverance by inspired individuals over the last 200 years. Franz Reisinger initiated experimental animal corneal transplantation in 1818, coining the term "keratoplasty". Subsequently, Wilhelmus Thorne created the term corneal transplant and 3 years later Samuel Bigger, 1837, reported successful corneal transplantation in a gazelle. The first recorded therapeutic corneal xenograft on a human was reported shortly thereafter in 1838-unsurprisingly this was unsuccessful. Further progress in corneal transplantation was significantly hindered by limited understanding of antiseptic principles, anesthesiology, surgical technique, and immunology. There ensued an extremely prolonged period of debate and experimentation upon the utility of animal compared to human tissue, and lamellar versus penetrating keratoplasty. Indeed, the first successful human corneal transplant was not performed by Eduard Zirm until 1905. Since that first successful corneal transplant, innumerable ophthalmologists have contributed to the development and refinement of corneal transplantation aided by the development of surgical microscopes, refined suture materials, the development of eye banks, and the introduction of corticosteroids. Recent developments, including the replacement of selected corneal layers rather than full-thickness keratoplasty, have the potential to improve or transform corneal transplant surgery in the future.