Dose-Related Visual Outcomes in the Treatment of Choroidal Melanoma with Stereotactic Radiotherapy.

Introduction: Stereotactic radiotherapy (SRT) in the treatment of choroidal melanoma (CM) may be indicated if the tumour is located close to the optic nerve or is unsuitable for a radiotherapeutic plaque. It is thought that the rate of visual decline and ocular sequelae with SRT is influenced by dose and location of radiation in relation to important visual structures. This study therefore aimed to look at these prognoses with respect to localisation and dose of radiation when treatment of CM with SRT occurs. Methods: A retrospective data analysis was conducted on all patients at Dunedin Hospital (DH) from August 2001 to May 2017 who were followed up for 4 years. SRT consisted of 50 Gy divided into five fractions over 5 days to tumours, with 2-mm treatment margins. The primary outcome measure was retention of functional vision - better than hand movements (HMs) within the treated eye. Secondary outcome measures included time to non-functional vision (HM or less) in relation to location, dose and tumour thickness, the presence of radiation retinopathy, local and metastatic tumour progression, enucleation, and disease-specific mortality. Results: Seventy-five patients were identified in this study. Follow-up was incomplete in 10 patients, and 4 patients became deceased within the 4-year study period. Twenty-nine patients (48%) retained visual acuity (VA) better than HMs in the treated eye at 4 years, and thirty-two (52%) of patients did not. Calculated dose to the optic nerve and macula and proximity of the tumour to the optic nerve and macula were not statistically determinative of vision outcomes, although presenting VA was. Fifty-six per cent of patients developed radiation retinopathy involving the macula. The local progression, metastatic progression and enucleation rates were 4.6%, 6%, and 12.3%, representing 3, 4, and 8 patients, respectively. Conclusion: This study demonstrates that approximately half of patients treated with SRT can expect to maintain functional vision better than HM at 4 years. The rate of visual decline and final vision outcome are independent of location of the tumour in relation to the optic nerve and macula. While it affirms that SRT achieves high rates of local tumour control and eye retention, preservation of functional VA remains an unpredictable endpoint for individual cases and highlights the therapeutic challenge of this treatment modality.

Ultrastable optical components using adjustable commercial mirror mounts anchored in a ULE spacer.

This paper describes a novel, to the best of our knowledge, approach to build ultrastable interferometers using commercial mirror mounts anchored in an ultralow expansion (ULE) base. These components will play a critical role in any light particle search (ALPS) and will also be included in ground testing equipment for the upcoming laser interferometer space antenna (LISA) mission. Contrary to the standard ultrastable designs where mirrors are bonded to the spacers, ruling out any later modifications and alignments, our design remains flexible and allows the alignment of optical components at all stages to be optimized and changed. Here we present the dimensional stability and angular stability of two commercial mirror mounts characterized in a cavity setup. The long-term length change in the cavity did not exceed 30 nm and the relative angular stability was within 2 µrad, which meet the requirements for ALPS. We were also able to demonstrate 1pm/Hz length noise stability, which is a critical requirement for various subsystems in LISA. These results have led us to design similar opto-mechanical structures, which will be used in ground verification to test the LISA telescope.

New Zealand adult ocular trauma study: A 10-year national review of 332 418 cases of ocular injury in adults aged 18 to 99 years.

IMPORTANCE: Ocular injury is a common, preventable cause of temporary and permanent disability. BACKGROUND: The current study evaluates the nationwide incidence, demographics and visual outcomes of adults with ocular injury in New Zealand. DESIGN: Nationwide retrospective review. PARTICIPANTS: New Zealanders aged 18-99 years from 2007 to 2016 with ocular injury requiring assessment by a registered medical practitioner. METHODS: New Zealand national and regional datasets were used to evaluate population-level statistics over a 10-year period. Visual and clinical outcome data were assessed using a random sample of 150 patients from a tertiary hospital. MAIN OUTCOME MEASURES: Annual incidence, aetiology, demographics, injury location, visual outcomes, protective eyewear use, surgical intervention and follow-up. RESULTS: A total of 332 418 adult eye injuries were recorded nationally. The annual incidence of eye injury was 1007/100 000 population/year. Patients were predominantly male (76.1%), of New Zealand-European ethnicity (74.6%) and aged between 20 and 29 years (21.1%). The most common mechanism of injury was "struck by object" (55.4%). Injuries occurred most commonly at home (48.4%), followed by commercial (15%) and industrial locations (13.8%). Injuries were more common in rural regions (P < .001). Protective eyewear use was reported in 6% of cases (n = 9, 95% confidence interval = 3.2-11.0). Most ocular injuries were managed exclusively in primary care (70.5%). CONCLUSIONS AND RELEVANCE: Adults with the highest risk of ocular injury are rural males aged 20 to 29 years. Protective eyewear use is uncommon in adults presenting with ocular injury and the majority of injuries are managed in primary care. Promotion of appropriate injury prevention strategies is an important public health message.

New Zealand childhood ocular trauma study: Analysis of 75 601 cases of ocular injury from 2007 to 2016.

IMPORTANCE: Childhood ocular injury is a common, preventable cause of potentially severe permanent disability. BACKGROUND: This study evaluates the nationwide incidence, demographics and visual outcomes of children with ocular injury in New Zealand. DESIGN: Nationwide retrospective review. PARTICIPANTS: All children in New Zealand aged 0 to 17 years from 2007 to 2016 with ocular injury requiring assessment by a medical practitioner. METHODS: New Zealand national and regional datasets were used to evaluate population-level statistics for ocular injury over a 10-year period. Visual and clinical outcome data were assessed using a randomized sample of 150 patients. MAIN OUTCOME MEASURES: Annual incidence, aetiology, demographics, injury location, visual outcomes, protective eyewear use, surgical intervention and follow-up. RESULTS: A national total of 75 601 cases were included with a mean incidence of 719/100 000 children/year. Cases were predominantly male (63.2%) and of New Zealand-European ethnicity (60.8%), aged 0 to 4 years (30.66%). Injury cause was most commonly "struck by object" (53.7%) and occurred in the home (50.9%). Tertiary hospital assessment and treatment was required in 17.7% where final visual acuity of 6/12 or worse was noted in 19.7% and protective eyewear use was reported in 2.7%. Maori and Pacific ethnicities were associated with higher rates of permanent visual impairment. CONCLUSIONS AND RELEVANCE: Children with the highest risk of ocular injury are males aged 0 to 4 years. Children of Maori or Pacific Island ethnicity and aged 15 to 17 years have the highest risk of ocular injury resulting in permanent visual impairment. Protective eyewear use is uncommon in children presenting with ocular injury. Promotion of appropriate injury prevention strategies is an important public health message.

Eyelid reconstruction using the "Hughes" tarsoconjunctival advancement flap: Long-term outcomes in 122 consecutive cases over a 13-year period.

This article evaluates the complications and long term functional and cosmetic outcomes of tarsoconjunctival advancement flaps for repairing a range of lower eyelid defects in a large cohort of consecutive cases. A retrospective series of 122 consecutive cases of eyelid reconstruction using tarsoconjunctival-advancement flaps was conducted at Waikato Hospital, or Hamilton Eye Clinic, New Zealand. All cases of lid reconstruction using tarsoconjunctival-advancement flaps between January 1, 2001 until April 3, 2014 were included for analysis. All patients provided written consent for surgery and the study complied with New Zealand Health and Disability Ethics Committee guidelines and the Declaration of Helsinki. Data were collected on patient demographics, lesion histology, defect size, adjuvant surgical procedures required for reconstruction, surgical and postoperative complications, cosmesis and patient satisfaction. Patients requiring lower eyelid reconstruction were predominantly male (56%) and basal cell carcinoma was the most common pathology (>80%). Male gender was associated with larger tarsoconjunctival-advancement-flap width (P-value = 0.0432), larger maximum flap width (20 vs 15 mm), and required on average more adjuvant procedures for reconstruction (1.80 vs 1.48, P-value = 0.02). Mean duration to flap division was 37 days and decreased over the duration of the study. Complicated cases were associated with shorter duration to flap division. Mean follow-up was 7 months, complications were observed in 14% with revision required in 4%. Tarsoconjunctival flap reconstruction of the lower lid is suitable for a range of defect sizes and produces excellent functional and cosmetic outcomes. Complications are relatively infrequent and may be associated in some cases with decreased duration to flap division.

Supratherapeutic anticoagulation at presentation is associated with reduced mortality in nonvariceal upper gastrointestinal hemorrhage.

INTRODUCTION: Warfarin is a widely used and easily reversible anticoagulant. Although bleeding is more likely in warfarin users, it may also be more readily treated. This retrospective observational case-control study compares the outcome of acute nonvariceal upper gastrointestinal hemorrhage in warfarin users with a supratherapeutic international normalized ratio (INR) and outcome in non - warfarin users. PATIENTS AND METHODS: Clinical and endoscopic data for patients presenting with overt upper gastrointestinal hemorrhage were collected between 23rd February 2001 and 12 October 2010. Patients with variceal hemorrhage were excluded. Warfarin users with a supratherapeutic INR (≥ 3.0) at presentation (supratherapeutic anticoagulation [SA] group) were matched to a cohort with upper gastrointestinal hemorrhage not taking warfarin at presentation (control group). Patients were matched by age, sex, Rockall score, year of endoscopy, inpatient or outpatient status, and the presence of disseminated cancer at presentation. The incidence rates of major outcomes in the two groups were compared. RESULTS: A total of 128 patients (SA group) were matched to 135 control patients. The SA group patients were less likely to die within 30 days (6.25 % vs. 15.5 %, odds ratio = 0.36, P = 0.028 by Test for Equality of Proportions). There was a trend toward more surgery in the control group (5 % vs. 2 %), and rates of blood transfusion (77 % vs. 70 %) were similar in the two groups. CONCLUSION: In patients presenting with nonvariceal upper gastrointestinal hemorrhage, a supratherapeutic INR at presentation due to warfarin use is associated with reduced mortality.

Factors at presentation predictive of a requirement for endoscopic therapy in patients presenting with overt upper gastrointestinal haemorrhage: a retrospective observational study.

INTRODUCTION: In patients with upper gastrointestinal haemorrhage (UGIH), endoscopic treatment of high-risk lesions reduces mortality. Performing out of office hours endoscopy places a strain on endoscopy services. This analysis aims to identify factors at presentation associated with lesions requiring endoscopic therapy, allowing triage of those likely to receive benefit from acute out of hours endoscopy. METHODS: Patients presenting between 17 March 2001 and 12 October 2010 with UGIH had clinical and laboratory features on presentation, endoscopic findings and administered treatment recorded. Patients with known cirrhotic liver disease were excluded. Logistic regression was performed, identifying factors at presentation associated with a requirement of endoscopic therapy (RET), which were then used to create a scoring system predictive of RET. RESULTS: In all, 1492 patients were analysed. The presence on presentation of fresh melaena (OR = 3.18, p<0.001), fresh haematemesis (OR=2.13, p<0.001), haemoglobin<130 g/L (OR=2.65, p<0.001), urea >10 mmol/L (OR=2.10, p<0.001), systolic blood pressure <100 mm  Hg (OR=1.85, p<0.001), inpatient status (OR=1.43, p=0.04), a history of peptic ulcer disease (OR=1.96, p=0.02), male sex (OR=1.45, p=0.01), presentation within 8 h of symptom onset (OR=1.48, p=0.02), coffee ground vomitus (OR=0.47, p=0.004) and warfarin use (OR=0.57, p=0.005) were associated with RET. Using a simple scoring system (fresh haematemesis=2, fresh melaena=2, haemoglobin <130=2, urea >10=1, BP <100=1, male sex=1, history of peptic ulcer disease=1), a score ≥7 was associated with RET in 45% of cases and a score ≤4 in 7%. CONCLUSIONS: Application of this scoring system when assessing patients presenting with UGIH out of office hours may help predict the likelihood of RET, and aid in the triage of endoscopy. Prospective validation of this score in an external cohort is required.