Vision in former very low birthweight young adults with and without retinopathy of prematurity compared with term born controls: the NZ 1986 VLBW follow-up study.

OBJECTIVE: There are few data on visual outcomes in adulthood of former very low birthweight (VLBW; <1500 g) infants. We aimed to assess vision at 27-29 years in a national cohort of VLBW infants born in 1986 and assessed for retinopathy of prematurity (ROP) when no treatment was available, compared with term born controls. METHODS: The cohort and controls attended a 2-day assessment in Christchurch as part of a larger study. Visual assessment included glasses prescription measured by focimeter, logarithm of the minimum angle of resolution (logMAR) distance visual acuity (VA), contrast sensitivity, autorefraction, retinal photographs and a questionnaire on vision-related everyday activities. Rates of reduced VA and myopia in the VLBW cohort at 27-29 were compared with the results of vision testing at 7-8 years. RESULTS: 250 VLBW adults (77% those alive) gave study consent and 229 (45 with a history of ROP) were assessed in Christchurch, plus 100 term born controls. VLBW adults with ROP had reduced VA compared with no ROP and controls (mean logMAR score (SD); 0.003 (0.19), -0.021 (0.16), -0.078 (0.09), P=0.001). There were no differences in myopia (>2 D) between the groups but high myopia (>5 D) was confined to those with ROP. VLBW adults with ROP drove a car less often and had higher difficulties with everyday activities scores due to eyesight. Between 7-8 and 27-29 years rates of reduced VA were stable but myopia increased. CONCLUSION: Former VLBW young adults with ROP have ongoing problems with vision affecting daily living and should continue in regular ophthalmological review. TRIAL REGISTRATION NUMBER: ACTRN12612000995875, Pre-results .

Hyperbaric oxygen in the treatment of acute retinal artery occlusion.

INTRODUCTION: Acute retinal artery occlusion (ARAO) is a major cause of sudden, painless visual loss, often leaving no useful vision in the affected eye. Its incidence is cited at 0.85 per 100,000 persons per year but may be higher because of under-reporting. The natural history is difficult to study, but a spontaneous resolution rate of < 1-8% for acute, non-arteritic ARAO has been cited. Occurrence in an only eye is devastating for the patient. There is currently no consensus regarding management of ARAO and little evidence to support any treatment modality. Despite only limited case series, hyperbaric oxygen treatment (HBOT) is recommended for ARAO by the Undersea and Hyperbaric Medical Society (UHMS) and by the European Committee for Hyperbaric Medicine. METHODS: Between early 2003 and December 2012, all ARAO patients presenting to Christchurch Hospital were referred for consideration of HBOT. These 31 consecutive patients' medical records were reviewed retrospectively. The time delay from onset of visual loss to commencing HBOT; the presenting visual acuity; various demographic data; the HBOT administered and the outcome visual acuity were documented. RESULTS: All 31 patients underwent at least one HBOT (median 4, range 1-7) at a pressure of 203-284 kPa for 1.5 to 2.0 h. One patient's treatment was terminated after 60 min at their request; another declined further HBOT and one suffered middle ear barotrauma. Thirteen patients also received anticoagulants at the discretion of the referring ophthalmologist. Twenty three patients had temporarily improved vision with the first HBOT. Seven patients had permanent, good visual recovery (6/18 or better; Snellen chart); and two only modest improvement (6/60). All nine patients who improved permanently were treated within 10 hours of symptom onset. CONCLUSIONS: Where available, HBOT is indicated for ARAO. Our protocol may not have been aggressive enough and the UHMS protocol is recommended. A multi-centre, randomised controlled trial is feasible, but would be logistically difficult and expensive and may be ethically unsupportable given the lack of alternative, effective treatments.

The New Zealand 1986 very low birth weight cohort as young adults: mapping the road ahead.

BACKGROUND: Very low birth weight (less than 1500 g) is associated with increased morbidity and costs of health care in childhood. Emerging evidence suggests these infants face a range of health and social problems as young adults. We studied all New Zealand very low birth weight infants born in 1986 (when 58% were exposed to antenatal corticosteroids) in infancy, with later follow-up at 7 to 8 years and 23 to 24 years. We now aim to assess the cohort at 26-28 years compared with controls. METHODS/DESIGN: The case sample will comprise a minimum of 250 members of the 1986 New Zealand national very low birth weight cohort (77% of survivors). Outcomes will be compared with a control group of 100 young adults born at term in 1986. Following written informed consent, participants will travel to Christchurch for 2 days of assessments undertaken by experienced staff. Medical assessments include growth measures, vision, respiratory function, blood pressure and echocardiogram, renal function, dental examination and blood tests. Cognitive and neuropsychological functioning will be assessed with standard tests, and mental health and social functioning by participant interview. A telephone interview will be conducted with a parent or significant other person nominated by the respondent to gain a further perspective on the young person's health and functioning. All those born at less than 28 weeks' gestation, plus a random subset of the cohort to a total of 150 cases and 50 controls, will be offered cranial magnetic-resonance imaging. Statistical analysis will examine comparison with controls and long-term trajectories for the very low birth weight cohort. DISCUSSION: The research will provide crucial New Zealand data on the young adult outcomes for very low birth weight infants and address gaps in the international literature, particularly regarding cardiovascular, respiratory, visual and neurocognitive outcomes. These data will inform future neonatal care, provide evidence-based guidelines for care of preterm graduates transitioning to adult care, and help shape health education and social policies for this high risk group. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12612000995875 . Registered 1 October 2012.

Randomized controlled trial of oxygen saturation targets in very preterm infants: two year outcomes.

OBJECTIVE: To assess whether an oxygen saturation (Spo2) target of 85%-89% compared with 91%-95% reduced the incidence of the composite outcome of death or major disability at 2 years of age in infants born at <28 weeks' gestation. STUDY DESIGN: A total 340 infants were randomized to a lower or higher target from <24 hours of age until 36 weeks' gestational age. Blinding was achieved by targeting a displayed Spo2 of 88%-92% using a saturation monitor offset by ±3% within the range 85%-95%. True saturations were displayed outside this range. Follow-up at 2 years' corrected age was by pediatric examination and formal neurodevelopmental assessment. Major disability was gross motor disability, cognitive or language delay, severe hearing loss, or blindness. RESULTS: The primary outcome was known for 335 infants with 33 using surrogate language information. Targeting a lower compared with a higher Spo2 target range had no significant effect on the rate of death or major disability at 2 years' corrected age (65/167 [38.9%] vs 76/168 [45.2%]; relative risk 1.15, 95% CI 0.90-1.47) or any secondary outcomes. Death occurred in 25 (14.7%) and 27 (15.9%) of those randomized to the lower and higher target, respectively, and blindness in 0% and 0.7%. CONCLUSIONS: Although there was no benefit or harm from targeting a lower compared with a higher saturation in this trial, further information will become available from the prospectively planned meta-analysis of this and 4 other trials comprising a total of nearly 5000 infants.

Dietary supplement use in the prevention of age-related macular degeneration progression.

PURPOSE: The Age-Related Eye Disease Study Group (AREDS) has found high-dose vitamin supplementation may have a role in preventing the progression of Category 3 and 4 age-related maculopathy. The aim of this study is to compare dietary antioxidant, zinc, and copper intakes of Australia, New Zealand, United Kingdom, and the United States to determine the difference between the actual and suggested AREDS intakes for these nutrients. A further aim is to investigate the constituents of commonly available single and multivitamin preparations in New Zealand and carry out a cost analysis. METHODS: The total median intake of vitamins A, C, and E; zinc; and copper is analysed from the most recent nutrition data published by the four countries. Forty multivitamin brands and 32 individual nutrient brands were analysed. An average price per tablet for each brand has been calculated in New Zealand dollars. RESULTS: The median intakes of antioxidants, zinc, and copper for these countries were comparable, but lower than the AREDS suggested intakes. Sixteen of the 40 multivitamin preparations contained all recommended nutrients. Of these, only two fulfilled the AREDS-recommended levels. The cost of different preparations is similar. CONCLUSION: Dietary supplementation is required to achieve the AREDS nutrient intake recommendations. This may be achieved by using any combination of multivitamin and individual supplement preparations available. Comprehensive tables have been constructed to guide ophthalmologists in the process of suggesting supplementation to prevent the progression of Category 3 and 4 age-related maculopathy.

The fourth New Zealand cataract and refractive surgery survey: 2007.

BACKGROUND: To examine the current practice and changing trends for cataract and refractive surgery in New Zealand (NZ) between 1997 and 2007. METHODS: A self-administered confidential postal questionnaire was sent to all consultant ophthalmologists practising in NZ in 2007, eliciting surgical volumes and technique, anaesthetic, preferred equipment and patient management. Results were compared with previous NZ surveys and international surveys of surgeons in Northern America, Europe and the UK. RESULTS: From the 113 ophthalmologists surveyed 88% responded, comprising 86 cataract surgeons and 20 refractive surgeons. Key findings for cataract surgeons were: 65% routinely used sub-Tenon's anaesthetic, 20% topical anaesthetic, 24% favoured intracameral antibiotics, 88% operated via clear corneal or anterior limbal incisions and 61% used temporal incisions. Acrylic foldable intraocular lenses (IOLs) were preferred, 27% of surgeons routinely used aspheric IOLs, 31% used presbyopia-correcting IOLs and 63% expressed high interest in toric IOLs. Of the refractive surgeons, 83% would perform bilateral LASIK at the same surgical event; phakic IOL was the treatment of choice for 30-year-old -12D myopes, and clear lens exchange for 45-year-old +5D hyperopes. CONCLUSIONS: The majority of NZ cataract surgical practice remains comparable with results from international surveys. A notable exception, as in previous comparisons, is a lower use of topical anaesthetic in NZ with a higher use of sub-Tenon's anaesthetic instead. Refractive surgery practice in NZ is generally comparable with that of American Society of Cataract and Refractive Surgery members.

Does observer bias contribute to variations in the rate of retinopathy of prematurity between centres?

PURPOSE: We aimed to indirectly assess the contribution from observer bias to between centre variability in the incidence of acute retinopathy of prematurity (ROP). METHODS: The Australian and New Zealand Neonatal Network (ANZNN) collected data on the highest stage of acute ROP in either eye in 2286 infants born at less than 29 weeks in 1998-1999 and cared for in one of 25 neonatal intensive care units (NICUs). Chi-squared analysis was used to detect differences in the proportion of stages of ROP for each neonatal intensive care unit. These proportions were compared with those reported in two large studies of treatment for ROP. RESULTS: The incidence of acute ROP in the ANZNN cohort was 42% and the ratio of stage 1:2:3 ROP was 1.5:1.9:1. There was considerable variation in both the incidence of acute ROP and the proportions with stage 1:2:3 ROP between centres. A chi-squared test determined that the assignment of stages 1, 2 and 3/4 ROP was not independent of centre (chi(2)(48) = 165.2; P < 0.0001). Treatment of stage 3 ROP varied between 15% and 120%, indicating some eyes were treated at less than stage 3. CONCLUSION: The data are highly suggestive of observer bias contributing to the observed between centre variation in the incidence of acute ROP. In neonatal intervention studies where acute ROP is an outcome it would seem important to have an accreditation process for examining ophthalmologists, and there are similar arguments for neonatal networks which collect these data.

The New Zealand ophthalmology workforce 2008.

BACKGROUND: The ongoing supply of quality ophthalmic care to the New Zealand (NZ) population depends on a sustainable ophthalmology workforce. The NZ population is growing and aging rapidly, placing increasing demands on ophthalmic services. Predicting future supply of NZ ophthalmologists requires an accurate description of the current workforce. METHODS: A confidential postal workforce survey, the fourth since 1997, was sent to all NZ consultant ophthalmologists in October 2007. A second survey conducted in January 2008 by email and direct telephone contact gained a complete dataset of NZ ophthalmologists. Results were compared with NZ population data, and the Australian Ophthalmology Workforce Model 2006 was used to estimate future demands on NZ ophthalmic services. RESULTS: There are currently 16-24 vacancies for consultant ophthalmologists in NZ, with another eight positions planned to be created by 2010, bringing the shortfall to 24-32. Retirement rates average to three per year, although 28 consultants are planning to retire by 2013. Retention of new NZ Fellows stands at around 71%. Increasing demands of an aging population are likely to increase the shortfall of ophthalmologists to 40-50 by 2015, and 46-69 by 2025. CONCLUSIONS: This report identifies a growing gap between supply of NZ ophthalmologists and demand for their services. We highlight the need for a comprehensive model with a detailed analysis of the many factors influencing supply and demand, enabling planning for an appropriate supply of ophthalmologists meeting the needs of the future NZ population.

Medical treatment of cataract.

The incidence of cataract continues to increase with the ageing of the population. Surgical treatment with phacoemulsification and intraocular lens implantation remains the only proven treatment. This, however, is associated with significant cost and is not readily available especially in the developing countries where the prevalence of cataract is the highest. Medical treatment of cataract is therefore a highly desired alternative. Since the last major review of medical treatment of cataract the search for an anti-cataract agent has advanced on many fronts. Some anti-cataract drugs, such as carnosine, have now reached clinical trials and showed encouraging results that warrant further investigation. The discovery of an effective medical treatment for cataract is likely to make global impact on eye health. The aims of this paper are to review the literature on the drug therapy of cataract and provide updates of the latest development.

A systematic review of the applicability and efficacy of eye exercises.

PURPOSE: To examine the current scientific evidence base regarding the efficacy of eye exercises as used in optometric vision therapy. METHODS: A search was performed of the following databases: Allied and Complementary Medicine Database, Cochrane Database of Systematic Reviews, Cochrane Register of Controlled Trials, EMBASE, and MEDLINE. Relevant articles were reviewed and analyzed for strengths and weaknesses. Pertinent sections of classic texts were studied to provide a historical basis and to serve as a source for additional early references. RESULTS: Forty-three refereed studies were obtained. Of these, 14 were clinical trials (10 controlled studies), 18 review articles, 2 historical articles, 1 case report, 6 editorials or letters, and 2 position statements from professional colleges. Many of the references listed by the larger reviews were unpublished or published in obscure or nonrefereed sources and therefore were not accessible. CONCLUSIONS: Eye exercises have been purported to improve a wide range of conditions including vergence problems, ocular motility disorders, accommodative dysfunction, amblyopia, learning disabilities, dyslexia, asthenopia, myopia, motion sickness, sports performance, stereopsis, visual field defects, visual acuity, and general well-being. Small controlled trials and a large number of cases support the treatment of convergence insufficiency. Less robust, but believable, evidence indicates visual training may be useful in developing fine stereoscopic skills and improving visual field remnants after brain damage. As yet there is no clear scientific evidence published in the mainstream literature supporting the use of eye exercises in the remainder of the areas reviewed, and their use therefore remains controversial.

Clear lens extraction for the treatment of persistent accommodative spasm after head trauma.

We report the case of a 28-year-old man with decreased visual acuity after closed head trauma sustained in a motor vehicle accident 16 weeks earlier. Several structures thought to be associated with the control of accommodation were injured. The patient had a persistent accommodative spasm causing up to 7.0 diopters of pseudomyopia. We present the patient's progress through the clinic, including manifest and cycloplegic refractions and results of a trial with atropine drops, and successful transition to bilateral pseudophakia 2 years and 9 months after the accident.

Globe rupture following penetrating keratoplasty: how often, why, and what can we do to prevent it?

PURPOSE: Traumatic globe rupture following penetrating keratoplasty is a life-long postoperative concern. We look at a series of penetrating keratoplasties in one institution and determine the rates of traumatic rupture and the outcomes following rupture. The reasons for persisting wound weakness are reviewed, and recommendations for eye protection based on wound strength are given. METHODS: A case-control study compared the postsurgical rupture rates for all cases of penetrating keratoplasty to those cases of globe rupture after extracapsular cataract surgery and phacoemulsification. A literature review of corneal wound healing was completed. RESULTS: Over 10 years 139 penetrating keratoplasties were performed. The incidence of traumatic rupture following keratoplasty was 5.8%. Fifty percent of those with ruptured globes had a visual outcome of hand movement vision or worse. Of the traumatic ruptures, 37.5% occurred in the first postoperative month. The indication for initial keratoplasty did not influence the rupture rate. In comparison, the general rate of penetrating eye injuries in the population was 2.2/100,000 per annum. The rupture rate for extracapsular cataract surgery was 1/221 (0.45%) and 0/6450 for phacoemulsification. Both of these rates were significantly less than after penetrating keratoplasty (P=0.005, P<0.0001). DISCUSSION: Penetrating keratoplasty cases have a higher rate of globe rupture than other ocular procedures. There are 5 important time periods of wound integrity after penetrating keratoplasty. The highest risk period is the month following surgery, when wound strength is derived almost entirely from sutures. The 18 months following surgery are moderately high risk. The month following removal of sutures is a second high-risk period. In the 6 months following this, the wound has a similar strength to the first postoperative year. Following penetrating keratoplasty the cornea never regains its preoperative strength and remains at risk for traumatic rupture for the remainder of the patient's life.

Bilateral ptosis caused by localized superficial eyelid amyloidosis.

A 70-year-old man had bilateral periorbital eyelid swelling. Eyelid biopsy confirmed amyloid infiltrate. Conjunctival involvement was not clinically apparent. The deposits were subsequently curetted with the use of a transcutaneous upper and lower eyelid blepharoplasty approach and found to be entirely pretarsal. No clinical recurrence of the ptosis was noted, but amyloid may have reaccumulated. We propose that in certain circumstances, debridement of localized amyloid should be considered and reaccumulation may not occur.

Unilateral versus bilateral medial rectus recession.

BACKGROUND: Unilateral medial rectus recession is suitable for some cases of small-angle deviation in esotropia. This approach limits surgery to one eye, leaves other muscles untouched, and should be quicker than bilateral muscle surgery. This study compared the results of a range of medial rectus recessions, both unilateral and bilateral, performed by one surgeon. METHODS: Data were collected on all pediatric patients who had undergone medial rectus recession, unilateral and bilateral, performed by one surgeon between August 1, 1995, and March 31, 2002. Postoperative deviations were calculated from the short- (2 to 8 weeks) and long-term (6 to 48 months) follow-up visits. RESULTS: Medial rectus recessions were performed on 107 patients, 56 unilateral and 51 bilateral. After exclusions were made, 45 (80%) of the unilateral procedures and 41 (80%) of the bilateral cases were studied. At long-term follow-up, the mean prism diopter (PD) change in deviation per millimeter recessed (at distance) for unilateral recessions of 5 mm, 6 mm, 7 mm, and 8 mm were 2.3, 2.2, 2.3, and 2.5, respectively. For equivalent bilateral recessions the mean changes in deviation were 4.2, 4.0, 4.3, and 5.0 PD/mm. CONCLUSION: Unilateral medial rectus recession is a predictable method for surgical correction of small-angle pediatric esotropia. The change in deviation per millimeter of recession after unilateral recession is significantly less than that obtained from equivalent amounts of bilateral recession (P <.01).

Endophthalmitis.

Australia and New Zealand continue to be at the forefront of endophthalmitis research. In this Clinical Controversy, an ophthalmologist from each country presents different approaches to the management of a 72-year-old patient with routine endophthalmitis following cataract surgery. Mark Elder concludes that this case needs aqueous and vitreous aspirates for culture and the initial treatment of choice is intracameral vancomycin and amikacin. The evidence for intravitreal steroids is equivocal. Systemic antibiotics are indicated if there is a possibility of a bacterial biofilm present on the intraocular lens. Nigel Morlet concludes that timely intervention with appropriate antibiotics delivered in the right concentration to the vitreous cavity is the crux of successful management of endophthalmitis. Aggressive treatment of the inflammatory response is also required to further reduce the damage to the intraocular structures. Both ophthalmologists agree that vitrectomy is not necessarily the most appropriate treatment option.

The first international consensus on mucous membrane pemphigoid: definition, diagnostic criteria, pathogenic factors, medical treatment, and prognostic indicators.

OBJECTIVE: We aimed to develop consensus-based recommendations for streamlining medical communication among various health care professionals, to improve accuracy of diagnosis and treatment, and to facilitate future investigations for mucous membrane pemphigoid. PARTICIPANTS: Because of the highly specific nature of this group of diseases, the 26 invited participants included either international scholars in the field of mucous membrane pemphigoid or experts in cutaneous pharmacology representing the 3 medical disciplines ophthalmology, oral medicine, and dermatology. EVIDENCE: The first author (L.S.C.) conducted a literature search. Based on the information obtained, international experts who had contributed to the literature in the clinical care, diagnosis, and laboratory investigation for mucous membrane pemphigoid were invited to participate in a consensus meeting aimed at developing a consensus statement. CONSENSUS PROCESS: A consensus meeting was convened and conducted on May 10, 1999, in Chicago, Ill, to discuss the relevant issues. The first author drafted the statement based on the consensus developed at the meeting and the participants' written comments. The draft was submitted to all participants for 3 separate rounds of review, and disagreements were reconciled based on literature evidence. The third and final statement incorporated all relevant evidence obtained in the literature search and the consensus developed by the participants. The final statement was approved and endorsed by all 26 participants. CONCLUSIONS: Specific consensus-based recommendations were made regarding the definition, diagnostic criteria, pathogenic factors, medical treatment, and prognostic indicators for mucous membrane pemphigoid. A system of standard reporting for these patients was proposed to facilitate a uniform data collection.