O'Keeffe, Benjamin MB ChB; Avery, Neil MBChB, FRANZCO; Aburn, Neil MBChB, FRANZCOEditor(s): Avery, Robert DO; Golnik, Karl C. MD; Froment, Caroline MD, PhD; Wang, An-Guor MD Author Information

Paraquat is a powerful herbicide still used in rural areas of New Zealand. We report the case of an 82-year-old man who had accidental exposure of 50:1 diluted paraquat to his right eye. He immediately irrigated the eye and presented two days later to his general practitioner with worsening vision. He was then referred to the hospital ophthalmology department. He was seen the same day with right visual acuity (VA) of 6/60 improving with pinhole (PH) to 6/30. Examination revealed severe papillary conjunctivitis with superior pseudomembrane and a devitalised corneal epithelium. There was no frank corneal epithelial defect or apparent limbal ischaemia. The pseudomembrane was debrided and he was started on hourly prednisolone (1.0%) drop (Bausch & Lomb, New Zealand) and chloramphenicol (0.5%) drop (Bausch & Lomb, New Zealand) four times daily (QID). On day three he had worsening discomfort and erythema. Examination showed 200 degrees of superior limbal ischaemia with a shallow epithelial defect. Oral doxycycline 100mg once daily, oral vitamin C 1g (QID), topical sodium ascorbate 10% every two hours (Q2H) and topical sodium citrate 10% (Q2H) were added to the existing treatment. By day fi ve, comfort was improved, with vision stable at 6/48 PH 6/24. There was 270 degrees of limbal ischaemia, with a large (80%) non-healing epithelial defect. Symblepharon was divided with a glass rod. A bandage lens was placed in case mechanical irritation from conjunctival papillae was contributing to the non-healing epithelial defect. On day nine an amniotic membrane graft was sutured to the limbus with interrupted 10–0 nylon and continuous 8–0 vicryl to the fornices. Complete epithelial healing occurred by day 14 post-operatively. Vision had improved to 6/15 PH 6/9. Chloramphenicol (0.5%) QID was continued for 14 days post-operatively and prednisolone drops (1.0%) tapered over two weeks. At two months post-operatively, vision was 6/9–1 PH 6/7.5 with mild inferior symblepharon.

AIMS: To investigate associations between socioeconomic status, retinal detachment type and post-operative visual outcomes in southern New Zealand.METHODS: A retrospective review of all cases of rhegmatogenous retinal detachments in Dunedin Hospital over two years was performed. Patient demographics and macula involvement at presentation were the primary outcome measures. The New Zealand Deprivation Index was used to group patients into low (30% least deprived), medium (middle 40%) and high (30% most deprived). Patients were excluded if they were not from New Zealand, or had traumatic detachments.RESULTS: During the study period, 95 retinal detachments in 94 patients were managed in Dunedin Hospital. Only 15% of retinal detachments occurred in the most deprived. More deprived patients had longer delays before assessment in hospital (mean of 29.8 days versus 10.1 days for the least deprived and 12.8 days for the medium category, overall p=0.025). There was no evidence of an association between deprivation and macula-off status (overall p=0.650) or visual acuity at one or three months (p=0.063 and p=0.328 respectively). Nor was there an association between referral pathway and macula-off status (p=0.242).CONCLUSIONS: Retinal detachment in southern New Zealand may be less common amongst those with the most deprived socioeconomic status who also experience longer delays till first treatment; but there was no association between socioeconomic status and patients being macula-off at presentation, or having poorer visual outcomes. More targeted patient education towards our most deprived citizens may reduce delays in treatment, and result in better visual outcomes.

This is an interesting case report on a 72 year old female who underwent an elective right hemicolectomy for a mucinous tumour. Histology revealed 15 lymph nodes with two entirely replaced by mucin without evidence of metastatic tumour cells. The rest of the lymph nodes were normal. After discussion at the local colorectal multidisciplinary meeting these were treated as lymph node metastases and the patient received adjuvant chemotherapy. There is little evidence around the management of colonic carcinoma with acellular mucin evident in lymph nodes.

Ms M is a 38 year female who has a history of severe endometriosis. She underwent resection of pelvic endometriosis, parital cystectomy and an anterior resection and loop ileostomy due to a rectosigmoid stricture. Post operative gastrograffi showed a patent anastomosis. The patient presented electively for closure of the ileostomy three months later. Under general anaesthesia, the patient was examined and it was found that the colorectal anastomosis was completely occluded. This article presents a novel procedure using a colonoscope with a cutting snare, Hegar’s dilators and a Controlled Radial Expansion (CRE) balloon to reopen the lumen.

AIM:To determine the likelihood of progression from M3 grade maculopathy, and therefore the safety of these patients remaining under the care of a primary screener.METHODS:Patients graded M3 at diabetic screening were selected from the Wellington screening database. Photographs for this visit and the subsequent visit were obtained, and graded by a consultant ophthalmologist. Photographs graded M3 were included and progression of maculopathy between visits, number of patients with a reduction in vision and duration between visits were determined.RESULTS:Mean duration between visits for all patients was 255 (plus or minus 59.5) days. Of the 54 eyes studied, 15 or 33.3% progressed to M4 maculopathy at the subsequent visit. Despite progressing from M3 to M4, none had a reduction of vision by more than one line of Snellen acuity at follow up due to diabetic maculopathy.CONCLUSIONS:Rates of progression of maculopathy from M3 to M4 were of clinical significance. Despite this none had worsening visual acuity due to diabetic eye disease. This suggests patients with M3 maculopathy could be maintained under a primary screening programme, as is the case in the United Kingdom.

To determine if primary selective laser trabeculoplasty (SLT) can be repeated with clinical benefit in patients with primary open-angle glaucoma (POAG). Forty-two eyes of 42 patients with POAG were studied. All patients underwent primary SLT treatment of 40–50 shots to the trabecular meshwork over 360°. The treatment response at the initial post-SLT visit (4 weeks), and second post-SLT visit (mean 4 months), clinical success and duration of clinical success were measured. SLT was repeated in all patients after failure to maintain target intraocular pressure (IOP). The same parameters were measured after repeat SLT. The main outcome measures were success of treatment (as defined by reduction of IOP by at least 20 % and below an individually determined target pressure), duration of treatment success and reduction in IOP. No significant difference between initial and repeat treatments was found for mean reduction in IOP or success rate, or duration of success. Survival analysis found significantly longer benefit for repeat treatment compared to initial treatment (P < 0.01). Repeat SLT treatment in eyes with POAG has similar efficacy to primary SLT treatment with respect to reduction in IOP and success rates, produces a longer duration of treatment success.

Self-diagnosis has been around for many years. In today's society with free access to information, particularly through the Internet, it is more prominent than ever. With new information sources available to patients, doctors may have their diagnostic process influenced. This is the case of a gentleman who self-diagnosed, and subsequently influenced his doctor's diagnostic process, with results detrimental to his outcome. It illustrates the importance of awareness of the risks of self diagnosis, and management of patients who present with information and preconceived ideas regarding their condition.