To streamline the cataract surgery pathway to improve the time from first specialist assessment (FSA) to surgery, while reducing the clinical priority assessment criteria (CPAC) score from 55 to 50. A quality improvement project using Lean Six Sigma tools and the Model for Improvement. Most data were collected from the i.Patient Manager (iPM) system and analysed using statistical process control charts. Change interventions included combining FSA and pre-admission clinics (PAC); post-operative telephone review by non senior medical officers (SMO); and using our own surgeons in private theatres. The standard cataract pathway was reduced from 5 to 3 appointments. This removed 1,514 hours of appointments, released 113 SMO hours and saved patients NZ$156,000 in indirect costs over a year. The average waiting time from FSA to surgery decreased from 90 to 77 days (-13.5%). The number of overdue patients reduced from 127 to 44 (-35%). The average number of patients on the FSA waiting list dropped from 322 to 205 (-40%). There was no change to the proportions of surgeries or appointment attendance rates by ethnicity. Average monthly cataract surgeries increased from 192 to 215 (+12%), and the CPAC score threshold was decreased to 50 in February 2021. Despite significant demand pressures, and the disruptions of COVID-19, we were able to reduce the CPAC score for accessing cataract surgery by optimising the clinical pathway to better utilise staff capacity and maximise value for patients.
A seasonal syndrome, presenting as corneal oedema and distinct from infectious keratoconjunctivitis, has been reported in sheep, goats, and camelids in New Zealand. This study details the diagnostic investigation on two properties, of multiple cases of corneal oedema in small ruminants. Outbreak 1 occurred in a mob of sheep in April/May 2023 in the Manawatū region, with 27/52 sheep affected. Outbreak 2 occurred in a group of farmed goats in February/March 2024 in the Auckland region, with 4/5 goats affected. A spectrum of corneal abnormalities, including focal and diffuse corneal oedema and bullous keratopathy/corneal hydrops, were observed in both the sheep and goats. All animals had normal menace responses and pupillary light reflexes, and there was no associated blepharospasm, epiphora or ocular discharge, except in five sheep that developed secondary ulcerative keratitis. These five sheep had severe ulceration or corneal perforation necessitating euthanasia, while the other affected sheep all recovered within 5 months. The corneal oedema in all goats improved over the following 6 months, but one required a thermokeratoplasty procedure to aid resolution of the oedema and the other three goats had residual focal oedema that did not appreciably affect vision. It is proposed that a primary corneal endothelial dysfunction was the cause of the oedema, but the aetiopathogenesis is not well understood. This is the first peer-reviewed description of this presentation in New Zealand. In contrast to other causes of corneal oedema in ruminants, seasonal corneal oedema is, in some cases, self-limiting with minimal impacts on production and welfare. However, secondary ulceration and corneal perforation may occur, which is painful and may lead to deep infections and permanent visual deficits. Topical antibiotic therapy does not appear to aid in the resolution of the oedema. MPI: Ministry for Primary Industries.
Ethnic disparities have been observed in treatment at first specialist appointments across various specialties within New Zealand. This study aimed to examine documentation and treatment decisions for diabetic retinopathy by ethnicity. Retrospective audit of first specialist diabetic retinopathy clinic appointments for 388 patients at the Department of Ophthalmology, Te Whatu Ora Te Toka Tumai Auckland. Multiple domains of care were assessed, including comprehensiveness of history taking, examination, investigations and treatment decisions. Europeans comprised 42%, Māori only 9.5%, Pacific peoples 13.19%, Asian 32.7% and Middle Eastern/Latin American/African in 2%. Māori patients were eligible for a significantly greater number of treatments (p=0.001). The comprehensiveness of history taking (p=0.809), examination (p=0.513), investigations (p=0.623) and proportion of eligible treatments provided (p=0.788) was similar but did not reach the gold standard of care across all ethnicities. The standard of care provided in first specialist appointments for diabetic retinopathy appear to be similar across all ethnic groups, although Māori were underrepresented and had a higher disease burden at presentation. Our data highlights the need to reduce barriers faced by Māori in accessing GP, optometry and retinopathy screening referrals in Auckland, and improving local consultation and treatment guidelines.
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The number of individuals with chronic conditions such as age-related macular degeneration (AMD) is increasing, and consequently the treatment burden for anti-vascular endothelial growth factor (anti-VEGF) intravitreal injections is also increasing. The use of nurse specialists to administer anti-VEGF intravitreal injections has been proposed to address this treatment burden. This was a prospective safety audit to determine the safety of nurse specialists for the delivery of anti-VEGF intravitreal injections. A prospective safety audit was undertaken for a nurse specialist-delivered injection service in the Ophthalmology Clinic, Greenlane Clinical Centre. The department's senior medical retinal consultant supervised the nurse specialist training programme. The clinical safety of anti-VEGF intravitreal injections delivered by nurse specialists, and the impact of this programme on clinical capacity at our Institute was reviewed. The nurse specialists administered a total of 2,900 injections over an 18-month period. Two patients developed endophthalmitis post injection (1 infective, 1 non-infective). Two patients had a vitreous haemorrhage, and five patients had raised intraocular pressure. The incidence of post-injection endophthalmitis, vitreous haemorrhage and raised intraocular pressure was 0.07%, 0.07% and 0.17%, respectively. The nurse specialist-delivered injection service is a safe and effective service for treatment of wet AMD, diabetic macular oedema and vein occlusion.
Our aim was to examine rate of recurrence of toxoplasmosis retinochoroiditis and risk factors for recurrence. No New Zealand epidemiological data on recurrence rates of toxoplasmosis retinochoroiditis have been previously published. Retrospective chart review of all patients with toxoplasmosis retinochoroiditis presented to Auckland District Health Board Department of Ophthalmology between 2006-2019. One hundred and twenty-six eyes of 115 patients were included with a median age at initial diagnosis of 36.7 years (IQR 23.7-53.8). Fifty-nine patients were female (51.3%), and 16 patients (13.9%) were immunosuppressed. Twenty-six of the 86 patients tested (30.2%) were IgM positive at presentation. Mean follow-up was 6.1 years and 73 recurrences occurred during the follow-up period in 36 patients (31.3%). Treatment was initiated in 87.4% of cases, with oral cotrimoxazole or clindamycin the most common options. Recurrence occurred in 14.8% in the first year (95% CI 10.3%-21.0%), and the risk of recurrence was increased 2x for every previously documented recurrence (HR 2.00; p<0.001). There was no statistically significant increased risk of recurrence with age, IgM positivity, immunosuppression or macular involvement. Toxoplasmosis retinochoroiditis had a 14.8% risk of recurrence in the first year, with each previous recurrence increasing the risk by two-times.
Over the last two decades there has been an increasing demand on health care services. This has led to increased waiting lists and waiting times to access public hospital services. In ophthalmic practice an aging population and technological advances have been major contributors to this situation. The challenge for health care providers is how to manage waiting lists within the resources provided and targets set by Elective Services, a department of the Ministry of Health (MoH). The Ministerial Taskforce on Nursing (1998) highlighted that nurses are an underutilised resource. Subsequent to the Ministerial Taskforce, the availability of interim funding from Elective Services and a skilled speciality nursing workforce the Ophthalmology Department at a large metropolitan hospital was able to implement an advanced nursing role with respect to glaucoma management. Early diagnosis is important in reducing the risk of permanent visual impairment from primary open angle glaucoma; therefore the length of time to diagnosis can have long term implications for the patient. Patients for the 'nurse-led' glaucoma clinic were recruited from specific categories of glaucoma patients on the waiting list. An audit of the impact on the waiting list was undertaken periodically over a two year period. The audit following the introduction of the clinical nurse specialist clinic shows a marked reduction in waiting list numbers and length of time waiting for first specialist assessment for glaucoma. The implementation of this role proved to be successful and has subsequently become a permanent nurse specialist position in the ophthalmology department.
To establish demographics, referral patterns and clinical characteristics of patients attending an emergency eye service within a major public tertiary teaching hospital and to identify possible targets to improve delivery of patient care. Retrospective study of all patients (N=504) attending an acute eye clinic over a representative 2-week period within Greenlane Clinical Centre, Auckland. Mean age was 42.4 plus or minus 20.6 years with mean visual acuity of 6/10. Referrals came from: general-practitioners (GP) (26.2%), self-referrals (18.6%), hospital medical-officers (7.4%), accident and emergency clinics (6.6%) and optometrists (2.2%). 39.1% of patients were follow-up reviews. Main presenting symptoms were pain, red eye and reduced vision. Average waiting-time was 119 plus or minus 98 min. Major diagnoses were trauma, uveitis and adenoviral keratoconjunctivitis (AKC). Males were more likely to present with ocular trauma, whereas females were more likely to exhibit uveitis, contact-lens related keratitis and AKC. Outcomes included follow-up (48.2%), referral to speciality ophthalmology care (19.0%), referral to other clinics (5.75%), and discharge (33.7%). A significant proportion of presentations could have been appropriately referred to outpatient departments or potentially managed by primary healthcare providers. Potential initiatives to manage excessive workload demands might target prevention of ocular trauma, improved contact-lens education, limiting the spread of AKC and improved GP education.
This study was conducted to describe the epidemiology of thyroid eye disease (TED) in New Zealand. One hundred and sixty-one subjects with TED seen over a 14-year period in Auckland, from a combined ophthalmology-endocrinology clinic, had data extracted from clinical notes. Median age at onset was 47.0±15.1 years and 77.6% were female. Crude yearly incidence of TED (per 1,000,000) was 12.6 in non-smokers and 67.3 in smokers (p<0.001).  On univariate analysis, female gender, Māori ethnicity and smoking were associated with incidence of TED. On multivariate analysis, female gender and smoking status were associated with risk of TED, and the difference in ethnicity was explained by smoking status. Māori subjects with TED were more likely to be current smokers (72.7%) compared to European (39.2%), Pacific Peoples (33.3%), Asian (8.3%) and Other (12.5%). Māori ethnicity and current smokers were associated with a higher clinical activity score at presentation (p=0.049 and p=0.027). A strong association was demonstrated with female gender and smoking status and rate of TED. Māori have increased rates of TED; however, this difference was explained by smoking. Eliminating smoking would result in at least a 28.1% reduction in TED incidence in New Zealand.
Stroke clot retrieval (SCR) is now considered a standard of care for select stroke patients with proximal large vessel occlusion (LVO) of the anterior circulation. Here we present the experience of regional Taranaki patients transferred by air for SCR and compare this to metropolitan Auckland patients who were transferred by road. The aim is to present and compare process metrics and outcomes between the regional and metropolitan centres. This is a retrospective analysis of consecutive patients with anterior LVO transferred to Auckland City Hospital (ACH) for SCR from Taranaki, Waitematā and Counties Manukau district health boards (DHBs) between November 2017 and December 2020. Thirty Taranaki patients were transferred for SCR, compared to 244 patients from Waitematā and Counties Manukau DHBs. Taranaki patients were seven years older and less ethnically diverse but similar in other characteristics. The proportion of patients with an independent Modified Rankin Scale (mRS) score between 0 and 2 at three months was the same as for the regional and metropolitan centres. In this real-world study, regional stroke patients can achieve similar SCR outcomes to metropolitan patients. Overcoming the post-code lottery for hyperacute stroke care can be achieved in a New Zealand setting.
To determine the demographic and clinical features of patients with ocular disease consistent with syphilis and positive treponemal serology in Auckland, and to compare patients who lived in a Pacific nation before 1960 with all other patients with regard to these features, considering a possible history of yaws infection. Retrospective review of subjects seen in uveitis and neuroophthalmology clinics at Auckland District Health Board between January 2006 and June 2019. Two thousand four hundred and ninety-three subjects were reviewed in uveitis clinics during the timeframe, of whom 45 were diagnosed with syphilitic uveitis (1.8%). Mean age was 56.2±14.8 years and 34 (75.5%) were male. Ethnicity was Caucasian in 16 (35.5%), Pacific peoples in 16 (35.5%), Māori in two (4.4%), Asian in six (13.3%) and other in five (11.1%). Pacific peoples were older at presentation (p=0.001) and 75.0% were aged >60 compared to 24.1% of non-Pacific peoples (p=0.002). Comparing Pacific people born prior to 1960 (aged >60) to the rest of the cohort, older Pacific subjects had lower RPR titres (median 3 vs 32 p=0.004), less optic nerve swelling (0% vs 28.0% eyes p=0.014) and less posterior uveitis (6.25% vs 32.0% eyes p = 0.033). No difference was observed in anterior and intermediate uveitis between the groups. No difference was observed in the resolution or recurrence of inflammation between the groups. Syphilitic uveitis is common in New Zealand, occurring in 1 in 55 patients seen in consultant uveitis clinics. Clinicians should consider a history of yaws in Pacific peoples presenting with ocular inflammation and positive treponemal serology. In these cases alternative causes of ocular pathology should be included as differentials. In cases of diagnostic uncertainty, the risk of treatment versus the potentially severe sequelae of untreated syphilis need to be considered.
This retrospective study was undertaken to review the clinical signs and management of patients with perforating eye injuries associated with regional anaesthesia for ophthalmic surgery. Fifteen consecutive patients presenting with inadvertent perforation of the globe were evaluated. Eleven required vitreoretinal surgery. The indications were retinal detachment (six eyes), vitreous haemorrhage (four) and an epiretinal membrane (one eye). Those eyes with retinal detachments generally had a poor functional outcome in spite of the retinae being attached in five of the six eyes. The operative findings of those eyes with vitreous haemorrhage but attached retina demonstrated varying retinal tear configurations. Eyes with perforating injuries following intraorbital anaesthesia are at risk of developing a retinal detachment. In those eyes presenting with dense vitreous but attached retina, consideration of vitrectomy and laser photocoagulation is advised.
Vision impairment has significant impact on quality of life and substantial economic consequences. Yet, in the Pacific Islands, as in other low resource settings, it is predominantly caused by chronic conditions that can be treated or prevented. A whole of health approach is required to rectify this, and must include an increase in workforce capacity, both in size and effectiveness, by providing competency-based education for eye care professionals. Training in curative clinical skills is not sufficient: broader competencies--including those for chronic conditions, issues of care quality, integration into the wider health care system, and commitment to professionalism and life-long learning--need to be addressed. Using current best practice approaches in education, and taking into consideration local needs, The Pacific Eye Institute, an initiative of The Fred Hollows Foundation New Zealand, aims to produce graduates with these core competencies who are capable of effectively and acceptably working in community or hospital settings to provide sustainable high quality, comprehensive eye care with ongoing desirable and consistent eye health outcomes.
Red reflex testing forms an essential part of newborn (within the first week of life) and infant (6 weeks of age) screening in New Zealand, as outlined in the Well Child/Tamariki Ora handbook. This survey of practitioners undertaking red reflex screening aimed to determine current practices and attitudes of screeners, as well as any barriers to screening. A short, multiple-choice, on-line questionnaire was sent to approximately 1,500 health care professionals undertaking red reflex screening, over a 4-week period. Four hundred and eighty-three survey responses were received from 267 GPs (55.4%), 153 midwives (31.7%), and 50 paediatricians (10.4%). Thirty-six respondents (7.8%) performed red reflex screening only when they had time to do so, 13 (2.8%) only undertook this when there were concerns raised by the parents. Most respondents (97.3%) used an ophthalmoscope to perform screening. Seventynine respondents (16.6%) felt they were "not sure/underconfident" at performing this test. Only 83 of 479 respondents (17.3%) had received any formal training. The development of an online resource or practical 'refresher' sessions would be well received and likely to improve current practices.
Photoscreening to detect amblyopiogenic conditions is particularly applicable for the child under three years of age because conventional testing is difficult. We have designed an eccentric photoscreener that is inexpensive, easily used and requires only one diagnostic photograph. Some 231 infants and children were refracted and photoscreened and results compared in a blind study. Compliance was good and all cases of strabismus, amblyopia, and amblyopiogenic conditions were diagnosed.
Behcet's syndrome is a rare chronic multisystemic vasculitis of unknown aetiology, is unpredictable and can cause life-threatening complications. This qualitative study aims to explore the experiences of patients living with Behcet's syndrome in New Zealand. Eight English-speaking patients participated in in-depth semi-structured interviews about their experiences of living with Behcet's syndrome. Interviews were recorded and transcribed. Data were analysed using a general inductive thematic approach. Five themes related to the experience of Behcet's syndrome emerged from the interviews: diagnosis (diagnostic challenge and closure), impact of disease (pain, fatigue, reduced vision, fear and uncertainty), loneliness and isolation (lack of support and information, invisible illness), acquiring resilience (coping, gaining sense of control, support group) and ongoing interactions with health system (specialist care, primary care, need for multidisciplinary care, doctor-patient relationship). Behcet's syndrome patients experience difficulties in obtaining a timely and correct diagnosis and contend numerous physical and emotional challenges, often experiencing loneliness and isolation. Establishing trusting doctor-patient relationships, allowing timely access to specialist care and recruiting psychosocial supports will help patients better cope with their illness. Diagnosis and management of Behcet's syndrome requires close collaboration and communication among specialists and general practitioners and improved education on Behcet's syndrome.
To provide information and comparison pertaining to visual impairment of Maori children with other children in New Zealand in particular: prevalence of blindness, causes of visual impairment, and avoidable causes of visual impairment. Retrospective data collection utilising the WHO/PBL eye examination record for children with blindness and low vision at Blind and Low Vision Education Network New Zealand (BLENNZ), Homai. Individuals not of Maori ethnicity or over the age of 16 were excluded from the study. 106 blind and 64 low-vision Maori children were studied. The main cause of blindness in Maori children is cortical visual impairment. Twenty-eight percent of causes of blindness in this population are potentially avoidable with non-accidental injury as the main cause. The prevalence of blindness and low vision in children amounts to 0.05% and 0.03%, respectively. The prevalence and causes of childhood blindness are comparable to the other ethnic groups in New Zealand. The main difference lies in avoidable causes of blindness, which appeared to be much higher in the Maori population. The leading cause of avoidable blindness in Maori children is caused by non-accidental injuries.
Vision impairment affects millions globally, and early detection is critical to preventing irreversible vision loss. Ophthalmology workflows require clinicians to integrate medical images, structured clinical data, and free-text notes to determine disease severity and management, which is time-consuming and burdensome. Recent multimodal large language models (MLLMs) show promise, but existing general and medical MLLMs perform poorly in ophthalmology, and few ophthalmology-specific MLLMs are openly available. We present VOLMO (Versatile and Open Large Models for Ophthalmology), a model-agnostic, data-open framework for developing ophthalmology-specific MLLMs. VOLMO includes three stages: ophthalmology knowledge pretraining on 86,965 image-text pairs from 26,569 articles across 82 journals; domain task fine-tuning on 26,929 annotated instances spanning 12 eye conditions for disease screening and severity classification; and multi-step clinical reasoning on 913 patient case reports for assessment, planning, and follow-up care. Using this framework, we trained a compact 2B-parameter MLLM and compared it with strong baselines, including InternVL-2B, LLaVA-Med-7B, MedGemma-4B, MedGemma-2