News briefs

“Post-Ebola syndrome” dogs survivors

Many survivors of the recent Ebola epidemic in West Africa are now returning to clinics complaining of mysterious symptoms: chronic headaches, debilitating joint pain, even eye problems that can progress to blindness, Wired reports. Doctors in the region have begun calling the suite of problems “post-Ebola syndrome” (PES) and they’re developing clinics devoted to caring for Ebola survivors. Until the latest epidemic, evidence of PES has been hard to find because survivors were rare. “But this most recent outbreak was unusual in the number of people who survived it — a new population to study. With 15 000 or so confirmed survivors in West Africa, epidemiologists ought to be able to nail down which symptoms are caused by Ebola infection”, rather than other suspects like Lassa fever or malaria.

Jail sentences for Bangladeshi paracetamol syrup poisoners

Six senior employees of the now-closed drug company BCI Bangladesh have been handed 10-year jail sentences for making toxic paracetamol syrup which allegedly killed hundreds of children in the 1990s, AFP reports. The men were charged in 2009 after it was found that the syrup had been adulterated with diethylene glycol, commonly used in the leather industry, and 10 times cheaper than the safe propylene glycol. Only one of the six men will go to jail, however, as the other five are still on the run. “Mohammed Hanif, a top paediatric nephrologist, has told AFP that local hospitals first started seeing children with kidney failure in late 1982. But it took another 10 years to establish the deaths were due to diethylene glycol. By then, Hanif says several thousand children had died.”

Second case of plague reported in California

Californian health officials are investigating another possible case of plague in a tourist who fell ill after visiting Yosemite National Park, the Sierra National Forest and surrounding areas — the second case in less than a month, Associated Press reports. “A child fell ill with the plague after camping with his family at Yosemite’s Crane Flat Campground in mid-July. The park reopened Crane Flat last week after treating it for four days with an insecticide. Park officials closed the Tuolumne Meadows Campground from noon Monday through noon Friday so authorities can treat the area with a flea-killing insecticide after two squirrels died of plague in the area.” A spokesperson for the Californian Department of Public Health said the risk to human health “remains low”.

Zebrafish doing their bit for diabetics

ScienceDaily reports that a group of American scientists are claiming to have identified 24 drug candidates that increase the number of insulin-producing cells in the pancreas, via experiments with 500 000 genetically modified zebrafish embryos. The transparent zebrafish embryos were modified so their insulin-producing pancreatic cells glowed yellow, and non-insulin-producing cells glowed red. Using high-throughput screening — using robotic equipment to dose tens of thousands of samples daily — researchers tested thousands of compounds from a Johns Hopkins library of drugs for ones that increased the amount of yellow glow. Originally reported in eLife, Associate Professor Jeffrey Mumm, professor of ophthalmology at the Johns Hopkins Wilmer Eye Institute, says that while more research was needed, “we think there’s potentially no limit on the diseases this screening technique could be applied to other than the human imagination”.

Pilots’ prostates can rest easier

Pilots concerned their risk of prostate cancer was elevated can breathe easier after the retraction of a recent meta-analysis that found they are at least twice as likely to develop the disease, Retraction Watch reports. The paper, recently published in Aerospace Medicine and Human Performance, was retracted for “including inappropriate data from two studies that should be ineligible”. The paper reviewed eight studies, but included two articles that reported on prostate cancer in all United States Armed Forces servicemen, and not just pilots. First author David Raslau, from the Mayo Clinic, apologised, saying: “I was at the infancy of my training in Aerospace Medicine … When I began working on this research project, the phrase ‘Air Force servicemen’ seemed equivalent to the term pilots to me. Now after having completed training in this field, I can easily see the folly of this assumption”.

Equity in vision in Australia is in sight

Implementing the roadmap to close the gap for vision — progress and more work to do

The roadmap to close the gap for vision was developed after extensive nationwide consultation and launched in 2012.1 It comprises 42 recommendations that span a whole-of-system approach to eliminate disparities in Indigenous eye health.2 These recommendations seek to increase accessibility and uptake of eye care services by Indigenous Australians; improve coordination between eye care providers, primary care and hospital services; improve awareness of eye health among patients and clinicians; and ensure culturally appropriate health services. The roadmap is a costed and sector-endorsed framework for a sustainable and efficient system. Community engagement is fundamental for achieving these objectives. It is essential that community and sector stakeholders drive and genuinely own this effort. This public health initiative includes activities to be implemented at regional, jurisdictional and national levels in order to achieve health system reform and improve patient engagement across the eye care pathway.

The roadmap aims at more than just improving eye health — it is about achieving equity. Up to 94% of vision loss in Indigenous adults is avoidable or amenable to treatment.2 Additionally, vision influences and is influenced by the social determinants of health. The child who can see the blackboard and the adult who can drive and participate in gainful employment have opportunities to improve their circumstances; social factors such as educational attainment and employment have a profound impact on a range of health outcomes. Vision also affects independence in activities of daily living, including self- and family care, and the ability to administer medication and manage other health issues. Finally, vision loss accounts for 11% of the health gap between Indigenous and non-Indigenous Australians,3 so it follows that fixing the eye care system to address avoidable vision loss will help to close the broader health and social gaps and will have flow-on effects well beyond eye health.

After decades of relative political inertia and a policy approach that has delivered periodic but short-lived activity,4 the roadmap has garnered considerable political and stakeholder support. Elements of the roadmap are currently being progressed nationally in several jurisdictions and in a number of health regions.

In this article, we report on the progress made in the 3 years since the launch of the roadmap, and call for support for these efforts from the broader medical and public health communities.

Regional activity

The roadmap identifies specific activities required at the regional level (Box 1). Regions take into account state or territory health department, Medicare Local and other boundaries, but should include a cataract surgical facility. Regional implementation requires the establishment of a collaborative network to coordinate and oversee regional activities. This group of key local stakeholders includes Aboriginal health services; the local hospital district; the Medicare Local; primary care; optometry and ophthalmology clinicians; and public health authorities. Regional implementation is iterative, requiring regular measurement of system performance and adoption of any necessary activity to bridge identified service delivery gaps.

To date, 12 regions have initiated this process (Box 2). They cover five jurisdictions and about 35% of Indigenous Australia. Regions are at different stages of implementation, and the factors influencing the assembly and composition of the collaborative networks have varied markedly, reflecting differences in local contextual factors and funding arrangements. A dedicated individual has been assigned to an eye health regional implementation role in some regions, either through specific additional funding or reassignment of existing staff resources. These individuals have often had a significant impact.

Regional implementation tools have been developed.5 These include an online calculator that provides first-order estimates of the expected burden of eye disease and associated need for eye care in a region; an eye care service directory template to be populated with local details; specification of regional data requirements for gap analysis and monitoring; and an implementation checklist to guide regional efforts.

The national program for trachoma control has had impressive results, with the prevalence in children reducing from 14% in 2009 to 4% in 2013.6

Expert technical advice and support spanning ophthalmology, optometry, health services management and public health are also available to regions through the Indigenous Eye Health Unit (IEHU) at the University of Melbourne. The IEHU maintains close communications with all regions and receives some federal Department of Health funding for this. The IEHU participates in national forums and regional collaborative network meetings as requested and facilitates the sharing of lessons learned and stakeholder networking between regions.

Jurisdictional and national activity

A number of roadmap recommendations have been fully implemented (Box 3) and we highlight some achievements and ongoing activities.

Governance

A national oversight function, reporting to high levels of government, is essential to govern the roadmap approach. The need for such national leadership and commitment to reducing disparities in Indigenous eye health has recently been noted in speeches in both the Senate and House of Representatives. A national oversight proposal has been presented to government and the appropriate ministerial/advisory forum to assume this function is currently being assessed.

Jurisdictional oversight varies across the country. In Victoria, an eye health committee sits within Koolin Balit, the Victorian Government strategic plan for Aboriginal health. Chaired by the state health department, this committee has broad membership including state and Commonwealth departmental authorities, clinicians and representatives of Indigenous health and eye health peak bodies. Elsewhere, such jurisdictional activity is less well developed, although a similar committee has been established recently in the Northern Territory, sitting within the Aboriginal health planning framework.

Eye health indicators and regular measurement of population eye health status

Regular monitoring of system performance is required at regional, jurisdictional and national levels, and parameters measured and reported need to be consistent across the country and over time. A series of indicators has been developed and recommended for periodic collection and collation at various levels of the health care system. These measures will ascertain the size of any service gaps, inform the nature of any action required to bridge disparities and measure impact over time.

Regular reporting on population-level eye health status is also required. After a 30-year deficit in national population-level eye health data, the National Indigenous Eye Health Survey was conducted in 2008 and its findings highlighted the gross inequities in the burden of avoidable visual impairment and blindness among Indigenous adults.7 National data are needed every 5 years to monitor progress and meet Australia’s international commitment to regularly monitor disease burden and reduce prevalence of avoidable blindness under World Health Assembly resolution 66.4.8 The Australian Government has recently committed funding for a National Eye Health Survey, to assess the eye health of both Indigenous and non-Indigenous Australians. This survey will update the data on vision loss, gauge the collective impact of roadmap activities and help inform future priority action areas.

Eliminating cost as a barrier to accessing eye care

To eliminate cost as a barrier to service uptake, the importance of cost-certainty and bulk-billing have been highlighted for clinicians.9 Approaches to health authorities have sought to reduce consulting fees charged above schedule and to ensure adequate public ophthalmology services.

Cost is also a potential barrier to accessing glasses. Criteria for nationally consistent subsidised spectacle schemes have been endorsed by eye care and Aboriginal peak bodies. Currently, availability, eligibility to access subsidies and out-of-pocket expense vary greatly between jurisdictions.10 Indigenous patients in Victoria can obtain subsidised spectacles at an out-of-pocket cost of $10. In other states, there is limited supply of free glasses under subsidy schemes. Advocacy continues for appropriate low-cost spectacle schemes in each jurisdiction.

Building eye health workforce capacity and coordination of care

Measures to increase workforce capacity, sustainability and resources include increased Commonwealth funding for visiting services, equipment and infrastructure; earmarked funding for ophthalmology training in outback services; and a Medicare item number for retinal photography to increase coverage of retinal screening for people with diabetes.

Recommendations for medical software packages include prompts for providers for annual eye examinations when an Indigenous patient with diabetes presents for care.

Commonwealth funds for visiting optometry and ophthalmology services will be allocated through jurisdictional fundholders from 2015. Significant efforts to improve funding arrangements, and for fundholders to improve the coordination of visiting services, will ensure the appropriate sequencing, frequency and mix of services.

Conclusion

Over the 3 years since the launch of the roadmap to close the gap for vision, progress has been made to increase services, improve efficiencies and support better Indigenous patient engagement with the eye care system. Demonstrable gains are being made and there is growing momentum around the roadmap initiatives, but much remains to be done, and increased government support is required. In partnership with Indigenous communities and organisations, the public health and medical communities have a responsibility to engage with this effort and help close the gap for vision. The template used for eye care has high relevance for integrating care between primary health and essentially all visiting specialist services. With concerted multisectoral effort, political will and a commitment to establishing a sustainable eye care system, the gross disparities in eye health that exist between Indigenous and non-Indigenous Australians can be eliminated. Equity in vision in Australia may well be in sight.

1 Roadmap to close the gap for vision: elements of regional implementation

2 Regional implementation of the roadmap, June 2015

3 Completed actions in implementing the roadmap, June 2015

Primary eye care as part of comprehensive primary health care

Online education resources developed in eye care, diabetic eye care and trachoma
Eye health training courses developed and delivered for Aboriginal health workers
Eye checks included in Medicare item 715 annual health assessments

Indigenous access to eye health services

Increased eye care delivered through Aboriginal Medical Services
Cultural training incorporated in funded outreach eye programs
Sector agreement on subsidised spectacle supply

Coordination and case management

Project officers assigned in some regions
Service directories developed in some regions

Eye health workforce

Increased linkage between optometry and ophthalmology outreach programs

Elimination of trachoma

New national guidelines released
National surveillance and reporting continued

Monitoring and evaluation

Gap and needs analysis for service requirements undertaken in some regions
National Eye Health Survey partially funded
Eye health included in the National Health Performance Framework
Annual roadmap progress reports released

Governance

Eye care and Aboriginal health sector support for the roadmap

Stakeholder networks established in some regions

Indigenous eye committees established in some jurisdictions

Health promotion and awareness

Trachoma health promotion continued
Eye care health promotion material for patients with diabetes being developed

Health financing

Trachoma surveillance and treatment funded to 2017
Roadmap cost estimates revised

The trumpet’s blown pupil

On the advice of a neurologist friend (author C P), a 42-year-old man was rushed to hospital with a fixed dilated pupil (Figure, A). His condition was otherwise normal, as were the findings of urgent magnetic resonance imaging and angiography of the brain.

By Day 3, his mydriasis had resolved (as did the mystery) when the patient asked his “learned” friend how common eye injuries with whipper-snippers were. He mentioned, in passing, that on the morning of the incident he had cut back his beloved Angel’s trumpet (Figure, B) — a member of the Solanaceae family, all parts of which are laced with anticholinergic alkaloids.

A detailed history, botanical or otherwise, will always trump the next best test.

Cataract surgical blitzes: an Australian anachronism

Surgical blitzes may achieve short-term gains, but they inhibit the development of sustainable local services

Surgical blitzes to treat eye disease are often used to redress shortfalls in service provision. In developing countries with scarce human and financial resources, such periodic visits from local or overseas health teams may be justified, as they are generally combined with building local capacity. However, Australia has no such resource constraints. Despite this, surgical blitzes occur year after year in some rural and remote locations in Australia, without concurrent development of sustainable local services. We see this as a particular problem for eye health in Indigenous people.

The first eye surgical blitzes in Australia occurred during the National Trachoma and Eye Health Program in the 1970s. At each site, an Australian Army field hospital team worked for a week, and about a hundred Aboriginal people had sight-restoring eye surgery.1 Over the years, similar army exercises were repeated across the Northern Territory, including, on one occasion, a tented field hospital being put up in a hospital car park.2

Everyone felt a very good job was being done, but nothing really changed. More recently, regular surgical blitzes, rebranded as “surgical intensives”, were started in Alice Springs and elsewhere in the NT; but these were also short-term fixes.

There is an ongoing need for more eye surgery in these areas.3 Aboriginal and Torres Strait Islander people have a sixfold greater rate of blindness than non-Indigenous Australians.4 They have 12 times higher rates of cataract blindness, but receive seven times less cataract surgery. A blind Indigenous person needing cataract surgery should be put on a surgical waiting list and operated on within 3 months.5 However, those who manage to get onto a waiting list will wait almost twice as long as non-Indigenous Australians,6 sometimes waiting several years or more before receiving surgery.

There are complex factors affecting Indigenous Australians’ willingness to attend for surgical treatment, but once a patient is ready for surgery, he or she should receive it promptly. Surgery may need to be delivered opportunistically for patients with competing community and cultural priorities. Multiple things can be done to prevent Indigenous patients from dropping out of the system: 35 such key points have been identified in the patient journey for cataract surgery.7

Blitzes seem to provide a quick and rewarding solution. Surgery gets done, patients get their vision back, and surgeons and staff feel satisfied. Blitzes usually receive government and private funding, so the investors feel good that something is being done and they obtain positive publicity. But the patients who turn up the next week do not feel so good. They do not know how long they will have to stay blind while awaiting another blitz. Those who were already on a waiting list but could not forgo family, community or cultural responsibilities for the surgery have to wait longer. The staff who worked so hard to make the blitz possible understandably need a break; until it is time to start planning the next one. The end result is that the system is never fixed and rolling blitzes become the norm in dealing with the aching unmet need.

Although there is still a long way to go, Indigenous life expectancy is improving. With an ageing population, the burden of age-related cataract is likely to double in the next 20 years,8,9 and an increasing number of older Indigenous Australians will need sight-restoring cataract surgery. We must ensure that Indigenous people do not experience unnecessarily prolonged visual impairment and blindness, to enable them to maintain quality of life and independence in these additional years of life.10 While poor vision is not the only unsolved problem in Indigenous health, it causes 11% of the health gap.11 Unlike many other conditions, most of this vision loss can be cured overnight with spectacles or cataract surgery.

What is required is adequate provision of sustainable, ongoing services.12 Surgical blitzes on their own are neither a long-term nor a sustainable solution. They may show what is possible with adequate resources over the short term, but no lasting change is implemented and the underresourced local service struggles on. Blitzes alone will not clear the growing backlog or provide sufficient volume of services to meet the increasing need for surgery; although targeted blitzes to clear a regional backlog, with concurrent development of ongoing coordinated surgical services, make sense.13 With the backlog reduced, the local service then requires appropriate resourcing to meet the ongoing need for surgery in a timely manner and to provide the direct personal interaction that is so highly valued by the Indigenous community and patients.

Unfortunately, despite the best of intentions and attempts at gaining government commitment through agreements and memoranda of understanding, the diversion of resources to arranging surgical blitzes means there are limited resources allocated to developing local services. So, paradoxically, blitzes prevent the development of the sustainable solutions needed to provide equity of care and to close the gap in Indigenous eye health.

Australia in 2015 has a sophisticated health system with the capacity to provide the services required. We cannot afford repeated short-term and unsustainable surgical blitzes. We are lucky that strong advocacy exists among vision care organisations to raise awareness of the need for long-term solutions and sustainable regional eye services.14 Australia should be leading the way in showing how to deliver eye care, rather than consistently showing how not to.

Cytomegalovirus disease in immunocompetent adults

To the Editor: We read with interest the review by Lancini and colleagues on cytomegalovirus (CMV) in immunocompetent patients.1 This topic and its associations with ocular disease has garnered increased recognition in the eye care community.

Clinically, CMV can cause an anterior uveitis (iritis) or, more rarely, retinitis, in otherwise healthy patients.2 The uveitis typically features a chronic and/or recurrent course with anterior segment inflammation, keratic precipitates, endotheliitis, iris atrophy and elevated intraocular pressure (IOP).3 CMV retinitis is characterised by confluent or semiconfluent areas of retinal whitening with haemorrhage.4

As with systemic CMV disease, oral valganciclovir appears to be effective treatment for ocular disease.3–5 CMV-associated ocular disease in immunocompetent adults is underdiagnosed due to low clinical suspicion and its capacity to mimic inflammatory eye disease associated with other Herpesviridae such as herpes simplex virus or varicella zoster virus.3,5 Misdiagnosis as other Herpesviridae can result in antiviral treatment that is ineffective in CMV disease. Thus, CMV ocular disease should be considered as a differential diagnosis in immunocompetent patients presenting with chronic unilateral anterior uveitis or retinitis. Where suspected, an anterior and/or vitreous chamber paracentesis with viral polymerase chain reaction (PCR) analysis should be performed for definitive diagnosis.3

A recent case illustrates this diagnostic challenge. A 53-year-old immunocompetent and systemically well man presented with a unilateral chronic anterior uveitis and elevated IOP. Treatment with topical corticosteroid eyedrops was commenced for non-infectious uveitis. After a poor response, an anterior chamber paracentesis was performed, which tested positive for CMV (on PCR). The uveitis subsequently became quiescent with oral valganciclovir.

The Sydney siege: courage, compassion and connectedness

To the Editor: Raphael and Burns highlighted the strong police response to the hostage situation in Sydney in 2014.1 Diversionary devices, such as the flash-bang grenades used in Sydney, have been increasingly used to distract and disorientate people in civilian hostage and riot situations internationally. While not intended to cause permanent damage, there are risks associated with their use.

Flash-bang grenades deflagrate using a powdered blend of aluminium, magnesium and ammonium perchlorate, which generates a spontaneous explosion. When initiated, illumination is produced through oxidation of the components, resulting in heat exceeding 38°C, a blast reaching 180 decibels and a brief flash of 1–6 million candela (up to 600 million lux) within a distance of about 1.8 m.2

The intense flash results in temporary bleaching of the photoreceptors in the eye. Ocular injury can occur if the flash-bang grenade explodes at close range, with possible thermal or mechanical damage. Other more powerful devices, producing a similar intensity of unidirectional light, have resulted in vision loss similar to that seen with laser weapons.2

Temporary hearing loss and aural pain results from a single or multiple blast of loud noise between 140 and 170 decibels. Damage to the sensitive structure of the inner and middle ear can result in hearing loss and tinnitus.3 Perilymphatic fistula of the inner ear may occur, necessitating immediate assessment and possible surgical treatment.4

Premature deflagration can also cause injury to the operator.5 As these devices continue to be used in civilian situations, it is important to remain aware of any potential hazards, to both the operator and bystanders.

Severe glaucoma and vision loss due to cosmetic iris implants

To the Editor: With medical tourism on the rise, public education concerning the risks of procedures performed abroad is imperative to the health and wellbeing of the Australian population. The insertion of cosmetic iris implants is a procedure currently promoted overseas. Here, we describe an example of the risks associated with this procedure.

A 26-year-old man presented with acute right eye pain, conjunctival erythema and a high intraocular pressure of 40 mmHg (normal intraocular pressure is 11–21 mmHg). Secondary angle closure glaucoma was diagnosed.

Three years before presentation, the patient had bilateral NewColorIris implants inserted in Panama City. Removal of the implants was recommended but the patient initially declined. Medical glaucoma therapy was instituted. The glaucoma progressed and the eye became inflamed. The right iris implant was removed (Box).

A trabeculectomy enhanced with mitomycin C was required to control the intraocular pressure. The left implant was subsequently removed due to progressive glaucoma, and the left eye also required trabeculectomy enhanced with mitomycin C. This trabeculectomy failed, and the patient has recently undergone left glaucoma tube insertion (Baerveldt BG 101-350 Glaucoma Implant, Abbott Medical Optics). The patient’s visual function declined due to progressive, irreversible glaucomatous visual field defects.

NewColorIris has been marketing and performing iris implants for cosmetic and non-cosmetic indications since 2006. To our knowledge, over 700 procedures have been performed at one site by one surgeon in Panama.

Recently, a new company called BrightOcular began offering artificial iris implants for indications such as iris heterochromia, albinism and aniridia, and for cosmetic use to change eye colour.1 The product is currently available in 10 countries worldwide.

To our knowledge, there are no published data on the safety of BrightOcular iris implants. However, given the complications associated with NewColorIris implants, as reported here and by others,2–4 we are concerned that similar safety problems may exist with this new device.

Cosmetic iris implants carry a high risk of irreversible visual loss. We highlight this risk for patients considering medical tourism and urge primary care providers to review the current literature before offering advice regarding this procedure.

Right eye of a 26-year-old patient with severe glaucoma before and after removal of a cosmetic iris implant

A: Cosmetic iris implant in the anterior chamber. B: Traumatic iris defects after implant removal.

Severe alkali burns from beer line cleaners warrant mandatory safety guidelines

To the Editor: Chemical burns from alkaline cleaning chemicals in the workplace can cause some of the most devastating and blinding ocular injuries, as noted by Samarawickrama and colleagues.1 Protection from alkalis is particularly important as these compounds are capable of deep penetration, especially in the cornea, and tissue destruction continues long after the initial exposure.2

The Work Health and Safety Act 2011 (Cwlth) requires anyone with a duty for ensuring health and safety to eliminate health and safety risks so far as is reasonably practicable.3 Where elimination of hazards is not possible, personal protective equipment (PPE) forms the last line of defence. The risk of splashes from very hazardous chemicals necessitates a full face shield, gloves, protective clothing and boots.4

Hotel owners and beer and chemical manufacturers should educate workers about the hazards of beer line cleaning chemicals and appropriate procedures to minimise the risk of injury. Education on risks, safety procedures, PPE and first aid remains critical for successful injury prevention strategies.5 Young and inexperienced workers should be a focus of education, as they are at higher risk of ocular injury due to their immaturity and lack of experience.

Appropriate first aid, including eye wash shower bottles or stations, should be in place. The reported cases represent a stark reminder to employers to safely manage the use of hazardous chemicals, in particular alkalis, that are an injury risk for workers.

Characteristics, management and outcomes of chemical eye injuries in Victoria

To the Editor: Chemical eye injuries are an ophthalmic emergency that can potentially result in visual impairment.1 A retrospective audit was performed to determine the characteristics, management and outcomes of chemical eye injuries in patients presenting to the Royal Victorian Eye and Ear Hospital (RVEEH).

The records of 176 patients who presented to the emergency department between 1 July 2012 and 31 December 2012 were analysed. The average age was 41 years (range, 7–85 years), with 110 (62.5%) being male. Forty-six patients (26.1%) had bilateral injuries. The characteristics, management and outcomes of injuries are outlined in the Box. Eighty-two injuries (46.6%) occurred at home, and 65 (36.9%) occurred in the workplace. Men accounted for 40 (48.8%) of the injuries that occurred at home and 52 (80.0%) of the workplace injuries. In 65 injuries (36.9%), cleaning was the activity at the time of injury. Of these, 33 injuries (50.8%) occurred at home and 24 injuries (36.9%) occurred in the workplace. At the time of injury, 123 patients (69.9%) were not wearing eye protection, with nine (5.1%) wearing spectacles alone. The causative agent was alkaline in 114 cases (64.8%).

One-hundred and thirty-eight injuries (78.4%) were irrigated before arrival to hospital, and 132 patients (75.0%) required further irrigation on presentation to the RVEEH to neutralise the pH. Using the Roper-Hall classification,2 most were mild injuries (92.6% were grade 1; 3.5% were grade 2; 1.7% were grade 3; 0 were grade 4 (the other 2.2% could not be determined from the notes). All injuries were managed medically. The median visual acuity at discharge was 6/6, and one injury was complicated by corneal scarring.

Similar to findings of previous studies,1,3 two-thirds of chemical eye injuries in Victoria occurred in men. While most injuries in men occurred at the workplace, both sexes were almost equally represented in injuries occurring at home. Most patients were not wearing any form of eye protection at the time of injury. Although there has been promotion and an increased awareness of the importance of protective eyewear,4 more education and reinforcement are warranted to reduce the incidence of chemical eye injuries.

Removal of particulate matter after injury and prompt irrigation, either with Hartmann’s solution or normal saline, until the pH of the injured eye is neutral are the most vital steps that can reduce the development of complications and improve visual outcomes.1,5 Our study suggests that although there was awareness of the importance of irrigation, many patients were still not receiving irrigation with adequate volumes. General practitioners and emergency medicine doctors are the initial point of contact in 40.9% of injuries and should be encouraged to not only adequately irrigate, but increase the awareness of preventive measures.

Prevention and early treatment of chemical eye injuries are vital. This can be achieved through increased awareness of the dangers of chemicals, careful handling of chemicals, wearing of protective eye-wear and immediate irrigation after injury. These are important public health messages that need to be continually emphasised.

Characteristics, management and outcomes of injuries in 176 patients presenting to the Royal Victorian Eye and Ear Hospital (RVEEH)

Characteristics of injuries

Patients
(n = 176)

Initial presentation

RVEEH

97 (55.1%)

General practitioner

38 (21.6%)

Other hospital emergency department

34 (19.3%)

Other

7 (4.0%)

Agent

Alkali

114 (64.8%)

Acid

45 (25.6%)

Other

17 (9.7%)

Management of injuries

Before RVEEH

None

25 (14.2%)

Irrigation

138 (78.4%)

Antibiotics

20 (11.4%)

Other

8 (4.5%)

At RVEEH

None

1 (0.6%)

Irrigation

132 (75.0%)

Mean amount of irrigation (range)

0.8 L (0–10 L)

Topical treatment

Steroids

78 (44.3%)

Antibiotics

147 (83.5%)

Lubricants

74 (42.0%)

Other

20 (11.4%)

Outcomes of injuries

Injuries
(n = 222)

Visual acuity (Snellen)

Median

6/6

≥ 6/12

216 (97.3%)

6/15 to 6/60

4 (1.8%)

< 6/60

2 (0.9%)

Surfboard-related eye injuries in New South Wales: a 1-year prospective study

Surfing carries a well documented risk of head and facial injuries1–8 and these injuries may have become more frequent in recent times with overcrowding at beaches and the streamlining of surfboard design. Ocular trauma caused by surfboards can be severe, with long-term effects on the work prospects and lifestyles of otherwise fit, young people.1 There is an increasing number of case reports of severe surfboard-related eye injuries (SREIs)5–7 and active discussion in the medical literature about the need for protective eyewear while surfing. Studies have found that protective headgear is seldom worn by surfers.8,9

No studies have examined the incidence of SREIs among surfers of all levels of experience in New South Wales or Australia. We need data on these injuries to establish the extent of the problem so that recommendations for the use of protective eyewear and headgear while surfing and guidelines for surfboard design can be developed for the Australian context, if required.

In this prospective study, we aimed to determine the incidence, nature and severity of SREIs in NSW over 1 year, between 30 December 2010 and 30 December 2011.

Methods

For the purposes of this study, an SREI was defined as any eye, orbit or eyelid injury caused by a surfboard.

We sought to involve all NSW ophthalmologists in reporting SREIs by including a one-page description of our study and an accompanying doctor questionnaire in two of the Royal Australian and New Zealand College of Ophthalmologists’ (RANZCO) quarterly newsletters. There are 308 Fellows of RANZCO registered in NSW. Ophthalmology trainees in NSW, of whom there are 61, were informed about the study at regular meetings which are attended by an overwhelming majority. We also made the questionnaire for doctors available via a link on the Save Sight Institute website. Patients with SREIs were given a study information card by their doctor with the contact details of the researchers, and when they contacted us, they were given a patient questionnaire to complete and return by email.

Sixteen coastal and teaching hospitals in NSW were involved in the study and human research and ethics committee (HREC) approval was obtained from them and from the University of Sydney. The lead HREC for this study was that of the Northern Sydney Central Coast Area Health Service (NSCCAHS). The NSCCAHS emergency departments’ data were monitored via their electronic database for patients presenting with SREIs during the study period. An article about this study appeared in The Sydney Morning Herald (SMH) near the conclusion of the study to capture any SREIs not reported to us via doctor questionnaires.

The de-identified doctor questionnaire included a description of the injury, date of injury, visual outcome, sex and age of the patient and place the injury occurred.

The de-identified patient questionnaire sought demographic information, details of the injury and its severity, details of the event during which the SREI occurred and information on the surfer’s level of experience. The questionnaire is shown in full in the Appendix.

Results

Nine SREIs were reported by five ophthalmologists and two trainees (Box) and one SREI was self-reported by a patient. Doctor questionnaires were completed for all but one patient who did not seek medical attention. This patient self-reported the injury to us (with an accompanying photo) in response to the article in the SMH. Eight of the 10 patients were male. They ranged in age from 9 to 71 years, with a mean age of 35.4 years. Most patients had a combination of eye injuries. There was one periorbital contusion and six patients had eyelid lacerations. There were four orbital fractures and two penetrating eye injuries resulting in loss of vision and loss of the eye in one case. There was one case of retained fibreglass foreign bodies in the orbit. We are aware of an additional case of globe rupture sustained while surfing, but the data are incomplete as a doctor questionnaire was not received; it has not been included in our data analysis.

Seven of the 10 patients completed patient questionnaires. SREIs occurred in seven separate locations and, interestingly, one of the eye injuries was sustained while using the surfboard in a backyard swimming pool. The other injuries occurred at Queens Head on the north coast, two different beaches in Shellharbour, Forster, Maroubra and Bondi. The injuries occurred throughout the year. Five of the seven patients were hit by their own boards and two were hit by someone else’s board. In all four cases of SREIs caused by a patient’s own board when surfing (the fifth SREI occurred in a backyard pool), the patient was wearing a leg rope. One patient was learning to surf while six others all surfed at least once per week.

In a 2011–2012 Australian Bureau of Statistics report on participation in sport and physical recreation, the number of people aged 15 years and over estimated to be participating in surf sports in NSW was 120 200,10 among a NSW population at the time of 5 853 800. Based on our study and using the mid P method, the incidence of SREIs in NSW is 8.3 per 100 000 person-years (95% CI, 4.2–14.8 per 100 000 person-years).

Discussion

Our study confirms that surfing does carry a small risk of severe ocular injury.

At present there are no government regulations or recommendations about surfboard design or wearing protective eyewear or headgear while surfing. It would be possible to attach soft rubber tips to the nose or tail of short boards and to make fins from flexible material such as rubber. Protective eyewear and helmets especially designed for water sports are available.5 Further research would be needed to assess the efficacy of surfboard modification and protective eyewear for preventing SREIs.

This is the first prospective longitudinal study of SREIs in Australia or NSW, and it has helped to describe and quantify the risk of SREIs. A limitation of the study is that we may not have captured all cases of SREI by our study method. It is possible that not all NSW ophthalmologists were reached through our communications in the RANZCO journal, or that they chose not to participate because, despite our best efforts to simplify the reporting, they found it too cumbersome or time-consuming. We are aware of one such unreported SREI. Also, we may have missed minor injuries for which patients presented to optometrists or general practitioners or to no health professional at all. Further, we cannot be sure that the emergency department data we used captured all SREIs. Finally, not all patients responded to the patient questionnaire, so our data are incomplete with regard to specific risk factors for SREIs. Despite possibly underestimating the incidence of SREIs, our study has documented that SREIs do occur and that they are predominantly associated with the hard projections of the surfboard.

We report 10 SREIs occurring over a year in NSW in a range of circumstances, ages and levels of experience. One fifth of the SREIs we report were severe. One fifth of the injuries were in children. All parts of surfboards may be responsible for SREIs, consistent with the findings in other studies.5 Most of the severe ocular injuries in the literature and one of the two severe injuries we report were caused by the nose of the surfboard. It may be most important to modify this part of the surfboard to reduce the incidence of SREIs.

Surfboard-related eye injuries: questionnaire results

Doctor questionnaire results*

Patient questionnaire results

Case

Description of injury and surgery

Severity and
visual outcome

Swell

Manoeuvre

Surgery

Board type

Part of board causing injury

Leg
rope

Surfing experience

Injury: brow, UL, LL and canaliculus lacerations
Surgery: lacerations sutured, Mini Monoka stent inserted

Mild
No change from previous vision

Standing

Yes, once

Short, own board

Fin

Twice/
week

Injury: corneal and scleral laceration, vitreous haemorrhage
Surgery: primary closure of corneal/scleral laceration

Severe
6/24 – blindness

1–2 m

Not standing

Yes,
3 times

Short, own board

Nose

Yes

Once/
week

Injury: orbital floor fracture
Surgery: no surgery

Mild
No impairment

1–2 m

Not standing

Long, own board

Fin

Yes

Learning
to surf

Injury (from photo; no doctor questionnaire completed): periorbital contusion

1–2 m

Standing

Short, own board

Side of board near nose

Yes

Daily

Injury: conjunctival, LL, lateral canthus and nose lacerations
Surgery: lacerations sutured

Mild
No impairment

No patient questionnaire received

Injury: UL laceration, orbital fracture, orbital fibreglass FBs, nose fracture
Surgery: laceration sutured, removal of fibreglass FBs, nose fracture repaired

Mild
No impairment

< 1 m

Standing

Yes, once

Short, own board

Nose

Yes

Daily

Injury: medial wall orbital fracture, posterior globe rupture and eyelid lacerations
Surgery: evisceration, eyelid lacerations sutured

SevereLoss of eye

No patient questionnaire received

Injury: LL laceration
Surgery: no surgery

Mild
Normal vision

1–2 m

Body
boarding

Long, not own board

Bottom edge

Once/
week

Injury: UL laceration
Surgery: no surgery

Mild
Normal vision

> 2 m

Standing

Long, not own board

Back side of board

Daily

Injury: orbital floor fracture
Surgery: open reduction and internal fixation of fractured orbit

Mild
Normal vision

No patient questionnaire received

FB = foreign body. UL = upper lid. LL = lower lid. na = not applicable. nd = no data.* Reported by five ophthalmologists and two ophthalmology trainees.