Ophthalmology

A 28?year?old man developed a painful left eye with purulent discharge two weeks after recovering from coronavirus disease 2019

Chloe Story · Tina Marinelli · Simeon Crawford · Amrita Ronnachit

Accessibility in research is an ongoing commitment that will continue to change based on the needs and preferences of the community. We must weigh up the impact of incorporating accessibility practices in research with the social cost of forgoing them

Eden G Robertson · Kate Hetherington · Meredith Prain · Julia Hall · Leighton Boyd AM · Rosemary Boyd OAM · Emily Shepard · Hollie Feller · Sally Karandrews · Fleur O'Hare · Kanae Yamamoto · Matthew P Simunovic · Robyn V Jamieson · Alan Ma · Lauren Ayton AM · Anai Gonzalez‐Cordero

Both health care costs and broader societal costs should be considered when evaluating the cost-effectiveness of new therapies

Benjamin Kamien · Rachael Heath Jeffery · Fred K Chen

To the Editor: Curtis and colleagues1 describe important implications for consideration as the metaverse begins to affect health care. These implications are particularly salient for individuals with specific physical impairments, especially vision loss. Emphasis on visual input in the metaverse may have implications for patients with vision loss. The lack of tactile input in the metaverse will disproportionately affect people with profound vision loss. The consequences include social isolation, motion sickness, and reduced access to services. In addition, people who lack stereopsis may also be disadvantaged in a metaverse. These individuals do not experience the stereopsis‐derived depth perception required for the three‐dimensional perception of the visual world. Efforts must be made to ensure that monocular depth cues, including linear perspective and motion parallax, are considered during metaverse development.2 Should health care be provided via the metaverse, vision impairment may limit access to these services. Difficulty accessing services may lead to deterioration in ocular conditions and potentially compound the initial vision loss precluding access.3 There are existing strategies that facilitate the use of visual media for people with vision impairment. These methods have been developed for telecommunication, cinematic and video game technologies. Mechanisms to improve accessibility, including having the capacity to increase text size substantially without disrupting user interfaces, could be employed in all screen‐based technologies.4 Effective accessibility features, such as adaptive audio description, must be available for visually impaired users. Ongoing technological development may facilitate metaverse access for people with visual impairment. There is ongoing research into the optimisation of head‐mounted and digital visual displays to facilitate use for those with vision impairment and visual field defects.5 However, this digital display technology will not facilitate access for people with profound vision loss, such as those with no perception of light. Moving forward, companies should strive to provide equal access to services to all individuals, including those with visual impairment. Regulatory frameworks may help to standardise this incorporation of accessibility. The proactive consideration of the needs of the visually impaired during the development of the metaverse may facilitate the implementation of more effective technology. Engaging disability stakeholders during testing phases of technology may help to identify issues at early stages of development.

James Pietris · Yiran Tan · Weng Onn Chan

To assess the cost-effectiveness of IRD treatments, the substantial societal costs of IRDs must be considered

Deborah Schofield · Joshua Kraindler · Owen Tan · Rupendra N Shrestha · Sarah West · Natalie Hart · Liny Tan · Alan Ma · John R Grigg · Robyn V Jamieson

A 12-year-old girl presented to a general practitioner with a two-day history of progressively worsening blurry vision

Nandini Singh · Kanika Chaudhri · Caroline Catt

A 55-year-old woman in the United States, with a history of interstitial cystitis diagnosed at age 33 years, was referred for pattern macular dystrophy

Aaron Priluck · Adrian T Fung · Mandeep S Singh

Elimination programs should be guided by the prevalence of markers of infection, not of disease

Jaki Adams · Sung Hye Kim · Anthony W Solomon

Assessing progress to trachoma elimination in Australia and elsewhere should therefore incorporate laboratory testing

Kathleen D Lynch · Wendy Morotti · Garry Brian · Lenore Ketchup · Kozue Kingston · Mitchell Starr · Robert S Ware · Beth Everill · Nazihah Asgar · Anne O'Keefe · Lisa J Whop · John M Kaldor · Stephen B Lambert

There is clearly an unmet need for timely, equitable access to cataract surgery in Australia

Alexander Foss

Timely and equitable access to cataract surgery can prevent fall-related injuries and support healthy ageing

Lisa Keay · Kam Chun Ho · Kris Rogers · Peter McCluskey · Andrew JR White · Nigel Morlet · Jonathon Q Ng · Ecosse Lamoureux · Konrad Pesudovs · Fiona J Stapleton · Soufiane Boufous · Jessie Huang‐Lung · Anna Palagyi

To the Editor: We thank Polkinghorne and Kerr1 for their editorial on the health care needs of people with chronic kidney disease (CKD). We write to highlight the burden of visual loss suffered by people with CKD and its effects on quality of life and mortality. The prevalence of eye diseases associated with visual impairment (combined World Health Organization definitions of blindness and low vision) in people with CKD is about 36%, rising to about 60% in people with end‐stage renal disease.2 The commonest causes of visual impairment are diabetic retinopathy (prevalence in patients with CKD, 19–46%), cataract (prevalence, 33–75%) and age‐related macular degeneration (prevalence, 8–36%).2 Increased incidence of retinal vein occlusions and hypertensive retinopathy are also associated with CKD. Patients receiving haemodialysis have increased risk of additional ocular complications. A recent study of 121 patients found at least one ocular finding in over 89% cases, including conjunctival (32%) and corneal (32%) calcification, and optic atrophy (19%).3 Ectopic calcification has been a common cause of irritated eyes in patients receiving dialysis, but this may be decreasing with modern dialysis methods. Increased risk of optic atrophy may be related to chronic anaemia and an increased risk of non‐arteritic anterior ischaemic optic neuropathy. Uraemic optic neuropathy is now an uncommon event. People with CKD are recognised to have an increased risk of dying from heart disease (up to 20 times that of age and gender matched people for people on haemodialysis).4,5 Vision impairment may incrementally contribute to increased mortality; a recent meta‐analysis demonstrated an all‐cause mortality hazard ratio of 1.43 (95% CI, 1.22–1.68) for visual acuity worse than 6/18.6 Vision‐related quality of life is potentially reduced in people with CKD, affecting their ability to complete activities of daily living and their social, emotional and economic wellbeing. Vision loss is associated with increased risk of falls and increased mental health burden, typically anxiety and depression, and may limit the ability to live independently, including self‐medicating with insulin and performing home dialysis. Multiple studies show people rate losing vision as worse than losing hearing, memory, speech or a limb.7 We agree that supportive care clinics for people electing to not receive kidney replacement therapy are important, and suggest that these clinics include regular eye care services.

Heather G Mack · Deborah J Colville · Judith A Savige

A 6-year-old girl presented with a 24-hour history of sudden onset, non-tender periorbital rash

Yi‐Teng Hung · Chun‐Bing Chen

A 67-year-old man presented to his rural GP with left facial pain

Timothy R Holmes · Jenny L Hepschke · Ian Jacobson · Anthony Maloof

To the Editor: We read with interest the perspective by Sonido and colleagues.1 We wish to highlight that Australian and New Zealand guidelines on screening for hydroxychloroquine retinopathy have been published by the Royal Australian and New Zealand College of Ophthalmologists (RANZCO),2 written by a panel of retinal specialists in consultation with relevant medical disciplines. Key recommendations in the RANZCO guidelines include: baseline examination within the first year of hydroxychloroquine use; annual screening after 5 years of use for patients with no risk factors; and consideration of earlier review for patients at increased risk, such as those who receive hydroxychloroquine doses > 5 mg/kg/day; have renal impairment; use concurrent tamoxifen; have concomitant retinal or macular disease; or receive chloroquine.2 The guidelines recommend baseline examination within 1 year of beginning treatment to exclude concomitant retinal and macular disease, which may confound findings or add to the effects of hydroxychloroquine maculopathy.2 This contrasts with the recently updated United Kingdom guidelines, which do not recommend any form of screening in the first 5 years of treatment.3 The RANZCO minimum requirements for screening include dilated fundus examination, automated visual field testing, and spectral domain optical coherence tomography of the macula. Although automated macular visual field testing is appropriate in Caucasian patients, additional wider field testing is recommended in Asian patients to detect pericentral changes. Fundus autofluorescence and multifocal electroretinography are additional useful investigations and require interpretation by ophthalmologists trained in their interpretation. Patients who are found to have signs of retinopathy at screening or who have equivocal findings should be promptly referred for specialist ophthalmologist retinal assessment. Using the 2016 American Academy of Ophthalmology guidelines (comparable to the RANZCO guidelines), the cost‐utility of screening for hydroxychloroquine retinopathy was found to range from US$33 155 to $344 172 per quality‐adjusted life year.4 By reducing unnecessary screening in the first 5 years of dosing, we anticipate costs in the lower range per quality‐adjusted life year for screening using the RANZCO guidelines. Education of prescribers is necessary. United States studies show that 27% of patients are prescribed dosages exceeding current retinal guidelines,5 with significant non‐adherence to screening recommendations by both prescribers and patients. We encourage all prescribers of hydroxychloroquine to educate patients regarding screening, monitor for all complications, and report to the Therapeutic Goods Administration to obtain a comprehensive Australian dataset of all complications.

Adrian T Fung · Vicky Lu · Heather G Mack

A 62-year-old man presented with left eye swelling and 3 weeks of intermittent epiphora without visual disturbance

Douglas Dunn · Sebastian Brown · Sartaj Sandhu · Domit Azar

A 75-year-old man presented with right hemiparesis secondary to a left thalamic haemorrhage

Julia Lim · Yi Chao Foong

A 61-year-old man was referred to our ophthalmology service 3 days after a tree branch injury to the left eye

Shivesh Varma · Yi Fan Tang · Salim Okera

An 88-year-old white woman presented with a subcutaneous mass on the left lateral brow

Tung T Hoang · Graham A Lee · Timothy J Sullivan