Orthopaedics Vol3 No4 - nmpb2b.co.za€¦ · Ku EC, Lee W, Kothari HV, Scholer DW. Effect of diclofenac sodium on the arachidonic acid cascade. Am J Med April 1986;80(4B):18-23. 3

WINTER 2012Vol 7 • No 3

COMPUTER-BASED SIMULATION AS AN E-LEARNING TOOLM Labuschagne

WHAT EVERY SCIENTIST SHOULD KNOW ABOUT CLIMATE CHANGE – PART 1WR Nunery

ETHICS AND MEDICO-LEGAL ISSUES FOR THE OPHTHALMOLOGISTAA Stulting

MEETING OF THE AMERICAN ACADEMY OF OPHTHALMOLOGY, ORLANDO, USA, OCTOBER 2011W Marais

CORRECTION OF APHAKIA IN THE UNDERGROUND WORKERBT Pienaar

The official journal of the Ophthalmological Society of South Africa

OSSA Winter 2012_Orthopaedics Vol3 No4 2012/08/20 9:01 AM Page 1


WINTER 2012SA Ophthalmology Journal

Vol 7 • No 3

The official journal of the Ophthalmological

Society of South Africa

ISSN: 2218-8304

Editorial BoardDr Deon Doubell

(President of OSSA)Dr Ellen Ancker

Dr Hubrecht BrodyProf Colin CookDr Petrus Gous

Prof David MeyerDr Joanne MillerProf Tony Murray

Dr Clive NovisProf Paul Roux

Dr Fritz StegmannProf Juzer Surka

Dr Chris van NiekerkDr Linda Visser

Editor-in-ChiefProf Andries A Stulting

(051) 405-2151

Co-EditorProf Trevor Carmichael

Managing EditorPatricia Botes

[email protected](011) 706-6934

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PRESIDENT’S REPORT 6D Doubell

EDITORIAL 8AA Stulting

CORRESPONDENCE 12

OBITUARY 14Retief Conradie (10 October 1955–29 March 2012)

INTRODUCING: PROF ISMAIL MAYET 18

ORIGINAL ARTICLE 20Computer-based simulation as an e-learning toolM Labuschagne

ORIGINAL ARTICLE 23Ethics and medico-legal issues for the ophthalmologistAA Stulting

ORIGINAL ARTICLE 29What every scientist should know about climate change – Part 1WR Nunery

CONGRESSES/MEETINGS 2012/2013 33

CONGRESS REPORT BACK 34Meeting of the American Academy of Ophthalmology, Orlando, USA, October 2011W Marais

BLAST FROM THE PAST 38Correction of aphakia in the underground workerBT Pienaar

RESULTS 42CMSA examinations, May 2012

CONTENTS


WINTER 2012SA Ophthalmology Journal

Vol 7 • No 3

The official journal of the Ophthalmological

Society of South Africa

ISSN: 2218-8304

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The views expressed by contributors to thejournal and the inclusion or exclusion of anymedicine or procedure, do not necessarilyreflect the views of the publisher or editorialboard. While every effort is made to ensureaccurate reproduction, the authors, advisers,publishers and their employees or agentsshall not be responsible or in any way liablefor errors, omissions or inaccuracies in thepublication, whether arising from negligenceor otherwise or for any consequences arising therefrom.

CONGRESS NEWS 44OSSA Congress, March 2012, Sandton

NEWS 48SAGS Travel Fellowship Grant

BOOK REVIEW 50Phaco Fundamentals: A guide for trainee ophthalmic surgeonsReviewed by AA Stulting

BELIEVE IT OR NOT … 52Believe it or not … it happened to me … and to Derek de Beer … and to Jan Talma!AA Stulting

BRODY’S (LAST ) CORNER 54H Brody

CLIVE’S CORNER 56C Norris

ETHICS ARTICLE 58Confidentiality - general principlesPrinted with permission from the Medical Protection Society

CPD QUESTIONNAIRE 60

GUIDELINES FOR AUTHORS 61

CEH-iNEWS 62

REGISTRAR WRITING COMPETITION 64

PRODUCT INFORMATION 65Allergan supports guide dogs for the blind

Great Ethiopian Run – the high altitude race against blindness

Dry eye relief never looked better

CONTENTS

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OSSA Winter 2012_Orthopaedics Vol3 No4 2012/08/22 5:42 PM Page 4


Page 6 • WINTER 2012 • Vol 7 | No 3 SA OPHTHALMOLOGY JOURNAL

P R E S I D E N T ’S R E P O R T

As ophthalmologists we have an extremely close and personal relationship with our patients.

Firstly, we are physically close to them when we examine their eyes and secondly, the eye and sight are very impor-tant to patients and they will only entrust them to a person in whom they have confidence.

When we manage to give them their sight back, and also in cases where sight cannot be restored or is lost, we forgea lasting relationship with our patients.

We must treasure this privilege and always be accessible to our patients.

Unfortunately, there is a tide of impediments to this relationship that is engulfing us at present.

I was in the queue at OR Tambo Airport customs recently, when I heard a well-respected medical practitioner tellingsomebody that he has given up his private practice. The reason is the way that medical aids are operating present-ly, which is creating a divide between him and his patients and he is not prepared to continue practising underthese circumstances.

Another factor that is creating distrust is the environment that has been created by the new Consumer ProtectionAct. There is an abundance of operators from different professions giving talks, at a fee, on how the patient candemand different privileges from us, for example, deciding that the anaesthetist we use on our lists is not to theirliking and then insisting on one of their choice – never mind the consequences and inconvenience to the practi-tioners.

On top of this the Honourable Minister of Health has recently stated, in public, that medical practitioners are notbeing sued enough for negligence by patients. It is a mystery to me what the reason for such a statement is, but ithas certainly led to a great degree of distrust between patients and practitioners.

Fortunately, we still have the best job one can think of and we must guard against being negative and strive toalways keep a positive and close relationship with our patients.

Dr Deon DoubellPresident: Ophthalmological Society of South Africa


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The topic of ophthalmology congresses has been discussed hotly by ophthalmologists recently. We, as oph-thalmologists, are very privileged to be able to attend so many outstanding congresses annually. During the

first seven months of 2012, we enjoyed the OSSA Congress in Sun City in March, the annual meeting of theSAVRS in Parys (Free State) in April and the SAGS Annual Congress at Kruger Gate in May. We can still look for-ward to the Jacaranda and Cape Eye Hospital Symposia and the SASOPS meeting at Elephant Hills in Zimbabwelater this year.

The key to any congress is the quality of the speakers. We are fortunate to attract world-class speakers to our meet-ings, nationally as well as internationally. It is important for us to spend time with our colleagues and to enjoy thesocial programmes where we can relax and strengthen our friendships and meet new friends. The Ophthalmic Tradeplays a vital part in exposing us to the latest equipment and sponsoring our meetings to a great extent.

The one problem that faces all of us is the number of congresses that are held annually. Many of our colleagues arecomplaining about this and the Trade has also been complaining about the many congresses they have to sponsorduring one financial year.

An innovative idea is being explored by the OSSA 2014 Organising Committee under the Chairmanship of Dr ChrisGouws.

The idea of subspecialty days as part of the bigger OSSA Congress is currently being entertained and an invi-tation letter has been written to the Presidents of SAGS, SAVRS, SASCRS and SASOPS to discuss with their EXCOs toorganise one day during the OSSA Congress Week, that will be held from 18 March to 23 March 2014 at theChampagne Sports Resort. The Subspecialty Day will be organised by the Organising Committee of that particu-lar group. OSSA presentations, meetings and activities, will be held over two days.

This arrangement may or may not replace their annual meeting for 2014 but the ultimate decision rests with theindividual subspecialty groups.

The advantage for the ophthalmologist may be that, although they will spend one or two days more at the ‘BiggerOSSA Congress’, they can have most of their meetings during ONE WEEK! There will be more free time during therest of the year to go to overseas meetings, or to be at their practice, or to have more time for the family (and holi-days!).

There will also be a huge financial benefit for the Trade as they will only have to exhibit ONCE during the year andthey will have more money available to plough back at the Congress, for example, bringing outstanding guestspeakers from all over the world!

Another interesting concept was discussed during the pastfew weeks about the venue of the 2013 SASCRS meetingwhich was originally planned to take place in August inCape Town. According to the Organising Committee, head-ed by Dr Asher Saks (who has organised four SASCRS con-gresses before), there is not a big enough venue in the Capearea, except for the Convention Centre. It is a very expensivecongress venue and the fact that the OSSA Congress will beheld five months earlier in March 2013, makes the area lessattractive.

The one problem that faces all of us is the number of congresses that are held annually


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The idea was put forward by the Organising Committee to hold the congress at the Victoria Falls and stay at the gor-geous hotels in Livingstone, Zambia.

A delegation from the Organising and the Executive Committees of SASCRS flew to Zambia in July to investigatethe possibilities. The group consisted of Prof Andries Stulting, Dr Jan Talma, Dr Asher Saks and Ms Christi Truter.

The group reported favourably regarding the hotel accommodation, the congress venues and the superb socialactivities that can be organised (trips to the Victoria Falls, helicopter flips over the Falls, bungee jumping and whiteriver rafting, visits to Chobe, the Okavango Delta and many more).

The costs will probably be higher for an individual, but as Dr Brody promises, ‘This will be a memorable congress, inthe same mould as the Berg-en-Dal congress in 1986, the Victoria Falls congress at Elephant Hills in 1998 and theBoat congress in 2003!’

It is with sadness that we heard about the death of Retief Conradie, CEO of Visicare, during the time of the OSSACongress in March. Our condolences go out to his family and many friends. His obituary appears in this issue.

Prof Ismael Mayet from the University of the Witwatersrand is introduced to our readership. We also heard that ProfPolla Roux entered private practice in Pretoria in May after serving as Head of the Department of Ophthalmologyfor 20 years. Prof Surka from the Walter Sisulu Hospital is also stepping down as Head of his Department. We wishboth Professors all the best for the future and thank them for their valuable contributions over many years.

And lastly, I would like to pay tribute to Dr Hubrecht Brody, whose last Brody’s Corner appears in this issue. Manyophthalmologists have complimented SAOJ on his excellent ‘Brody’s Corner’. Thank you VERY MUCH Hubrecht!Luckily, he promised to write to us as he remembers more and more ‘Incidents from the Past,’ which we will continue to publish in this journal. Good luck to Clive Novis, whose first ‘Clive’s Corner’ also appears in this edition.

The Editorial staff hopes our readers enjoyed a GOLDEN sports month in August and we hope that you continue toenjoy the SA Ophthalmology Journal!

Prof Andries StultingEditor-in-Chief




CORRESPONDENCE

From: DR M J CAREY [[email protected]]Sent: 30 May 2012Subject: Young Ophthalmologist Programme

Dear Dr Doubell and OSSA Exco

Thank you for the wonderful opportunity to participate in this initiative over the last year. It was great to be involvedwith such a dynamic organisation and especially to see first-hand the incredible amount of work that is done forOphthalmology in this country.

I think it is valuable to continue this programme to bring in dynamic young people and make them feel part of thedecision process. It is also vital that this reaches out to a wide spectrum of doctors as only in diversity will our futurebe secure.

Thanks again and I will endeavour to play a small part in the future of Ophthalmology.

RegardsMalcolm Carey

Letter to the Editor

Dear Sir

Hubrecht Brody’s leaving his ‘Corner’ signifies the end of an era. For many ophthalmologists, Hubrecht’s often amusing and always forthright column was compulsory reading. Hubrecht, we salute you, and thank you not only for your regularpolemic contribution, but also for many years of sterling service to OSSA.

Hubrecht would, I hope, forgive me for sharing this: Six years ago a stalwart colleague inVR surgery in SA retired in Bloemfontein. Hubrecht made the trip to Bloemfontein toattend and speak at the function. It was winter in the Free State, and bitterly cold. My wifeand I were fortunate enough to host Hubrecht, who spent the night in a cottage in our garden, used from time to time by visitors. The morning after the function, I met him on thedeck outside his quarters with a cup of coffee in hand. Hubrecht drily remarked that FreeStaters were probably tougher than he had always thought. Knowing Hubrecht, I realised this could be no idle remark and tried to get a reason out of him. Aftersome careful probing by me, Hubrecht respectfully expressed his admiration forBloemfontein stoics who could shower so cold every morning. He had been thefirst visitor in some time, and we had forgotten to switch on the geyser tothe bathroom! Hubrecht, please accept my apology!

Chris Gouws, Bloemfontein


OSSA Winter 2012 BU_Orthopaedics Vol3 No4 2012/08/22 1:44 PM Page 13

Retief Conradie (10 October 1955–29 March 2012)


Retief Conradie, Managing Director of Visicare, died on 29 March 2012 in Milpark Hospital in Johannesburg. Hewas admitted to the hospital with a massive brain haemorrhage on 22 March, the day when the OSSA Congress

opened in Sandton. The medical staff tried their utmost for a week to try and save his life but were unsuccessful.

Retief grew up in Vereeniging and moved to Johannesburg in 1972 where he matriculated from the High SchoolHelpmekaar in 1973. He did his army training as a parabat in 1974 and commenced his studies in 1976 as a First YearB Comm student at the University of Stellenbosch. He married Rinette Loubser in December 1978, one of his class-mates. He obtained his MBA degree in 1984 at the University of the Witwatersrand.

He was married for more than 33 years and he and Rinette had four children. His family and friends remember himas a wonderful family man. He always described himself as a ‘’n regte ou huiskat …’ He was so proud of his children– his family photos on Facebook had inscriptions such as ‘my kingdom’ or ‘this is what the richest man in the worldlooks like!’

He had the warmest and most beautiful smile … a true friend, hardworking, a man of faith and integrity. Someonewith wide interests: star-gazing, doing philosophy courses, writing poetry, always at the cutting edge of the newesttechnology. He was a good cyclist who completed the Argus race at the age of 40 years in under 3 hours andattempted the dangerous ‘black slopes’ in Switzerland.

He was positive and passionate about making Visicare successful and he worked tirelessly to take his company tothe next level. He was very loyal and had great appreciation for his great friend, Casper Venter. Their friendship of40 years strengthened them both and carried each other through many years of happiness and hardships! We willalways miss him!

Casper Venter and Rinette Conradie

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Introducing: Prof Ismail Mayet


Prof Ismail Mayet was appointed as Adjunct Professorof Ophthalmology at the University of theWitwatersrand in 2010.

Prof Mayet was born in Johannesburg in 1958. He went to theNirvana High School in Lenasia where he matriculated in1975. He attended the University of Natal where he obtainedthe MBChB degree in 1981. He presented two papers at theMedical Student Congress, one in 1979, the other in 1981.Prof Mayet did his internship at the Leratong Hospital inKrugersdorp in 1982 and worked as a medical officer in vari-ous departments during 1983 to 1984 at the Chris HaniBaragwanath Hospital. In 1985 he was a lecturer in theDepartment of Anatomy at the University of theWitwatersrand. He became a registrar in the Department ofOphthalmology at the University of the Witwatersrand in1986 where he worked in the St John Eye Hospital and theHillbrow Hospital. He obtained the FCS Ophthalmology (SA)in 1988 and the FRC (Ophth) UK in 1991.Prof Mayet worked as a Specialist Consultant inOphthalmology at St John Eye Hospital from January 1990 toDecember 1993 and as a Senior Consultant from January1994 to July 1997. He was appointed as Principal Specialistand Clinical Head of St John Hospital in August 1997. In May2010 he was appointed as Adjunct Professor in the Divisionof Ophthalmology, Department of Neurosciences at theUniversity of the Witwatersrand.

Academic experience1. Lecturer: He taught the MBBCh 5th year medical stu-dents from 1995 to 2004 and the post-graduate studentsin Basic Sciences Ophthalmology from 2000 to 2003.

2. Examiner:MBBCh 5th year medical students from 1995 topresent at the University of the Witwatersrand and theGEMP 3 Mixed Block exam co-ordinator. Prof Mayet alsoexamined for the Colleges of Medicine of South Africa:• Diploma in Ophthalmology: Pretoria 2002;Johannesburg 2004 (convenor)

• Ophthalmology Fellowship Exams Part 1:Johannesburg (2006); Pretoria (2007); Johannesburg(2009); Bloemfontein 2010

• Ophthalmology Fellowship Exams Part 2:Johannesburg (2004 and 2006); Durban (March2012)

3. Teaching: Active in the following programmes:

• Weekly journal club meetings on Mondays• Weekly strabismus presentations on Wednes-days

• Weekly fluorescein angiography meetings onThursdays

• Overseeing the registrars’ case presentations andtalks, presented at our combined grand meetings onFridays

• Operating room duties: training junior consultants inmore intricate procedures in ophthalmology, specifi-cally in vitreo-retinal surgery and complicated paedi-atric and strabismus procedures

Service functions• From 1994 to 2002: Head of one of the two units at StJohn Eye Hospital, managing the running of wards, clinicand theatre.

• With the advent of specialised clinics, Prof Mayet nowruns the following special clinics: the Vitreo-Retinal Clinicon Mondays, the Paediatric Ophthalmology andStrabismus Clinic on Wednesdays.

• Operating room duties: Tuesdays and Thursdays.• Established a screening programme for retinopathy ofprematurity in the Neonatal Department at Chris HaniBaragwanath Hospital.

• Works in close collaboration with the paediatric oncolo-gist in the treatment of cancer patients (and serves onthe Retinoblastoma Working Group).

Projects1. Research projects• Treatment Outcome in Congenital Glaucoma – 1990 to1995 (presented at various workshops including interna-tionally).

• Efficacy of Trabeculectomy ab externo in Primary OpenAngle Glaucoma – 6 months follow up (E Dahan, I Mayet,S Saks & M Drusedau: presented at the OSSA Congress in1995)

• Screening for Retinopathy of Prematurity at Chris HaniBaragwanath Hospital 2001–2003 (presented at theOSSA Congress 2005 and published in Eye, Jan 2006)

• Management of Cyclodialysis Cleft (L Farber & I Mayet:presented at the OSSA Congress 2005

• Retinoblastoma – 16 year experience at the Chris HaniBaragwanath Hospital (I Mayet, S Poyiadjis & RDWainwright: presented at the OSSA Congress in 2006 andsubmitted for publication in 2009).

I N T R O D U C I N G


SA OPHTHALMOLOGY JOURNAL Vol 7 | No 3 • WINTER 2012 • Page 19

2. Current projects• Effectiveness of Diabetic Vitrectomy at the St John

Eye Hospital (A Makgotloe and I Mayet)• Sickle Cell Disease – Frequency of Ocular

Manifestations (Dr H Alli, Prof I Mayet & Prof M Patel)• Aetiology of Childhood Uveitis (A Makgotloe, H Kana

& I Mayet)

3. Contract research• Pfizer’s Multicentre Anti-Fungal Trial 2001–2002 – in

the role of Screening Ophthalmologist• Direct Medical Diabetic Study 2003 – in the role of

Screening Ophthalmologist• Sucampo Multi-Centre Vernal Trial 2004–2005 – as

Principal Investigator and Chief Investigator in SouthAfrica

• Takeda Trial 2005–2007 – as Second Ophthal-mologist

• Pfizer – Safety of Latanoprost in ChildhoodGlaucomas 2008 – as Principal Investigator

• Pfizer – Latanoprost versus Timolol in ChildhoodGlaucoma study 2009 – Principal Investigator

• Tamara Trial 2009 – Sanofi – as ScreeningOphthalmologist

• Merck International 2010 – Tafluprost vs Timololstudy – Sub-Investigator

• Alcon Vernal Trial September 2012 – National co-ordi-nator

4. Supervisor for research projects• Dr H Alli (completed MMed project)• Dr A Botha• Dr H Kana (protocol pending)• Dr R Dolland• Dr B Payne (protocol pending)• Co-supervisor: Dr J Engelbrecht, Department of

Paediatrics.

Publications1. Accredited

• I Mayet, C Cockinos. Retinopathy of Prematurity in aTertiary Hospital in South Africa. Eye 2006;20(1):29-31(online Jan 2005).

• W Mthembu, L Levitz, I Mayet, T Carmichael. CiliaryBody Leiomyoma – First Report in Africa. SAMJMarch2002;92(3):214-15.

• C Daras, W Grayson, I Mayet, C Novis, NH Welsh.Langerhans Cell Histiocytosis of the Eyelid. BritishJournal of Ophth. 1995;79:91-92.

• A Moosa, MI Mullah, I Mayet, A Rubige. NutritionalStatus of Children with Acute Meningitis. J of TropicalDiseases 1982.

2. Peer-reviewed publications• I Mayet (Guest Editor). Diagnosing Ocular Problems –

a case of Look and See. Pedmed July 2005.• I Mayet. Approach to Strabismus in Childhood.

Journal of the Islamic Medical Ass. of S.A. 2000.• I Mayet. Ocular Sarcoidosis. Ophthalmic News 1990.

3. Reviewer for Eye chapter – in Paediatric Handbook ofUniversity of Cape Town.

Presentations1. National

• Seven, dating from 1990-2012

2. Co-author of papers presented at OSSA 2010• Three

3. International• One, in 2003

4. Poster presentations• Five, dating from 2009-2012

(Full details available from Pat, email: [email protected])

Congresses and workshops attendedProf Mayet regularly attends congresses of theOphthalmological Society of South Africa, the South AfricaGlaucoma Society, the SA Vitreo-Retinal Society, as well asworkshops in Paediatric Ophthalmology Community andStrabismus. He has also attended international congresses inJapan, the USA, England, Spain, Germany and Malta.

Membership of professional organisations• Ophthalmological Society of South Africa• South African Vitreo-Retinal Society • South Africa Glaucoma Society • Colleges of Medicine of South Africa• Royal College of Ophthalmology (United Kingdom)• Ophthalmology Advisory Board of Discovery Health

Medical Scheme• Member of the Scientific Advisory Board of Retina South

Africa• Member of Retinoblastoma Working Group of South

Africa• South African Medical Association• Islamic Medical Association of South Africa – National

Secretary 1984–1985

Personal life and community serviceProf Mayet is married to Chrissanthie. He has four children,namely, Mohammed, Imraan, Sameera and Sophia.He loves playing golf, squash, cycling and reading. He is also very involved in community service:• Actively involved in Saturday Cataract Surgery Lists since

1997. He presented this project at the ImpumeleloAwards in Cape Town in 2001. These awards were pre-sented to innovative projects that were deemed benefi-cial to society/community.

• Participated in Tours for the Bureau for the Prevention ofBlindness and has done a Tour every year since 1990(except for 2001).

• Conducted an Eye Camp in Nampula, Mozambique, aspart of the Islamic Medical Association in 1996.

• Rendered medical services in Somalia and NorthernKenya, in 1992.

• Was invited by the Mauritian Government in May 2005 toassist in establishing a Vitreo-Retinal Unit and to teachstaff in a government Eye hospital in Moka, Mauritius.


Computer-based simulation as an e-learning toolDr Mathys Labuschagne MBChB(UOFS), MMed(Ophth)(UFS), PhD(HPE)(UFS)Department of Ophthalmology, University of the Free State, Bloemfontein


What are e-learning tools?The following e-learning tools are described by Border,Stoudt and Warnock (2006: Online):

Content/course or learning managementsystem (CMS/LMS) • Where a shell is created to organise the content of

instruction, e.g. BlackBoard®, Moodle®, WebCT®. • Self-contained surveys or assessments to track indi-

vidual learner use of the course site and the compo-nents thereof.

• Create forums for asynchronous and synchronouslearner-to-learner and learner-to-instructor commu-nication.

Synchronous collaboration applications • Real-time communication via voice and video is

allowed.• Virtual whiteboard, text chat, application sharing

capabilities and webinar (seminar with the help ofthe Internet, where students and lecturers can haveonline discussions).

Computer tools/applications (includingasynchronous collaboration applications) • E-mail, instant messaging, blogs, podcasts, Web

surfing, CDs, DVDs mp3s and online and offlinecomputer applications can be used to deliver e-learning.

• Almost any computer application can be an e-learn-ing delivery or collaboration tool.

Game play or game simulation software • This is the upcoming e-learning delivery tool and

includes flat-screen simulation and virtual realitysimulation.

O R I G I N A L A R T I C L E

IntroductionTeaching does not mean that students learn. Educators have to think innovatively to make sure that deep learn-ing takes place. Superficial learning happens when students ‘cram’ the study material. Deep learning happenswhen students relate different knowledge and theory and apply this knowledge in practice. The domain of theknowledge is contextualised and cross-linked and the motivation is internal. Conventional teaching results in knowledge transfer by means of presentation of information, guidance of

students, practice and assessment. E-learning makes use of electronic technology to deliver education andtraining applications. This can happen anytime, anywhere and by anyone. Self-assessment takes place duringthis process. E-learning meets the terms of the demands of the four types of adult learners as described byStillsmoking (2008: 768), namely: kinetic (hands-on, have to touch and manipulate); audio (hear, listen to stories,read out loud); visual (movies, PowerPoint slides, creator of drawings and maps); intellectual (reflecting, makingconnections, think through problems). E-learning and adult learning are summarised in Figure 1. Different e-learning tools can be utilised to reach these goals.

Figure 1. E-learning and adult learning

Readiness↓

AnywhereAnytime

Experience↓

Buildsknowledge

Autonomy↓

Independentlearning

Relevance↓

Applicationof knowledge



The tools for the different categories are illustrated inFigure 2.

Computer-based simulationComputer-based simulation, often called flat-screensimulation, is outcomes driven and students are usuallyin favour of this kind of learning because it fits in withadult learning principles. Students are usually comfort-able and in favour of self-directed learning, resulting inbetter outcomes. Flat-screen simulation (virtualpatients) teaches students how to analyse problemsand learn to reason about problems, and it gives them agreat sense of gratification when they solve a problem.Simulation provides a safe and non-threatening envi-ronment where students can learn without harm topatients.

Computer (Web) applicationComputer application is a computer-based program,delivered locally or through the Internet that repro-duces actual systems or equipment entirely or in part. AWeb application makes use of a Web browser to run theprogram or application. The programs can be runthrough intranet or Internet and the developer of a pro-gram uses a client–server environment in which multi-ple computers share information through an Internetserver. Tutorials, hypermedia drills and simulation games aremore fun and students are more engaged. This results inan interactive e-learning platform. These applicationstest knowledge, e.g. instruments (vitreoretinal surgery,phaco machine settings, identification of parts of theslit-lamp, anatomy of structures). With e-learning, thereis a 60% faster learning curve and 50–60% increasedlearning consistency. Learning systems include inter-active software and interactive CDs.

The advantages of Web applications are that thedeveloper of the program does not have to write pro-grams that are compatible with different computers orprograms, because it runs through the Internet server.The use of Cloud technology improves the availabilityand quality of material. Collaboration between institu-tions improves the quality of material available. The disadvantages of Web applications are that theydepend entirely on the availability of the server deliver-ing the application. If there is interruption of theInternet connection, sessions can be terminated with-out warning and work can be lost and total security can-not be guaranteed. There are possibilities for assess-ment, but at the moment, they are very limited and notrecommended.

Virtual worldVirtual world comprises computer-based programs thatallow the student to be immersed, through a screen-based interface, in the digital recreation of an environ-ment or setting. The student often interacts with thesimulation through a digital persona or ‘avatar’. The usesof the virtual world are to recreate a virtual world (i.e.virtual hospital or virtual clinic) where the student doesa simulation in a virtual world and the student can belike a virtual immersion. Students can learn how to per-form indirect ophthalmoscopy with the aid of virtualreality. Computer programming can produce differentconditions that can be observed with the aid of virtualreality and these programs can aid in assessment ofcompetence and knowledge.

Figure 2. Tools for the different categories

Content converters

Media editors

Testing assessment

Website authoring

Course authoring

Create

Web servers

Learning management systems (LMS)

Learning content management systems

Collaboration tools

Course management systems

Media servers

Offer

Webbrowser

Media playersand viewers

Access

Simulation provides a safe and non-threatening environment where students can learn without

harm to patients



The advantages are that students can be ‘transposed’to any setting, and any condition can be created, result-ing in almost unlimited opportunities. The fact that it iscomputer-based makes it relatively cheap and studentswith the Internet can use it anywhere. If students are oncommunity rotation, they can still do simulation – allthey need is a computer or even a Smartphone andInternet connection. In most rural settings this is possi-ble. It is computer-based resulting in cheaper introduc-tion and maintenance of systems. A virtual patient has great practical value for students

because they learn how to apply prior theoreticalknowledge; it helps them with honing their reasoningskills; and it helps them to compile a problem list andmotivate their diagnosis. Students can do their cases intheir own time so lecturers save time. This tool can bedeveloped for different levels of students, making it ver-satile. The disadvantages are that it is Internet- and com-

puter-dependent and it can therefore be a problem toaccess in very remote areas. The fact that students inter-act with a computer can have a limiting effect on inter-personal skills development and communication. Thereare possibilities for assessment with a virtual worldsimulation, but it is still limited.

AssessmentAssessment of students is mainly used for self-assess-ment and formative assessment. Summative assess-ment with computer-based simulation is not recom-mended at this stage, because security cannot be guar-anteed. Assessment and measurement using simulationinclude the following: clinical observation; role play;patient-based scenarios; video; computer-based clinicalskills (interactive); and human patient simulators. It isimportant to develop standardised tests that are reli-able and valid and should evaluate the performance ofstudents. Assessment of clinical skills comply with theprinciples of Miller (1990) of knows (knowledge), knowshow (competence), shows how (performance) and does(action). The assessment tools that are utilised includewritten exams (computer-based multiple-choice ques-tions, essays and portfolios), Objective StructuredVirtual Examination (OSVE) and competency evaluationby means of computer feedback of the simulation.Some of the examples are illustrated in Figure 3.

The use of computer-based simulation as an e-learn-ing tool will improve deep learning and comply withadult learning principles. This is a new and exciting toolto be utilised fully. In the words of Plato ‘Someday, in thedistant future, our grandchildren’s grandchildren willdevelop a new equivalent of our classrooms. They willspend many hours in front of boxes with fires glowingwithin. May they have the wisdom to know the differ-ence between light and knowledge’. (E-learning quota-tions, 2006).

BibliographyBorder J, Stoudt K and Warnock M. 2006. E-learning tools.http://iit.bloomu.edu/Spring2006_eBook_files/chapter4.htm

Glasgow Caldonian University. (2004). E-Learning Guides.http://www.learningservices.gcal.ac.uk/apu/eguides/intro.pdf

Horton W, Horton K. 2003. E-learning tools and technologies: Aconsumer’s guide for trainers, teachers, educators, and instruc-tional designers. Indianapolis, Indiana, Wiley PublishingInc.http://www.freesimulationgames.net/http://world.sec-ondlife.com/place/bb0c1f35-8ec2-8118-af06-9b904e011d66?lang=en-US

Miller GE. 1990.The assessment of skills competence perform-ance. Academic Medicine (Supplement) 1990;65:s63-s67

Stillsmoking KL. 2008. Adult learning: Practical hands-onmethods for teaching a hands-on subject. In Kyle, RR & Murray,WB. (Eds.) Clinical Simulation. Operations, Engineering andManagement. First edition. USA: Elsevier Inc.

Figure 3. Examples of computer-based and virtual reality simulation

Dr Mathys Labuschagne received his PhD degree in Health Professions Education from the University of the Free State inJune 2012 with the title: Clinical simulation to enhance undergraduate medical education and training at the Universityof the Free State. (Editor-in Chief)


Ethics and medico-legal issues for the ophthalmologistProf Andries A Stulting MBChB(Pret), MMed(Ophth)(Pret), FCS(SA)(Ophth), FRCOphth(UK), FEACO, FCMSA(Hon)Paper delivered at the 42nd OSSA Congress, Sandton, Gauteng, March 2012


IntroductionMedical negligence is on the increase in South Africa and ophthalmologists must keep their eyes open toescape the long arm of justice.• The most frequent charges made against ophthalmologists include:• Negligence: Retinopathy of prematurity (ROP)• Exchanging intraocular lenses (IOLs)• Endophthalmitis

Retinopathy of prematurity(Figure 1)What is the pathogenesis of ROP?• The retina is unique among tissues – it has no bloodvessels until the fourth month of gestation.

• At 4 months vascular complexes emanate from thehyaloid vessels at the optic disc and grow towardsthe periphery.

• These vessels reach the nasal periphery at approxi-mately 36 weeks of gestation and on the temporalside at 40 weeks.1

• A model of ROP suggests that the avascular retinaproduces VEGF which in utero is the stimulus forvessel migration in the developing retina.

• With premature birth the production of VEGF isdown-regulated by the relative hyperoxia and vesselmigration is halted.

• Subsequently the increased metabolic demand ofthe growing eye allows excessive VEGF productionwhich leads to the neovascular complications ofROP.2

• Although an important contributing factor, oxygenis no longer considered the sole factor in thepathogenesis of ROP.3

• Other factors also increase the risk of developingROP:• genetic predisposition• low birth weight• a short gestational period

• Factors, such as intercurrent illnesses, blood transfu-sions and pCO2, although statistically associatedwith the outcome in a univariate sense, failed tomaintain a significant association when consideredin a multivariate analysis.

• ROP has been reported in :• full-term infants (possibly Familial ExudativeVitreoretinopathy (FEVR)

• stillborn infants (no supplemental oxygen)

O R I G I N A L A R T I C L E

Figure 1. Premature born baby inincubator (top slide) and draggingof the disc in the left eye (bottomslide)



Which babies should be screened for ROP?• All infants with a birth weight of less than 1500

grams• A gestational age of 30 weeks or less4

• Selected infants between 1500 and 2000 grams or• A gestational age greater than 30 weeks with an

unstable clinical course (high risk)5

When should a baby be screened for ROP?• The first examination should generally be performed

between 4 and 6 weeks of post-natal age or alter-natively

• within the 31st to 33rd week of postconceptionalor postmenstrual age, whichever is later.6

The question should be asked: Are ophthalmologistsscreening babies for ROP in their respective areas?Thefollowing reasons may be responsible for ophthalmolo-gists not screening babies for ROP:• No screening protocol in place• Not enough hands to screen• No paediatric facility available• Not enough incubators at the hospital • No blenders available

At what level should the oxygen concentration be kept in the incubator?• Between 88% and 92%

What is the meaning of ‘plus’ disease?• ‘Plus’ disease signifies a tendency to progression and is

characterised by:• dilatation of veins• tortuosity of the arteries• involving at least two quadrants of the posterior

fundus

What is the meaning of Rush disease?• Aggressive posterior disease:

• uncommon• if untreated usually progresses to stage 5• posterior location• prominence of plus disease• most commonly observed in zone 1• does not usually progress through the classical

stages 1 to 3

What is the meaning of threshold disease?• Threshold disease is defined as:

• five contiguous or• eight cumulative clock hours• of extraretinal neovascularisation (stage 3)• in zone 1 or zone 2• associated with plus disease• and is an indication for treatment

When and how should infants with threshold disease be treated?• Infants found to have threshold disease should

receive retinal ablative therapy (either cryotherapyor laser photocoagulation) within 72 hours of diag-nosis.

What is the STOP-ROP Trial?• A clinical trial, the Supplemental Therapeutic

Oxygen for Pre-threshold ROP, was designed totest whether supplemental oxygen would decreasethe progression to threshold ROP in infants who hadpre-threshold ROP.

• The STOP-ROP trial demonstrated that the use ofsupplemental oxygen at pulse oximetry satura-tions of 96%–99%:• did not cause further progression of pre-thresh-

old ROP• did not significantly reduce the number of

infants requiring peripheral ablative surgery.

What is the Light-ROP trial?• In the Light-ROP study, exposure to ambient light

was found to have no effect on the incidence orseverity of ROP.

What is the role of vitamin E in ROP?• Vitamin E and other anti-oxidants were investigated

for their potential efficacy in decreasing the inci-dence of ROP.

• Interest in testing the use of anti-oxidant therapy ina multicentre trial diminished due to concernsabout side effects of vitamin E and because of thedemonstrated efficacy of surgical intervention inpatients with threshold ROP.

What is important to know about cryotherapy in ROP?• Cryotherapy to the avascular anterior retina in ROP

eyes with threshold disease has been demonstratedto reduce, by approximately half, the incidenceof an unfavourable outcome, such as maculardragging or retinal detachment.

• NB!! Cryotherapy should be performed in con-junction with paediatric consultation because5% of treated patients can develop respiratoryproblems or cardio-respiratory arrest!

In the Light-ROP study, exposure to ambient light was found to have no effect on

the incidence or severity of ROP



What is the treatment of ROP?• Laser photocoagulation• Intravitreal anti-VEGF agents• Lens-sparing pars plana vitrectomy

Laser photocoagulation• Laser photocoagulation of avascular, immature reti-

na is recommended in infants with threshold dis-ease.

• This is successful in 85% of cases, but the remainderprogress to retinal detachment in spite of treatment.

• Laser therapy has largely replaced cryotherapybecause visual and anatomical outcomes are superi-or, and because laser induces less myopia.

Intravitreal anti-VEGF agents• Bevacizumab has been introduced in many centres

for the treatment of ROP, but optimal timing, fre-quency and dose are yet to be established.

• The potential for systemic complications and long-term effects is also undefined in this age group.

Lens-sparing pars plana vitrectomy• Lens-sparing PPV for tractional retinal detachment

not involving the macula (stage 4a) can be per-formed successfullywith respect to anatomical andvisual outcome.

• The visual outcome in stages 4b and 5, in whichthe macula is involved, is often disappointing,despite successful reattachment.

True or false: Due to the increased survivalof high risk neonates, there is an increase inthe incidence of ROP.• The answer is false! Although there is increased

survival of high-risk neonates, this is not associatedwith a universal increase in the incidence of ROP7–10

• This trend may reflect improvements in ventilationtechniques and perinatal care, specifically the pro-phylactic use of surfactant10 and the maternaluse of ante-natal steroids.11

Intraocular lens power calculationsThis can be discussed under the following headings:1. Previous corneal refractive surgery2. Incorrect IOL power

1. Previous corneal refractive surgery• Previous corneal refractive surgery changes the

architecture of the cornea such that standardmethods of measuring the corneal power cause it tobe underestimated (myopia) and overestimated(hyperopia).

• Radial keratotomy (RK) causes a relatively propor-tional equal flattening of both the front and backsurface of the cornea leaving the index of refrac-tion relationship the same.

• Photorefractive keratectomy (PRK), laser-assistedintrastromal keratomileusis (LASIK) and laser-assist-ed epithelial keratomileusis (LASEK) flatten onlythe front surface.

• In myopic eyes, this changes the refractive index cal-culation creating an underestimation of thecorneal power by about one dioptre for everyseven dioptres of refractive surgery correctionobtained.

• The major cause of error is the fact that most ker-atometers measure at the 3.2 mm zone of the cen-tral cornea, which often misses the central flatterzone of effective corneal power; the flatter thecornea, the larger the zone of measurement.

• Methods to estimate true post-operative cornealpower:• Clinical history method (to be discussed)• Contact lens method (to be discussed)• Maloney corneal topography method• Koch modification of Maloney method• Ronje method• Shammas no history method

Clinical history method• This method is based on the fact that the final

change in refractive error the eye obtains fromcorneal surgery was due only to a change in theeffective corneal power.

• If this refractive change is added to the pre-surgicalcorneal power, the effective corneal power the eyehas now will be obtained.

• All patients having corneal refractive surgeryshould be given the following data to keep:• pre-operative corneal power• pre-operative refractive error• post-operative healed refractive error (before

lens changes affect it).• It is not beneficial to vertex correct the spectacle

refraction because it causes underestimation ofthe K reading!

• For this method, the estimated effective cornealpower (K) can be calculated using the following for-mula:K = K (pre-op) + R (pre-op – R (post-op)Where:K = corneal powerR = refractive error

Laser photocoagulation of avascular, immature retina is recommended in infants with threshold disease



Contact lens method• This method is based on the principle that, if a hard

PMMA (not rigid gas permeable) contact lens (CL) ofplano power (P) and a base curve (B) equal to theeffective power of the cornea, is placed on the eye,it will not change the refractive error of the eye.

• That is, the difference between the manifest refrac-tion with the contact lens (RCL) and without is(RNOCL) is zero. The formula to calculate the estimat-ed corneal power is:K = B + P + RCL – RNOCL where:K = corneal powerB = base curveCL = contact lensP = power of contact lensR = refractive errorNOCL = bare refraction

• Several computer IOL power calculation programsare available:• Hoffer programs12

• Holladay IOL Consultant• Further reading13,14

• Considerations After Refractive Surgery, in Basicand Clinical Science Course, Section 13,2008–2009, AAO, pp 223-26.

• Jack T Holladay: Measurements, Chapter 39 inOphthalmology, 2nd Ed., Myron Yanoff, Jay SDuker, Mosby, 2004, pp 287-92.

2. Incorrect IOL power• Placement of an incorrect power IOL is usually the

result of a pre-operative error in:• axial length measurement or• keratometry readings

• Choosing the correct power IOL is more difficult inpatients:• undergoing simultaneous PKP• with silicone oil in the vitreous• who have had prior refractive surgery

• Inverting the IOL or placing it in the sulcus, either ofwhich causes anterior displacement, changes theeffective power of the IOL.

• Mislabelling or manufacturing defects are rarely thecause.

• Incorrect lens power should be suspected early inthe post-operative course when the uncorrectedvisual acuity is less than expected and is confirmedby refraction.

• If the magnitude of the implant error is likely to pro-duce symptomatic anisometropia, the surgeon canconsider several options:• replacing the IOL with one of the appropriate

power• inserting a piggyback IOL or • performing a secondary keratorefractive proce-

dure

• High patient expectations for excellent UCVA makeaccurate IOL power determination even more criti-cal here than in cataract surgery.

• IOL power formulas are less accurate at higher levelsof myopia and hyperopia.

• In high myopia, a posterior staphyloma can makethe axial length measurements less reliable.

• Careful fundus examination and B-scan ultrasoundcan identify the position and extent of staphylomas.

• The SRK/T formula is generally considered to bethe most accurate in moderate and highlymyopic patients.

• The Hoffer Q formula is more accurate for mod-erate and highly hyperopic eyes.

• It is best to use several formulas to determine IOLpower for a refractive patient.

• Software programs now available can give the sur-geon IOL predictions calculated by several formulas.

• In the ‘piggyback’ IOL system, two posterior cham-ber lenses are inserted, one IOL is placed in the cap-sular bag and the other is placed in the ciliary sulcus.

• The following formulas can be used to calculate pig-gyback IOL power:• Holladay 2• Hoffer Q• Haigis

• WARNING! Be sure the Index of Refraction of theIOLMaster is set to 1.3375 in the Setup screen ofthe computer for the Hoffer Q formula to meas-ure accurately.15

• When piggyback IOLs are used, the combinedpower should be increased + 1.50 to + 2.00 D tocompensate for the posterior shift of the posteri-or IOL.

• One serious complication of a piggyback IOL is thepotential for developing an interlenticular opaquemembrane.

• These membranes cannot be mechanicallyremoved or cleared with the Nd:YAG laser; theIOLs must be removed!

• Interlenticular membranes have occurred mostcommonly between two acrylic IOLs, especiallywhen both IOLs are placed in the capsular bag,which is why this type of piggyback IOL implanta-tion should be avoided.16,17

Silicone oil in the vitreous• If planning silicone oil injection into the vitreous

space, perform an accurate axial length measure-ment BEFORE doing so and make this informationavailable to the patient.

• It is practically impossible to measure a silicone oileye (try using a velocity of 1000 m/s) (Standardphakic volocity = 1555 m/s)



• The Zeiss IOLMaster is the ONLY WAY to get an accu-rate measurement in silicone oil-filled eyes.

• WARNINGS!• Measuring an eye containing a silicone IOL withstandard phakic velocity (1555 m/s) can amountto an error of 3–4 D.

• If the axial length is very difficult to obtain andthe eye appears to have a length greater than25 mm, suspect a staphyloma.

• PRACTICAL TIP! Use the IOLMaster!!!

Handling the IOL power surprise1. An error in measuring the axial length – most com-mon cause

2. Incorrect measurement of the corneal power3. Healed effective position of IOL4. The use of formulas5. Miscellaneous causes

1. Incorrect measurement of the axial length

• Using the wrong average ultrasound velocity.• Eyes longer than 25 mm – higher incidence ofstaphyloma.

• Using the wrong average ultrasound velocity.• The average speed for a short 20 mm eye is

1560 m/s and 1550 m/s for a long 30 mm eye.• Poor IOLMaster readings that are not recognised bythe examiner also cause error in axial length and aremore common if the density of the cataract isincreased or the patient is not able to fixate proper-ly.

• Silicone-oil filled eyes are a vexing problem sincethe ultrasound wave is slowed.

• The IOLMaster must be used.• Remember that there is something like ‘THE EYETHAT JUST CAN’T BE MEASURED!’

2. Incorrect measurement of the corneal power

• Overestimation of the corneal power is the rule ineyes that have had previous corneal refractive sur-gery.

• It is important to have a schedule of calibrating allkeratometers to prevent errors in the measure-ment.

• The IOLMaster has a setup screen that allows theoperator to change the index of refraction (IR).Most users are unaware of this.

• In cataract patients that wear contact lenses, thereis a corneal warping factor that produces incorrect Kreadings (especially true in patients wearing a hardcontact lens).

• This can be corrected by asking the patient toremove the contact lens for two weeks in the eyeto be operated.

• Corneal scarring, especially in the centre, can causea great problem in measuring the corneal power.

• Eyes that will need corneal transplantation also posea problem in predicting pre-operatively what theultimate healed corneal power will be.

3. Healed effective position of the IOL• This is referred to as the A constant, the surgeon fac-tor (SF) or the Hoffer anterior chamber depth (ACD).

• Holladay instituted the replacement term, effectivelens position (ELP).

• Errors may occur if the IOL settles in a deeper orshallower position than that predicted by the for-mula.

• Another cause of error is when the ACD constantshave not been personalised to the individual IOLstyle, surgeon and clinic.

4. The use of formulas• The use of formulas is a cause of IOL power error,especially regression formulas, for example the SRK1 regression formula, when used in eyes outside thenormal AL range of 22–24.5 mm.

5. Miscellaneous causes• A rare manufacturer labelling error• Wrong IOL power handed to surgeon by ORnurse/sister

• Transcription mistakes

Take home pearls1. Make it a routine to perform a manifest refraction onpost-operative day 1 so as to discover the problemearly enough to take the patient back to the OR andcorrect the problem in the first 48 hours.

2. Consider the use of a piggyback IOL or phakic IOL ifthe eye has healed beautifully and removal of theerrant IOL would be more traumatic to the eye.

3. Consider delaying the IOL implantation until thecornea has healed after a penetrating keratoplastyrather than performing a ‘triple procedure’.

4. Be sure to set the IR to 1.3375 in the setup screen ofthe IOLMaster.

5. Never use the SRK Regression formulas (SRK 1 or 11)!6. Use the SRK/T formula in eyes longer than 26 mm.7. Use the Holladay 1 formula in eyes 24.5–26 mm inlength.

8. Use the Hoffer Q formula in eyes < 22 mm and inpost-refractive surgery eyes.

9. Use the IOLMaster for measurement in silicone-filledeyes



10. Keep contact lenses out for 2 weeks prior to ker-atometry (at least in one eye.)

11. Calibrate your manual keratometers regularly.12. Consider not charging for exchanging a lens for an

incorrect measurement! This is controversial but may prevent medico-legalproblems. Patients may not understand why youhad to operate twice on their cataract while anotherpatient only had to pay for one cataract procedure!

References1. Basic and Clinical Science Course, Section 12, AAO, 2008-2009, Chapter 5:

Retinal Vascular Disease, page 139.2. Jack K Kanski, Brad Bowling. Clinical Ophthalmology, A Systematic

Approach, Saunders Elsevier, 7th Edition, 2011, chapter 13, page 573.3. Basic and Clinical Science Course, Section 12, AAO, 2008-2009, Chapter 5:

Retinal Vascular Disease, page 140.4. Basic and Clinical Science Course, Section 12, AAO, 2008-2009, Chapter 5:

Retinal Vascular Disease, page 137.5. Basic and Clinical Science Course, Section 12, AAO, 2008-2009, Chapter 5:

Retinal Vascular Disease, page 137, 138.6. Basic and Clinical Science Course, Section 12, AAO, 2008-2009, Chapter 5:

Retinal Vascular Disease, page 138.

7. Hussain N, Clive J, Bhandari V. Current incidence of retinopathy of prema-turity, 1989-97. Pediatrics. 1999; 104 (3): 26.

8. Vyas J, Field D, Draper ES, et al. Severe retinopathy of prematurity and itsassociation with different rates of survival in infants less than 1251g birthweight. Arch Dis Child Fetal Neonatal Ed. 2000; 82: F145-49.

9. Rowlands E, Ionides ACW, Chinn S, et al. Reduced incidence of retinopathyof prematurity. Br J Ophthal-mol. 2001; 85:933-35.

10. Pennefather PM, Tin W, Clarke MP, et al. Retinopathy of prematurity in acontrolled trial of prophylactic surfactant treatment. Br J Ophthalmol. 1996;80: 420-24.

11. Bullard SR, Donahue SP, Feman SS, et al. The decreasing incidence andseverity of retinopathy of prematurity. J AAPOS 1999; 3: 46-52.

12. Kenneth J Hoffer: Intraocular Lens Power Calculation in Cataract Surgery,ed. Roger F Steinert, Saunders Elsevier, 3rd Ed, 2010, pages 38-40.

13. Complications of Cataract Surgery, Chapter 9: Incorrect IOL power in BCSC,Section 11, 2010–2011, AAO, pages 181-82.

14. Intraocular Surgery, Chapter 8 in BSCS, Section 13, 2008 – 2009, AAO, page176.

15. Considerations After Refractive Surgery, in Basic and Clinical ScienceCourse, Section 13, 2008–2009, AAO, pages 223-26.

16. Jack T Holladay: Measurements, Chapter 39 in Ophthalmology, 2nd Ed.,Myron Yanoff, Jay S Duker, Mosby, 2004, pages 287-92.

17. Kenneth J Hoffer: Intraocular Lens Power Calculation in Cataract Surg. ed.Roger F Steinert, Saunders Elsevier, 3rd ed, 2010, pages 35, 50-52.


What every scientist should know about climate change – Part 1William R Nunery, MD, FACSClinical Professor of Ophthalmology, Indiana University, University of LouisvilleDepartment of Ophthalmology and Visual Sciences

Paper delivered by Prof Nunery at the WAGO meeting during the OSSA Congress which was held in Sandton in March 2012.


History of life and climate• Bumpy ride• Sudden lurches to alternative climate states• New equilibrium points• Mass extinctions

Elizabeth Vrba, SA paleontologist (Yale)• Turnover pulses• Bursts of extinction and speciation fuelled by rapid

climate change

Mass extinction events (>65% lossof plant and animal species)• Ordovician 440 M years: (80–85%)• Devonian 365 M years: (80–85%)• Permian 250 M years: (95–97%)• Triassic 210 M years: (70–75%)• Cretaceous-Tertiary (KT) 65 M years: (65%)

KT (65M) extinction• Dinosaurs (supreme for 140 M years)• Chicxulub asteroid (10 trillion tons TNT) (Figure 1)• ‘nuclear winter’• 20% loss of solar energy (aerosols)• 8–13 years of freezing in a tropical world

Permian (250 M) ‘The Great Dying’ • 97% extinction of all life• 19 m band of mudstone without fossils• Rubidge, B (Wits), Smith, R (SA Museum)

• 12C isotopes show lush plant world• Suddenly dead, glut of 12C• Lasted 5–12 M years

Permian (250 M) mass extinction• Volcanism (Siberian Traps) (Figure 2)• Minor CO2 warming• Positive feedback amplification loops with sudden

climate change

Permian era• Early (300–270 M years ago)• Cold, similar to recent ice ages• Late (end era boundary)• Warm, ice gone or going fast• Ocean heat conveyor shifted or stopped• Severity of extinction• Rapid warming, anoxic stratified ocean• Methane, hydrogen sulfide in atmosphere (Knoll,

Harvard paleobiologist)

Permian extinction• Sudden warming (6 °C) over several thousand years• PCC predictions for 21st century• ↑ 3 °C average global temperature• Above 0.7 °C ↑ 20th century

Urgent questions• What causes climate change?• Why do small drivers trigger amplification loops to

sudden, new equilibrium?

ORIGINAL ARTICLE

Figure 1. Chicxulub asteroid (10 trillion tons TNT) (Picture: www.shutterstock.com)



Investigation• Climate science (Nature, Science journals)• Geology, Paleobiology, Atmospheric and Space

Sciences, Meteorology, etc.• Intergovernmental panel on climate change (IPCC),

1988 by U.N., reports 5–7 years• Consensus, conservative• Computer models (e.g. Hadley Center in Exeter)

Climate change drivers• Solar energy

• sun spots• Milankovitch cycles

• Catastrophic events• volcanoes• asteroids

• Anthropogenic (man-made)• Burning fossil fuels or biomass• Land use• Habitat and plant destruction• Positive Feedback Amplifiers

• greenhouse gases• albedo, ice melt• methane release• sinks to sources• ocean heat conveyor

• Canfield Ocean• stratified• hypoxic bottom• hydrogen sulfide release into atmosphere

Solar energy to Earth• Some reflected by albedo and clouds• 168 W/m2 warm Earth

Natural solar cycles (Figure 3)• Milankovitch cycles:• Elliptical to round orbit (100 000 years cycle)• Axis tilt – 21.5° to 24.5° (41 000 years)• Precession (26 000 years cycle)

Solar pulses• Composite 22 000 years cycles• Energy delta 0.5 W/m2

• Ice Ages 5–10°C colder• Sudden switch

Greenhouse gas in atmosphere• Sun radiates in visible light and UV spectra (6 000 °C)• Earth radiates infrared (59 °F/15 °C)

Earth’s atmosphere (Figure 4)• Traps and reflects infra-red back to Earth, insulation

blanket• Trace elements• Water vapour, CO2, methane• CO2 – 0.037%• Atmospheric CO2 and temperature

Figure 3. Natural solar cycles (Picture: www.wikimedia.org)

Figure 4. The Greenhouse effect (Picture: www.shutterstock.com)

Figure 2. Volcanism (Picture: www.shutterstock.com)



Greenhouse gas recycling• Water vapour – weeks• Methane – 10 years• CO2 – 100 to 1 000 years• Carbon cycle in atmosphere and ocean – dynamic

balance• Deep Earth sequestration (third space) fossil fuel – if

released, stays in carbon cycle for 1 000 years• Temperature rises for hundreds of years after CO2

rise

Energy balance equations for Venus, Earth and Mars

Predicted Actual

Venus +55 °C +500 °C (850 °F)• 960K ppm CO2, retains heat adequate to melt leadEarth 0 °F/−19 °C +59 °F/15 °CMars −50 °C −42 °C to −63 °C• Lost atmosphere

Heat trapping effects of CO2• Jean Baptist Fourier and John Tyndall – 1850s:• Fourier equations, Tyndall effect• Arrhenius – Nobel Prize (1903):

• ↓CO2 by 1/3 to ½ will ↓ temperature by 9 °F cancause ice age

• 2X CO2 - ↑ temperature 10 °F/6 °C, verified bylater ice core gas samples

500 M years since Cambrian explosion• Dinosaur ages (225 M to 65 M), earth warmer• 7 Trillion tons of carbon progressively stored as fos-

sil fuel• CO2 gradual ↓ from 2000 ppm• CO2 ↓ 1/10 000 of current rate of ↑• CO2 now higher than in 20 M years• Most extinction events triggered by sudden

changes in CO2 levels• Past 200 years, add 220 billion tons CO2 in atmos-

phere due to fossil fuel burning

Fossil fuel burning (Figure 5)• Release from ‘Third Space’• Half to atmosphere• Half to ocean and Earth• Keeping atmospheric CO2 curve – Mauna Loa

• 315 ppm (1958)• 390 ppm currently• now ↑ 2 ppm/year since 2002

• 550 – 900 ppm by 2100

Anthropogenic alterations ofatmosphereAnthropogenic forcing• Moving away from natural cycles, dramatically since

1970

• Direct 150 year temp measurements – 20/21warmest years since 1985

• Earth temp ↑ 1.3°F/0.7°C in 20th century

? Sun spot activity• Solar activity correlates well with global temps, from

1850 to 1970• Poor correlation since 1970• Earth should be approaching ice age• Currently absorbing 1 W/m2 more than releasing

(NASA climate models)

Positive feedback mechanisms • Albedo (Earth’s reflectivity)• Snow cap reflects 90+% of solar energy• Dark ocean absorbs 80%–90%• Melting ice cap >> heat absorption• Threshold event, energy to melt followed by surge

of heat and temperature rise• Earth warming greatest at poles• Earth Surface Albedo (Reflectivity)

• Earth’s albedo – currently 30% of sun’s UV radia-tion

• If Earth’s albedo decreases to 27%, same effectas increasing CO2 5X

• Polar Ice Albedo• Arctic sea ice 40% thinner in 90s than 50s• Lost additional 20% since 1990s• 2006 study – Greenland losing 180 M acre-feet

of land ice per year• 2x rate of 1996 (Figure 6)

Antarctic ice shelf (Figure 7)• March 2002 – sudden, unexpected collapse of

Larsen B ice shelf• Size of Luxembourg, 650 feet thick• 500 billion tons ice• Zwally (Science, 2002): ‘mechanism for rapid, large

scale, dynamic response of ice sheets to climatewarming’

Figure 5. Fossil fuel burning (Picture: www.wikimedia.org)



• Larsen C and Ronne shelves now moving 8x fasterthan prior to Larsen B collapse

• Champagne cork removed from bottle• British Antarctic survey team – full-time mathemati-

cians, fractals and chaos theory to predict next col-lapse

Ice melting• Poles warming 6x faster than rest of planet• Arctic ocean ↑ 1.6 °C in 20th century• Arctic air ↑ 2 °C in past 30 years• 2000 – water at North Pole first time in over 2 M

years• Svalbard Island – 68 °F/20 °C 600 miles from North

Pole (2005)

Sea level rise• 2004 IPCC – gradual ice melting thermodynamics, -

13’ (35 cm) this century, (1–2 cm in 20th century)• Greenland – 23 feet (7 m)• West Antarctic ice sheet – 23 feet (7 m)• East Antarctic 200 feet (63 m) (2 M years old)• ‘Recent scientific evidence shows that major and

widespread climate changes have occurred withstartling speed.’ (Richard Alley, US National Academyof Sciences, 2002)

• Temperature ↑ of 5 °F/3 °C this century (IPCC)• Highest global temp in 3 M years• Last time, sea level 75 to 100 feet/30 m higher• Hansen (NASA’s Goddard Institute) expects 6 feet of

sea level rise this century, 6 – 12 feet (3.5 m) nextcentury

• Pierce (author, Speed and Violence) – 23 feet/7.2 mrise this century is possible, ice free Arctic by 2040

• 100 M people within 1 m of sea level rise• Tuvalu (Pacific) Alentians• Nile Delta, Bangladesh, Louisiana, New York

Tropical glaciers receding (Figure 8)• Himalayan glaciers provide water source to India/

Pakistan (2 Billion people)• Expected to melt by 2050–2100

Part 2 of this paper will be published in the Spring2012 edition of the SA Ophthalmology Journal.

Figure 7. Antarctic ice shelf collapse (Picture: www.nasa.gov)

Figure 8. Himalayan glaciers expected to melt by2050- 2100 (Picture: www.nasa.gov)

Figure 6. Greenland Ice Sheet (Picture: www.shutterstock.com)

In a 2006 study, Greenland was losing 180 M acre-feet ofland ice per year, which is 2x the rate measured in 1996


CONGRESSES/MEETINGS 2012/2013


SEPTEMBER 2012

6–7 September 3rd EuCornea Congress, Milan, Italy: www.eucornea.org

6–9 September 12th EURETINA Congress, Milan, Italy: www.euretina.org

7–9 September 2nd World Congress of Paediatric Ophthalmology and Strabismus, Milan, Italy: www.wcpos.org

8–12 September XXX Congress of the ESCRS, Milan, Italy: www.escrs.org

OCTOBER 2012

13-14 October Jacaranda Eye Symposium. Overseas guest speakers: Dr Gordon Plant UK) and Dr Andy Lee (USA). Contact Dr Niel Cornelius, Pretoria Eye Institute, email: [email protected] or cell number 082 875 1255 or 012 343 8035/6/7 or fax 012 343 8038

18-20 October Cape Eye Hospital Symposium. Overseas guest speakers: Dr Gordon Plant UK) and Dr AndyLee (USA). Contact Cape Eye Hospital, www.cape-eye.co.za or fax 021 948 8855 or Mr Andrevan Wyk, email: [email protected], tel: (021) 948-8884 or cell: 084 491 0135; or DrRizwana Amod (email: [email protected], tel: (021) 930-8999 or cell: 083 6807786)

NOVEMBER 2012

10-13 November American Academy of Ophthalmology (AAO)/APAO Joint meeting, Chicago, Illinois, USA.Website: www.aao.org

18-23 November SASOPS, Victoria Falls, Zimbabwe. Overseas guest speaker: Dr David Verity (UK). Contactperson: Covee-Ann, tel 082 562 6195 or 011 467 2538 or Charmaine Watkins atSmoothevents on 071 600 8098 or 011 025 5038/9

FEBRUARY 2013

15–17 February 17th ESCRS Winter meeting, Warsaw, Poland, www.escrs.org

MARCH 2013

14–17 March Annual Congress of the Ophthalmological Society of South Africa (OSSA). Cape TownInternational Convention Centre. Congress Organisers: Mr Rhyno Kriek and Sanet van derHeide, tel. 051 436 7733 or 083 265 0 265. Fax.: 086 60 60 555. Email:[email protected] Website: www.ossa2013.co.za

APRIL 2013

19–23 April ASCRS/ASOA Symposium & Congress. San Francisco, CA, USA. www.ascrs.org

JUNE 2013

8–11 June European Society of Ophthalmology (SOE). Copenhagen, Denmark. www.soe2013.org

JULY 2013

17–20 July 5th World Glaucoma Congress. Vancouver, Canada. www. WORLDGLAUCOMA.ORG


Meeting of the American Academy of Ophthalmology, Orlando, USA,October 2011Dr W Marais MBChB, MMed(Ophth)UFSDepartment of Ophthalmology, Faculty of Health Sciences, University of the Free State


Refractive surgery

New combined procedure for keratoconus• Topography-guided photorefractive keratectomy

for keratoconus with simultaneous collagen cross-linking using the iVIS laser.

• Contact lens-intolerant keratoconus was previouslytreated with invasive procedures, such as PKP intra-corneal ring segments.

The introduction of corneal collagen cross-linking (CXLnot FDA-approved)• CXL has slowed or stopped the progression of kera-

toconus.• Patients who were contact lens intolerant remain

visually incapacitated due to extremely high myopiaand high astigmatism.

A Canadian Health Protection Bureau (HPB) trial led byProf David TC Lin• University of British Columbia showed promising

early results in the above patients.

A case series of 12 eyes with 6 months’ follow-up found:• 83% of eyes had UCVA of 20/40 or better. • 66% had improved BCVA following simultaneous

topography-guided photo refractive keratectomy(TG-PRK) and CXL using iVIS laser.

• Mean astigmatism decreased from −3.25 D pre-operatively to −0.95 D.

• No signs of progression were noted by Prof Lin andco-author Simon P Holland.

• iVIS does a tiny central ablation – regularising thecornea and then doing CXL afterwards.

The iVIS has specific benefits for keratoconus:• iVIS precision takes up to 50 high resolution images

per second.• 1000 Hz laser shoots about twice as fast as the 500

Hz systems.• iVIS includes active cyclotorsion.

• Using an all-surface laser, the TGPRK brings the cen-tral optical zone treatment area down to 1.5–2.0mm, reducing the amount of corneal tissue that isremoved.

• iVIS performs a concurrent larger transepithelial all-laser debridement which increases permeability forRiboflavin and speed re-epithelialisation.

Cataract surgery• Phaco with Femtosecond takes less time, energy.• Research group led by Prof Zoltan Z Nagy, University

of Semmelweis, Budapest, compared the outcomeof Grade 4 nuclear cataracts in 40 eyes.

• LenSx Laser was used to pre-fragment the lens intofour quadrants to 90% of the lens thickness.

Prof Nagy found that:• The total phaco time was 48% less in the laser-

assisted procedures.• 51% less total ultrasound energy expressed as

cumulative dissipated energy.• Although the laser:

• cuts the access incisions and• the capsulorrhexis• and pre-fragments the natural lens,

• you still need the surgeon to divide the lens,remove the cortex and to implant the IOL.

Phakic IOL vs corneal proceduresFocusing on choices• Both patients and physicians benefit when there is

more than one good treatment option, as is now thecase with refractive procedures for moderate tohigh myopia.

• Still, this situation can present a quandary when theoptions appear to be well balanced.

• Currently available phakic IOL: USA only two PIOLare currently approved by FDA:• Posterior chamber vision implantable (Collamer

lens ICL, Staar).• Iris – fixated Verisyse lens (Abbott Medical Optics)known as the Artisan lens in Europe.

CONGRESS REPORT BACK



• In the US the only indication is for myopia.• In Europe, several other lenses are available to cor-

rect hyperopic toric as well as myopia• Veriflex• Toric ICL• Acrysoft Cachet

• Dioptres as definers.• According to Prof Jason E Stahl, University of Kansas

in Kansas City, PIOL is a viable treatment alternativein patients with moderate to high myopia who arenot good candidates for corneal refractive proce-dures.

• Prof Stahl defines myopia as:• Moderate: −3D to −6D• High: greater than −6D

• Refractive surgeons are generally comfortable withcorneal procedures in patients with moderatemyopia.

• In cases of −8D or worse, you are in the territorywhere PIOL outperforms laser vision correction.

• Several studies showed that PIOL is superior interms of:• BCVA • contrast sensitivity• safety, efficacy, stability, predictability.

The corneal thickness• Karl G Stonecipher noted the PIOL is preferable in

patients with thin cornea less than 500 μm.However, some surgeons will perform PRK as longas the corneal topography and anatomy are normal.

• Devices make a difference in high myopia.• Dr Stonecipher feels that the device does matter. In

a recent publication he reports results comparing 3and 6 month results of the Allegretto wave 200 Hzand 400 Hz for treatment of patients with −6 to −12 D of myopia, up to 3 D cylinder.

• At 6 months the 400 Hz group was superior inrefractive predictability and visual acuity. 92% ofpatients with −7 to −11 D myopia and up to 3 Dcylinder achieved 20/20 vision.

• However, he found better low-luminance contractsensitivity and night vision in PIOL patients.

Other considerations• Age: 46 years and above cut off for PIOL refractive

lens. Exchange is a better option.• Hyperopia +4 D higher refractive lens exchange

with consideration of multifocal IOL.• Dr Roberto Zaldivar (Argentina) also recommends

combination procedure (Bioptics).

CorneaTreatment for corneal ulcersCXL• CXL has been widely reported to effectively treat

keratoconus and post-LASIK extasia.• In New Delhi, at the All India Institute of Medical

Sciences (AIIMS), it was found that infectious kerati-tis was successfully treated with this novel therapy.

• Six eyes with non-responsive corneal ulcers (fourwith hypopyon) were treated with CXL as an adjunctto topical antimicrobials and cycloplegics.

• Symptoms improved in all eyes within 48–72 hours,thus avoiding impending perforations.

• Hypopyon was completely resolved within 2–4 days.• Re-epithelialisation was noted in all eyes after 48

hours and completed in 10 days.• Ulcers completely resolved within 3–5 weeks,

though all eyes showed either macular or leucoma-tous corneal opacity.

• CXL is inexpensive and simple to perform making itan ideal treatment for potentially vision-threateninginfections which is especially prevalent in develop-ing and under-developed countries.

Among the theories why CXL heals wounds• Inactivation of pathogens by direct damage of their

bacterial DNA.• Increased stroma tensile strength and rigidity of

corneal collagen, preventing melting.• The immediate symptomatic relief in the study and

the drastic decrease in the oedema surrounding theulcer can probably be explained by the anti-inflam-matory and anti-nociceptive properties of riboflavincombined with the increased packing density of thecollagen fibres and reduced stroma swelling rateafter CXL.

• Prof Panda considered CXL acted as an adjunctbecause all of the patients had received antimicro-bial therapy 4–12 weeks prior to CXL.

High levels of Gram-negative keratitis in retrospectivestudy• Shaldi documented the highest levels of Gram-neg-

ative keratitis in any known retrospective surveyand points to a trend of increasing Gram-negativeinfections.

• There is a link between their findings and the signif-icant rise in soft contact lens wear in the UK.Currently 5% (3.5 million) wear such lenses.

• In vitro testing showed widespread Gram-negativeresistance to chloramphenicol (74.1%) with declin-ing sensitivity over the 10 year study.

• There was 97.3% sensitivity to combination gen-tamicin and cefuroxime.

• 94% sensitivity to ciprofloxacin.

Refractive surgeons are generally comfortable withcorneal procedures in patients with moderate myopia



• The current treatment protocol: second-genera-tion fluoroquinolone monotherapy to treatmicrobial keratitis in the UK.

• Note: The authors found ciprofloxacin resistance in17% of Gram-positive isolates.

ConjunctivaSquamous cell CA• Is aggressive in immunosuppressed patients.• Shields et al have found that immunosuppressed

patients should be carefully observed for SCC giventhe rate of tumour recurrence and the aggressivenature of the disease.

• Surgical resection combined with topical interferonalpha–2B may reduce the risk for recurrence andappearance of a new tumour.

• Invasive and aggressive SCC behaviour was seen inall 13 patients.

• Four patients had recurrence or new tumour forma-tion.

• Three required extraction/enucleation.• One patient died as a result of brain invasion.• The remaining five patients were treated with exci-

sion and prompt topical interferon alpha-2B andnone showed recurrence or new tumour.

• The authors point out that this aggressive behaviouris in contrast to conjunctival SCC in the immune-competent patient.

GlaucomaStudy shed new light on implant efficacy• Patients with refractory glaucoma did better two

years after implantation of the Baerveldt 350 aque-ous drainage device than patients who receivedthe Ahmed-FP7 valve according to a seven-centreinternational clinical study to compare the devicesover a 5-year period.

• Prior studies were retrospective and indicated simi-lar success rates.

• Prof Iqbal I Ahmed, from the University of Toronto,indicated that inherent study design factors made itdifficult to draw salient conclusions.

• To resolve this issue a prospective of 238 refractoryglaucoma patients were randomly assigned toreceive either Ahmed-FP7 or Baerveldt 350 implant.

• Note: Study revealed a higher success rate in theBaerveldt group thus far, it is important to note agreater number of interventions and complica-tions occurred in the Baerveldt group: ‘These arehigh-risk eyes and the surgeries are considered rela-tively invasive.’

Device issues/complications• Malpositioning.• Shallow AC: rule out choroidal effusion.

• Iritis.• Corneal oedema: occurred more commonly in the

Baerveldt group.• Bleb encapsulation: occurred more commonly in

the Ahmed group.• Complications were directly correlated with the

device configuration and implantation procedure.

The Ahmed valve• Is flow restrictive and designed to reduce post-oper-

ative hypotony.• This permits early post-operative flow and tends to

result in higher rates of encapsulation with associat-ed high IOP.

The Baerveldt implant• Is not flow restrictive; patients are at a greater risk

for developing hypotony-related complications.• As the device requires manual ligature of the tube,

AC reformations and tube revisions were more com-mon.

RetinaSupport for bi-monthly injections for AMD• Bi-monthly injections of anti-angiogenic drugs ver-

sus the standard protocol of monthly injections con-tinues to gain strength, based on results with thedrug aflibercept (VEGF Trap eye).

• Researchers report one-year results from the phase3, VIEW 1 and 2 studies, which are the largestprospective, interventional studies for patients withwet AMD.

• The VIEW studies were designed to demonstrate theefficacy and safety of intravitreal aflibercept com-pared with the current gold standard monthly injec-tions of 0.5 mg of ranibizumab.

• 2 457 patients were randomised to intravitreal injec-tions:• 0.5 mg ranibizumab monthly• 0.5 mg aflibercept monthly• 2.0 mg aflibercept monthly• 2.0 mg aflibercept every two months

Results Patients losing fewer than 15 ETDRS letters:• 96.1% of those receiving 0.5 mg aflibercept monthly• 95.4% receiving 2 mg aflibercept monthly• 95.3% receiving 2 mg aflibercept bi-monthly• 94.4% receiving 0.5 mg ranibizumab

Dexamethasone intravitreal implant in vein occlu-sion with macular oedema• According to Haller et al, dexamethasone (DEX)

intravitreal implant 0.7 mg at a six-monthly intervalis safe and tolerable over 12 months.



• Although this was chiefly a safety investigation, effi-cacy analyses indicated that improvements in BCVAand central retinal thickness after the retreatment atsix months were similar.

Treatment-related adverse events:• Vitreous haemorrhage.• Endophthalmitis.• Retinal detachments were extremely rare.• Cataract progression did appear to increase after

the second DEX implant.• Further studies showed similar results with the 0.7

mg and 0.35 mg implants.

Aqueous flare identifies those at risk for proliferative vitreo-retinopathy• Schröder et al found that an aqueous flare reflects

the blood-ocular breakdown in rhegmatogenousretinal detachment.

• Retinal detachment represents a major risk factorfor PVR re-detachment.

• The laser flare-cell meter provides a rapid and non-invasive method to measure the protein content inthe AC: it may serve as a valuable tool to help sur-geons identify those patients who could potentiallybenefit from intra-vitreal drugs to prevent PVR.

• In eyes with flare values exceeding 15 photonscounts per millisecond, the odds of PVR re-detach-ments increased 16-fold.

Study of bevacizumab for ROP sparks controversyShould Avastin supplant laser for treating Zone 1 ROP?• BEAT ROP investigators reported that, infants with

Zone 1 Stage 3+ disease, had a recurrence ratewith Avastin of 4% compared with 22% withlaser.

• Based on these results, the language in an accom-panying editorial was emphatic: ‘Intra-vitrealAvastin should become the treatment of choice forZone 1 ROP.’

• At this moment, however, significant questionsremain.

Retrospective reports• It was first reported in 2007 that intra-vitreal beva-

cizumab could induce regression of AP-ROP withretinal detachment.

• Laser has an unfavourable outcome with AP-ROPand progresses to rapid complete retinal detach-ment.

Prospective reports• The first case series was published in 2008 involving

18 eyes of 13 infants.• Their patients were divided into three groups:- Stage 4a/4b that did not respond to convention-al treatment- Threshold ROP with poor ocular media clarity,making conventional therapy difficult.- High risk pre-threshold/threshold disease.

• After injection with Avastin neovascular regressionwas observed in 17 of 18 eyes.

Randomised trial BEAT-ROP• Bevacizumab Eliminates the Antigenic Threat of

ROPwas the first prospective controlled, randomisedtrial of one dose of bevacizumab 0.625 mg for ROPstage 3+ without combining laser and Avastin.

• The primary outcome was ROP recurrence in one orboth eyes requiring re-treatment before the 54-weekmark.

• Six of the 140 eyes in the Avastin group had recur-rence compared to 32 of the 146 eyes in the lasergroup.

Lingering questions include:• Safety• Long-term outcomes• Appropriate dosage

Safety and pharmacokinetics• Drs Guinn and D Wallace are concerned about the sys-

temic/blood levels• because reports done in 2007 on rabbits showed the

half-life (1.25 mg) is 4.32 days in rabbits. Researchersnoted, however, that humans have larger serum com-partments, thus systemic exposure may be less.

• Dr Helen A Mintz has not seen systemic toxicity at theUniversity of Texas at the 5-year follow-up.

Ocular outcome• Avastin, unlike laser, does not destroy the periph-

eral retina or induce cystoid macular oedema.

Protocol for follow-up• Follow-up is according to the recommendations of

the early treatment for ROP. • Late recurrence occurs around 50 weeks post-men-

strual and can be treated with another injection.• Dosage: 0.625 mg – half adult dosage


Correction of aphakia in the underground workerBT Pienaar MBBCh, DOMS (RCP Lond, RCS Eng)216 Sanlam Building, Welkom 9460, Orange Free State

This paper was published in the South African Archives of Ophthalmology, Vol 6: Nos 1–4: January–December 1979.


The purpose of this paper is to discuss some prob-lems relating to the correction of aphakia in the

underground worker and to relate my experiencewith intraocular lenses and demonstrate theiradvantages in certain occupations, particularly theunderground miner. Although visiting ophthalmol-ogists have discussed intraocular lenses, there hasbeen very little discussion on the subject by SouthAfrican ophthalmologists. This is surprising, as oneof the early pioneers of the pupillary fixationintraocular lens, is a South African, Dr EdwardEpstein.

In the gold mining industry there are two main causesof cataracts, namely traumatic and senile, occurring intwo completely different population groups, black andwhite workers. The surface worker of the gold miningindustry works under similar conditions to any otherworker in heavy industry, but the underground workingcondition is unique to mining and the depth at whichthey work peculiar to the gold mining industry.The principal cause of traumatic cataract in the gold

mining industry is the penetrating eye injury, which Idemonstrated in a paper read to this Society in 1977and which occurs in the gold mining area in which Iwork at a rate of about 6 cases per month.1 The maincauses are rock injury, wire injury and intraocular for-eign body.Senile cataracts which may develop in an under-

ground worker will only create special problems if theyoccur between the ages of 45 and 62.5 years. At 62.5 theminer retires from underground work and his problemis then similar to that of other cataract patients in thatage group.The black and white population groups differ. The

black underground worker is seldom over 40, is amigrant worker who signs a contract for 6 months, afterwhich he may return if he wishes to the rural areas ofSouth Africa or the neighbouring black states fromwhere he was recruited. He is unsophisticated, unedu-cated and often illiterate and because of the age group,virtually all aphakia in this group is due to trauma.

The white underground workers, on the other hand,range in age from 18 to 62.5 years, a very large percent-age of them making mining their careers. They are moresophisticated and better educated. In this group we getboth traumatic and senile cataracts.The correction of aphakia is possible by:• spectacles• contact lenses• intraocular lenses.

Spectacle correctionWe are all familiar with the disadvantages of the apha-kic spectacle lens:• Magnification of the image by 25% precludes its use

in the correction of the unilateral aphakia, and itgives the bilateral aphakic a false spatial orientation.

• Spherical aberration, which causes a pincushion dis-tortion.

• Poor co-ordination of manual movements, whichcauses clumsiness with simple tasks.

• Restricted peripheral fields, due to ring scotoma andunrefracted field of vision outside the spectaclelens. This is very dangerous in working under-ground.

• Continued adjustment of aphakic spectacles, partic-ularly in the underground situation where specta-cles are often knocked off one’s face. There is alsothe nuisance of spectacles continually misting upand having to be cleaned.

From this it is obvious that not only is the bilateral apha-kic with spectacle correction an inefficient worker, buthe is also a danger to himself and his fellow-workers.

Correction with contact lensesThe advantage of a contact lens in aphakia over a spec-tacle correction is well known and the main points are:• There is no significant magnification. Therefore it

can be used in unilateral aphakia and there is nofalse spatial orientation.

• There is no spherical aberration and therefore noperipheral distortions.

• There is no ring scotoma. Therefore there is a normalvisual field and thus safe for use underground.

B L A S T F R O M T H E PA S T



Until 1977 no attempt was made to correct unilateralaphakia in the black underground worker. Towards theend of 1977 we started a contact lens clinic at the ErnestOppenheimer Hospital and found that although it usuallytook longer to teach the black worker to use the lens, itnevertheless could be done quite satisfactorily. Only hardlenses are used, as they are more durable.However, in some respect the prophets of doom werecorrect in that after two years I have only six black contactlens wearers working underground out of a possible 20who could attain a visual acuity of 6/12 or better with anaphakic correction.

The reasons for failure are:1. Ocular irritation underground – three patients admit-

ted that they did not wear the lenses undergroundbecause they were uncomfortable.

2. Three patients gave up during the fitting and adapta-tion stage because they felt that the binocular visionattained was not worth the trouble.

3. In most of the patients there was a lack of motivationeven to attempt to use the lenses, as they were eagerto go home. After recovering from a major penetrat-ing injury, the patient is usually nearing the end of his6-month contract and wishes to return home. Here Ibelieve we have a communication problem.

In the unilateral aphakic white worker under the age of45, there is no real problem and his aphakia can be cor-rected with a contact lens. Again, however, very few ofthese patients wear their contact lens underground. Twofactors are repeatedly blamed for the discomfort and irri-tation when wearing a lens underground, viz.:• Heat• Dust particles.The temperature in the gold mine increases with thedepth of the mine. In the Free State gold mines, mostmines operate between 1 200 metres in the west to 2 400metres in the east, as the gold reef slopes from west toeast. The maximum temperature allowed by law is 31 °Cand the average temperature at the deeper levels is about29 °C with a humidity of about 90%. The workmen per-spire profusely and when perspiration unavoidably entershis eye, the wearer of a contact lens becomes extremelyuncomfortable. To rub the eyes, when this occurs, canlead to loss of a lens.Dust is not a great problem in most places. However,there are still work situations which unavoidably create acertain amount of dust, e.g. drilling (where the rock isbeing broken) and in the vicinity of a ventilation system,e.g. large ventilation vents and passing through a ventilation door. The strong draught coming through aventilation vent or when opening a ventilation door, oftencontains a lot of grit which blows into one’s eyes andwhen this is trapped under a contact lens, it is extremelyirritating and painful.

Poor lighting plus dirty conditions, including one’shands, prevent removal of the lens in the haulage shaftor stopes and therefore time is wasted as the workmanhas to go to the nearest dressing station to remove thecontact lens. This may take as long as 30 minutes ormore. After this has happened to a workman once ortwice, he becomes fed-up and leaves his contact lens athome.After about 45 years of age another factor creeps in,i.e. poor manual dexterity. These men of 45+ have spentthe best part of 20 years underground, doing manualwork, and their ability to cope with these lenses isamazingly poor. The problem becomes very serious ifsuch a workman develops bilateral cataracts. At thisstage of his career he is usually in a more senior positionas a shift boss, mine captain or sectional manager, has alot of underground experience and, more important, isnot trained for any other type of work. If he cannot berehabilitated to doing his mining job underground, heis given some surface work, with a large drop in hisearnings, or faces early retirement with a much reducedpension. I have been associated with the mining indus-try since 1964 and up to 1974 I have been unsuccessfulin rehabilitating this group of aphakics for undergroundwork because of the aforementioned disadvantages ofwearing contact lenses.

Aphakic correction with an intraocular lensThe advantages of intraocular lenses are mainly:• Almost total convenience and no ocular irritation• Instant vision• Still less magnification, about 7% for a contact lens

and 2% for an intraocular lens.The disadvantage is an increased surgical risk.

The black unilateral aphakicAs very little work has been done with intraocular lens-es in the highly pigmented eye to assess its reaction, Ibelieve it is not justifiable at this stage to implant theselenses in the eyes of patients who will then go home torural parts of South Africa or to their own countries,where adequate ophthalmic follow-up is not possible.At this stage we will keep persevering with contact lens-es in spite of the disappointing results.

If he cannot be rehabilitated to doing his mining job underground, he is given some surface

work, with a large drop in his earnings, or faces early retirement



The unilateral aphakic white worker under 45 years of ageAs good binocular vision is not essential in most under-ground work, but the peripheral field is, I am conserva-tive in my approach to the uni-ocular aphakic whiteworker in this age group and correct his aphakia with asoft contact lens. However, if their efficiency is impairedbecause of only using one eye, I will seriously considerimplanting an intraocular lens.

The white aphakic underground workerover 45 years of ageIn 1974 I started using intraocular lenses for the correc-tion aphakia in this group of underground workers. Atpresent I have 12 white underground workers betweenthe ages of 48 and 59 years working happily under-ground without any problems whatsoever, with theiraphakia corrected with an intraocular lens. Althoughthis might not appear to be a great number, it assumesgreater significance if one considers that from 1964 to1974 I was singularly unsuccessful in rehabilitating anyunderground worker developing cataracts in this agegroup, whereas since using the intraocular lens, I havenot had one failure.To establish whether this is a feasible proposition, I

present my first 50 cases of lens implantations amongwhich are the 12 underground workers (Table I).Only two patients have bilateral lenses, one of them

an underground worker.Six patients have a contact lens in one eye and an

intraocular lens in the other. They hardly ever wear theirspectacle correction, as they have good distance visionwith the contact lens eye and read well with the intraoc-ular lens eye. However, all these patients keep askingme to implant a lens in the contact lens eye. This I havesuccessfully resisted.Six secondary implantations were done, double

Fleiringer rings being used in all of them. Vitreous lossoccurred in one case. This was followed by partial ante-rior segment vitrectomy with implantation of the lens;visual acuity 18 months later is 6/10.

Half of the patients in this series (Table II) had an unaid-ed visual acuity of 6/18; 94% had 6/12 or better, whichcompares well with Binkhorst’s series of 90.3% in a largeseries of 800 patients.2

The causes of visual acuity less than 6/24 included onecase of known senile macular degeneration, one ofcorneal oedema due to surgical complications, and onepatient who developed hyphaema with a vitreous haem-orrhage, which has still not absorbed.

There was no case of disastrous myopia (Table III).Although ultrasound would be very helpful, a good histo-ry and particularly a spectacle script before the age of 40years is very useful. An axial myopia of 6 dioptres or moreis a contraindication to lens implantation, because of thepossible retinal problems which might occur and the highmyopic residual refraction unless an intraocular lens ofpre-determined power is implanted into the eye.

Complications occurring in anycataract procedure• Incarceration of the iris occurred in two cases. This is

easily corrected through the corneal incision, which Iprefer to use. Both patients vomited incessantly post-operatively.

• Glaucoma. Two cases occurred lasting about 3 weeksafter surgery and now stabilised at an intraocular pres-sure of 16 mm Hg without treatment. These wereboth, I believe, steroid-induced glaucoma.

• Vitreous loss. There were two cases of which one wasa secondary implantation.

Table I: First 50 cases of lens implantations

Total number of eyes: 50

Bilateral lenses: 2With one aphakic contact lens: 6Secondary implantation: 64-loop Binkhorst lens: 45Fyodorov lenses: 2Epstein Maltese cross lens: 22-loop Binkhorst lens: 1

Table II: Visual acuity

Unaided: 6/36 to 6/6: 50% 6/18With correction: 6/6 : 21

6/7.5 : 166/9 : 76/12 : 3

Less than 6/24 : 3

Table III: Refractive errors

Myopic: Below 2.50 D : 39 cases−2.50 to −3.25 D : 6 cases

Hypermetropic: +0.25 to 1.50 D : 4 casesAstigmatic: 0 to 1.00 : 23 cases

1.25 to 1.50 : 19 cases1.75 to 2.25 : 7 cases

An axial myopia of 6 dioptres or more is a contraindication to lens implantation, because

of the possible retinal problems which might occur and the high myopic residual refraction



Complications made more seriousbecause of the intraocular lens• A flat anterior chamber: one case. The lens was

removed after two attempts of reforming the anteri-or chamber had failed. However, the endotheliumhas been damaged, resulting in corneal oedema.

• Hyphaema and vitreous haemorrhage: one case.The vitreous haemorrhage is still absorbing. Visualacuity at present is 6/36.

• Retinal detachment: one case (a horseshoe-shapedtear in the upper temporal quadrant of the righteye). Detachment surgery is difficult because of therestricted pupillary dilatation. Encirclage plusplomb was used successfully and visual acuity is6/12.

Complications due to the lensThese include:• Anterior dislocation of the lens, which occurred in

five cases. Three were reduced by dilating the pupiland positioning the patient’s head, and two had tobe taken back to the theatre, the anterior chamberopened and the lens replaced in its proper position,because there was no iris suture used in these twocases.

• Posterior dislocations: one case. This was reposi-tioned by dilating the pupil and the positioning ofthe patient. This gives an incidence of 12% of dislo-cation in this series, which is certainly not accept-able in comparison to Binkhorst’s 2.8% of 831 cases.3

However, some authors have reported an incidenceof 30%. In these first 50 cases, I think I was overkeento prevent posterior synechiae formation by dilatingthe pupils too frequently and too vigorously.

• Spontaneous haemorrhage: two cases. Both clearedup completely without any visual impairment. Inone case it occurred 6 months post-operatively andin the other a year post-operatively. The causeremains unknown.

• Corneal oedema: two cases, one after developing aflat anterior chamber referred to above, where thelens was removed. A flat anterior chamber post-oper-atively in intraocular lens surgery is an emergency andif the anterior chamber cannot be reformed success-fully and immediately, the lens should be removed.The other was a case of temporary oedema, whichcleared up completely in 12 months.

Although, therefore, there were a number of complica-tions in this series, they were all treated successfully,except for two cases, viz. a flat anterior chamber wherethe lens was removed; and the vitreous haemorrhagewhich could occur in any cataract operation. What ismore important, all these complications are avoidable. Itherefore believe that intraocular lens implantation forthe correction of aphakia is a worthwhile procedure.

ConclusionI think we should move away from the concept of con-tact lenses vs intraocular lenses in the management ofaphakia and should use the best method available tosuit each individual patient’s requirements.Herbert L Gould (New York) states that the continuouswearing of a soft lens in one eye plus an intraocular lensin the other eye, presents the ultimate in the currenttechnology in aphakic management.4

Certainly it is my experience that the intraocular lens isthe only method of successfully rehabilitating theunderground aphakic worker after the age of 45, thusenabling him to continue with the work for which hewas trained until retirement.

References1. Pienaar BT. 1977. The Epidemiology of Ocular Trauma in the

OFS Goldfields. S Afr Arch Ophthalmol, 4:972. Jaffe, Galin, Hirschman and Clayman. Pseudophakos, p. 1913. Jaffe, Galin, Hirschman and Claymon. Pseudophakos, p.

195, Table 13/13.4. Gould HM. In The Intraocular Lens in Perspective, p. 23. Ed.

By Worthen DM and Vinder PS.

PUBLICATION OF ETHICS ARTICLES

Aregular feature in SA Ophthalmology Journal is an article covering one or more topics related to ethics inthe practice of medicine (see page 60). Not only does this enhance the status of the journal but it also

helps doctors to earn those rather elusive ethics CPD points. A questionnaire accompanies the article and doctors are encouraged to send in their answer form in order to qualify for ethics CPD points. The instructionsare on the bottom of the questionnaire sheet.


‘Work & Play’ Academic sessions will take place in the morning each day, leisure time in the afternoons and evenings!

More exiting speakers to be confirmed! Look out on the SASOPS website for more info! Coming soon!

www.sasops.co.za

SASOPS

2012Congress

Victoria Falls

Elephant Hills Resort

November 201218th – 23r

18th – 23r

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Moorfields Eye Hospital, Consultant, MD, MA (Oxf), BM BCh, FRCOphthDr David VIntern

November 2012

Moorfields Eye Hospital,

MD, MA (Oxf), BM BCh, FRCOphtherity vid V Verity

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MD, MA (Oxf), BM BCh, FRCOphth

Mor

and evenings! ning each daymor

Academic sessions will take place in the ork ‘WWork & Play’ International Speaker:


and evenings! e time in the after, leisurning each day

Academic sessions will take place in the ork & Play’


noons e time in the afterAcademic sessions will take place in the

London, UKMoorfields Eye Hospital,

om smoothevents on 071 600 8098 or 011 025 5038/9

Moorfields Eye Hospital,

or call charmaine fr082 562 6195 or 011 467 2538TO BOOK YOUR PLACE A


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Results of Colleges of Medicine of SA examinations held in May 2012 in Durban


FC Ophth(SA) Primary 1A3120396 BOTHA, Theunis Christoffel3120397 DE LANGE, Johannes Tobias3120398 FREED, Irene Marthina3120399 GAEBOLAE, Keslilwe Sampson3120401 GNANAPRAGASAM,

Uthayachandhiran3120404 KHANTSI, Boitumelo3120407 MAJOLA, Nonhlanhla3120414 MOFOKENG, Salamina Mathabo3120416 MOODLEY, Sanushka3120417 MTHETHWA, Sibongile

Constance3120418 NAIDU, Natasha3120419 NAUDÉ, Malcolm3120421 NKOMBYANI, Lucky3120423 SELELE, Thekiso Mzwandile3120424 SEOBI, Teboho3120425 SMITH, Suzanne Mari

3120430 VAN DER MERWE, Pieter JacobusStephanus

3120431 VAN TONDER, Riaan3120432 VERWEY, Vincent Francois3120433 WANG, Louise

FC Ophth(SA) Intermediate 1B3120437 FERNANDES, Gareth3120438 GERBER, Willem-Martin

FC Ophth(SA) Final3120441 ABRAHAMSE-PILLAY, Helga Inez3120442 AGHDASI, Shabnam3120443 DOLLAND, Riana Sarita3120444 GOODING, Caroline3120445 GOVENDER, Veloshni3120447 HEYDENRYCH, Leonard Goussard

3120448 MBAMBISA, Bayanda Nothemba3120449 MOHAMED, Nabiel3120451 NAIDOO, Lavindren3120452 ROGERS, Graeme John3120453 SHABALALA, Jabulani Welcome3120454 VAN ZYL, Cornelis Johannes

Petrus Gerhardus

Dip Ophth(SA)3121653 BOTHA, Ruan Theo3121654 DEBEILA, Khutsiso Mamorake

Sekgololo3121655 LE ROUX, Etienne Philip3121656 MALHERBE, Lodewicus Francois3121657 MAPHAM, William Eric3121658 MUSTAK, Sayeed Hamzah3121659 YORK, Nicholas John

RESULTS



OSSA Congress, March 2012, Sandton


CO N G R E S S N E W S

Figure 1. Dr Louis Kruger receives a specialthank you for excellent services rendered toOSSA by the President of OSSA, Dr DeonDoubell.

Figure 2. Dr Johan Eloff receives theHumanitarian Award from the President ofOSSA, Dr Deon Doubell.

Figure 3. Dr William Earl (Convenor) is seenhere with Ms Christi Truter of Consider ItDone, who organised the 2012 OSSACongress.

Figure 5. Seen together at the OSSA Congress, from left to right: Dr Andrew Ivey, Dr Chris Gouws and Dr Johann Slazus.

Figure 4. Dr Karin Lecuona receives a special thank you for excel-lent services rendered to OSSA by the President of OSSA, Dr DeonDoubell.

Figure 6. Invited guest speakers, from left to right: Prof William Nunery (the WAGO guest speaker); Prof John Kempen (OSSA Uveitis speaker); Prof Rand Allingham (OSSA Glaucoma speaker); Dr Stefan Pfennigsdorf (Allergan guest speaker); Prof Alan Cruess (HennieMeyer guest lecturer). Absent: Prof Alon Harris (Alcon guest speaker).



Figure 11. Prof Colin Cook is flanked here by Dr Mike Mesham tohis right and Dr Peter Alexander to his left.

Figure 10. Dr Klaas Stempels from George enjoying a break at theOSSA Congress.

Figure 9. Dr Bill Nortjé was the DJ Wood Memorial Lecturer for2012. Here he is with his family, Simson, wife Bonnie andCatherine.

Figure 8. Seen at the OSSA Congress in Sandton in March 2012.From left to right: Dr Nicky Welsh, Dr Sue Williams, Prof TrevorCarmichael and Dr Shelley Biddulph. Dr Welsh and ProfCarmichael were responsible for the Academic Programme andthe WAGO meeting.

Figure 7. DJ Wood Memorial Lecturers over the years having a great time at the OSSA Banquet 2012. Front, from left to right: Dr LouisKruger, Prof Andries Stulting, Dr Bill Nortjé. At the back, from left to right: Dr Jan Talma, Prof Colin Cook, Dr Johann Slazus, Dr Johan deLange.



Nidek Specular Microscope CEM-530The art of eye care

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Highlights• Unique paracentral specular microscopy • Complete analysis automatically performed in two seconds • Auto indication of optimal image from a choice of 16 images –helps to select most suitable image for data analysis, enhancesdata reliability

• 3-D auto tracking, auto shot and tiltable touch screen allow forfaster, more accurate measurement

• Instant printout of analysed data and images of the endothelialcells with built-in printer

• LED light source for flash reduces power consumption, lastslonger and saves on operational costs

Oculus Pentacam® and Oculus Pentacam HR®The gold standard in anterior segment tomographyThe measurement principleThe Oculus Pentacam® is the only instrument on the market able to measure true elevation rather than just curvature values. It performs a precise and complete measurement and analysis of the centre of the cornea

Highlights• Automatically rotating Scheimpflug camera provides an overall view of the anteriorsegment of the eye in a matter of seconds

• Optimised optics offers absolute perfect image quality and impressive representationsof IOLs and phakic IOLs

• The degree of cataract is made visible by the light-scattering properties of the eye lens• Automatic measurement activation with quality test guarantees fast, reproducible anddelegable measurements

• Data provides the basis for a 3D model of the complete anterior eye segment• A supplementary pupil camera corrects for eye movements during the examination• Measurement is non-contact and entirely agreeable to the patient• Can be upgraded upfront or later to include software packages for refractive surgeryand/or cataract surgery and other optional modules to suit your needs



Clarity RetCamA complete digital eye exam for all newbornsThis advanced fully integrated wide-field digital imaging system has been completelyredesigned for ease of use and intuitive operation. It offers the next generation of ophthalmic visualisation and photo documentation with a new, redesigned cart, software user interface and ergonomic hand piece

Highlights• Lightweight ergonomic hand piece for easy manipulation and image capture• Extended video duration allows two minute recording• Captures brilliant colour images in full screen mode for immediate assessment of the

retina and anterior chamber• Frame-by-frame review after video capture allows user to select optimal images • Five interchangeable lenses• Digital photo documentation facilitates physician review and follow-up• Pull-out keyboard with soft key controls plus photo and text printer• Fluorecein Angiography mode provides customisable on-screen information display,

including timer, frame number and frame rate• Tri-function foot control• DICOM-compatible patient files to transfer into your EMR system• Redesigned imaging cart with flat panel display, new console and colour printer

Righton Zoom Slit Lamp NS-2DDigital Photo Set/Clinical SetA brighter vision

Righton NS-2D Digital and Clinical Slit Lamps provide full zoom optics anda high-resolution internal camera that captures both video and stillimages

HighlightsDigital photo set• CCD digital images captured with a simple press of joystick button• Captures both video and still images• Still images can be captured from video• No delay on motion image with frame rate of maximum 30fps• Combined with simple image file “NS File”• Automatically indicates right or left eye on NS File• Three brightness levels for NS File to suit eye colour or eye condition• Beam-split ratio 70 for camera, 30 for eyepiece

Clinical set• Traditional fine zoom optics• Zoom ratio: 5.5x 5.9x to 32.5x or 71.x to 39x available, according to eyepiece• Maximum slit length: 16mm• Wide view field ø38.3mm• Built in barrier filter• CCD digital set can be mounted on NS-2D Clinical Set



SAGS Travel Fellowship Grant

Congratulations to Dr Aritha du Bruyn who was the successful applicant for theSouth African Glaucoma Society Travel Fellowship that was advertised inNovember 2010. She will be going to Moorfields Eye Hospital in London, England,to participate in her glaucoma observership from 29 October to 9 November 2012.We include some of the information from the SAGS flyer, Dr Du Bruyn’s letter ofmotivation, and the letter of endorsement of her application by Dr Linda Visser.

NEWS

Dr Aritha du Bruyn




Title: Phaco Fundamentals: A guide for trainee ophthalmic surgeons

Author: Matthew Anderson and Jeremy ButcherYear of Publication: 2011ISBN: 978 1848765- 177Publisher: MATADOR Reviewer: Prof Andries Stulting

Phacoemulsification is one of the most important surgical tasks that the trainee ophthalmic surgeon should master. The learning process of phaco is complex as the procedure is not as easy as one would think when

starting out!This book is very handy as it guides the young trainee through every step of phacoemulsification in a step-by-step

manner. This 100-page book with well over 100 intra-operative colour photographs and drawings on glossy paper is a

good book for the trainee surgeon to read.There are 13 chapters which describe the individual steps of phacoemulsification and are intended to equip the

trainee with the necessary knowledge required to complete his or her phaco from start to finish.Chapter 1 deals with Setting up and concentrates on the use of the operating microscope, for example, moving

the operating microscope, setting your interpupillary distance, correcting for your refractive error, adjusting theangle of the eyepieces, the use of spacers, controlling the foot pedal of the operating microscope and centring themicroscope, as well as setting a comfortable working position.Chapter 2 deals with Draping while Chapter 3 discusses the Corneal section. A useful tip suggested by the

authors is to push the eye into slight depression, thus bringing the corneal epithelium and endothelium roughlyparallel to the horizontal plane. This makes it easier for the surgeon to get the keratome blade parallel to these surfaces. Chapter 4 is devoted to the Paracentesis and the authors make the point that the slit knife should be advanced

until about one-third of the length of the cutting edge has entered the anterior chamber.Chapter 5 deals with the Capsulorrhexis. The authors emphasise the fact that the longer the flap extends before

you regrasp it, the less control you have. Therefore the authors suggest that one should regrasp the flap frequentlyduring the rhexis, before it extends more than a quarter of the circumference of the final capsulorrhexis. One shouldendeavour to make the capsulorrhexis 5 mm in diameter.Chapter 6 covers Hydrodissection. The authors stress the fact that it is important to realise that subsequent steps

are dependent on the hydrodissection. A thorough hydrodissection makes later steps much easier. In Chapter 7 Phaco equipment and settings are discussed in detail.Chapter 8 is devoted to Phacoemulsification. Many practical tips are given, for example, grooving the nucleus,

rotation of the lens, cracking the nucleus into quadrants and emulsifying one quadrant at a time. The use of the second instrument and protecting the posterior capsule are discussed in detail. Chapter 9 is devoted to the Removal of the epinucleus while Chapter 10 discusses Irrigation and aspiration.Chapter 11 describes the Preparation for the insertion of the IOL while Chapter 12 describes the Insertion of

the IOL. Loading the IOL into the cartridge and injecting the IOL into the eye is beautifully explained.Chapter 13 deals with the Final steps, for example, properly removing the viscoelastic and what to do when the

eye is too hard or too soft at the end of the phacoemulsification operation. The authors achieved their objective to produce a single, safe way to perform phacoemulsification surgery. However, the book lacks information on subjects like anaesthesia, biometry, patient counselling and the

management of intra- and post-operative complications, although the authors explained in the Foreword that theyhave intentionally avoided those subjects as they wanted to focus on the operative steps. In my mind, adding theabove-mentioned chapters will enhance the contents of this primer to phacoemulsification.

B O O K R E V I E W


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Believe it or not … it happened to me …and to Derek de Beer … and to Jan Talma!


In 1990, Jan Talma asked me to join him on a trip to China. As a compulsive globe trotter, I didn’t even think formore than 5 seconds, before I answered: ‘Of course, Jan, I will join you!’

We both decided to attend the World Congress ofOphthalmology, which was held in Singapore. I

decided to fly via Mauritius, where I spent three daysexploring that beautiful island. A Muslim driver, calledAdam, picked me up at my hotel every morning and, forR100 per day, took me to a different part of the island. Iwas able to take pictures (another of my hobbies!) at myleisure. We had tea at the expensive hotels (St Geran was THEhotel at the time, costing a R1000 per day) and Adamshowed me where I could sleep (for free!) on the white,pristine beaches next to the luxurious hotels. Heshowed me the tourist attractions, but also where thelocals bought their food. Mauritius was a great experi-ence for me! I still have a dream – to go back to Mauritius one daywith my wife and maybe, to organise a boat trip toMauritius and an Eye meeting there before flying backto South Africa (of course, we will only have morningsessions for work and the afternoons and evenings freefor enjoyment!). Another memorable congress – seeHubrecht Brody’s comments expressed in the Editorial!My memories from Singapore include the beautifulclean city and the train ride where you could see fromone carriage to the next and the floors sparkling clean(at the time there was a fine of 500 Singapore dollars foreating in the train or throwing papers onto the pave-ment!). I also remember John Muller of SOS who had tothrow his grand day suit away after sweating profuselyin the Singapore summer one day!I remember a talk by Fydorov from Russia, famous forgiving radial keratotomy to the world. After telling theaudience that ALL of his patients could see 20/20 afterRK, there was a question from the audience regardingthe safety of the RK procedure. Fydorov replied:

‘To undergo RK is safer than to fly back to your countryafter this meeting!’I religiously attended the lectures but was urgentlycalled away by Dr Derek de Beer to accompany him toLucky Plaza, a famous area in Singapore, where he hadjust bought a Canon camera. Derek was very unhappybecause, when he left the shop, he saw the same cam-era costing less at the shop next door! He asked me tocome and complain to the guy who had sold him hisCanon camera.I took me an hour of negotiating and … at the end …I left the shop after buying a new Canon for myself, witha brand new zoom lens as well as a video camera, cam-era bags included!!! Lucky Plaza was good to me too!Jan told me to meet him at the Hong Kong airport tocatch our plane to mainland China. In 1990, only smallgroups of four people were allowed to visit China forfour days and Jan, through his Hong Kong connectionswith TFC, were able to arrange this visit and link up witha German couple. I asked Jan WHERE EXACTLY he want-ed to meet me, but Jan just said vaguely ‘at the airportin Hong Kong’.We both left Singapore on different planes for HongKong and the planes were scheduled to leave within 45minutes of each other! I got a few white hairs as Jan’splane was delayed by four hours and he had our ticketsfor China with him! I eventually caught up with him(and the tickets!) and was VERY HAPPY to see my friendagain!We boarded the CAAC plane that evening and couldnot believe that passengers entered the plane withchickens and stuff! It was amazing! What was NOTamazing, was that the flight was cancelled later thatevening (CAAC stands for China Airways AlwaysCancel).

B E L I E V E I T O R N OT. . .



We were booked into a hotel in Hong Kong for thenight and flew to Guilin the next day where we had awonderful time, going on a boat ride and looking at thebig, round and green mountains and the buffalo work-ing in the fields.Beijing was an exciting experience where we visited

the Forbidden City, Tiananmen Square, where the stu-dents had been shot a few months before, the GreatWall of China (where Jan gave me a white hat with theold South African flag on it), a factory (where we sawwomen working for many hours a day for many daysbefore getting one day off ), a market and the house ofa tourist guide who showed us a Bible in CommunistChina! We visited an Eye hospital with really old equip-ment and even enjoyed the famous Peking duck (hopeit was not a GENERIC product!!)One morning we hired bicycles from the hotel and

decided to explore Beijing before breakfast. We made amistake and entered a one-way street! We almost fell offour bicycles when four lanes of cyclists bore down onthe two of us! (Of course, we did not have a clue whatthe Chinese words for one-way street were!)While cycling blissfully along in the early morning, the

air full of smog, we passed a butchery where the meathung on hooks outside the shop! Then we saw aChinese man on his bicycle, just after he had bought apig and put it into the carrier of his bicycle! The pig wasstill bleeding! But don’t ever forget, Jan is always schem-ing and a man full of ideas! He decided to take a videoof this guy with his new video camera which he boughtrecently … at Lucky Plaza in Singapore, of course! Jancycled as hard as he could, passed the man with thebleeding pig, stopped his bike, turned around andfocused his video camera on the oncoming spectacle.The man and his pig whooshed by and the chase start-ed all over again!

The man was desperately trying to get away from Jan,because he probably thought that this lanky, blondeguy who looked a little bit underfed, wanted to steal hispig!But Jan is not a guy who lets go easily! (Just ask the

guys from Bonitas what he did to them recently in hisfriendly, diplomatic way!)Eventually, Jan got his video pictures, while I sat next

to the road, splitting myself for witnessing this greatspectacle, which I will never forget!After our four-day visit to China, we went to Hong

Kong and ended our tour there with a booze cruise onthe river. Jan is also a man of surprises and produced hisown bottle of South African wine. Jan told me he hadcarried this bottle of wine all the way from South Africaand he was not holding on to it any longer! We had tofinish the bottle that night!The only problem was that we had no cork screw with

us and had to ask the waiter to open the bottle for us!The cork fee was equivalent to R104, which was quiteexorbitant in 1990! We drank the wine slowly, enjoyingevery drop!When I visited Beijing again after 20 years, I was truly

amazed at the transformation of the city. The city wasnot grey anymore (in 1990 all colours like red, green andblue that were used in the Forbidden City, were forbid-den in Beijing. Nowadays, Beijing looks like any moderncity with colours everywhere! The bicycles have beenreplaced by modern cars. And you know what? VisitingBeijing again, but without Jan Talma, was not thesame for me!!!

Prof Andries StultingEditor-in-Chief


Incidents

Afew thoughts … first of all, a major regret! I sincerely regret that the ophthalmologists did not demonstrateinterest and cohesion in my vision for ophthalmology to combine financial forces. If half of the ophthalmolo-

gists ‘staan pa’… took the responsibility for one million rand, (take note… out of your pocket only perhaps R300000!), there would have been a HUNDRED MILLION RAND to make a communal investment … and with that in handwe would have been in a strong bargaining position! Investors have offered a rand for a rand … so, it is up to TWO HUNDRED MILLION RAND! That rand-for-rand oppor-tunity did exist six years ago.To obtain that amount of money opens up incredible opportunities! But as we are in a comfort zone in our BMW5s and ML 4x4s we let slip the possibility of making a MAJOR investment, dissipating our efforts in the office withtwo or three secretaries and a number of fancy expensive instruments. This disappears into insignificance!Is there anyone willing to accept this challenge? I regret the opportunity lost! And so will you! The pleasure is in the hunt!As my last contribution to the Corner, and as I feel it very difficult to completely cut the umbilicus with ophthal-mology and colleagues, I have decided to convey to my colleagues a number of incidents that crossed my way inpractice. In my early days as a GP I experienced some memorable incidents. A call at 12 pm … ‘This is Auntie Lambrechts. The uncle is ill. Oh, is it not doctor XYZ? … Then it is OK. Goodbye.’(No confidence in the new doctor).A call at 01:00 am … a moonless night!‘This is Auntie Lambrechts. The uncle is now very ill! Will doctor please come?’‘Where do you live? On a farm? Excuse me, WHERE?’ I responded.A long explanation followed. ‘Drive down the highway from Fochville, then left at the split, to the far right, past thewater tank, through the collapsed wire gates, then to the left, right, down, up … Doctor will see farm house downvalley on left. What is doctor’s name? To second farmhouse on the left … BUT HURRY! The uncle is now very, veryill! Severe pain in the chest …Yes … right shoulder …’ I was a locum in the practice and did not know the district at all! I apprehensively, but bravely, started my Volksiewith my new doctor’s bag and scanty medical knowledge and less knowledge of the local topography.GPS! Where were you when I needed you? It was mid-winter on the Highveld. Brrrrrrrrrrrrrr.I was totally lost … I had to wake up people fast asleep in cottages with wide-awake monster, barking dogs;through rickety gates made of barbed wire attached to tree stumps, past dilapidated creaking windmills, fierce-looking Afrikaner bulls, snorting at my attempts to drag and close the gates.Greatly relieved, eventually … the light of the second farmhouse on the left. A silent prayer floated out of theVolksie’s window past cackling geese.‘Where has doctor been so long? The uncle is VERY, VERY ILL!! What is doctor’s name again?’Sure enough! The uncle was VERY, VERY, VERY ILL! The BP was down, the patient was sweating and pale, his pulsewas irregular, the patient had chest pain going down to his right shoulder and arm. No ambulance! No phone, theexchange was closed!I established his BP, I digitalised him as he was in failure and zapped him in the bum with Omnopon, gr1/3.I did what inexperienced and stressed GPs would have done in those dire circumstances. The patient was com-fortable at last and I was exhausted.‘Does doctor want some coffee … before the sun comes up?’ ‘Please Auntie!’


B R O DY ’S ( L A S T ) CO R N E R

The era of Brody’s Corner is about to close. You are very fortunate to have an enthusiastic colleague, Dr CliveNovis, taking over. So welcome to … CLIVE’S CORNER in the future! (Clive’s Corner will follow Brody’s Corner in THISjournal – Editor)Clive is one of the few individuals in the history of the Corner who has communicated with the Corner.

Fortunately, complimentary!



After I had my coffee, I went out to my Volksie … and to my astonishment, I saw that there was a huge pumpkinon the left front seat. One of those green ones with the long curled nozzle! But BIG! ‘Auntie?’ ‘Where does this pump-kin come from?’‘No, Doctor, the Uncle got it from the roof while we were having coffee!!’ Sure enough … there was the ladder with a collection of pumpkins on the roof and the Uncle was back in bed!!The next incident almost had me in court before even beginning my career as a MD!My very first locum was in Fochville. The GP could hardly be understood as he had the most pronounced split

palate ever deconstructed by beserk DNS.But I understood that I had to be there at eight. And so I was at the practice, exactly on time, just like my Professors

taught me. The secretary looked at me with widely, dilated pupils: ‘Doctor, they wait for you at the hospital!’ I sped to the hos-

pital, which proved to be a converted house and rushed into a make-shift theatre.Two ghostly figures stood looking at me with even wider dilated pupils, in full theatre regalia, clasping their

gloved hands in front of their chests. I gathered who Dr XYZ was as I could not understand him.On the theatre table lay a smallish old man. The theatre sister whispered that the Uncle is going to have an appen-

dicectomy and they were waiting for me to put him under anaesthesia. Ye Gods!!I was flabbergasted! I had never seen the patient before; he was an old man, toothless, I did not know the theatre;

this would be my FIRST entry into private GP practice.So, perhaps this was how things were done in the world of Medicine in the rural areas?I anxiously looked around me. There was scoline and a longer-acting one … the name evaded me. There was the

laryngoscope. There was GAS … so time to get started! Pentothal … Scoline … Intubate …But that was easier said than done. The patient had a large wobbly tongue and flabbier soft palate and glottis …

which became bluer by the second. I just could not visualise the laryngeal aperture. I tried it blindly … no luck! I was sweating profusely, and so was the old man.The ghosts stared at me with extremely dilated pupils peering over their masks and clasping their hands in front

of their chests, looking at each other with knowing, concerned glances.Dogghhtteerrr … the one ghost gasped.I looked into the dark blue chasm … of no teeth … no oxygen … no larynx, no chance … my future in Medicine

declining before my dilated pupils. I had just begun my career in Medicine!Please, Lord!!I should have refused. ‘Yes, Your Honour, I was taught otherwise. No, Your Honour, I never saw this patient before.

Yes, but he did look rather old. I gave the anaesthetics. Yes sir, I should have known better, YOUR HONOUR!’ What else did you do as an intern? Paediatrics, of course! YES, PAEDIATRCS! And I was adept at blind intubation of prematures through the nose. Yes … that was the answer

before the final exit of the blue old man. I grabbed the laryngoscope, bent back his flaccid neck and shoved it rightthrough the pharyngeal, glossal black and blue invisible behinds, first shot … into the trachea! A pumped the bagand his chest started to heave up and down! Salvation … for the old man … and me!!‘He is a bit stiff’ … the one green ghost mumbled.I swore under my breath and shoved the patient a dose of longer acting

Flaxedil!

Hubrecht BrodyMMed (Ophth) FC (Ophth)



C L I V E ’S CO R N E R

Greetings colleagues and welcome to Clive’s Corner! Hats off to Hubrecht Brody who has been writing Brody’sCorner for the last six years!

A few days ago, I went through all of the Brody Corner articles. It was a fascinating read! Hubrecht has given us sucha memorable view of many ophthalmology topics and ideas. His command of the English language is remarkableespecially in view of the fact that his home language is Afrikaans!

Here are just a few of the highlights that stuck in my mind from Brody’s Corner:• Hubrecht has made a very valuable contribution to the Cape Eye Bank Foundation. His work and efforts have resultedin far more corneas than would have otherwise been available. Remember: improve public awareness by encourag-ing all your patients to become cornea donors.• FMCs is Hubrecht’s acronym for Foul-Mouthing Colleagues. Read this classic line from Hubrecht’s Winter of 2008 arti-cle: ‘If there is one issue which raises my ire, it is the FMC. The FMC should not be under the impression that his innu-endos and accusations, made against a colleague, do not reach the victim of his venom.’• Orthoptists. I agree 100% with Hubrecht about the value of orthoptists and about their scarcity and danger of extinc-tion. In his Winter of 2009 article Hubrecht wrote: ‘If we as ophthalmologists do not actively encourage the functionsand talents of orthoptists, we will live to regret it.’• Ophthalmic assistants. Same thing here. ‘An ophthalmic assistant is not a luxury. She is essential. How do you practisewithout her?’• OSSA and OSSA congresses. We should be more appreciative of our association and the wonderful congresses itorganises. Shame on those practicing ophthalmologists who are not paid up OSSA members. ‘It is beyond my com-prehension that certain practicing ophthalmologists are not members of OSSA’. Shame on those who never attendcongresses or other meetings. I am guilty of this myself relying far too much on the internet. ‘Attending the annualOSSA Congress is just about compulsory’, Hubrecht said and after reading these words I paid my admission fees andbooked myself a place at the recent OSSA congress in Sandton.• Hubrecht established the ophthalmology section of the Adler Museum of Medicine in Johannesburg. When did youlast visit this interesting place?• Hubrecht coined the term pseudo-pseudo-strabismus. These are true squints in babies diagnosed as pseudo-squintsand dismissed by the GP, paediatrician, optometrist, and even ophthalmologist. ‘The parents were reassured that pseu-do-squints get better by themselves. The common error is that they were only seen once.’ This clever double negativename helps remind us never to assume too quickly that a child only has a pseudo-squint.• In the summer of 2011 edition Hubrecht came up with the idea of an OSSA bank. This would function to finance oph-thalmic procedures.• The Annual General Meeting (AGM) at the annual OSSA Congress is the most important meeting of our discipline. Ifyou only attend one meeting per year, this one should be it. • As you can see in the final Brody’s Corner article, Hubrecht has come up with this very intriguing idea of a combinedophthalmology investment company. Combine our resources and buy something worthwhile that will help us all toretire in comfort one day. Anyone who has ever read any of Robert Kiyosaki’s books knows that this idea needs to begiven very serious consideration.

Following Hubrecht’s writing will be a difficult task. I do not have the depth ofknowledge and experience that he has, especially with matters political.Therefore, I will leave the political ophthalmological issues to Jan Talma andothers who are more involved with this. Clive’s Corner will rather be a pot-pourri of all things of clinical and general interest to South African ophthal-mologists.

Please feel free to contribute to Clive’s Corner with your own stories and ideas.Write to me at [email protected].

Clive NovisDip Optom, MBBCh, MMed(Wits), FCS(Oph)


Hp

Tollfree: 0800 601 098


Confidentiality - general principles


Confidentiality is at the centre of maintaining trust between patients and doctors. As a doctor, one has accessto sensitive personal information about patients. Therefore there is a legal and ethical duty to keep this infor-

mation confidential, unless the patient consents to the disclosure, disclosure is required by law or is necessaryin the public interest.

General principlesThe duty of confidentiality relates not only to sensitivehealth information but to all information held about thepatients.Any profession that deals with people’s sensitive per-

sonal information is bound by the same expectations ofconfidentiality and healthcare is no different. However,the duty of confidentiality relates not only to sensitivehealth information but to all information held about thepatients.The National Health Act (no. 61 of 2003) declares that

this information must not be given to others, unless thepatient consents or the disclosure can be justified. Thisincludes demographic data and the dates and times ofany appointments the patients may have made, or con-sultations they may have attended. The fact that anindividual may be a patient or registered with the prac-tice is also confidential.Doctors are only permitted to reveal confidential

information about a patient in certain circumstances –the most obvious of which is with the permission of thepatient in question, assuming that they have sufficientcapacity to consent to this. According to the HPCSA, theother appropriate scenarios are:• In terms of a statutory provision• At the instruction of a court• When it is in the public interest• With the written consent of a parent or guardian of

a minor under the age of 12 years• In the case of a deceased patient with the written

consent of the next of kin or the executor of thedeceased’s estate.

One should take care to avoid unintentional disclosure– for example, by ensuring that any consultations withpatients cannot be overheard. When disclosing infor-mation, ensure that the disclosure is proportional –anonymised if possible – and includes only the mini-mum information necessary for the purpose.

Consent to disclosureBefore disclosing any information about a patient to a

third party, the doctor should seek the patient’s consentto the disclosure. There is a variety of reasons for whichpersonal medical information may be requested: edu-cation, research, monitoring and epidemiology, publichealth surveillance, clinical audit, administration andplanning, insurance and employment.The patient’s consent to release this information may

be implied or express. Implied consent can be deemedsufficient in instances such as dictating a referral letterto the medical secretary. However, in the case where apatient’s personal information will be shared amongthe healthcare team, it is wise to check that the patientis aware of this. This is not necessary if the patient hasalready expressly consented to the particular treatment.Express consent is needed if patient-identifiable data

is to be disclosed for any other purpose, except if thedisclosure is required by law or is necessary in the pub-lic interest.

E T H I C S A R T I C L E

Except in the case of an emergency, a doctor/healthcare worker must obtain a patient's agreement (informed consent)

to any course of investigation, treatment or research



Valid consentIn order for consent to disclosure to be valid, the patientneeds to be competent to give consent and must havebeen provided with full information about the extent ofthe disclosure. Adult patients are assumed to be com-petent, unless one has specific reason to doubt this.When taking consent for disclosure of informationabout a patient, ensure the patient is aware of whatdata will be disclosed and to whom.

Disclosure required by lawIn some circumstances, doctors are obliged to discloseinformation to comply with a statutory requirement. Anexample is the requirement to notify certain communi-cable diseases. In such cases, the information should bedisclosed – even without the patient’s consent. Thepatient must be informed of the disclosure and the rea-son for it.

Disclosures in the public interestIn some cases, it is not possible to obtain the patient’sconsent, such as when the patient is not contactable.Alternatively, the patient may have expressly refusedtheir consent. If disclosure is necessary in the publicinterest and the benefit from disclosure will outweighthe risks from doing so, it may be justified to disclosethe information, even without the patient’s consent.Such circumstances usually arise where there is a risk

of death or serious harm to the patient or others, whichmay be reduced by disclosure of appropriate informa-tion. If possible, seek the patient’s consent and/orinform them of the disclosure before doing so.Examples of such a situation would include one inwhich disclosure of information may help in the pre-vention, detection or prosecution of a serious crime.

Patients lacking capacityIn emergency situations, the superintendent of the hos-pital may give consent.A patient may be considered to be immature, too ill or

lacking in mental capacity to give valid consent, yetthey could request that information not be disclosed toa third party. In such cases, the HPCSA advises one to tryand persuade them to allow an appropriate person tobecome involved in the consultation.

Under the terms of the National Health Act, if no per-son has been legally appointed to give consent on apatient’s behalf, then the following order of preferencefor obtaining consent should be followed: a spouse orpartner, parent, grandparent, adult child or adult broth-er or sister.Where none of the above persons exist, then the High

Court may be approached for relief. In emergency situ-ations, the superintendent of the hospital may give con-sent.

Children and young people under18 yearsIf a young person is able to understand the implicationsof the disclosure, they are able to give their consent,regardless of age. However, the above rules regardingimmaturity apply.If the child is believed to be a victim of physical, sexu-

al or emotional abuse, yet they are incapable of givingconsent, their information must be passed on to anappropriate responsible person or statutory agency.This is where the disclosure can be given without con-sent, in the patient’s best interests.

After a patient has diedThe duty of confidentiality to the patient remains afterdeath. In some situations, such as a complaint arisingafter a patient’s death, the relevant information shouldbe discussed with the family, especially if the patientwas a child. If one reasonably believes that the patient’swishes that specific information should remain confi-dential after their death, or if the patient has asked forthe information to be kept confidential, such a wishshould be respected.The “personal representative” of the patient (usually an

executor of the will) can apply for access to the relevantpart of a patient’s medical records, as can someone whohas a claim arising out of the patient’s death e.g. for alife assurance claim. Always seek advice when consider-ing such a request.

Printed with permission from the Medical ProtectionSociety – www.medicalprotection.org.

Correct as at April 2011.



C P D Q U E S T I O N N A I R E

QuestionsTrue or False

Information about a patient can be released if it is necessary in the public interest.

Confidential information includes demographic data.

Doctors are permitted to release confidential information regarding a minor under the age of 12years without written consent of the guardian.

Express consent is needed if patient-identifiable data is released as required by law.

In emergency situations, the superintendent of the hospital may give consent.

If a young person is able to understand the implications of disclosure, they are able to give theirconsent regardless of age.

The duty of confidentiality does not remain after the patient’s death.

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SURNAME INITIALS

YOUR HPCSA REGISTRATION NO.

Address:

Telephone: Fax:

E-mail:

INSTRUCTIONS: 1. Use a blue or black pen only. 2. Answer all questions. 3. Email sheet to [email protected] or post sheet to PO Box784698, Sandton, 2146 or fax to +27 086-729-1490 4. SA Ophthalmology Journal holds no responsibility for any answers not received by fax or post. 5.Credit for these CPD modules will be issued for the year at a later date.

This is to state that I have participated in the CPD-approved programme and that these are my own answers.

Signature Date

MP

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SA Ophthalmology Journal is a peer-reviewed scientific journal and the official mouthpiece of the Ophthalmological Society of SouthAfrica and appears on a quarterly basis.

1. A cover sheet is to be submitted with each manuscript. It should contain the title of the manuscript, the names of all authors in thecorrect sequence, their academic status and affiliations. The main author should include his/her name, address, phone, fax and e-mailaddress.

2. Articles should be the original, unpublished work of the stated author. All materials submitted for publication must be submittedexclusively for publication in this journal. Written permission from the author or copyright holder must be submitted with previous-ly published figures, tables or articles.

3. The Editor reserves the right to shorten and stylise any material accepted for publication.

4. Authors are solely responsible for the factual accuracy of their work.

5. Articles should be between 3 000 and 5 000 words in length.A 200-word abstract should state the main conclusions and clinical relevance of the article.

6. All articles are to be in English and are to follow the Vancouver style.

7. Abbreviations and acronyms should be defined on first use and kept to a minimum.

8. Tables should carry Roman numerals, I, II etc., and illustrations Arabic numbers 1, 2 etc.

9. References should be numbered consecutively in the order that they are first mentioned in the text and listed at the end in numerical order of appearance. Identify references in the text by Arabic numerals in superscript after punctuation, e.g. …trial.13

10. The following format should be used for references:

ArticlesKaplan FS, August CS, Dalinka MK. Bone densitometry observation of osteoporosis in response to bone marrow transplantation. ClinOrthop 1993;294:73-8. (If there are more than six authors, list only the first three followed by et al)

Chapter in a bookYoung W. Neurophysiology of spinal cord injury. In: Errico TJ, Bauer RD, Waugh T (eds). Spinal Trauma. Philadelphia: JB Lippincott;1991: 377-94.

11. Please submit the article to the Editor-in-Chief, Prof Andries Stulting at the following e-mail address: [email protected].

12. Articles are to be submitted by e-mail. The text should be in MS Word. Pages should be numbered consecutively in the followingorder wherever possible: Title page, abstract, introduction, materials and methods, results, discussion, acknowledgements, tablesand illustrations, references.

13. Where possible all figures, tables and photographs must also be submitted electronically. The illustrations, tables and graphs shouldnot be imbedded in the text file, but should be provided as separate individual graphic files, and clearly identified. The figures shouldbe saved as a 300 dpi jpeg file. Tables should be saved in a PowerPoint document or also as a 300 dpi jpeg.If photographs are submitted, two sets of unmounted high quality black and white glossy prints should accompany the paper.Figures and photographs should be of high quality with all symbols, letters or numbers clear enough and large enough to remainlegible after reduction to fit in a text column. Each figure must have a separate self-explanatory legend.

14. Remove all markings, such as patient identification, from radiographs before photographing.

15. Authors should state that they did not receive any financial benefits for publishing their article.

G U I D E L I N E S F O R AU T H O R S



CEH-iNEWS





Heia Safari ranc H turned forty in October, after Franz Richter bought the property in 1970. Heia officially opened to the public in 1976 with only six hand-built bungalows. Franz was a great teacher and he together with his team eventually built and finished all but three of the 50 bungalows currently on the property.Although the property is only 30 minutes from Johannesburg and Pretoria, in 1976 the journey there was predominantly on dirt roads. That has changed although the drive from the newly revamped entrance gate to thereception area is still the original road.Set in indigenous Bushveld, it offers guests an unique African experience that is enhanced by the giraffe, zebra andspringbok that roam the grounds. Richter’s daughter, Gaby, says: “When we opened there was no restaurant andthe guests would eat in the farmhouse that was on the property. In order to make ends meet and to continue tobuild we grew green peppers, aubergines and instant lawn which we sold locally and exported.”Each of the 50 thatched two-bedroom bungalows offers a bathroom with both bath and shower facilities, whileheaters in the bathroom and bedroom help keep the cold at bay. Guests can relax and enjoy sundowners on theirprivate veranda while and watching the sunset.

In 2002, Franz got permission to dam the Crocodile River that forms the lower boundary of Heia. Lake Heritage,as it is known, offers guests the opportunity to canoe or sit and fish. The Franz Richter Dam Wall, his legacy toHeia, recently had a bar added and is an ideal spot to enjoy sundowners while watching the water birds settle infor the night.Guests can try the ‘Vlok and Fordyce’ running trail that traverses the property or indoor games such as table tennis, chess and a full sized snooker are available. The main buildings contain a conference centre and an Africanthemed bar and a la carte restaurant. Reasonable rates and ongoing specials make this an affordable family holidaydestination. for more information, call Heia Safari ranch at 011-919-5000 or fax 011-919-5078. email [email protected] or visit www.heia-safari.co.za

REGISTRAR WRITING COMPETITION

Media24 Magazines Business & Custom together with itsmedical journals extends an invitation to all registrars to enteran article in our annual writing competition.

• The topic of the article should be relevant to your field ofstudy

• Articles must be between 2000 and 4000 words long• Referenced in Vancouver style

The winning article will be published by Media24 MagazinesBusiness & Custom in the relevant medical journal/s.

The winner will receive a 3-night stay at Heia Safari Ranch.

Judging will be done by the managing editors and editors- in-chief of the relevant journal/s. The judges’ decision is final.

The competition closes on the 30 September 2012.

Entries must be submitted to:Media24 Magazines Business & Custom PO Box 784698Sandton 2146Tel 011 217 3210Fax 011 217 3158Email: [email protected]

Media24 Magazines Business & Custom wish to thank you foryour valued support.

The entry form to be submitted with each article:

Title and full names:

Company/Institution:

Specialty:

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Tel: Fax:

Cell: Email:

Signature of entrant: Date:



Allergan supports guide dogs for the blind

During the annual OSSA congress that was held from 22 to 25March 2012 at the Sandton Convention Centre, Allergan,

one of the leading ophthalmic companies in South Africa,launched a new glaucoma drug. They marked the occasion witha donation to the South African Guide-dogs Association for theBlind. This donation will be used to fund training for a specificLabrador pup called ‘Whisper’ that is currently being trained byMorag Crease. Whisper (pictured here) was also present at theOSSA meeting in Sandton where puppy trainers shared someinformation about guide dogs with the delegates of the con-gress. Morag has since been keeping Allergan up to date aboutWhisper’s progress and he is doing very, very well!

P R O D U C T I N F O R M AT I O N



Great Ethiopian Run – the high altitude race against blindness

Eye care professionals who enjoy adventure are invited to jointhe South Africa team going to Addis Ababa, Ethiopia for a longweekend in November to take part in the Great Ethiopian Run. The annual 10 km run in Addis Ababa is one of Africa’s biggestroad races – with over 36 000 runners – and, at over 2 300 metresabove sea-level, one of the highest races in the world. On 25November 2012, a team of South African runners will be taking upthis high-altitude challenge in a fight to save sight, running onbehalf of international eye health non-profit organisation ORBIS.ORBIS’ mission is to improve eye health services around the worldand prevent people from going blind just because of a lack ofmedical care. ORBIS has been working to save sight for 30 years and since 1982has trained over 288 000 doctors, nurses and other medical pro-fessionals in 89 countries. They have helped to provide medicaland eye treatment to 15 million people, almost a third of whom(4.7 million) were children. Sub-Saharan Africa is a priority regionfor the organisation, and since opening an office in South Africa,three specialised paediatric eye care centres (in Durban - SouthAfrica, Gondar - Ethiopia and Kitwe - Zambia) have already beenbuilt.

Charlotte Coleman Smith, Clare O'Dea, Tracey Stafford and Susan Brennan completed last year’s race

‘Eighty per cent of all blind people suffer from treatable condi-tions,’ explains Dr Robert Walters, Global Chair of ORBIS and one ofthe runners who participated in the Great Ethiopian Run last year.Our vision is a world where no one, especially children, should goblind from causes that are preventable.’Legendary Ethiopian runner Haile Gebrselassie is a co-founder ofthe Great Ethiopian Run, which was first held in 2001, and is part ofthe international Great Run series of road races. Some of Ethiopia’stop running talent competes. In 2011 both winners wereEthiopians; Mosinet Geremew was the fastest man in 28:37 min-utes and Abebech Afework won the ladies in 32:59. Howeverbecause the high altitude affects many runners the average time isaround 80 minutes, so this isn’t a 10 km to aim for a personal best.

To find out more about how to join the ORBIS team at the 2012Great Ethiopian Run please contact Joni Watson on 021 447 7135or [email protected] or visit www.orbis.org.za or www.face-book.com/ORBIS-SA.

Dry eye relief never looked better

Alcon Laboratories is pleased to provide health care practitioners with a valuable resource to help patients understand Dry Eye Diseaseand the effective treatment that can be obtained with Systane® Ultra Lubricant Eye Drops.

Simply log on to www.systane.co.za and discover useful information and practical tips on how to manage dry eye – a condition thataffects the quantity and quality of tears, causing eyes to feel dry and irritated.Since dry eye cannot be cured, treatments can help soothe the symptoms. Systane® Ultra is clinically proven to reduce both the signsand symptoms of dry eye, offering dry eye sufferers immediate and lasting relief.The website contains a non-invasive dry eye test for patients to assess if they need to see a health carepractitioner to diagnose or treat a dry eye condition. The website also allows patients to interact with thebrand by providing their stories of the dry eye relief they have experienced.You and your patients can learn more about the science behind Systane® Ultra with its unique intelligentdelivery system which provides immediate comfort, enhanced lubrication and extended protection of theocular surface.

For more information, please contact René Karg on (011) 840-2300. Alcon Laboratories (SA) (Pty) Ltd.

Please refer to the package insert for further information.


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Documents

Orthopaedics Vol3 No4 - nmpb2b.co.za€¦ · Ku EC, Lee W, Kothari HV, Scholer DW. Effect of diclofenac sodium on the arachidonic acid cascade. Am J Med April 1986;80(4B):18-23. 3