Includes abstract. / Includes bibliographical references.

Background Cataracts are the main cause of blindness worldwide. Cataract blindness is reversible with surgery, a procedure which is well recognized for its clinical and cost effectiveness. Several approaches are used to reduce the cataract burden. They include a “reach out” approach, a “reach in” approach and a combination of the two. The Aravind Eye Care System in India, performing over 250 0000 cataract surgeries annually, exclusively utilizes the “reach in” approach. In neighbouring Nepal, with its large rural population residing in mountainous areas, outreach services still play an essential role in addressing cataract blindness. In South Africa, there are several non-governmental cataract surgery services utilizing the “reach out” approach. Objectives The primary objective of this study is to investigate the visual outcomes of a nongovernmental organization providing outreach cataract surgery services (referred to as the “Outreach Service” from now on) in South Africa. This was done by directly comparing them to the visual outcomes obtained at a permanent hospital-based cataract surgery service. The secondary objective is to compare the visual outcomes in both these settings to the recommended day one postoperative visual acuities as set out by the WHO. Methods A retrospective comparison was made of the day one postoperative visual acuities of patients who underwent cataract surgery during outreaches conducted by the Outreach Service and the day one postoperative visual acuity of patients who were operated on at Groote Schuur Hospital. The study period was from July 2014 to December 2014. Results A total of 1067 cases from the Outreach Service and 584 cases from Groote Schuur Hospital were included in the study. The patients who underwent surgery at Groote Schuur Hospital had significantly better day one visual acuities (Pearson chi square test, p< 0.0001). The day one visual acuity in cases performed during outreaches also did not fulfil the minimum day one visual acuity as set out by the World Health Organization (WHO). Conclusion Despite its limitations, our study does raise concerns about the quality of cataract surgery performed on these outreaches. Our recommendation is that non-governmental outreach cataract surgery services should audit their four to six-week visual outcomes. Should they still not meet the WHO’s criteria, the necessary steps should be taken to identify and rectify the reasons for these poor outcomes. Ultimately, South Africa should strive towards establishing more permanent eye care centres.

OBJECTIVES: To describe the clinical features of Duane’s retraction syndrome in a cohort of South African children and analyse subtypes for ethnic differences. METHODS: Retrospective case series of 120 patients seen in the period from 1997 to 2017 at the Red Cross War Memorial Children’s Hospital. RESULTS: Of the 120 patients, Type 1 was present in 76 (64%) of cases, with Type 2 in 27 (23%) and Type 3 in 16 (13%).Type 2 was most common in black children (54%), while Type 1 predominated in mixed race (68%) and white children (94%). A female predominance was seen in white children (69%) and mixed race children (59%), while there was a male predominance amongst black children (62.5%) Left involvement was the most common (44%), followed by right (41%) and bilateral involvement (14%).The average age of presentation was 2,85 years. A positive family history of squints or Duane’s was present in 6 (0,5%). Congenital systemic abnormalities were present in 12 (1%) and congenital ocular abnormalities in 2 (0.4%). Squint in primary position was present in 57 (46%), of which 39% had esotropia and 61% exotropia. Squint was more common in black children (71%) than in mixed race (39.4%) and white children (41%). An abnormal head position was present in 59 (50%) and was most common in Type 2 (67%). Up and downshoots were seen in 58 (48.3%). Ametropia was found in 94 (79%), and of these 88 (93,6%) were hyperopic and 6 (6.4%) myopic. Amblyopia was present in 15 (12.5%). Surgery was performed in 41(34%). CONCLUSION: This study is the first to provide robust data on the profile of paediatric DRS in the 3 main South African ethnic groups, and shows clear ethnic differences in DRS. In black patients, males are more often affected, the proportion with Type 2 DRS is more frequent, and surgery is required more often. Further population-based studies on the epidemiology of DRS in children are needed to clarify the role of race as a potential risk factor.

Includes bibliographical references (leaves 80-90). / To report on the visual outcomes and complications of cataract surgery done at a South African training hospital. Literature review and retrospective observational study of all patients undergoing cataract surgery on the cataract surgery project lists during 2006. Follow-up occurred till last discharge visit. Primary outcome: Uncorrected visual acuity at the last visit of 6/6 - 6/18 visual acuity was achieved in 73.56% of the phacoemlusifaction group and in 65.77% of the scleral tunnel extracapsular cataract extraction group. (p=0.103). Secondary outcomes: Intraoperative complications were noted in 7.34% in the phacoemulsification group and in 12.87% of the scleral tunnel extracapsular cataract extraction group. (p=0.031). The posterior capsule rupture rate was 3.94% in the phacoemulsification group and 7.6% in the scleral tunnel extracapsular cataract extraction group. (p=0.066).

Includes bibliographical references (leaves 35-37).

Background: Corneal pathology is one of the leading causes of preventible blindness in South Africa. A corneal transplant procedure can restore, or significantly improve vision in most of these patients. In current South African clinical practice however, there is a gross shortage of corneal tissue available to ophthalmologists to perform these procedures. There is little published data on corneal donations in South Africa describing the magnitude of the current problem. Objectives: To describe trends in the number of corneal donors per year, the number of corneal transplants performed each year, the origin of corneal donors, the allocation of corneas to the public or private sector and the demographics of corneal donors in South Africa. Methods: A retrospective review of all corneal donations made to South African eye banks during a 15-year study period from 1 January 2002 to 31 December 2016. Results: A progressive year-on-year decline in corneal donors was found over the study period, from 565 donors per year in 2002 to 89 donors in 2016. As a direct result, there has been an 85.5% decrease in the number of corneal transplants performed per year using locally donated corneas, from 1049 in 2002 to 152 in 2016. 48.8% of donors originated from mortuaries, 39% from private hospitals and 12.2% from government hospitals. Donors originating from mortuaries showed the most significant declines over the 15 year period, decreasing by 94.8%. 79.3% of donated corneas were allocated to the private sector while 21.7% were allocated to the public sector. Demographic data showed that 69.1% of donors were male, while 30.9% were female. 77.2% were white, 14.0% coloured, 6.3% black and 2.5% Indian/Asian. Age of donors demonstrated a bimodal peak, at 25 and 55 years. Conclusion: The number of corneal donations in South Africa has markedly declined, causing the burden of corneal disease requiring corneal transplantation to continually rise. This study describes the magnitude and trends of the current problem in South Africa. The demographic data has identified certain low donor rate groups within the South African population, where there are possible cultural and other objections to corneal donation. These should serve as a major focus of future research and initiatives aimed at reversing the current trends.

Background: Cataract remains the leading cause of blindness in Africa. We sought to review the available literature relating to barriers to cataract surgery in Africa. Methods: A review of the literature was undertaken using PubMed and Google Scholar using the search terms "barriers, cataract, Africa, cataract surgery, cataract surgical coverage (CSC), and Rapid Assessment of Avoidable Blindness (RAAB)". The review covered the period 1999-2014. Results: In RAABs, barriers related to awareness and access were more commonly reported than acceptance, while non -RAAB studies reported cost as the most commonly reported barrier. The few qualitative studies tended to report community and family dynamics with regard to barriers to cataract surgery. CSC was reported as lower in females in 88.2% of the studies. Conclusion: Studies of barriers to cataract surgery give variable responses. This may be due to the study context but also may be due to the type of data collection. It is likely that qualitative data will give a deeper understanding of the complex social, family, community, financial and gender issues relating to barriers to uptake of cataract surgery in Africa.

Includes bibliographical references.

Penetrating keratoplasty is a full-thickness corneal transplant procedure with a relatively long post-operative visual rehabilitation period. Post-operative corneal astigmatism often causes refractive error resulting in suboptimal vision, despite a clear graft. In order to reduce this issue, surgeons selectively remove sutures from the transplanted cornea to manipulate and control the levels of post-operative astigmatism present. In order to identify tight sutures causing astigmatism, corneal topography instruments have been developed which use reflected light patterns to reconstruct topographical images of the corneal surface and provide measurements of corneal steepness and astigmatism. Currently, standard conventions limit suture removal to one to two sutures per visit at an interval between four and six weeks. This experiment sought to determine the feasibility of multiple suture removal following corneal transplant by evaluating the change in astigmatism occurring immediately after suture removal in corneal transplant patients and comparing the change to any occurring one month later. Four separate samples were obtained and analyzed to determine if topography-based decision immediately post-suture removal matched suture removal decision one month later. Topography-guided decisions immediately following suture removal incorrectly identified the appropriate subsequent suture in all samples. Data was analyzed using Fisher’s exact test to determine statistical probability of results, and there was a statistically significant difference between topography-based decision immediately after suture removal and standard topography-based decision at one month. This demonstrated that the period of time immediately following suture removal was not reliable in determining the correct subsequent suture to be removed. Limitations of this study included a small patient sample size, potential graft-host junction override in samples, and the weight of subjective determination by the surgeon. While penetrating keratoplasty has been found to be an effective treatment for patients, further research is warranted to investigate the timeline behind corneal astigmatic stability following surgery and to identify opportunities to shorten long rehabilitation periods.

BACKGROUND: Increased intraocular pressure (IOP) in the eye is a primary risk factor for development and progression of primary open angle glaucoma (POAG). Increased IOP partially results from increased resistance to aqueous humor outflow in the trabecular meshwork (TM). One of the candidates that significantly contribute to increased resistance to aqueous humor outflow is thrombospondin-1 (TSP-1), which functions as a remodeler of cell-matrix interactions. TSP-1’s most significant function is activating transforming growth factor-beta2 (TGF-β2), which stimulates extra-cellular matrix (ECM) secretion in the TM, resulting in increased resistance to aqueous humor outflow. Previous studies have shown that a steroid dexamethasone (DEX) treatments for five weeks significantly increases IOP in mice. This study tested the hypothesis that DEX treatment for five weeks will increase the expression of TSP-1 and TGF-β2 in the TM compared to the saline treatment in WT and TSP-1 deficient (TSP-1-/- ) mice, and that there is a positive correlation between the expression of TSP-1 and TGF-β2 and IOP. METHODS: Wild type (WT) and TSP-1-/- mice were divided into saline or 0.1% DEX groups (n=42 per group). The treatments were administered twice a day through eye drops. 14 mice (equal amounts of females and males) from each group were sacrificed at weeks 1, 2 and 5 respectively. Six randomly selected eyes (equal amounts of males and females) from each group were then enucleated, cryo-sectioned and processed for immuno-staining to analyze the expression of TSP-1 and TGF-β2. The intensity of the staining in the TM, ciliary body (CB) and corneal epithelium (CE) were analyzed using ZEN© software. RESULTS: The staining intensity of TGF-β2 was significanlty increased in the TM in WT and TSP-1-/- mice treated with DEX at the end of five weeks compared to mice treated with saline. The staining intensity of TSP-1 also significantly increased in the TM in WT mice treated with DEX at the end of five weeks compared to mice treated with saline. There is a significant positive correlation between mean IOP and mean TGF-β2 (R2=0.8255, P< 0.001) and mean TSP-1 (R2=0.8590, P< 0.01) staining intensity in the TM over the course of five weeks. There was no significant positive correlation between TGF-β2 and TSP-1 staining intensity in the TM when plotting the raw data (R2= 0.0350, P> 0.05). There were no significant differences in TGF-β2 staining intensity in the CB and CE in WT and TSP-1-/- mice treated with either DEX or saline (P> 0.05). There were also no significant differences in TSP-1 staining intensity in the CB or CE between WT mice treated with DEX or saline (P> 0.05). CONCLUSION: The results support the hypothesis that TSP-1 and TGF-β2 expression in the TM is positively correlated to IOP, suggesting that both TSP-1 and TGF-β2 signaling play an important role in regulation IOP by affecting aqueous outflow via the TM.