Ethics in South Africa: new challenges.

One of the reasons why ethics is so much spoken about nowadays is that the moral certainties of previous times no longer exist. Recent events in South Africa have called into question many of the values and principles formerly adhered to. Formerly, we had confidence in the moral consensus that was shared by our families, religious organizations, educational institutions, professional associations and judicial system. Nowadays we have pluralism, and we live in a society with many competing moralities. Whereas in traditional societies, there is considerable agreement on values, in pluralistic societies, such as South Africa, individuals are subject to a clash of values and have the difficult task of deciding which should prevail. Euthanasia and assistance in suicide are currently hot issues in South Africa. Ethical conduct of medical practitioners dealing with cases of AIDS is an ongoing task. New issues like Telemedicine and the ethics involved therein, are a concept in South Africa and will receive much attention in this year.

Fundus fluorescein angiography of patients with severe hypertensive nephropathy.

PURPOSE: To analyze the fluorescein angiograms of patients with hypertensive renal failure. METHODS: Fluorescein angiograms were obtained of 34 patients with hypertensive renal failure. The glomerular filtration was less than 20 ml/min in each patient. RESULTS: Capillary nonperfusion and a coarse retinal capillary bed are the hallmark of the hypertensive retinopathy. Tortuous retinal arterioles or tortuous retinal arteriovenous anastomoses are observed. It is suggested that capillary collaterals shunt arteriolar obstructions or short-cut nonperfused capillary beds; these remodel into tortuous arterioles or arteriovenous anastomoses with regular caliber. Elschnig spots and delayed choroidal filling are signs of hypertensive choroidopathy. Depigmentation spots of the retinal pigment epithelium without a central pigment clump are considered atypical Elschnig spots. CONCLUSIONS: Retinal pigment epithelial changes are permanent scars of hypertensive choroidopathy, while coarse retinal capillary bed and tortuous retinal arterioles or arteriovenous anastomoses are the result of hypertensive retinopathy in these patients with hypertensive renal failure.

The efficacy of two bupivacaine hydrochloride injection products.

OBJECTIVE: The relative efficacy of two bupivacaine hydrochloride injection products was investigated in patients who were undergoing intra-ocular eye surgery. DESIGN: Patients took part in this double-blind, randomised, parallel-group study and received either Macaine (Keatings) or Regibloc (Intramed), according to the randomisation schedule. SETTING: The study was carried out in the ophthalmology operating theatres of National and Pelonomi Hospitals, Bloemfontein, South Africa. PATIENTS: Thirty male and 74 female patients who needed extra-capsular lens extraction plus intra-ocular lens implantation, extra-capsular lens extraction, or trabeculectomy were selected for the study. OUTCOME MEASURES: Akinesia was evaluated after 10, 15 and 20 minutes. In the event of incomplete akinesia after 20 minutes, an additional injection was administered, and after 5 minutes another evaluation of akinesia was done. Anaesthesia was evaluated at the beginning of surgery. RESULTS: The proportions of patients who received no additional anaesthesia were 57.7% for Macaine and 70.8% for Regibloc (difference 13.1%, 95% confidence interval (CI) -5.5 - 31.7%). The proportions of patients with adequate akinesia (possibly after additional anaesthesia) were 90.4% for Macaine and 89.6% for Regibloc (difference -0.8%, 95% CI-12.6 - 11.0%). The proportions of patients experiencing no pain or discomfort at the beginning of surgery were 88.2% for Macaine and 87.5% for Reglibloc (difference -0.7%, 95% CI-13.6 - 12.1%). CONCLUSION: The study results indicate that Regibloc is at least as effective as, or superior to, Macaine in achieving adequate akinesia.

Prevalence and incidence of blindness due to age-related cataract in the rural areas of South Africa.

OBJECTIVES: The Bureau for the Prevention of Blindness is responsible for the provision of cataract surgery to the rural indigent population of South Africa. It is important for the Bureau to know both the prevalence and the incidence of cataract blindness in the population. DESIGN, SETTING AND SUBJECTS: Blindness prevalence surveys were conducted in KwaZulu in 1990 and 1993. OUTCOME MEASURES AND RESULTS: The prevalence of cataract blindness was 0.59% (95% confidence interval 0.21) in 1990 and 1993. The prevalence of aphakia was 0.1% in 1990 and 0.2% in 1993, demonstrating a probable increase in the delivery of cataract surgical services, although this had not produced a demonstrable fall in the prevalence of cataract blindness. The calculated annual incidence of cataract blindness was 0.14%. CONCLUSION: Among a rural population of approximately 19 million South Africans, there is a backlog of 113,000 unoperated cataract-blind people and an incidence of 27,000 new cataract blind per year. The implications of this backlog for cataract blindness in our rural areas are discussed.

Impact of a sight-saver clinic on the prevalence of blindness in northern KwaZulu.

The prevalence of blindness in the Ingwavuma district of northern KwaZulu was 1% (95% confidence interval 0.75 - 1.25) in 1990, and the prevalence of blindness due solely to age-related cataract was 0.39% (95% CI 0.24 - 0.54). Eight sight-saver clinics were held between 1990 and 1993. Nine hundred and thirteen patients were seen and 113 cataract extractions performed at a cost of R62,000. The prevalence of blindness due solely to age-related cataract was reduced by 25% to 0.29% (95% CI 0.17 - 0.41). The overall prevalence of blindness was reduced by 4% to 0.96% (95% CI 0.72 - 1.20). The provision of aphakic spectacles to aphakic patients whose spectacles have either been lost or broken would effect a further 11% reduction to 0.85% (95% CI 0.63 - 1.07). The establishment of a permanent sight-saver clinic staffed by an ophthalmic medical assistant who is working full-time in this capacity would facilitate an improvement in the delivery of eye care in the area.

The results of posterior chamber lens implantation in a teaching hospital.

In 1984 extracapsular cataract extraction with the implantation of a posterior chamber lens became the procedure of choice in the treatment of cataracts at this institution. A retrospective study was carried out to assess the results of this operation in the hands of registrars. The results suggest that extracapsular cataract extraction with the implantation of a posterior chamber lens can be performed safely and effectively in a residency setting when accompanied by appropriate education and faculty supervision.

Ophthalmoscopy versus non-mydriatic fundus photography in the detection of diabetic retinopathy in black patients.

The contribution of non-mydriatic fundus photography in the detection of diabetic retinopathy before and after dilatation of the pupils in black diabetics was investigated and compared with direct ophthalmoscopy. Eighty-six patients were examined and good-quality photographs were obtained for 54.7% of eyes before and 86.6% of eyes after dilatation. Photographically documented retinopathy was detected by ophthalmoscopy in only 64.7% of eyes. The two methods were concordant for the presence of retinopathy in 62.2% of eyes before and 56.9% of eyes after dilatation. Photography through dilated pupils also improved the rate of detection of diabetic retinopathy from 24% to 30%. The 45 degrees non-mydriatic fundus camera was found to be a valuable adjunct in the detection of diabetic retinopathy in a busy diabetic clinic.

Results of laser treatment for sub-retinal neovascular membranes.

A retrospective study was carried out to determine the results of laser treatment for choroidal neovascular membranes in age-related macular degeneration in 92 patients in whom fluorescein angiography was performed for this condition over a 7-year period. Twenty-nine of these patients, treated with the argon laser, were followed up regularly for 15 months. The treatment comprised overlapping laser spots of 200 microns and an average power of 390 mW. The results of this study demonstrated that: (i) the majority of membranes were closer than 500 microns from the foveola; (ii) the second eye involvement rate in the same patient was 15,79% over 15 months; and (iii) a 37,5% significant visual loss or 41% two lines or greater visual loss was seen after 15 months, which compares favourably with results of laser treatment reported by other institutions.

[Radial keratotomy in perspective]. / Radiale keratotomie in perspektief.

Radial keratotomy is a surgical procedure to reduce or eliminate myopia. Advocates of radial keratotomy stress the dependence, inconvenience and restrictions of glasses or contact lenses. However, opponents of this procedure stress that invasive surgery on a healthy eye, regardless of the reason, is unethical. Candidates for radial keratotomy include adults with myopia between -2,00 and -8,00 diopters and who cannot tolerate contact lenses or glasses. The pre-operative evaluation and surgical techniques are briefly discussed. Complications of this procedure include sensitivity to glare, fluctuating vision, perforations, postoperative infections and corneal scarring. Overcorrections and undercorrections may also occur. It is shown that, although radial keratotomy is effective in the low-to-moderate myopia group, its effect in individual eyes is not totally predictable.

Ophthalmological findings in AIDS. A case report.

Ophthalmological findings in AIDS include retinal cotton-wool spots, retinal haemorrhages, cytomegalovirus retinitis, conjunctival manifestations of Kaposi's sarcoma, and cranial nerve palsy. About 75% of patients with AIDS have ophthalmological abnormalities. All patients with AIDS, as well as those at high risk who have any ocular symptoms, should have a thorough ophthalmological evaluation. A case study is presented.

The effects of forskolin eye drops on intra-ocular pressure.

Two studies were performed to investigate the effects of forskolin (Hoechst Research) on intra-ocular pressure (IOP). In the first study two 1.0% formulations of forskolin eye drops were compared with placebo in 10 healthy volunteers. Oxybuprocaine eye drops were used for local anaesthesia before measurement of IOP by applanation tonometry. This was followed by instillation of either medication or placebo on a randomised cross-over basis and hourly measurement of IOP. No significant differences were present between the forskolin treatments and placebo. For 6 hours after drug application a definite decrease in IOP relative to base-line values was observed after each of the forskolin treatments as well as after placebo. In a subsequent study only one formulation of 1% forskolin was compared with placebo. Proxymetacaine eye drops were used for local anaesthesia. Forskolin resulted in a significant reduction in IOP relative to placebo. It is concluded that forskolin reduces IOP in healthy volunteers, and that oxybuprocaine reduces IOP in its own right.

Bilateral cataract extractions in one session. A report on 134 consecutive cases.

One hundred and thirty-four bilateral cataract extractions are discussed. Intra-operative and short-term postoperative complications are compared with those of unilateral cataract extraction. Bilateral cataracts may be extracted in one session for socio-economic reasons, since the incidence of bilateral postoperative endophthalmitis is low.

External ophthalmomyiasis caused by Oestrus ovis.

A 16-year-old White girl presented with a foreign-body sensation in her right eye. Seven Oestrus ovis maggots were removed with the aid of a cotton wool-tipped probe. The subsequent history has been quite uneventful. This appears to be the fifth reported case of ophthalmomyiasis externa in southern Africa.