November 2007




Refractive and cataract surgery in South Africa

Johann Kruger, M.D.


South Africa is a country that is very much in transition at this time. It has a very highly developed infrastructure and a standard of care in the urban areas with respect to medicine that is excellent. During apartheid, South African ophthalmologists felt somewhat isolated from the rest of the global ophthalmic community. However, they have been active participants over the past decade, internationally, and many have arisen as international leaders, including Johann Kruger, M.D., who is a very well-known and popular eye surgeon in South Africa. He has participated in most of the African meetings and is often in attendance and on the podium at international meetings as well. In this month’s column, he is going to give us an overview of the current status of cataract and refractive surgery in South Africa today.

By I. Howard Fine, MD


Cataract Surgery

Each country has its unique problems. In South Africa there is a huge backlog for cataract surgery in the rural areas. The population in South Africa (SA) is 45 million people, and 40 million of these are dependent on the state. Only five million have medical aid/private insurance. And 80,000 blind people are awaiting surgery.

The SA Society for the Blind arranges tours, called “blind tours” for doctors to the rural areas. Mostly registrars and state medical officers are traveling into the homelands and rural areas to operate patients in the rural hospitals. Some private ophthalmologists are also undertaking some blind tours. This is largely voluntary work. This is a huge opportunity to gain experience and is very rewarding and helpful to the black rural communities.

I remember traveling to Twenlinzini and Kopani in my registrar days and seeing 250 people on the first day and then the following 2 days, needing to operate on 40 patients a day that had white cataracts and were totally blind in both eyes. Only one eye would be done due to lack of resources. In those years we used extracapsular and intracapsular techniques.

I would start operating at 6 in the morning. At 7 a.m. the staff stop for prayers for 30 minutes whereafter you continue. These indigenous people are Christian and highly religious. The work continues until 8 p.m. at night.

The next morning at 6 a.m., I would start the ward round to see the previous days’ patients. As I walked into the ward they would start singing joyous religious songs of thanks and gratitude. They were ecstatic about their vision and new life before them. Many of them had been blind for many years and were then smilling with tears in their eyes. This was quite an emotional experience. At 7 a.m. it was prayer time again and everyone would stop working. At 8:30 a.m., you would start again and the staff would be ready. What an eye opener! This was very rewarding. The third day the patients of the previous day were seen and then I would head back to Cape Town. What a wonderfull privilege as a registrar! As phacoemulsification is done primarily in the state hospitals on a limited basis due to financial constraints, extracapsular surgery is performed more widely. Registrars are trained to do phacoemulsification but are first trained to do extracapsular surgery to learn basic principles of eye surgery. Overall, topical surgery caught on very slowly in South Africa. Most surgery was done under local anesthesia and to a lesser extent topical surgery.

Multifocal implants started in 1996. The Storz refractive IOL (Bausch & Lomb, San Dimas, Calif.) and Array (Advanced Medical Optics, AMO, Santa Ana, Calif.) lenses were used at first. In the last few years the ReZoom (AMO), ReSTOR (Alcon, Fort Worth, Texas) and Tecnis (AMO) multifocal have grown in popularity but are still not routinely done. Dedicated refractive surgery centers are performing more multifocal procedures. Nowadays most surgery is done with local blocks but about 30% is done topically. However some practices are performing topical surgery almost exclusively. Ninety-five percent of my surgeries are topical combined with phacoemulsification.

Refractive Surgery

Most of the big companies are represented in South Africa; therefore, in the private sector, state of the art lenses and technology is available. Whereas in the state hospitals, PMMA lenses and less expensive good quality acrylic and silicon foldable lenses from India are also used.

Laser refractive surgery came to South Africa in 1993 at the N1 City Hospital in Cape Town. I started to do PRK there and later in 1994 LASIK. At first PRK was popular but soon LASIK procedures dominated from 1994 and 1995. The broadbeam lasers and the higher incidence of haze influenced the decline in PRK procedures. By 1999 wavefront surgery had started at the Tygervalley Eye and Laser Centre in Cape Town. Whilst Cape Town had the first laser, Johannesburg had the first microkeratome. There are presently 20 excimer laser units in South Africa. Several laser centers closed down when numbers declined since 1997.

Recently we have started to do PresbyLASIK at the Tygervalley Eye and laser centre, who purchased the first VISX Star 4 IR Laser (AMO), in Cape Town and South Africa. This promises to grow in popularity in cases who do not want a more invasive procedure as a refractive lensectomy. Zyoptix lasers, Nidek (Fremont, Calif.), LaserSight (Winter Park, Fla.), and WaveLight (Erlangen, Germany) are represented in South Africa.

About 10000 laser refractive surgery procedures are done in SA annually. Annually LASIK procedures have declined from 1994 to 2007. LASIK is the most popular procedure. From 1994 to 1998, subsidized medical aid covered LASIK procedures readily. The procedure was patient driven due to the dramatic visual results. Soon medical aid started to decline benefits and reimbursement and thus the procedure itself became mostly privately funded. This caused LASIK and PRK numbers to decline dramatically and caused a few laser centers to close down. Some of the medical aids are giving limited reimbursement for refractive surgeries. Patients are required to pay the difference. The mechanical keratome is still the most popular refractive procedure. Recently femtosecond technology was introduced to South Africa. There is a problem of affordability for refractive surgery and I think that femtosecond technology will be too expensive for South Africa at this point. Wavefront surgery is not that popular yet in South Africa. Many surgeons in South Africa are not doing wavefront surgery yet, but I suspect this will change. For the past 8 years I have been doing wavefront guided surgery, and 80% of my surgeries are now wavefront guided. The cost of LASIK surgery in South Africa starts at about R8000 to R9000 (700 US$ or 500 € per eye) for standard LASIK procedures , going up to 1000 € per eye for customized wavefront LASIK per eye.

Phakic IOLs namely the Staar ICL (Staar Surgical, Monrovia, Calif.) and the Artisan lenses were introduced in 1996. Few surgeons are using these lenses. Cost issues are limiting the growth of this market. Toric Staar lenses and Toric Artisan lenses are also used. Overall, technology is available in South Africa. However, the quintessential issues of access to appropriate health care and subsidizing costs become the decisive factors in determining who of those deserving optimal ophthalmic care actually receive it.


Johann Kruger, M.D., is a specialist at the Tygervalley Eye and Laser Centre, Cape Town.

honorary part-time consultant, University of Stellenbosch Medical School.

Founder of the first black empowerment eye facility in South Africa.

Refractive and cataract surgery in South Africa Refractive and cataract surgery in South Africa
Ophthalmology News - EyeWorld Magazine
283 110
283 110
True, 11