Episode 2

Meet an Innovative Optometrist from South Africa

In the latest episode of GlobalEyes, hosts Dr. Melissa Barnett and Dr. Tom Arnold speak with Dr. Annelize van Zyl from Pretoria, South Africa, about her innovative practice and involvement with the Boston Keratoprosthesis. Dr. van Zyl shares her experience with specialty lenses and low vision patients.

Tom Arnold, OD, FSLS (00:42):

Hello everyone, and welcome to this edition of GlobalEyes with your hosts Melissa Barnett and Tom Arnold.

Melissa Barnett, OD, FAAO, FSLS, FBCLA (01:07):

GlobalEyes is a podcast which provides a nexus for eyecare practitioners all over the world. Each month a different specialist will be featured for a lively discussion of the status of the eye care profession in their country. We will explore the educational systems, techniques and methods, patient demographics, and what they see as not only the biggest obstacles, but also the greatest opportunities. Along the way we'll learn a little bit about their personal lives, hobbies, and interests. A relaxed, loosely structured, and fun atmosphere will be encouraged. Join us as we travel the globe.

Dr. Barnett (01:48):

Our guest today is Annelize Van Zyl out from Pretoria, South Africa. Annelize, or Annie, completed her optometry degree at the University of Johannesburg in 2007. She has worked in a variety of practice of settings, including general optometry, low vision, and specialty contact lenses. She currently practices at the prestigious Pretoria Eye Institute, South Africa's first private eye hospital, where she runs the low vision clinic and is a scleral lens specialist. Annie helped revive the contact lens society of South Africa, and has been a core member of the planning committee, which organized two international meetings in 2017 and 2019. She is a vivacious and passionate speaker who loves wine and travel. Welcome to GlobalEyes.

Annelize Van Zyl, MS, Optom (02:42):

Thank you very much Melissa. I'm very honored to be part of this.

Dr. Barnett (02:45):

Well we're thrilled to have you on GlobalEyes. So please tell us a little bit about yourself. Where do you live and practice?

Dr. Van Zyl (02:53):

As we said, I live in Pretoria. But what a lot of people don't know is that Pretoria is actually the capital city of South Africa. It's not Cape Town. And the Pretoria Eye Institute is luckily like 15 minutes from my house. And I've been working there since 2009. I work for a corneal specialist, Dr. Eduard Sevenster who is also my step dad. And at his practice I see a lot of patients with things like chemical burn wounds, Stevens-Johnson, and so on as he absolutely specializes in chemical burn wounds, and was also the first ophthalmologist in South Africa, and actually the only that is doing the KPro procedure. So we have done 29 of them in the country. And I'm very involved with the treatment.

Dr. Barnett (03:42):

Wow, 29.

Dr. Van Zyl (03:44):

Yes, even with the type 2 through the eyelid for the Stevens-Johnson's patients as well. And I do dry eye treatment, which works very well with the Stevens-Johnson's as well. And then I do refractions before Lasik operations and cataract procedures. That's half of my week. The rest of my week I'm at my own low vision practice, also in the Pretoria Eye Institute. And we have 26 ophthalmologists working in the hospital, or referring to me for their low vision. And it's wonderful to be able to connect with ophthalmologists in the same building. So I can run out back to the doctor. And then we also connect to a multidisciplinary low vision team. So I do refer to orientation, mobility, and a psychologist. It just depends on what is necessary. And I am currently engaged and trying to plan a wedding in a year with COVID. So I've been quite busy.

Dr. Barnett (04:44):

Wow, that all sounds fascinating. And congratulations on your upcoming wedding. Do you fit contact lenses after the KPro, and if so what type of contact lenses do you fit?

Dr. Van Zyl (04:54):

Yes, we do fit contact lenses over the KPro. In the beginning the articles were all talking about the contour lens from the US, and a 9.8 base curve, which is a very flat lens. But we found that in the eyes in South Africa, the eye is actually quite steeper than that afterwards. So we needed to have lenses made with steeper base curves. And the whole idea of why we do a contact lens over the KPro is because you're looking at a PMMA button that the light is actually going into the eye. And then you have a titanium plate at the back keeping the integrity of the eye together. So it's actually very hard to explain this without a picture, but basically we do a KPro procedure when the patient mostly has 360 degrees of limbal STEM cell death. So the patient can't use a cornea transplant as they keep on rejecting them.

Dr. Van Zyl (05:58):

So when we do a KPro we actually don't need the corneal tissue to have the light going into the eye. So we use a PMMA lens button that is helped to keep in place with the titanium plate. And this PMMA button on the front of the surface of the eye, right next to it we have corneal tissue, even though it's scarred. And that junction needs to stay wet with the contact lens. And the first articles from the US, it all said that it had to be a contour lens with a very flat base curve of 9.8.

Dr. Van Zyl (06:35):

But we found that with the South African eyes these lenses were too flat. So we started experimenting with different base curves, and we found that they actually tend to be quite a lot more steeper. And then in eyes that had chemical burn wounds we had synechiae and things like that. So we were actually struggling to get the very large lenses into the eye. So we played with smaller base curves until we had amnion membranes, and so on that we had more movement inside the eye.

Dr. Van Zyl (07:04):

So we haven't really tried scleral lenses in the first couple of years because we didn't know how to fit them, and because there's scarring and things going on. And I tried some in the beginning, but couldn't get the lens to seal on the eye, and was actually didn't have the courage to try it for quite a long time after that.

Dr. Van Zyl (07:28):

And then about two weeks ago I fitted one with Peter Brauer, where we did a patient with binoculars. She has KPros in both eyes, and we got the one lens to sit beautifully on the EyeSpace lens from New Zealand. But the other eye had no form like a cornea in the middle. It was actually just like flat. So it was very hard to get the lens to stabilize. So we'll see what those look like. I'll probably have them in two to three weeks. So it's going to be very interesting to see that. And then also we did OCT over it. So the pictures are incredible. I'd love to show them to you when I see you again.

Dr. Van Zyl (08:10):

And I think the big change for us is going to be when we get the EyePrintPRO into South Africa, where we can actually mold the eye and then try it, especially with the burn wound patients where we have the ocular burn wounds, where if we can mold it onto the eye we're going to get much better results.

Dr. Barnett (08:29):

I can't wait to hear the results from that one patient, and agree that impression based technology is very helpful. There have been publications of hybrid and scleral lens use over KPros, and I look forward to hearing the South African experience too.

Dr. Arnold (08:49):

That's incredible. Well I remember South Africa with Christian Bernard I think did the first heart transplant surgery way back in the sixties. So medicine in South Africa certainly has a tremendous legacy, and you and your clinic are certainly carrying that on.

Dr. Van Zyl (09:07):

Well thank you, Tom. It's great to be part of all things scleral, and the future just looks bright. And with the new information about the impression based lenses that aren't turning on the eye, where we can start really moving the optical center and so on. I'm extremely excited to see what's coming.

Dr. Barnett (09:31):

No, it's wonderful. And I know I've had patients who have had huge blebs, gigantic where nothing else will work, and the impression-based technology is just amazing. And it really helps rehabilitate the ocular surface, and provide improved vision, and most importantly improves the quality of life.

Dr. Van Zyl (09:52):

I have found that doing specialty contact lenses, and low vision as well, has been extremely rewarding for my patients, as a lot of them when take their lenses out, they have low vision. And even with the KPro patients, the rehabilitation that they need, as lots of them will go blind with time because of glaucoma, which we cannot stop because of the anterior surface, there's just too much damage where I never thought that low vision and specialty contact lenses would go hand in hand as they do. And yeah, who knew? Absolutely amazing and something that I actually teach a lot of my colleagues about. And they send their patients to me to get little things to help them in the house.

Dr. Barnett (10:37):

That's so true, so incredibly true. No, I definitely agree. I fit a few KPro patients, but had not had success yet actually with scleral lenses. But there are articles out there that say that patients have been successful with both hybrid and scleral. So I look forward to your experience, and I think that an impression based lens could definitely be a great idea.

Dr. Van Zyl (11:01):


Dr. Barnett (11:02):

So stepping back a little bit, what initially interested you in optometry?

Dr. Van Zyl (11:08):

I started wearing spectacles at the age of 12 when I became myopic. And I think I knew what my optometrist was all about. And by the time that I needed to choose, I liked optometry more than I would say the dentist. So I decided on optometry. And when I asked Eduard about studying optometry, he actually told me I should not go and study it because the market is saturated. And now I'm working for him. So that worked out quite well.

Dr. Barnett (11:39):

That's a great story.

Dr. Arnold (11:41):

It's so great to have you, and we're so happy that you could join us today. And I sure enjoyed my visits to South Africa, and getting to know you and your colleagues. Tell us a little bit about the educational path of an optometrist. I know students graduate from a secondary school or upper secondary school, and how do they decide on a career path? And are there any special requirements for entering the optometric program?

Dr. Van Zyl (12:09):

Things have changed a little bit since I actually went to university. When I went you had to have a average of 64 or higher grades math, and 64 science. And we have something called an M score. It's like a metric exemption to be able to go to the university, which they work out with subjects like math and science has a higher rating than something like art would have. And if you have an exemption you could go. But at this stage they've changed it a bit. So now you actually have to have language requirements as well. So they do look at your English, as all classes are now being presented in English. And they're looking at math, science, and biology. So things have changed a bit. Oh, and only 50 students are accepted a year because of the limitations at the facilities, that everybody could be seen in the workshops and the clinic itself.

Dr. Arnold (13:15):

Okay. And how long is the optometric program, and what is the final degree that's conferred on an optometrist?

Dr. Van Zyl (13:23):

It's a four year degree, full time. And you do get a bachelor's of optometry, which is an honors degree in optometry. So from there you would decide if you would want to do a master's, but we don't have an MSC optometry like some other countries. We have a research based master's. So it is all with a dissertation. So you won't be doing any classes or anything like that. You choose a research project and you work with a mentor or supervisor on that. If you do it part time, you normally do it within three to four years, and full time as master's would be two years.

Dr. Arnold (14:01):

And you did that I believe on cross-linking. Is that correct? That was your dissertation?

Dr. Van Zyl (14:07):

Yes, I did mine on cross-linking. And thinking back, I think the six month follow up after the cross-linking procedure, that is what really made mine difficult, because the patients didn't all come in one month. They came in drips and drabs. And the six month follow up took me three years to get all that data in.

Dr. Arnold (14:25):

So it just proves patients are patients all over the world.

Dr. Van Zyl (14:29):


Dr. Arnold (14:30):


Dr. Barnett (14:32):

So switching to a different subject, what sparked your interest in low vision?

Dr. Van Zyl (14:37):

I actually really was not interested in low vision, but Eduard wanted to do some charity, and I had to do the charity, so I started to work at the National Council for the Blind on every Wednesday morning. And I just realized the big need that is out there, and that there's not enough people looking at patients with low vision. So I started shadowing my old lecturer, my old low vision lecturer. And I went to a low vision course in New York at Lighthouse International, and just really started to appreciate what low vision practitioners do.

Dr. Van Zyl (15:14):

And it has been such a rewarding experience because these patients, nobody really climbs into what they need. It's such a holistic approach. How you actually throw yourself a cup of tea, pouring tea, reading, so many different things, just using a cell phone or not using a cell phone, and education to the family, sighted guide, all kinds of things like that. And it just opened my eyes to a whole new part of optometry that is so untouched. So I think Eduard wanting to do charity really changed my life there.

Dr. Barnett (15:55):

Well that's fascinating.

Dr. Barnett (16:45):

Annie, tell us a little bit more about the low vision clinic that you run.

Dr. Van Zyl (16:49):

The low vision clinic is in the Pretoria Eye Institute on the first floor. So 26 ophthalmologists in the building actually bring their patients down to me. And so I get to know exactly what the diagnosis is, what procedures have been done, how many Avastin in this eye, or if it's diabetes and a macular degeneration, etc. So I get a very good full report. And we do just low vision at this practice. It's really strictly a low vision practice. So it's low vision examination, low vision rehabilitation, and device training. So we do a lot of iPad training.

Dr. Van Zyl (18:32):

We have the OCam, so OCR software. We try to also really get the patient to be settled at home. So we connect to teachers that go to schools and help the teachers there to integrate the younger patients. And orientation mobility in South Africa is a free service. Somebody about 50 years ago left a very large amount of money in a trust for the Guide Dog Association of South Africa. So we send the names of our patients to them, and they go to the patient's house and teach them orientation, mobility, teach them how to pour tea, everything in the house. And it's literally a free service. So it's something that I really tried to get all my patients to be part of.

Dr. Barnett (18:14):

That is so amazing that it's a free service. And the orientation and mobility is just so incredibly valuable. I know for my patients, but sometimes it's an issue getting that service. So how fantastic that all of your patients can get it.

Dr. Van Zyl (18:32):

I think one of the most interesting things about orientation mobility in South Africa is in our very rural areas, if you look at some of the villages that actually still have huts, you normally have three huts. You have the hut where you're making food, the hut where you are sleeping, and then the hut which is actually your bathroom. And some of these patients can't see how to get from one to the other hut. And they don't have the financial means to build things for them. So these ladies, these orientation mobility specialists that we spoke to, they actually take the plastic bags that we get our groceries in, and they keep them in different colors. And they make a long rope with these connecting the huts to each other. And that is how these patients actually get from one place to the other, that they can stay independent. It is absolutely fascinating to see it.

Dr. Arnold (19:29):

That is amazing, truly.

Dr. Barnett (19:32):

So both Tom and I of course work a lot with specialty lenses as do you. And we know that these lenses can really change our patients' lives for the better, and change the lives of their family, and get them working and functional. How did you get into the process of fitting RGPs and scleral lenses?

Dr. Van Zyl (19:51):

When I started working for Eduard, he wanted me to start fitting hard lenses for his patients, because obviously as a corneal specialist he sees a lot of keratoconus. And at university I wasn't equipped to actually start fitting RGPs when I left. So I literally put a lens on my one friend's eye that it was too steep, and then when there was too flat, and that was the experience that I had. So we read an article about Rose K lenses, and we brought in all three sets.

Dr. Van Zyl (20:24):

So the post graph said the K2 set for the nipple cones and then the irregular cornea set. And when I got the sets, because we didn't have a distributor yet, and we had to bring them all in from the UK, I asked Eduard, "So what are we going to do with all the mistakes that I make? How are we going to fund that?" And he said he'd fund all of them for three months. But at that stage I didn't ask any of the patients any funds to actually do the fitting. So I would get a patient and fit them for three to four hours an eye to get it perfect.

Dr. Van Zyl (20:59):

And I had this little nuke in my room with a patient, couldn't see me where I was washing my hands. And I would fit the lens, and I would go there and tell them, "Ooh I've touched a lot of things. I have to wash my hands." And I'd wash my hands and look at myself in the mirror, and I'd mouth the words steeper or flatter. And then I'd make a decision, go back, do what I wanted to do. And I'll say, "Ooh, I touched a lot of things again," and go back and say, "steeper," or, "flatter."

Dr. Van Zyl (21:24):

And when I started after, because you have to know a little bit of something before shadowing someone. So then I started shadowing Peter Brauer so that I was on the right track. And from there I did a lot of webinars. And I went to the BCLA conference in 2011 to see what's going on there. And then with sclerals coming out, oh, even more webinars. And me and my one friend, she worked for the ophthalmologist next door. She's actually moved to Germany now. The first time we got our scleral lenses. And oh, we have our sets, FaceTime, we're going to fit each other. And I remember her putting the lens in my eye, and I was like, "It's not in. It's just not in." And she's like, "Annelize, the lens is in your eye," because it was so comfortable. And we just knew everything changed from there.

Dr. Barnett (22:13):

Wow, those are great stories.

Dr. Arnold (22:15):

That's remarkable. That is, that's remarkable. I tell people, I learned to fit scleral lenses off of YouTube. Because you get your first set. And I've been in practice for many years. And I got my first set and opened it up, and nothing was familiar, you know, sags, and landings, and all that.

Dr. Arnold (22:35):

But let's talk a minute about your patient demographics. I know there's a lot of different tribal regions in South Africa. Can you tell us a little bit about the demographics of the people, and are there different conditions amongst the different tribes that you see?

Dr. Van Zyl (22:54):

I wouldn't say it's different conditions amongst different tribes. I would say that our African population, we do see more vernal conjunctivitis. So we get the typical eye with the brown sclera and the thick lids. We see a lot of that. And then the rubbing and keratoconus that goes with it. But most of our patients, it doesn't matter what tribe, or Caucasian, or whatever. Most of us have pterygiums. We have sunlight all year long, and we have a lot of UV exposure. And even Christine Sindt said that when she was here fitting patients at our conference last year, that just about every patient has a pterygium. And it's very true. We see them all the time. And when we do our dry eye, people always come in complaining, "It's red in this little corner." And yes it is. And it's all sun exposure. So we need to wear sunglasses more, and sunblock all the time. I'm extremely fair. So I put sunblock in my middle part of my hair as well, because that's where some of us are getting cancer.

Dr. Arnold (24:03):

That's a good tip for me as I have a great big landing zone on the back of my head that’s exposed to the sun. So that's a good tip. Well I know you've traveled a lot and so forth. Do you speak any of the other African languages? And I know you speak obviously Afrikaans and English. Any of the tribal languages?

Dr. Van Zyl (24:27):

No, I actually don't. When we are in primary school we do have an African language. So depending on which province you are, which one you'll learn. So I did do Northern Sotho. So I know what milk is. And hello's dumela, and things like that, but probably as much as I know French just from reading a menu. So it's not really necessary for us to be able to speak a tribal language, because everybody can speak English. So yeah, I think that's the main thing at this stage. I think for any practice where you walk in, you have to be able to speak English, except for low vision you actually need to be able to speak Afrikaans. Because when I look at my demographics for my low vision practice, we have, I'd say 80% is macular degeneration and Caucasian patients, older English or Afrikaans people.

Dr. Van Zyl (25:28):

And we have the weird and wonderful thing that our African population does not get macular degeneration. I know it's a big problem in Nigeria where they still get a lot of AMD, but we have some gene that's actually protecting our African population against macular degeneration, which is fantastic.

Dr. Barnett (25:51):

Annie, that's absolutely fascinating. So I love that you like to travel just as I do. If you could choose one place in the world to travel, where would you go?

Dr. Van Zyl (26:02):

I think this is the most difficult question that you've asked me.

Dr. Barnett (26:08):

Okay, you can say three places, or a list, whatever you want.

Dr. Van Zyl (26:12):

My favorite place in the world will have to be Monterosso, the little town part of Cinque Terre in Italy. And being part of lockdown now and COVID, that's where I dream to go to. But my top two new places would be St. Petersburg in Russia. I'd love to see the Hermitage. I love to go and see art when I'm overseas, and just the whole Russian culture, which I know nothing about. And then I'd also love to see Prague.

Dr. Arnold (26:41):

I've been to St. Petersburg Annie actually twice, and it is a beautiful city especially for art lovers and lovers of architecture. It's a great city, and we have lots of friends there. So if you get to go, I want you to let me know.

Dr. Van Zyl (26:59):

Tom, you should let me know when they have a conference there. I like to combine my travel with a conference.

Dr. Arnold (27:05):

That's exactly what I did. Several years ago we traveled to Moscow, visited some ophthalmologists friends in Moscow, had a great time. And then Donna and I, and our family, took a river cruise from Moscow to St. Petersburg. And we went to the White Knights conference, which is there in St. Petersburg. It occurs the first week of June every year. Of course this year they had to cancel it, but it's called the White Knights because those are the long days, because they're near the Arctic circle. So it's definitely worth going to, a beautiful city, good food. And so let's put that on our bucket list.

Dr. Van Zyl (27:43):


Dr. Barnett (27:44):

And let's all meet together there, sounds great.

Dr. Arnold (27:46):


Dr. Van Zyl (27:48):

I like not to call it a bucket list. I like to call it a to do list.

Dr. Arnold (27:53):

Yes, there you go, much better.

Dr. Barnett (27:55):

Annie, what has been one of your favorite optometry moments?

Dr. Van Zyl (27:59):

I really like being part of the Contact Lens Society of South Africa, and our conferences, the Contact Connect 2017 and Contact Lens 2019 have been phenomenal for me, all the interaction between the optometrists themselves.

Dr. Van Zyl (28:14):

But if I have to think about a moment in the last couple of months that was really good in practice, I had this nine year old boy with very high myopia. And we put him into soft contacts for the first time. And teaching him how to put them in, take them out, the whole bit. He struggled with actually inserting the lenses. Mom had to help. And on his two week follow up had to take the lenses out, check the cornea, everything was fine. And then afterwards I put his lenses back in. And when I put the one lens in, he looked at me with these massive eyes and he started clapping his hands. And I was like, "What is going on now?" And he said, "That was extremely quick." And I thought, "Yeah, right? Wasn't it? Why don't all our patients clap?"

Dr. Barnett (29:02):

That's wonderful. And one final question for you Annie. Who has been a memorable mentor? And it's all right to list more than one too.

Dr. Van Zyl (29:12):

I'd say the first and foremost would be Eduard Sevenster my stepdad, the ophthalmologist. He is, oh... How can you put this? He rushes in where angels fear to tread sometimes. He has a way of making a plan when it seems that there is no plan. He had so many patients with Stevens-Johnson's and things like that. And he just decided he was not going to let it go. And he started the KPro when nobody else did it. And it was just such a inspiring moment to see where some of these patients were led into our practice, and then after their procedures they would be sitting reading the newspaper. So the way that he approached things and actually made things easy, as he would say, "Wash this eye," after they had a KPro. I've never watched an eye on my life before that, or even really touched an eye except with the contact lens, where I quickly learned that you have to do what you need to do.

Dr. Van Zyl (30:11):

And he's been very good with, he wants me to do as much education as possible. So once a year I get to go to an international conference. And also he really supported me with my master's degree, gave me all the time that I needed to actually go to the university, and go and work on their systems, etc. So I would say that would be the first. I learned a lot from him.

Dr. Van Zyl (30:36):

Then second would be Mr. Peter Brauer. He is just such a wonderful man, and also has supported me throughout my career, really from the start. And he encouraged me throughout, and also approached me to become part of the Contact Lens Society. So he saw something in me that I didn't even know was there.

Dr. Van Zyl (31:01):

And then the third person I would say would be Professor Wayne Gillan, that was the supervisor for my master's. This man is absolutely phenomenal, and is such an open mind. The questions that he asks, and that he's willing to answer and look at is absolutely phenomenal. And the structure that he did. So what he did with me is he actually made me write an article before I started my master's, that I can see what the process is about before he decided that yes he will be my supervisor. And just to see what is actually needed, and the dedication, and so on. And I've been very blessed with lots of mentors in my life.

Dr. Barnett (31:41):

Oh wonderful. I think there are so many people who have been mentors. And it's a gift to have mentors and also be a mentor. And I'm sure that you also have people that you mentor as well.

Dr. Arnold (31:59):

I think that's one thing that's really gratifying about the specialty contact lens field all over the world, is that they are just a host of wonderful people who have been on the vanguard of this and, and always look to the next best thing to help our patients. And so I think we're just really in a great field.

Dr. Arnold (32:21):

Well Annelize, thank you so much for joining us today. You have done so much in your career, and your experience is so extensive. Anyone who knows you or follows you cannot help but be very, very impressed. We're looking forward to following you and your career as you proceed. And I know there's big things in store for you. And thank you again for joining us here today on GlobalEyes. And we look forward to seeing you again very, very soon.

Dr. Barnett (32:55):

Yes, thank you so much. And I look forward to seeing you in person.

Dr. Van Zyl (32:59):

I'm also looking forward to seeing you both next year in Miami. And thank you for inviting me to be part of this. And I'm extremely honored to be on GlobalEyes. Have a lovely evening.

10/22/2020 | 33:39