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Preston see this many people here there’s a Nobel laureate who’s speaking right now on campus I saw a lot of advertisement for that talk so you guys made the right decision he only invented sequencing so not much on his CV number of you were here two weeks ago and heard a great talk by Geoff Gavin comes a friend and colleague Murthy of Utah about the work that they’ve done internationally I certainly can’t match Jeff’s accomplishments so I won’t even try I want to really gear this though towards majority of you I believe are first-year medical students give me an idea at least from my perspective what’s involved in global health and some of the lessons which I’ll hopefully convey to you I think could be applied to any area this case have to deal with ophthalmology so the talk is science of sight as you see and I’m trying to advance this as a new laptop but I’ve not used before because mine just died on a flight a week ago and unfortunately it is not advancing let’s see huh who would have thunk I hope we don’t do that every slide there we go so by way of disclosure I have no financial interesting in the products that I may mention during this presentation unfortunately and as Tom said I’m a clinician scientist I have a NIH funded research lab I have a very busy clinical practice some of the medical students here have been with me in the O R in the clinic we went till 8:30 or so last night so these are long days but I think that influences the way I approach international health my case ophthalmology I approach it like a scientist and just as we would never conduct a scientific experiment and not analyze the results I think you should never be involved in international global health in a project or with a group that does not really critically look at the outcomes of their intervention and so I approach this and I’m approaching this talk like a scientific experiment where the purpose of methods and analysis of the results and then finally conclusions so we’ll start with a purpose and I want to introduce the nonprofit foundation which I’m involved with visionaries and national we have four members currently but we work with other ophthalmologists around the globe myself Roberta Pineda who is a corneal specialist of Massachusetts Eye and Ear Infirmary which is Harvard’s ophthalmology program Sophie dang my colleague on the cornea service of the Jule Styne Institute and dr. Samar but Salk who was the D shot Hospital in Kolkata and who’s the highest volume of corneal transplant surgeon in India by far so a good guy to know our mission is really to reduce the global burden of corneal blindness as you can see through enabling cranial surgeons throughout the world to perform both traditional forms of corneal transplantation as well as nominal forms of corneal transplantation the challenge we face is significant there is really a an inadequate number of corneal surgeons throughout the world especially in the developing world and the corneal surgeons that are there don’t often have the ability to have corneal tissue so they’re often not as well trained as they should be not no fault of their own they just simply don’t have corneas available to transplant additional lack of corneal tissue they also have a lack of resources in many cases proper microscopes proper equipment as far as sutures instruments etc that are needed to perform corneal transplantation and if you’re going to give these surgeons all of this that they needed then you have to worry about the patient’s their ability to buy antibiotic drops steroid drops returned to the surgeon for follow-up care etc dr. Taven spoke mainly about cataract surgeries and cataracts are one of the largest causes of blindness worldwide we talk about corneal transplants it goes beyond just a surgery in that you do not have good outcomes unless you have good careful follow-up so that burden as far as the post-operative care is much greater when you’re talking about corneal transplant surgery and long-term success as compared to cataract surgery so our objectives are to provide Cornell surgeons the developing world with surgical training courses in both basic and advanced forms of corneal transplantation and well as the resources that they need to perform corneal transplant successfully and also I’m very involved in developing and the capacity of local high banks provide corneal tissue for transplantation and that’s taking me to shine out actually tomorrow so those are the purpose that is the purpose what about what methods are we going to employ or have we employed to try to achieve our purpose well you want to first identify causes

of vision loss and as a corneal transplant surgeon I’m interested in corneal blindness primarily you want to learn where to invest your resources dr Taemin spoke about the Herculean effort it took to get the instruments they needed the microscopes etcetera in to access that remote buildings where they were in Sudan it’s admirable it’s incredible they’re able to do what they did if you have limited resources limited time I think you really think about where can we have the greatest impact with our intervention surgery skill transfer we have fellows with us for a year we have residents with us for three years during which time they learn surgery can you teach surgery to somebody in four days is that even possible and then how do you increase the supply of donor corneal tissue let’s start with corneal blindness blindness overall 314 million individuals are visually impaired worldwide of which 45 million are considered blind blindness in the different definitions but usually 2200 or worse in the better seeing eye with best correction 8 million of that 45 million it was probably close to population of Los Angeles are blind secondary to corneal disease and almost 90% of the world’s visually impaired live in the developing world so although we’re doing great things here in Los Angeles as far as taking care of our patients the Jill Stein’s to it the greatest need is not in Los Angeles the greatest need is in developing world this was an article that was published by one of my mentors the partner Foundation Jack Witcher dr. Srinivasan who’s a legendary figure who practiced for many years at urban hospital and mothering on a global perspective of corneal blindness this was published now about 12 years ago and as they described what are the causes of blindness worldwide diseases affecting the cornea are a major cause of blindness second only to cataract as far as overall importance so if you looking at 45 million 20 million due to cataract but if you look at the next neck next most common cause probably trachoma which is 4.9 million luckily that incidence is going down over time but other common causes including trauma corneal scarring vascular zation etc syrup Thalia Biman a deficiency has been a common cause of blindness in some countries but luckily again that incidence is decreasing over time if you’re interested in doing something regarding global health especially for instance international homology you have to think about okay well where I’m going what are the causes of corneal blindness because it differs from country to country region to region so for example if you’re in stood in Vietnam interested in finding out what are the cause of Cornel blindness and children that study has already been known for you many countries there are population surveys that have been performed to determine what are the cause of blindness but many reasons this has not been done in Vietnam for example population-based surveys of all kids in 16 different provinces of Vietnam and looking at children who are in schools for the blind found that corneal conditions causing blindness is and you see in this table accounted for about a quarter of all causes of blindness second only to retinal conditions it’s a little bit different I was you’re not seeing cataracts as commonly in a pediatric population so if you want to do something as far as lending your skills to help eradicate blindness you have to make sure that your skill set matches what the need is in the population that you would like to serve so management the United States populations 308 million maybe 315 million I think so in the last census last year we performed almost 47,000 corneal transplants United States so by far the most commonly performed type of transplantation is corneal transplantation which makes me the highest going transplant surgeon at UCLA I’m not going to pretend this isn’t anything near this complicated as all those liver transplants we’re doing across the street so about one in maybe sixty six hundred people receive a corneal transplant each year in this country Indonesia the fourth most populous country in the world 230 million people 200 corneal transplants in the last year from which I have data 2010 200 corneal transplants the entire country of Indonesia one for 1.15 million people remember that 90 percent of the court burden of blindness is in the developing world such as in Indonesia so this is just this is basically it’s non-existent in Indonesia a corneal transplantation so how do we decide where to invest our resources is it where the burden of blindness is the greatest well maybe or maybe not this was a this is a map that was developed by the folks at site life sign life is a very large I Bank based in Seattle they distribute tissues throughout the world though for corneal transplantation by volume probably the third highest volume I Bank in the world behind the one in Tampa and actually one and I bacon Tehran which may be the largest eye bank in the world they are committed to doing what they can to eradicate corneal blindness worldwide and so they did a study looking at the

burden of corneal blindness which is represented by the size of the countries depicted in this map so obviously a large burden in Africa India Southeast Asia etc not much here in North America but the colors represent readiness for iBanking and corneal transplantation and that is key and from the legend down in the bottom left you can read it the blue color represents countries such as India that already they have eye hospitals they have trained surgeons who are well versed in performing character jury there’s no sterile technique you have operating microscope set cetera so all they need basically is increase supply of corneal tissue and surgeon training Africa see most of it’s in yellow problem is we have lots of corneal blindness but we don’t have the infrastructure there that’s necessary to come in and teach corneal transplantation develop iBanking and that’s unfortunate so because of this sight life has focused their efforts India and because I work with site life I have also largely focused my efforts on India here’s a graph depicting the tissue supply which is in orange in India going back three years projected towards 2020 the goal of site life is to increase the number of corneal transplants in India to a 100,000 per year by the year 2020 a very ambitious goal right now India is probably second behind United States this is fairly accurate around 25,000 corneal transplants per year getting a hundred thousand worldwide so almost 50 thousand US twenty five thousand India there was only twenty five thousand for rest of the world each year however the blue dotted line shows the number of corneal surgeons or the number of surgeries that can be performed based on the number of corneal surgeons who are presently active and you’re going to see that in the year 2015 the tissue supply will exceed surgeon capacity so this goal where the stars will never be achieved unless we can train more corneal surgeons in India and again if you’re going to train more surgeons more people coming out of residency you have to see a career as a corneal transplant surgeon they have to have to sure to work with then they have to have the skill set to practice their trade so that’s where we come in and many other groups with surgery skills transfer give a man a fish and you feed him for a day teach a man to fish and you feed him for a lifetime so this is really the the theory the mantra that we have in visitors international which is its skills transfer we’re training the trainer’s I don’t have to do 200 corneal transplants on the trip all I have to do is train one person at a bigger Hospital in Delhi or in Mumbai or in Bangalore and then they train others we then in turn train others and we have evidence that this works and I’ll show that to you in a little bit so types of corneal transplants again I think most of you I’m not seeing corneal transplant surgery so I’ll give you this a very brief review of what it is we’re talking about in this picture you see that the person is missing part of their cornea this is a full-thickness corneal transplant so if somebody has disease of the corneal scarring let’s say with love growth somebody had a corneal ulcer for example then we’ll do a full thickness corneal transplant – you see we’re not removing the entire Cordia there’s a central 2/3 this is done with a round cookie cutter in essence called a trephine and then we take that central cornea from my eye that’s somebody who has just died donated their eye for transplantation and then put that new cornea into place suturing into place another surgery called deep anterior lamellar keratoplasty you see depicted here on the right where we will leave this inner layer of the cornea called des amis membrane in place this is for patients I say with keratoconus if you’ve heard of this condition where the cornea has an abnormal shape becomes cone-shaped distorting vision but the inside layer is healthy and if you can keep that inside layer intact the patient retains their own inner layer then that layer of course won’t reject but is not transplanted so that’s another technique that we teach endothelial care to plasty there’s another surgery that we teach in this case I have an animated video since you’re eating I don’t want to show any blood this is the opposite of the deep end to lamellar keratoplasty you’re the only layer that’s replaced is the inner layer this is for patients who have let’s say damage to the inner layer of the cornea from cataract surgery or an inherited condition of the cornea called fuchs dystrophy in this case you see that the first step is to strip off that inner layer by going inside the eye and then we take the inner layer from an eye that’s donated for transplantation just the inner layer and in this video you see being folded there’s many different ways of introducing this into the eye basically that new inner layer is in place inside the patient’s eye and if air bubble is used to push it up against the back of the patient’s cornea so just replacing Li doesn’t like this it’s an animated video I got this off and I got to have a Nickelodeon so there we go

so that’s D sacrum is an other surgery that we teach this is the one I teach probably the most is artificial corneal transplant surgery in this case you take a donor cornea does not have to be good quality we use this is a dermatological in punch that we still from the dermatology department make an opening in it and then that opening as you see through it the optic of the artificial corneas place the patients are looking through a optical cylinder made out of poly methyl methacrylate there’s a backplate that is then used to secure the donor cornea between the front and the back plate so doesn’t go anywhere and then this little locking ring which goes into place again to prevent disassembly inside the eye which is considered poor form this is for patients let’s say who have repeat corneal transplant failure our patients with bad chemical injury or stevens-johnson syndrome who are not a candidate for additional corneal transplantation this prosthetic cornea does not reject they look through the plastic part some retain clear vision this however has the highest burden of post-operative care so even though you can do the surgery anywhere you really have to critically evaluate each patient their living circumstances how close they are to the operating surgeon etc to decide whether they’re a candidate for this so the surgery skill transfer process is a complicated one my wife who’s sitting here tells me I make it overly complicated but I don’t think so I really think it’s it has to be approached like you would a scientific experiment with careful attention to detail if you’re really going to do help do good and not do harm especially you’re talking about corneal transplantation where bad outcomes mean permanent loss of vision for the patient’s so before we even go we want to make sure we have it clear as to what the host institution wants to get out of a skills transfer course what the causes of corneal blindness are can we that address them with these surgeries that we can train them to perform we often have sponsors to help maybe Alcon or Allergan which are two large ophthalmic manufacturing surgical and equipment manufacturing companies who will have their name on the banners and it will help provide on writing for the event we have specific objectives not just for their overall skills transfer course but every day we have objectives and we assess where those objectives were meant or met or not there’s a timetable or so I won’t bore you with but there’s a lot of work that goes in before the skills transfer course and a lot of work that goes in after it and dr. Vose back here one of our fellows has been with me to Vietnam a couple of times she luckily only really has to be exposed to the work at the time she is aware of what’s before and what’s after but I want to make sure everybody here is aware of that so you appreciate what goes into international work we do a lot of screening we vet the surgeons before we go there’s no use in my teaching somebody to perform artificial corneal transplantation if it turns out they don’t even know how to perform a standard corneal transplant this has happened before in Indonesia first I went to Jakarta I’m gonna go teach artificial corneal transplant surgery and I saw a surgeon is struggling just to do simple suturing of the cornea so I will not make that mistake again so I always know pay the surgeons surgical experience prior to going and decide if there’s ten surgeons which five are which three I want to Train sometimes people have their feelings hurt but that’s okay they could be trained later once they get to the point where they become facile with a more basic transplant techniques pay some screening also Orbis is an organization you may or may not have heard of they do I think dr. Kevin may have mentioned them in his talk started about 28 years ago they have a large plane that’s equipped with the operating rooms examination rooms lasers and first class is actually a lecture hall interestingly enough they developed this telemedicine program called cyber site which we were the only people besides Orbis who have the ability to use this very helpful way to screen patients prior to surgery so here’s a little cutie we saw in Vietnam last year bilateral coil pacification at Birth you can see the glasses she’s had her lenses removed from her eyes so on the left is the photos that we look at the history and then there’s text boxes where I will then ask them questions the surgeons that will respond to go back and forth so even before I show up in Hanoi or Saigon I know exactly which 40 patients I’m gonna see on that first day I’ll know which tests need to be ordered all those tests will be have done ahead of time you cannot do all the appropriate testing day prior to surgery all this has to be done ahead of time and it’s really facilitated with this sort of a program I take it compulsion to the nether level I want to see also exactly where different places are located where is the operating room where is the wet lab etc so this is from Pondicherry oh if you recognize this Rose was in Pondicherry a few months ago where they say okay here’s the auditorium here’s the operating room or the OT as they call it very helpfully get pictures of operating rooms you can see what the operating microscope slike in this case very good the two tables is a good sign as dr. Taven showed you and places like Nepal and India where they have very good very quick surgeons they’ll often have several patients

lined up ready to go that means they’re doing surgeries quickly enough that for efficiency’s sake they have to have at least two tables at all times with patients coming on and off of them so that’s a good sign if I see that that means they do a pretty quick cataract surgery which means they’re experienced surgeons so I look for the dual table sign as well as the good microscope sign and again wet lab in operating room we found when we’re in Saigon at the wet lab although it was beautiful was about 30 minutes away so if you have a detailed schedule for each day and nobody tells you that the wet lab is another building that’s half a mile or half an hour away then everything’s gonna be off that day so you really have to know exactly where everything is obviously ideally you do a site visit prior to the skills transfer course that’s not always possible so if it’s not possible you need to do it as much of this as you can ahead of time sometimes you don’t have to do a site visit this is King Khalid I a specialist hospital in Riyadh Saudi Arabia dr Stross my hair in the front row has been there you know all I know is Saudi Arabia Riyadh they probably got box and sure enough this is the I think the men’s locker room here I don’t need to ask what microscopes they have I know it’s gonna be gold-plated I know it’s gonna be nice so again you you you sort of tailored the amount of betting you do depending on your destination even if you’ve done all this planning but you forget something as small as the fact that they don’t have the instruments you need it’s all going to be for waste I have not been able to that D SEC surgery in Armenia before just because they didn’t have needles small enough to do it successfully we have large gauge needles as they did only 23 gauge needles not 30 gauge needles you cannot get air to stay inside the eye and that one little tiny issue made the whole trip unsuccessful how to go back when I had 30 gauge needles with me so I don’t want to know I have a list here of easy instruments that are necessary and instruments that are optional and the institution then fills this in and told me what they have and I want them to assure for me of course that they’re forceps in good working order that the teeth actually meet one another I mean you have to have this down to this level of detail I really think in order to really have these successful skills transfer courses as I mentioned we have objectives for each day I’m not going to go through this but the basic structure of a skills transfer course is day one you show up you see the patients that you have screened on Cyprus site or whatever a program you’ve used for pre-screening of patients you decide who’s going to have surgery decide which surgeons are going to be doing surgeries I’m looking at the cases I’m going to choose for live surgery those are cases are typically easy with a good view so that everybody can see and a very Placid patient you don’t want somebody who’s jumping around patient gets anxious during surgery etc both surgeon and patient have that have excess stress when you’re doing live surgery so you’ve really gotta have a very calm patient typically it’s an older woman just the way it is you never want a young man to operate on during live surgery unless you want the grief other thing I like to do is the day one is do surgery do one case myself that way I understand how the microscope works understand how the foot pedal works do those of you have not seen al Tomic surgery our feet and our hands are all doing something separately I have I have a pedal for my left foot which usually works the fake-o machine which works the the fluid coming in out of the my right foot is working the microscope as far as zooming up zooming down and XY function and then my right hand and left hand are both inside the eye doing different things so you really have to learn to split your mind in four different ways and if you’re working with a petal that’s reversing what you’re used to the whole time you’re doing live surgery people think this guy can’t do it in the garage it’s focusing the wrong direction etc so I always think it’s a good idea to do a case first you get comfortable the microscope etc prior to going to live surgery often pre-screening day looks like this it’s just lots and lots and lots of people they’re patient but there’s a lot of patience there’s a lot of patient patience so this is the way it is sometimes you think oh my god are these people all here for me and they’re all looking at you because you’re lighter skinned you’re like super tall you know you’ve got the white coat and and many of these people you can help most people gonna say we can’t do anything for you now but I’m here to train your doctor and your doctor is going to do your surgery in the future remember it’s one patient at a time it’s just like we have in our clinics here it’s one patient at a time like in this woman here with corneal edema in the right eye this patient also you can see the cloudy cornea hopefully can see it in the light here in the right eye the diseases may be a little different but the basic skills that you use here and the same as you’re gonna use somewhere else and the same way you interact with patients here is the same so even though it’s unfamiliar environments to you once you start taking care of these patients see them one by one things begin to feel more familiar and more comfortable to you so we divide and conquer this is dr. Sophie ding my colleague I mentioned Jule Styne this is me this is in Vietnam we have all the local doctors here and they’re very helpful just bring these patients up one by one there’s no HIPPA there so you don’t have like a closed room and you know private

discussion the discussion about their syphilitic aortitis is right there in front of everybody that’s just the way it is unfortunately a lot of little guys they’re everywhere you go you’ll see children many of whom you think you would really like to help but again have to stop and think about this this little kid is I know how walled maybe three years old but you’re not doing a transplant here with a follow-up you’re going to have here this kid maybe from 200 kilometers away from Saigon I may not be able to return you need to assess how involved with the parents etc and many times the best thing to do for these people is nothing even though it’s very hard to say no to parents of these children there are some people like this poor gentleman who was burned in a fire you can’t help can’t help them here you can’t help them they’re the last thing you want to do is to try to do something again and make this person’s situation worse there are conditions you’ll have never seen in the United States that you will see when you go abroad these two are brother and sister from Bangalore India with Zermatt pigmentosum you may ever seen or heard of this condition so they get Diamond dimer formation and expose UV light and they the lack the normal DNA repair mechanism that’s required to prevent Sun induced damage often died in their 20s from cutaneous cancers the girl here was one of the first patients in India to receive the artificial corneal transplant then there’s conditions you do see here but you don’t quite see at this degree this is a patient we saw in jakarta who had hyperthyroidism with probably the worst thyroid eye disease i’ve ever seen in this case the corneal pacification is doing the fact he hasn’t completely blinked for about two years so obviously in this case what he needs first is decompression of the orbit allow the eyes to recess backwards and then corneal transplantation which is exactly what we did for him so on the main day of the skills transfer course once you’ve screened everybody you’ve done your practice surgery you work to figure out how to work the microscope pedal then it always starts with didactic instruction obviously this is an educational process and you tailor that to the level of sophistication and knowledge of the surgeons that you’re training so we will often do is have a large attendance so in Mumbai we did a decent training course two years ago we had a hundred and sixty people attend the lectures I wanted to raise awareness amongst all the ophthalmologists in Mumbai about this new surgery that could be used to help people with corneal damage from from cataract surgery but I’m not trying to Train 160 people by far I’m only trying to Train three or four or maybe up to ten at most and then the other doctors now they’re aware of this surgery and how much it is from what has been available in the past will they refer those patients to the surgeons who are doing the surgery just liking this talk but many times you go abroad you have to wear a number of different hats so to speak stuff this one on the right is in Lumbini Nepal where this is I guess what they do to visiting speakers make him feel like a jackass it helps to have people come with you so this is such action of a son who’s a doctor in the UK but who trained it Earvin so when he came back to air even in July to help through this desex skills transfer of course he knew air event he trained there but he’s coming with a perspective from the UK and with the skills that he developed when he was practicing in the UK I think it’s a good idea whenever you can to pair with a local surgeon somebody is sort of a point person for these training courses and they’ll be a go-to person for their local surgeons in that area we don’t have one as we did for this course but it’s also nice to bring in somebody who’s familiar with the environment in which you’re practicing this is doctor ding you know she and I both do that surgery I showed you but we do it differently I think one of the best things that we’ve done lately is the doctor from Kolkata India doctor pisaq does that desex surgery for a total cost of about $200 including the cornea UCLA if one of you guys wanted to pay cash out of pocket for that surgery it’d run you about $20,000 huge disparity so he does it on a shoestring budget so he can show surgeons in rural Vietnam for example rural India how to do this surgery at very low cost whereas I show the surgeons and the bigeye hospitals who have these all these instruments and things available to them how I like to do it so we show a variety of ways of doing these different surgeries and you see somebody with a microphone very important that this is interactive you guys are involved in these sort of national ophthalmology are you’re doing effective skills transfer it’s not lecturing to people it’s sharing with them you have to find out what their limitations are what their questions are you have to make it interactive I really think to effectively transfer skills once you’ve done with the lectures in the morning and typically move to the O R or ot as I say in most countries and again this is where the Heat’s on your jet-lagged you may well have diarrhoea you’re working at a microscope you never usable or instruments that don’t really work great but you can’t say anything about it you’ll be The Ugly American you are not able to communicate with the scrub nurses many times this is why I almost always have a fellow with me who functions as my scrub nurse so they hand me instruments without even

saying anything that is so nice as a surgeon to have somebody with you who knows what you want and you got a lot of people watching both in the room and the many times in an auditorium so do not think about going and training surgeons unless you have done that surgery hundreds and hundreds of times you can do it under duress because you often will be under duress when you’re doing live surgery not just in your own country but in a foreign country especially when you do it enough you can literally do it in your sleep and I told my patients here that I’ve done D SEC in my sleep in many different countries so you’re in good shape here we will often broadcast as I mentioned there’s people in the room but often you can have too many people in our room of course we’ll typically broadcasted by television like this to a jacent room or sometimes I can just was in Chile a few months ago to an adjacent auditorium here was a room that was in Moscow a few years ago we did it cut across pieces training course the room was full when I started talking and this is about ten minutes in I think I drove out about half the pepper luckily you guys are staying here with me I appreciate that and this is in Pondicherry India just a few months ago then after you do the live surgery then really the skills transfer the actual hands-on begins we do a wet lab session just as you guys now may be aware that you have this this surgery skills building here is being built correct as far as having expectation simulation through simulation same thing here we don’t have the ability to buy simulated simulation instruments for these countries but we do have wet labs so this is in Moscow we did a wet lab just before we did kaypro training course here in Vietnam again what we’re demonstrating it and then they do it and we typically we found it most successful to have a pairing of a mentor surgeon like myself and a surgeon I’m mentoring and then we work together in the white lab I show them my technique like I said we all did surgeons who are demonstrating the surgery of different techniques so it’s very good to have us somebody work with you they practice your technique in the wet lab and when you satisfy they can do that then you move on to the operating room in some countries like as we had here in Vietnam beautiful what labs facilities some places not so then the next day of the course is the patients is the surgeons who are we are training is their turn and it’s hard to do this it’s hard to do this here when you’re turning over surgeries to fellows and residents it’s really hard in a country like this where somebody’s only seen you do one or two surgeries and then it’s their turn to do this but this is a I think this is probably more stress on the coronaries than doing the surgery yourself but it’s a necessary part of the process here serious some are my Salk assisting with desex surgery is Roberto Pineda here in Sudan assisting with artificial corneal transplant surgery this is me in Chile with sebastian perez great guy happen to be a great surgeon so he’s actually teaching me while i was doing his first artificial coral transplant surgery showed me a few things and sometimes you do you are pleasantly surprised like that and then sometimes you see you my hands will just clasp this is my good friend anna Hovik Eemian who’s in Yerevan Armenia I’ve worked with her maybe about five different trips this when I go back there now I just sort of show her some new technique and she takes to it right away so I just sit there with my hands clasp usually not paying attention to what she’s doing and then the last day of this typically a four-day skills transfer course is devoted to cleaning up any messes we might have making sure that everybody looks good before you leave and if you have any cases where the transplant fails you’ve got to fix that either at that time or when you go back and every trip there’s always a follow-up trip within 6 to 12 months so ever I go somewhere I tell them I’m coming back like it or not and you must do that to follow the results we do it for the patients of course – cute little ladies there there’s a patient in Yerevan with day one after D second you see a little bit of an air bubble there you see the circle inside the cornea that’s the new cornea adherent to the back of it very nice visual result here’s a patient from Yerevan this is from 2005 had a severe injury to both eyes and their long-standing war with Azerbaijan he was the first artificial corneal transplant recipient in Armenia and he is now almost nine years out still maintaining 20-40 vision coming from only being able to see bear movements of a before his face this is you probably know she’s from Ames medical students visiting us from Ames McGaw which is the big giant Hospital in Delhi India this is Radhika Tandon who’s on the cornea service there and this little guy between us was the first artificial coral transplanted to recipient as far as I know in India and I think he’s still doing well here’s a patient whom he was had a severe injury and Tahir Square during the sea uprising a couple years ago and he was the first artificial coral transplant recipient in Egypt with Roberto Pineda there on the left who assisted with his surgery and again after you’re done you’re not done you go home that’s not the end of this girl’s transfer that’s the beginning of the long follow-up so you can see here this

is a patient we operated on in July I have three week follow-up I have three month follow-up will be getting six month follow-up on and on whenever something changes regards a patient’s vision I get an email if you commit to going and you commit to doing skills transfer that means you also commit to answer those email and answer them in a timely manner so that the surgeons that you’ve trained don’t feel abandoned and so their patients don’t be abandoned so finally increasing supply of donor corneas this is one of the hardest things I’ve probably the hardest thing what we try to achieve because this is really not in our control many countries have social religious cultural barriers to organ donation to a corneal transplantation the easiest thing to do is well just bring corneas with me so you can do that but that is not sustainable most countries other than the Saudis can’t buy corneas the United States at the price that we ask for so really what you need to do is to try to maximize the tissues available and facilitate their own development i banking system in the country which you’re visiting we can with good quality tissues split the cornea in two as you see here on this picture and have one cornea benefit to different recipients so here’s a cornea and the middle we see that we’ve taken off that inner layer decimates membrane and we’ve transplanted it to this patient who has a disease just of the inner layer this is a surgery called DMACC so their vision is restored then the rest of the cornea then goes to this patient with keratoconus whose inner layer is healthy and is retained as I talked about earlier but who has a problem with the body of the cornea of the stroma stroma and their vision is restored so one cornea can be used to benefit two recipients the United States were not allowed to do this in other countries this is done thankfully routinely also this is the worst tomatoes are used to make ketchup the worst corneas now don’t have to be thrown away those corneas that are donated that have low cell count not really optically clear etc they can be irradiated then kept in albumin up for two years in a jar and then used as a carrier as you see here on the right for the artificial corneal transplant the patient’s not looking through the cornea it’s just serving as a carrier for the artificial cornea so this patient is five years out with the sterile irradiated cornea and these are available much lower cost than traditional corneas one of the barriers I found early on when teaching people how to do artificial corneal transplant surgery was the cost of the artificial cornea or the Qatar prosthesis the Boston kiddo prosthesis that we use here costs $5,000 each five thousand dollars each that’s awesome – no go in most other countries in the world the makers of it have kindly given it to me at 500 or a thousand dollars each for use in different countries depending on the GDP of these countries that still has too much money so about 2009 I guess it was I took the boss and cut across theses to our lab this is a very large company I think dr. David mentioned this it’s a sochi of the arab in a hospital in modern india which is the largest eye hospital in the world they have a manufacturing facility that makes all their own intraocular lenses sutures viscoelastic all these things they use during surgery and I said can you guys make this and they said what’s it made out of I said poly methyl methacrylate they said no problem we make a million intraocular lenses out that material every year so now they have the our lab care – prosthesis which I’ve implanted and now surgeons across India are implanting available for 6000 rupees which is 120 US dollars they say they can make it cheaper than that even so that’s one of the big financial burdens that we overcame as far as increasing supply of corneal tissue in India been significant improvement over the last ten years you can see from this graph with increased utilization rate and this again is going to continue to expand and as we have more tissue again we need more surgeons trained to do corneal transplant surgery I have about five minutes so I’ll just go quickly through the results here as I mentioned approach this I would encourage you to approach international work like you would a scientific experiment as I mentioned before you never do an experiment and not analyze the results so we’ve done that this is an article published an editorial in one of our journals a few years ago we’re going to potential utilities of the Boston kiddo prosthesis the artificial cornea in the developing world the potential utility but there’s really not there was nothing that was published on outcomes of the artificial cornea in the developing world so I decided well why not so this was an article that was published and draw tamale last year international results with the Boston type one care two prosthesis this is the largest series ever published from artificial corneal transplant surgery and what I did is I looked at so you see here in the left column international 113 procedures performed by surgeons at 11 different centers and eight different countries that I had worked with so Armenia Indonesia Saudi Arabia Philippines Nepal India on and on and then the next columnist is UCLA these are a matched group of 110 procedures I perform to UCLA the point being we can’t really analyze the outcomes internationally as we have some standard against which to compare so here we have

the same technique could I train all these surgeons versus what I’m doing looking at outcome what we found was the outcomes were about the same if you look at vision for example look at what’s been great here those patients who have the best vision 2020 2025 out to tears after surgery you see the percentages are pretty darn similar in the international series versus UCLA series this is true for each one of these visual categories as far as complications which is the main thing we worry about are we going to be hurting these patients during a surgery that requires lifelong topical antibiotic use if a patient doesn’t understand that if a patient has poor hygiene or they can get infected the only complication that was more common in the international series than in my series was infectious an alpha minus which is infection inside the eye which is the most dreaded location 9% we need to get that lower I think a lot of this is because the patient who did have an optimized for those who live very far away from the operating surgeon who did not follow up as instructed it was actually poor patient selection but again this is the initial series or we learn from that and then we modify our patient selection criteria and I’ll tell you that 9% is actually lower than series public from UC Davis and it rules our Hospital in Philadelphia where I did my residency so my rate fortunately is low the national rate is higher than we like but it’s actually in line with the rate in the United States so we see similar vision similar complications and here we’re looking at retention how many of these artificial coins and we put in are still there let’s say three years after surgeries you look at 36 months in the red lines International Series in the blue line you see la series you see this the same 75% and what if we had gotten more corneal tissue to do a third corneal transplant a fourth one how they’d have done you see the solid lines down below that survival of those repeat transplants much much lower so this is the right surgeries to do for these patients we’re very encouraged by these results so in conclusion the burden of coin on blindness is greatest in the developing world that’s where the greatest need is no question about it strategies to adjust address corneal blindness should be planned and performed similar to a scientific experiment you must analyze the results of intervention the first time I went with Orbis to Jakarta Indonesia 2010 when I went back year later saw how they’re doing with the D sex surgery that we trained them to do they had done zero and nobody knew that they had done zero I thought how can this be how can you put all this time and effort into a surgery skills transfer course spend what was probably over a hundred thousand dollars flying everybody in doing all this and nobody be aware of the fact that that had resulted in zero surgeries being done afterwards unacceptable no knock again tortoise I’m just saying that this is not unique and the greatest impact really comes from not necessarily going somewhere in doing as measured as you can in a week although that does no question benefit those patients but the greatest impact obviously is teaching somebody how to and ensuring sustainability of your activities through in this case of establishing a non-profit so we could apply for donations from individuals from corporations etc and really for training you guys getting you guys interested in global health so that you will carry these price these programs on in the future so when I thank you very much for your attention for instant learning more about our nonprofit this is a website I’m happy entertaining questions you might have

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