 Good morning, everyone. We're going to get started with our grand rounds for this morning. We have a special grand rounds today. The theme is international ophthalmology, and we have our very own global fellow here in the country, in person now. Avnisha, who's going to talk about her year and her experiences in various countries and projects she's been a part of. Then I heard the food is coming. There's just been a little mix up with the catering, so we'll take a brief intermission. And then Bradley Jacobson, who's our PGY2, will also be talking about his experiences in Mwanza this year and plans for the future as well in Mwanza. And then they'll do a sort of combined presentation, finish up with Avnit then. Thanks, Srav. So for those of you that don't know me, I'm the Global Outreach Fellow, finishing my year here at the Moran. And this is just basically a recap of what outreach has been up to in terms of our partnerships internationally over the last year and sort of my role in some of that. So these are the countries where I spent my year. The blue countries, India and Nepal is where I did some training. Ethiopia and Australia, I went to some conferences. And then Haiti, Tanzania, Sierra Leone, and Micronesia, some teaching and surgery. And then this is just where we've had observers from this year in the outreach department. So I'm going to talk about our existing partnership. So Haiti, Micronesia, and Tanzania, specifically Dodoma and where we are with those. India and Nepal are also partners of ours, but Ereban and Telangar are kind of out of the scope of this talk, so I won't really talk about them. And then new places that we went this year, Sierra Leone and Mwanza. And this is also a new partnership. So in Haiti, just a little background, there's 11 million people there. It's the poorest country in the Western Hemisphere by far. 5% of the population are either blind or vision impaired. And the problem in Haiti is that there are not an insignificant number of ophthalmologists, but the training program there is not very good right now. It suffered a big hit after the 2010 earthquake in terms of resources, infrastructure, and the teaching is not very good. And so when the two to four residents per year graduate from residency in Haiti, they typically have not done enough surgery to feel comfortable doing cataract surgery. So very few Haitian ophthalmologists actually operate, only about 12, as of the last count. And another issue there is that pay for surgery is not very good. And so Haitian ophthalmologists find that they actually make more money to survive by selling glasses. So they cater their practice more towards refraction than actually doing cataract surgery. So that's a big problem in Haiti. In terms of the residency there, it's a government hospital. It's called HUEH in Port-au-Prince. There have been recent changes in administration there. And like I said, a lack of resources and instruction until very recently, we have better resources there. But about two years ago, there weren't any slit lamps. And the residents were just using direct retinoscopes and pen lights for their exams. And there's no fellowships in Haiti. So if anyone had the ambition to do a fellowship, they'd have to leave the country. So this is HUEH, the hospital in Port-au-Prince. Thankfully, there are a lot of people collaborating there now, a lot of different organizations that are working in Haiti focusing on the residency. Dr. Dan alters a retina surgeon in the Midwest. Who's really invested almost all of his personal time in building up this residency. He's procured a lot of new equipment for the residents. They did recently hire some recent graduates as faculty there. So there was a little more instruction than usual, although questionable caliber, because they also graduated from this program when it wasn't really too good. So four of us went this year, so the two Wills Fellows. And then I went right after them. And then Anna, who's a fellow at the University of Kentucky, medical retina fellow, just recently went along the same time as Dr. Chaya. And we focused a lot on mainly didactics for the residents. So even just someone to staff them in clinic when they're seeing all the disasters that walk in. This is the only public hospital in all of Haiti. And so patients that can't afford to go to a private hospital will come here. And so you really see all sorts of things. And the residents haven't had that much one-on-one teaching. And so it's really everything from here's how you aplinate, here's how you do conioscopy, to making more higher level diagnoses and doing surgery. We did wet labs with them. I had about two or three hours of lecture that I gave every day, surgical teaching. And then they had their first journal club when I was there as well. And that's them talking about the Oates article. So basically for Haiti recently, there's been some exciting changes. The residents are going to start doing a rotation up in Capatian in the north with Dr. Dupuis. That's the partner we've been working with the longest. He's probably the most skilled ophthalmologist in Haiti. He has now gotten glaucoma and retina training as well as being able to do comprehensive ophthalmology. And so the residents are going to go up there. And they're going to get much better surgical experience up in Capatian with him. So that should be good. We're going to develop a wet lab with video capability so that we can do some surgical teaching remotely. And then start, we've been talking about this all year, but really start teleconferencing with academic institutions here in the US so they can be a part of our grand rounds and morning reports and stuff like that as well. This is brand new. A private residency was started by one of the partners, one of the ophthalmologists there, Mike Mangret. There's one resident that he has taken on that's being funded by his hospital. So we'll see how that goes and see if that ends up expanding into something more. And then further subspecialty training for Dr. DePuis, Dr. Shakur is going to go continue his retina training this fall. But there's always a struggle in Haiti. So socioeconomically, there's always unrest and instability. Even when I was there, there were a couple days we couldn't go to work because of riots and people throwing rocks in the street. That's always there. Administrations always change. The residents, for a good six months this year, were not paid anything. So it's really just a question of if the residents, these residents who are very intelligent, very smart, hungry, are getting a lot of good instruction, if they end up going somewhere else for a fellowship, for example, are they going to come back to that kind of environment to work? And that remains to be seen. And one of the best parts of traveling with your attendings is seeing them kind of let loose. So says Dr. Chaya. Don't know what's in that glass there. And having a good time. So Micronesia, Micronesia is an archipelago of several hundred islands. It's divided into four states right here. And Micronesia is a challenge mainly because of geography. So there aren't a ton of people here. It's only about 120,000 people. But because of all of the islands being so distanced apart, it's difficult for the one ophthalmologist who resides in Ponepe and the capital to really deliver care to all of the people on these islands. So that's sort of been our task there is to try and make that easier. So the proposal and what we've started doing is to train nurses from the specific states. So each of the four states sent two nurses to this nurse training we did in the winter of 2018. We basically taught them how to screen for eye disease. And we're going to use them to basically go and they already have been doing this is to go within their state among the many islands and find patients that need Dr. Padwick's care so that they can more easily be brought to him or that he can come to the state and kind of see all of them at once. And so that's worked pretty well to date. We went in the spring to do a surgical outreach and those nurses, a lot of them came with us. They were part of the pediatric screening and they worked in the sort of clinic and OR setting with us, refining their skills. We also brought Dr. Gallin and Ortley Faco machine so that when he does travel to these other states he can actually bring his Faco machine and do Faco surgery as well. We did the first pediatric screening in Micronesia. That was Dr. Sophia Fang organized that and that was excellent. So we basically went to 18 different schools in the Chuuk state, went on a boat island to island and went to elementary schools, screened for eye disease. This was prompted by a question about vitamin A deficiency and possible subjective night blindness in this group. 9% of the kids failed. The rest of the kids did actually really well. And of those kids, some of them had some refractive error. Some had subjective nyctalopia but normal exams and then you have corneal scars, macular scars, signs of trauma, things like that. So we're gonna compile that data and kind of analyze it and figure out if there are any specific recommendations or interventions for that population. So that was a neat thing that happened this year. Future direction for Micronesia. So we will plan to visit the other two states that we haven't been to Yap and Costa Rai this year for surgical outreach. And something really cool, the nursing school there in the FSM has asked that we actually put the nurse training that we did in December as part of the curriculum of the nursing school so that nurses if they want can take this ophthalmology elective to try and become ophthalmic nurses. So that's hopefully something we can implement in the next couple of years. And then we want them to find a national eye care coordinator to really help Dr. Padwick deliver care to his patients when we're not there. Some of the challenges that I think we're gonna see in Micronesia. Right now Micronesia is federally supported with grant money from the US directly and that is going to end in 2023. There's a trust that's been established that is supposed to help fund FSM after that. But the preliminary reports don't really show that as being very successful in terms of funding everything that's being funded now. And the hospitals right now are not functioning sustainably at all. There are some patients that have private insurance but the way that it works is that the insurance companies fix an annual agreement with the hospital of we're gonna pay this much money and then patients come, public patients, private patients, anyone, they get free services which is funded by our money from here. So that's gonna have to change a lot in the future when that money runs out. And this is the many game faces of Henry Barrera in Micronesia. So Tanzania, we've been involved into DOMA here for a few years and now we're in Moonsad as well. 50 million people there, 27 ophthalmologists are mostly either in Dar es Salaam or in Moshe. And it's a rather large country and patients here live on three, three and a half dollars a day. So very difficult to travel to these places if they need care. There's two training programs, KCMC and Muhinbili and KCMC currently is not taking new ophthalmology residents which is unfortunate because they're by far the better training program in Tanzania. There's an unfortunate political situation where the current leader is really heavily favoring public institutions and making it very, very difficult for private institutions to continue educational activities. And KCMC is a private institution and they're currently not able to meet the very stringent requirements that the government has newly put upon them. So right now Muhinbili is the only training program. It is a government residency but from what I hear from our partners over there it's very poor training and not comprehensive. So right now if you're in Tanzania and you wanna go into residency you either have to go to Muhinbili or you have to go out of the country which is difficult. So we've been going to the University of Dodoma since 2016. There's one ophthalmologist there that we've been assisting Dr. Frank Sandy, that's him in the picture. And over this time we've really helped furnish his clinic, helped him with surgical training, training for his scrub tech and with his surgical backlog. There are significant challenges here in Dodoma, one being that Frank is the only ophthalmologist has other commitments besides clinical care. He has a big commitment to the medical school in terms of administration and teaching and so he can't always be in the clinic seeing patients. He has limited staff and there's a pretty inefficient flow to his clinic and he doesn't do any outreach. So basically patients that are able to make it to the hospital can get care but patients around there it's very difficult and there's no public transportation taking people to the hospital so it can be tough. So our trip this year, we accomplished a number of things. I went a couple days early and taught Frank how to do Ahmed valves and cook dual blade goniotomy so that he's able to care for some of the glaucoma patients he sees. We did a screening in three different villages in the Dodoma region and then quite a large surgical outreach along with surgical and scrub nurse training for Frank and his staff. Lyco is the capacity building consultancy arm of Aravind and we're very lucky to have Aravind as a partner especially here in Tanzania. So one of the representatives from Lyco actually came with us to both sites in Tanzania both to Doma and Wansa and gave an assessment in terms of how can they build their capacity, improve their efficiency, what are sort of the first steps to doing that and that'll really help guide us in this partnership going forward. And then for the first time, Frank is participating in some outcomes tracking data of post-ops in the villages after we leave. These are just some pictures from that trip. So we did over 300 surgeries, screened a couple thousand patients and I think we gave out like six or 700 pairs of eyeglasses. So in the future here in Dodoma, there's a new ophthalmologist who just started a couple of weeks ago. She was working for the Ministry of Health, hasn't operated in a while, may not be operating for some time but may be able to at least initially take some of that clinical load off of Frank so we'll see how she fits in. We really wanna see those Lyco recommendations implemented as much as possible to improve the OR and the clinic flow and the amount of patients that can be seen at that clinic there. And I will be going actually on Sunday for another week to Dodoma to help him with this as well as help reinforce some of the surgical stuff that we went over in February. And then something we've been talking about doing is a nurse and community health worker training for the Dodoma region. So one of the challenges we saw in the villages was that the community health workers responsible for care of the village citizens really had no ophthalmology training whatsoever, not surprisingly and so it's very difficult to get those patients referred to the right place. And so we wanna do a similar type of nurse training that we did in my Grenesia and kind of adapt it for community health workers in the Dodoma area and kind of create this district hospital referral system. There are six districts within Dodoma where those community health workers can then refer patients to the district hospitals and Frank can do a rotation through the district hospitals every month. So hopefully that's something that we can implement over the next couple of years. He's also been working on a residency curriculum. We're gonna help him hopefully with that. And this is Dr. Petty in his natural state. So Sierra Leone, this is a new country for us. This is a place that I went kind of on my own but I think would be a really good opportunity for collaboration because a lot of other organizations are getting involved here and it's really ripe. So Sierra Leone's country in West Africa, seven and a half million people. There are four ophthalmologists, only three of which are practicing, a few cataract nurses and almost everyone is in Freetown which is like right there. So if you're anywhere here, you have to go all the way there for your care. There is a rural clinic in Sarabu which is closer to the center of Sierra Leone. This is run by a private ophthalmologist out of Tennessee and she goes there twice a year and does a bunch of fake-go cases but the rest of the year there's really no care there. And the nearest subspecialty care if it's needed is in Ghana so of course not all patients can travel there. So the ophthalmologist that I worked with over there, her name is Jelika Mustafa. She's a young woman, probably my age, recently graduated from residency a couple years ago in Kenya and she's facing some significant challenges working within a government hospital system. It's extremely patriarchal there and so even though she's by far the most skilled and most qualified person there, she basically is at the whim of the other males in the department. They're the ones that order supplies and it can be very erratic. So when I was there we had Alkan lenses and Alkan viscoelastic but there was no tropicomide. There were only size eight gloves. It was just kind of strange. So that's a challenge for her there. Sitesavers is an NGO that's been very involved in Sierra Leone. They've had many, many positive impacts including this department within the Conaut Hospital, the public hospital but it's been very difficult for them to pull out because the government is sort of depending on them to handle all of the eye care needs over there and so the government won't really give much of their resource and so Sitesavers kind of has to stay and be that safety net. Cost of care can be significant. So cataract surgery can be $40 even in this public hospital which is a lot more than a lot of patients can afford and there's no insurance whatsoever so everyone just has to pay that. So Jelika has been an excellent perfect partner I would say to work with. She's extremely intelligent. Has excellent clinical judgment. She's a fantastic surgeon. She's very, very motivated and has interest in glaucoma and oculoplastics and basically functions at the level of a fellowship trained glaucoma surgeon and clinician just from being interested during her residency. So it was really fun to work with her. She's also an amazing chef and baker and so I got to also benefit from that but we did some glaucoma surgery when I was there. I taught her Ahmed valves. Again, dual blade goniotomy and then also trabecuotomy. She sees a lot of pediatric glaucoma there and she just picked it up right away. She did excellent and is doing all of these procedures now even after I've left and they're bringing more supplies for her because she's run out of all her stuff so really just an awesome partner who did really, really well. So again, I think it might be a good place for us to get involved just because of the potential for collaboration. HCP is gonna get involved there. Colorado and Will's already sort of have a relationship with her and the goal is really to help her open up a private clinic so that she can have a tiered payment model, reach more patients and expand the services that she can provide along with the public hospital where she's currently working. She's about to do an ICO fellowship in glaucoma at the University of Colorado. That's a three month training so that'll be great for her and then hopefully down the line some FACO training and a friend of mine is most likely gonna go do some oculoplastics training with her in 2020 so that would really be great.