 Good morning everybody. We want to welcome you to Grand Rounds and on behalf of the Global Outreach Division, we're so delighted to have Dr. Kalpana Narendran here with us. This is something that Alan Crandall craved. He craved the experiences. Travel was fun for him for a variety of reasons, but what he really enjoyed was interaction, the exchange that we had with our international colleagues to be able to share ideas. And we have so much to learn from the world and we're so grateful here that Dr. Kalpana is here to give her testimony of her experience and to really inspire us to move to the next level. So with that, thank you so much. We welcome you to Salt Lake and have Jeff come up and do our formal introductions now. Thank you, Greg. You're in for a treat. I wish you all could get a few moments to meet Dr. Kalpana Narendran. She's a delightful human, delightful surgeon. She's certainly done more cataracts than I will ever dream to do and that's as a pediatric ophthalmologist, no less. Dr. Narendran received her medical degree from the University of Madurai and then went on in the Aravind Eye Health System to receive her board diplomat and ophthalmology. She's a member of this extraordinary ecosystem and family that is the Aravind Eye Care System. She's the head of Pediatrics in Kambator, which is one of the four major Aravind Eye Hospitals. For those of you who are hearing about Aravind for the first time, whether you're a medical student, perhaps early residents, they are kind of truly, truly the hallmark that we hold an ophthalmology for a successful eye health system. They're driven by mission. That mission is to provide highest quality eye care to everyone, regardless of ability to pay. And their entire, their entire ecosystem of these multiple hospitals and centers is all driven around that idea, an idea of innovation. In global ophthalmology, we have far more to learn from them than we could ever dream to teach them. Dr. Narendran is actually well trained within the United States. She spent time at Wilmer, also at Jules Stein, at Willseye Hospital, among others. We're honored to have you look forward to learning from you and thank you again for gracing us with your presence. Thank you for having everybody. And thank you. It's such a honor and, you know, pleasure to be here at the Moran Eye Center. I actually am only familiar with Dr. Alan Crandall, and I always wanted to come here. And so when the invitation came up, I said, yes, I would take the opportunity to, you know, come and visit the place and I've been taking care of so well and I'm enjoying the hospitality. It's such a pleasure to be here. So, you know, coming to my presentation, it's going to be a very simple presentation and I'm talking from my heart, like what I have done all these years as a pediatric ophthalmologist. And my role in this, I started my career as a pediatric ophthalmologist, I also do a little bit of 30, 40% of my time goes into administration, and I'm also the regional HR director of Coimbatore. Today, I'm going to take you through the journey, what I as a pediatric ophthalmologist did in my career and what I am here today. And I will share with you the insights and the experiences I gained through this journey. So the Aravind Eye Care System, like Dr. Jeff was mentioning, it started in a very humble way in the year 1976 as 11 bedded hospital. And these are the founding members of the Aravind Eye Care System. And the mission was to eliminate needless blindness by providing compassionate, high quality, affordable eye care to all. And at Aravind, we do almost 40% of them are paying patients and 60% are free patients or subsidized patients. And the building blocks, this is our founder, fondly called as Dr. V. The core building blocks of Aravind are the value system, the delivery system and the innovations, which constantly happens there. And most importantly, the sustainability. So the sustainability is a key thing which has, you know, made Aravind to grow so much and that is what people outside in the world look at us for the sustainability. So what started as 11 bedded hospital today is seven specialty care or tertiary eye care centers with the eighth one on the pipeline. And we have seven secondary eye care centers where only the cataract surgeries are done and six comprehensive eye care centers. And this is all in the state of Tamil Nadu. So it is all down south except one in another state called Andhra Pradesh. And we have 107 primary eye care centers, which are called as a vision centers, which are manned by the ophthalmic personnel. We have one refractionist we call them and the ophthalmic personnel, they are manned them. And that is a vision centers and it and it is managed through tele consultations. So on an average, we would get around 20 to 30. One day we will have around 300 to 400 consultations every day and each hospital has a daily consultation room. So on an average day at Aravind, we see around 16,000 outpatients, 1,700 surgeries and lasers. It might be unrealistic, but people have been to Aravind will, you know, know the magnitude of how many patients we see and of course you know the population of India we've just met China so. And then outreach camps with around 1,750 patients examine and 300 we do a base hospital approach where we bring the patients to the base hospital operate them and send them home. And there are of course classes and training going on for both for post graduates and ophthalmology and also we have other programs for training nurses and administrative skills and technicians. So my journey will what started from residency. So my affiliation with Aravind I get system was from my residency. So I joined an 89 and then completed my residency. And then the first pediatric ophthalmology and Strabismus Clinic in India was started in the year 1983 in India. Strabismus Clinic, it was the All India Institute of Medical Sciences, but combined pediatric ophthalmologist and Strabismus Clinic was started. And it under the mentorship of the Merlin Miller. She everybody in the pediatric ophthalmology, you know, world know that she was a very keen person in developing global, you know, pediatric ophthalmology setups everywhere all over the world and India and Africa and other parts. Dr. Vijay Lakshmi, the person in the middle is the, the first person who got trained under Dr. Miller, and then she was the one who was under the leadership of Dr. Miller, she set up the first clinic. So why did I take a pediatric ophthalmology, when I finished my residency it was a evolving subspecialty. There were not many people in the specialty. So it goes, you know, my man, my leader Dr. Vijay Lakshmi my mentor was a very approachable kind person. So and then my, my love for children so that is why I chose pediatric ophthalmology. So then, after I finished my residency, my fellowship I was working there till about 96. And in the year 97, Aravind branched out to another city in the state, which is called Coimbatore, it is the second largest city in Tamil Nadu. Coimbatore is the Manchester of South India. It's a well-developed lot of cotton mills. So it was a, it more like an industrial town. So when we moved there, this is a team, the first team we moved to Coimbatore, and I set up the first pediatric ophthalmology department and I was the first pediatric ophthalmologist for that 1.3 million population in Coimbatore. And in a small way I started. So this is the outpatient statistics. So what we started in the year 97 and what we are today. So it was a very slow gradual growth, except for a dip in the COVID time. And again, our statistics, we have a very strict audit meeting. We call it the parameter audit meeting, which happens every six months, where there's a scale across the system that how many outpatients are we growing how many publications, it's a very strict audit which happens once in six months. The first six months will be internal team, but the one year thing will always be done by another team from another hospital who will come and audit us. So it's a very interesting thing so that it always helps us to grow and also to compare with the other hospitals in the system to know where you are and where you have to improve. And coming to the observation fellowships definitely has a good, you know, influence on us, you know, as budding pediatric ophthalmologist. So this really helped us my observations with, you know, pioneers like Dr. David Gaitan, and, you know, I was with Dr. Sherwin Eisenberg. I was with Joseph Calhoun and Will's High Hospital. So, and then I was with Robert Peterson and Children's Hospital Boston's I did not come for a longer period because of family concerns so it was always three months in one place but that gave me a lot of insight. And these kind of collaborations gave us long term connections and, you know, and also helped us to grow. And then, you know, once the department was growing we were focusing on, you know, things like, you know, pediatric cataracts, because we had a big burden for us. Like we almost do around 2500 pediatric cataracts across the system, which is unusual here in this part of the world. So and then we did a study on the etiology and then in the 97 that was a major study we found out that Rubella almost 20% of the pediatric cataract was caused by Rubella. So some parts of the, you know, in the country the Rubella vaccination was not very popular. So we've recommended but the numbers have come down now, definitely have come down but then we have other causes of cataract coming in now. And then of course, Strebismus was the next, oh, he's here, Ethan, I need some help. I'm so sorry, I'm not a big tech, sorry. He's so spoiled back home, yeah. Yes, please. How often are those pediatric cataracts visually significant from birth versus, you know, acquired in the first couple of years and how soon are you able to do them, I'm sure there's difficulties with getting those infants to you in a timely manner. It is, I mean, unless it is something depends on the, if it is a white cataract then people come to you immediately. It's a lamellar cataract where you really can't see it, then they don't come to you. They come, you know, very late. So and I'll be going through what we did differently to get that addressed also. So, and again, Strebismus, simple Strebismus surgeries were done. And then we moved on to, you know, do complex Strebismus surgeries with the help of a lot of other things. So once the department was there. So we have to grow the department. So what we did next was so to increase the human resources. So we started doing a fellowship training program. See the establishment of the fellowship program offers. It's a multidisciplinary collaboration. You know, you attract more people to come into the department and then we'll help the department to grow. So the program started in 2000 so far we've trained around 64 national pediatric ophthalmologist, and we also have trained eight from international. So we have people from Tanzania, Abuja, Bangladesh and the first pediatric ophthalmologist of Sri Lanka was trained by us in Coimbatore and right now we have somebody sponsored fire from more and from Tanzania just was landed there yesterday and he's going to be with us for a year. So this actually is a mutual thing it helps us to grow also. And it also is helping someone to grow as well. So in the process is very important to have, you know, conferences and continuing medical education programs in our society it's called the specialty of India. So one is to, you know, exchange knowledge, and then get skills and also to showcase that what you are doing to the community. So this again helps us to grow and then you get attracted to more residents and those to take up the specialty. So the initial years not everybody wanted to do pediatric ophthalmology because they thought, you know, it's not very, you know, lucrative, you know, things like that but it's getting better now. And again, our best played a major role for the development of the pediatric ophthalmology subspecialty we all know that our bus, you know, in India in early or probably in early 2000 had a very major role because pediatric ophthalmology as a subspecialty got into the limelight after the influence of the our bus. So our bus did a hospital based training program and the flying program so we were very fortunate. We had three hospital based training programs so the doctor Thomas and then Dr Stephen Kraft. So at different points of time they were there so this helped us to improve our skills in complex traditional cases. So it is always we come here and observe but we never get to do hands on, but this was a real good help for us so when they came they spent almost a week or 10 days with us, where we could collect patients and operate and that helped us a lot. So with this, you know, brief period of time the insights we gained was how important is to have a strong laying foundation, and then you need to become a pioneer in the field. And this will help you to pave the way for the future generation. So this was a landmark thing which happened in Irwin Coimbatore. So when I was observing with Dr Robert Peterson, he used to take me for the ROP screening to the children's hospital. But we had no such thing in back at home in in Tamil Nadu that they were doing ROP screening, but we used to get babies but the numbers were very low there's not much of exposure even with the pediatricians. They were not, you know, fully equipped intensive neonatal intensive care units. So then when I was observing with Robert Peterson. So I thought this was interesting. So when he, you know, again under the influence of Dr Miller, Dr Robert Peterson came almost 10 times to Irwin. So every year, he would come and then as if there's a new special branch of I mean new open branch and there's a new pediatric ophthalmologist, he will go be there for two weeks to guide that person. So it was like that so when he came we started the ROP screening project and one of the NICUs in Coimbatore. So the numbers grew up. And there was one dedicated retina specialist who was very interested in pediatric retina. And then in 2003 the first red cam of India came to Irwin Coimbatore. So the pediatric department retina department, the numbers grew. So then we said, you know, if from the pediatric department, we were not able to support. And then we said, and there was a lot of opportunities for the department to grow. There was a lot of resistance when people said, why do you want to branch out into pediatric retina you may not get patients and things like that but then the pediatric retina department and the leadership of Dr. Paraksha started in the year 2011. And again, Arbus had a role. They came out with the, you know, advocacy and new treatment protocols with the Indian babies, the weight and the presentations were very much different from the, you know, the babies, what it was presenting here. So it was Kalithwansi and Anna else, you know, they came there stayed there for a week and guided him. And the numbers grew and there was a lot of need for more people to get trained the short term training program was started at Irwin for the ROP screening. So it was usually retina specialist or pediatric ophthalmologist would come and stay for a month and get exposed to train. And it was also an art to, you know, get to see indirect and small babies and also to do indirect laser. So we have trained so far 108 candidates from India and abroad in the short term training program. And there was also need for surgical training to do vitrectomy in these small babies. So in 2016, they started a surgical pediatric retina fellowships, mainly for vitrectomies and advanced ROPs. And USAID grants and you all know very well, but these, you know, this writing grants was also in the process in Irwin. So we had a system where we could grow as a department and we will get support and so the Irwin tele-screening program, this grant from USAID it's called ROP SOS retinopathy of prematurity eradication, save our site. So this program was launched in August 2015 and it catered to 22 towns of South India. And, you know, I'll show a video which will give you a better understanding. So they would travel almost 150 kilometers. So I think this video will give you a picture of what we are doing. So this is the retinopathy of prematurity. This is a hospital you can see. So we created a team and they were all technicians. So we have trained them to do a red cam and we customized a small little box for the red cam to be carried in the van. So every day in the morning, the bus would leave to different parts of the state. So they had a schedule. So Monday, because there was no such facility in smaller towns for the screening of ROP. So Tuesdays was like that. And, you know, so every day there was a place where they would go and screen these children. So it was every day from Coimbatore. They would go and come back. And so it was 18 towns regularly every week. And again, the government also paid a lot of emphasis. So all the government hospitals, this is a government hospital, they started developing good neonatal intensive care units. So there was a demand for the screening. So this is how the red cam was transported. These are all our, you know, we call them the mid-level of thermic personnel. The nurses, we take them after the 12th grade and then we give them three years of training and they become mid-level of thermic personnel. That's what we call them. So for our populations, very difficult for a doctor to go and screen everything. So they do the picture and the images are taken and it will be transported by the technician to the base hospital. So the images are being captured and then at the base hospital, the consultant would review them and give the opinion. There is also a person who's going to counsel this parent regarding what is to be expected. If it is a child which needs a laser, then it would be referred to the base hospital. Or if you just have to educate that preemie, I mean, these children can develop other eye problems. So it is very important to follow up with the ophthalmologist at a later date. So this is just to show what's happening there. And there's a video. I don't know if it gets stuck. I'm so sorry. Okay, I need to go to the next slide. Yeah, that's it. Yeah, okay. Good. So this was a very successful project. So then they wrote the next project wherein they wanted to test artificial intelligence and ROP. This happened just finished in February 2022 to 23. So they were using tested smartphone based cameras. So this helped us to expand the tele-screening to another two Aravindaya hospital centers, one in Salem and the other one in Tirupati. So this way we can reach out to more children. And also this led to publications, you can recognize Paul Chan. So they did a lot of studies and then came out with these papers. And the proud moment for us was Dr. Parag, our period retina specialist, got an invitation for the ICROP classification three, which was, you know, such a nice thing that he got the recognition. He's a very dedicated person. You know, I mean, this is really a success story I wanted to share. Like, you know, yesterday I was telling somebody that next, our next project will start a pediatric neurology. Because when we started the pediatric department, that guy said that, oh, you know, you don't have to do this. But then you can see the story like and but one important thing is choose the right person. And then, you know, one who's very passionate that he can lead the team. The same thing with retinoblastoma was the next major problem which we were facing and then we thought it would be good because we were catering to two states, Tamil Nadu and Kerala. And there was no good oncologist oncology clinic except in Chennai. So the oncology clinic was started where they would, you know, take up these kids and chemotherapy we had a association with another oncology hospital so the kids would be referred there and most importantly we started the therapy because otherwise if these kids needed a plaque therapy they have to go to Mumbai, which is quite far away. And most of these kids are low socioeconomic status. So the plaque therapy was introduced initially with iron 125 seeds and now they're doing the ruthenium plaques and they say the cost has come down by almost 10 times. So this is what the oncology clinic does and then they almost see around 419 cases of new retinoblastoma have been treated. And this is very important when you have patients like this, we have a big follow up and we have a long term follow up this kid so every year we do this in a big way, because mainly for the new patients who are diagnosed, the older patients who are living now, and you're doing well in life. It's always a sharing. So that gives a lot of motivations for newly diagnosed patients. This is always a big event in the hospital that we take efforts for people to come and talk about their success stories. And so this is regarding the retina and the oncology clinic. So again we were associated with USAID. So we were just starting up the low vision clinic in the hospital. And then we there was opportunity for us to write a grant. So one of our consultants wrote a grant to rehabilitation of these low vision in our district. So this project was mainly to identify children, less than 14 years with low vision, and then to refer them to the base hospital give them the proper devices so that they can see better because a lot of times the children do not have chance. They either they are into Braille or they are just, you know, doing nothing they just, and we don't have enough rehab schools. So, so we did this, and that's mainly to bring them at an earlier stage and then to direct them to proper rehabilitation services. So in this project we trained a lot of teachers and, you know, technicians, field workers, and, you know, so this had helped for people to be aware, and we did a lot of screening in low vision children so this is the numbers, just to show you that the total children screen on 784,000, and the children low vision identified was 1000 to 159, and the treated children were almost 555, and we not only did that we also gave them glasses if there's underlying reference hi my opus label blame blind. And it was in he was in the blind school so those kids were treated. And very interestingly there were almost 42 catrat patients. Bilateral catrax not knowing that there is simple surgery can give them back vision. They were labeled as blind and kept in the blind school. So these were identified and operated. And this is the publication which came after that. And again, like you're asking about pediatric catrat. So we all knew that the awareness was not much, even with the pediatricians every whenever you say that your child is cataract oh I thought cataract come only adults not in children. So we did this recently from 21 to 23 again with the US side we wrote a grant, and our main focus was to eliminate child is blind as a pilot blindness due to cataract in South India and we were focusing on screening evaluation management and training and rehabilitation to treat children. So we focused on training pediatricians and ICU staff, ophthalmologist residents in ophthalmology and in pediatrics health care workers optometrist and school teachers. So that's mainly to identify at the early stage and refer these children at a proper time so give them a better life. Our project intended to screen around 650,000 children, and we had trained around 1380 healthcare providers and plan to perform around 4000 surgeries and give 4000 glasses and reach around 10,000 referrals. So during the process we came out with these, you know, we developed a curriculum for the training of pediatric catrat. So the focus was on some of our trainees are fellows who finished and gone. Now we started more advanced techniques are there to do pediatrics so they came back for two weeks training program and then came out with these awareness posters. So, and very interestingly, this one was my baby project, the eye health card. So, you know, like, we always have this trouble to, you know, make the parents understand that you need to come back to us or they're not even aware of the visual milestones. So the vaccination schedule is one thing which is, you know, I think it has taken off very well all the parents are aware when their child has to go to the vaccination that is now part of country. So they the pediatrician once you go there they give you this vaccination schedule and the growth chart. So they, you know, that kind of thought that it'll be very nice to bring out this kind of health card which has the visual milestones and the you know what the child should be expected of to see at that age. So, and then, you know, this is, so now every any new patient who comes to the clinic gets this. It has a follow update and if the parents are myopic then we mentioned that all the families revive problem, then we mentioned that so that has definitely helped us. So this was the impact of the project I'm not going to the details of this. And we also, through the project we're able to operate these kids with cat track with the normally in a very young children we do a three piece acrylic lens in in. Yeah, usually, that's what I prefer and very young children less than five six years because later on when they grow. If there is a myopic shift and then if you want to and I will exchange a three pieces always a lot more easier to exchange it. So with this, you know, what did we gain during this process we thought just, you know, sharing knowledge is just not only, you know, helps others but also your individual capability gets better. And this investments in training and mentoring it's a ripple outwards, it reaches more people. And the next interesting thing is the setting up institutions outside your comfort zone, like I was saying that you know I'm also partly into administration. So I will reflect here my experiences I had opportunity to work with two hospitals which I was involved right from the recruitment process, even some of them from the infrastructure in the construction. So the first hospital in 2007 was this in Gujarat. So I am down here in South Enquirement to this hospital is in Gujarat. And the culture is very different. This is called a managed care hospital. So I haven't did this for some time, they manage the care hospitals where where somebody philanthropist or somebody who believes in the urban system and wants to replicate this system in a hometown of somewhere else. And if our philosophies agree together, and then we would go and support them and help them with this. So this was a family trust. He was a big pharmacy company in Mumbai and he wanted to do it in his hometown. So this was I'm really in Gujarat. So you can see me. And that's the inauguration so this was started in the year 2000. So I was involved right from the construction the infrastructure how to set up the OR, and then the recruitment. So I was there with one of their support staff, and one of our HR person so we did the recruitment of the nurses there. And the training was done here at Irwin. So they would come to Irwin stay with us for eight to 10 months and then we select you know, like what is our selection criteria. We take girls from the 12th grade when they complete. And then we have a segregation we take a bunch of girls for counseling for a fraction with max and physics background, and then we take girls for outpatient department. So that's how and then girls with computer knowledge will go for medical records. So all, you know, almost our 80% of our nursing staff or trained by us. So this training was done. And today I'm really, this is the statistics you can see what is unique here is, once we train the staff in the initial period, if there are 20 of their staff, at least seven of our staff are there. So every department will have one person from Irwin. If it's operation theater or it's outpatient or it's medical records. So they are there for two years, because we do not want to fail the system. Because sometimes you train them and then put them there. So it doesn't happen, you know, so we want to make sure that the system is once it becomes habit, then they don't forget. So that's what we do uniquely. So they are there and we also have an administrative staff and we have one doctor who's trained by us who knows the system well and believes in the culture. So he is there. So this is I'm really, and the next opportunity came in 2018. So now I'm really expanding they're coming out with an additional, you know, building which is very nice and I still have a good relationship with them. I used to go once in three, four years before I used to operate. Now at least I go once in a year for their annual, you know, get together. So this opportunity came in 2018. This is in Nigeria and Abuja. Abuja, this Tulsi Chandra Foundation is a foundation there into a lot of business they've been working in, they're basically Indians, but they're working in Nigeria for 150 years, almost three generations I think. So they wanted to give back something to the community. So, and they believed in the Arabian Philanthropy. So, so when this option came up and you know they said would you like to, it was a challenge. And again, when you take a project like this, it's a challenge but sometimes, you know, your department grows our hospital staff also grow. You know, then only then it tests your capacities. You know, when you bring people from the other, you know, other part of the world, the culture is very different. And we're always worried, you know, nothing wrong should go. I'm always worried whether they will go out alone so many things comes in but then it really helps to build your, you know, your man for your human resources. So the initial challenges we had first we had to go there and understand what is their rules and regulations because they are training system is very different. I think what you're working in Tanzania you would know that they have the ophthalmic nurses, the program is for almost five and a half years. They are very well and very good at knowledge, but then the skill is not very good. So and then there's another thing which is called the choose they call the community health extension workers. So we had to first identify what is our need, and then how many people are we going to take, and then they also have a good optometrist training program, but the skill is not as good as you would want it to be. So then we had to go in for the recruitment process. And I was there for three days and then interviewed candidates. People always ask how is that you were, you know, I just went with the open mind, even today, and they call you mama. I don't know. In Nigeria, they call ammas a very South Indian word, which is like they say ma ma and you know, some of I got very connected. You know, and so it was, it was nice and then we did to doctors with them and Dora, and then the paramedicals were there and then instrument technicians always in the trade. Another nice thing was, there's one doctor moment real one, he was from Abuja, who was at the time getting trained in urban with us and pediatric ophthalmology. So he gave me, you know, a lot of insights of what to expect and you know, what is the system and all that. So the training was done here at different levels, and then we put a lot of energy for team building. And then, you know, a lot of effort and we also had a major and we set up a separate hostel for them everything has to be taken care of. And so this happened for almost eight months and then this is what they're doing now. And again, the same thing we sent our staff there for two years during COVID period they got stuck we were very worried because parents here, but it all went out well. So this is the, you know, statistics and and I think yesterday or day before they made a record outpatient visit. So they're also planning to expand and so we have one of our doctors that one doctor Deepak is there, and one administrator trained by us is there. So this is the story of my experience in Abuja in Nigeria. Again, success is not only defined by transferring skills, but then it is very important, you know, to understand the local culture, and then go with it. And we all know that the heart and soul of institution or its people. And then next is the air, you know, I just have few more slides I'll be done. Embracing technology so we all know that, you know, the scope of services get expanded then you see, you know, diverse range of eye conditions, and complex surgical interventions and then this came up. We all know that myopia is becoming a burden now. Certain parts of the world like in China, Taiwan and Singapore, we know that almost 80% of the population is myopic. In India, when I started my career in the early 90s, it was 4% in rural and 7% in urban, that was the prevalence of myopia. But today, it is almost 21.5% and the projection according to this paper and we see it really will be almost 50% of the population will be myopic in 2050 in India that's mainly because of the gadgets. You know, all the schools have you know, iPads and all these mobiles have a big influence and your work. So this myopia clinic and we all know that they've come out this peripheral defocus lenses which are in the market. We do use load those are tripping but we are very conservative. But this has helped up helped us to you know screen this patient center be very good data off, because they do not have Indian data of how it is progressing. So this setting up this clinic and with data probably we can come out with good results in future. The next problem is the the cortical visual impairment again low premature infants and you know early birth and all that has get to increase prevalence of CVI and we had to do something for those children. So we during the low vision project with us site with and again. Dr Miller's influence Dr Linda Lawrence. She's a bombing. If I'm right. So she had a very active role to play during the low vision project. She helped us set up the clinic in in Madurai and one of our consultants of Sandra as a passion for low vision. So she developed this model of hybrid care model during the covert time. They did the rehabilitation of CVI know she would connect the patients as well. So they were presented to Linda Lawrence, and you can see this every week they have this going on, they present the case, and she would give her expertise. So this definitely you know it's so much help to the patient reduces the economic burden, and you know it's so helpful for the patients. Again, this is a, you know the we've started because it was a demand, we found a therapist who comes to the hospital twice a week. So we collect these children they come there, and then it's a big help for us because she's there because at least we can do something for these children. Again, it's very important to, you know, embrace these technology in the changing world because it will help us to bridge gaps, improve access, and also, you know you can give a redefined patient care. So understanding community is very important as a pediatric ophthalmologist because in India still the awareness is not that people go to a pediatric ophthalmologist. They would go to pediatrician so we need to work closely with community with NGOs with the government with the pediatricians so this association is very important. And the school training program is very active in India. We have the district blindness control society which has a, you know active role with the education system. If you do this every year the government would allot like you know schools 10, 15 schools to you. So you would go and screen these children, and then you know get them back for referral and some of them get free glasses as well. So that's very important. I'm not going to the detail of this. And so the understanding is what I felt through this part of the journey was, you know, do continuously adapt for changes, and then, and always look for the needs of community, and give them timely and relevant solutions. Nothing is complete with the good research and publications. We have quite a number of research and publications, but I would truly say that because our volume of patients are focused. I think now our focus in the coming years will be because of the volume of data we have never put a lot of effort I think we can come out with, you know, that's my next focus so we can come out with good research and publications to tell the world what we are doing. And my journey so far started as a single ophthalmologist, we have like eight consultants and we train three pediatric ophthalmologist fellowship every year. And now the city of Coimbatore has at least five centers who all my alumni who have gone to other hospitals and started pediatric ophthalmology department, and they also have two of them have started a fellowship program as well. So, that's my journey and legacy continues. So these are all my junior colleagues that's Rapa Sandra, Amrita and Sashi Kala. They also have been trained here. So this exposure definitely, you know, gives them of this, this was, I think they haven't been coming for almost seven, eight years now. So this was Dr. David Hunter and Dr. Miller as you recognize. I definitely would like to, you know, give this lecture as a tribute to the Miller, because she was such a, you know, person that her mentorship gave a very profound impact that, you know, on our institutions growth especially I think I also did with Alex me. So she like believed in Dr Miller and Dr Miller at every I think she came almost 30 times to India. So it was not only Dr. Vijay Lakshmi, I knew her personally and she was the one who linked us with Paul Chan, rekindle the relationship with the UIC signed an MU with them. And then she took us to Nigeria, she took us to Cape Town to share the story. So, you know, I think she's one person that that that she constantly provided guidance, expertise and, and you know, she steered the institution in the right way so what we are today is mainly because of the, you know, her mentorship. And this was the 25th anniversary we celebrated Dr Miller she was there. We were all in mother a celebrating the 25th year of the department then so. And not only once even after they finish and go, they would have a contact with Miller. So she was such a person. So what I am here today is mainly because of my mentors, our founder Dr V was constantly pushing you to go to greater highs and make it. Make the impossible possible. That's what he always said. And so that helped us to shape at least a little bit of excellence and pediatric ophthalmology. And so it's a journey of compassion growth and partly success still a long way to go. So to conclude, I think I would just reflect on this journey becomes very obvious and obvious that dedication, advancing knowledge, willing to face challenges to choose the right team and always grab opportunities and take a collaborative effect with a compassionate spirit that will definitely pay away for the future generation, and also you to grow. And this is the, the vision for the pediatric clinic. So we say that children have the right to site. So we strive it to give it with all our might preventing me less blindness is what we do with care and kindness. Thank you very much and finally I also have to thank my family you've been constantly with my, you know, with me my husband is an ophthalmologist retina specialist at two boys and I'm also a grandmother. I do grandkids my eldest son is an ophthalmologist and my daughter in law is also an ophthalmologist who's doing a retina fellowship my younger son didn't want to do ophthalmology is a mechanical engineer. So that's the story. Thank you very much for the opportunity. I kept trying. It's only 40 minutes. Dr compound that was wonderful. You've done remarkable things. And I echo your thoughts about Merrill Miller I think everybody that worked with her. I mean we were co conspirators trying to obtain funding for various programs. And we all miss her. Do you have advice for any of our residents that want to do international work to go out and do good things to get them started on their journey. I think sometimes we think that you know, it's a win win for both of us like, you know, it's just not that when we go to Nigeria we learn something from them. So I think it'll be definitely because I was exposed to global ophthalmology just because of my mentors. It is definitely like you can see how you know when I came here as a resident for I mean as a learner as an observer. I think a lot of, you know, things from here. So traveling and this global ophthalmology definitely will give you a different perspective and will be beneficial for anybody's career. I think it should be a part of the curriculum I would say. Thank you, sir. Thank you very much. Yeah. It is very amazing to see what can evolve. I mean Dr V had a vision, very humble man. And he had a desire to see that things could dramatically change in regards to providing care and and look what's evolved and happened from that so truly a a stated individual and the effort that has been provided from that very early humble start is an inspiration to all the world. Thank you, sir. Actually, I've been because I was with him from, you know, very young years. Sometimes we never believed when he would talk about this teleconsultation 20 years before. He said how is it going to be possible and then he talked about doing intraocular lenses when we were still doing cryo extraction. I mean, like we are nowhere near anywhere. And then he said, no, we're going to get and he was very persistent. He was very persistent and then he was a visionary, he was a visionary. And once he visionizes some things, he'll make sure it happens. Very persistent, very strong person. And a lot of people ask that how was that he's able to give it to so many of you like, you know, I'm third generation and I run. So I think he would pay attention to all of everybody in the organization. So I think that's how sometimes you may not like it initially he will on a Sunday call you for a management meeting Sunday morning breakfast meeting. It was a little, but then now we enjoy the benefits of that. Now we appreciate as you get older. So whatever we are today is only because of the, you know, his guidance and his vision. Yeah, thank you Dr help and I was a great talk it was amazing to see how, how many different programs you've established and across South India and even North India. I would love to work with you if you talked about last night about the pediatric neuro ophthalmology and setting up, maybe some sort of collaboration. I, when I was at Arvind Madurai there was a regular meeting between the neuro ophthalmology division and another university in Chicago, Chicago, yes, Peter McIntosh. That's right. Yeah, so we could easily set up something like that we could meet regularly and discuss. We will include you that really nice I will go and talk to my pediatric and also I said Dr Amrita is going to be pediatric neuro ophthalmology department. She's already doing for the past two years, but we haven't separately labeled but we're going to do we will definitely keep in touch we'll be very happy to work with you. That'd be great. Thanks. On behalf of the Marani Center thank you we. This is a story we're telling a little bit, a little bit of Alan's legacy. So I first arrived in Tanzania, circa 2012. There were two hospitals we were working in one ophthalmologist at one of them, Dr Frank Sandy. The three consecutive years this young Tanzanian would show up every day I didn't even know he was initially was a medical student. Eventually Alan ended up coming actually Alan came the same year that Vivek Venicana didn't came from the Irvind Eye hospital to to console. At any rate, Alan being as magnetic as he was had, it was just surrounded by the trainees and the doctors and this young doctor. Amen wanted to do ophthalmology residencies. However, ophthalmology residencies quite expensive. And it's something that you have to pay out of pocket for he really had no means pathway of doing that so Alan being Alan of course when he got wind of this decided Alan would sponsor him so for the first two years of his residency Alan just personally sponsored him in his residency. Eventually, and then sadly Alan passed. We were able to continue funding him through the end of his residency and amen is the new pediatric ophthalmology trainee that just landed in your hospital and we're so honored to make that connection. I know that you met Alan meant a lot to you and moderate. So on behalf of Moran here is a bolo tie that Alan wears for you to take back and thank you very much. Thank you.