 We're going to go ahead and get started with our great rounds this morning and our speakers don't really need an introduction but I was assigned to be the moderator so we'll be hearing from Dr. Mifflin and Dr. Duffin about humanitarian trip they did in Bolivia. Thanks Leah and we're also going to hear from Caballeros from Bolivia who's a third year resident there so we are delighted to have her here most of you have met her I think rotating on retina and we met her I don't know if Dr. Duffin met her a few years ago but I met her for the first time on our trip it's really a pleasure to have you here Claudia stand up so everybody can see she's going to give us a little you know a little talk as well so I wanted to talk a little bit about the it's just it's just kind of a taste of this this is not comprehensive at all but some of the challenges of kind of international corneal transplantation the i-banking aspects and this is really not going to give you any real solutions for that but maybe raise some questions and maybe get some people interested and excited and hopefully some residents and fellows can be you know kind of interested in this because I think there's a real opportunity to do good in the world in the area of i-banking and corneal transplantation so we we took a trip to uh Olivia in August which one advances randy there we go I just wasn't hitting it hard enough so my disclaimer is there may be true experts in the room like Craig uh Mike Duffin maybe others but I am not one of them in terms of you know humanitarian projects and things that I don't claim to be an expert but I do have some expertise in i-banking really the heroes of corneal transplantation and donation are the donors their families but also i-bankers you know the people like Michael Ye and all his staff and you know many many people around here who make this kind of stuff happen and there's a lot of selfless service and hard work that goes into um this gift this is just a picture of the I don't know if you guys haven't been down to the main library there's a really nice donor memorial it's called the donor wall and it has names of donors etched in this beautiful glass memorial and there's a park there and if you haven't been there I would encourage you to go visit it it's really it's really touching and so i-banking requires a lot of logistics organization regulation certainly a lot of technical aspects there are a lot of economic and social issues that go into kind of being successful in i-banking and then there's the humanitarian aspect of providing the gift of tissue for those in need and in our country it's a well worked out process the FDA and the i-bank association of america regulate the process there's a lot of self regulation basically the profession of i-banking if you will regulates itself and it works very well and the standard set by our association are kind of that we we set up criteria to make it safe basically and those would include things about determining suitable donors the techniques and the actual very very detailed procedures that have to be followed to get a consistent product if you will and that would include things like storage and distribution as well and some of the really important criteria and i can just kind of think about international donation as you're you know thinking about developing countries and in this country we have things like driver's license registries which have been incredibly successful in promoting donation most of you are probably donors and you were asked when you went down to the DMV if you wanted to be a donor and you click yes or you know check it on the form and then it's something that can actually be tracked if someone passes away the first thing they do is check the driver's license registry and you know the family will be informed that hey your loved one wanted to be a donor and you know the process is rolling but you can imagine how that may not be so easy in a developing country where you might not even really know the person's name address anything like that so just kind of think of the international part of donation as we go through this once the person is kind of enters the donation process a very detailed history needs to be taken usually from the next of kin but could be from a physician or somebody like that who knows the medical history to to rule out communicable disease a physical assessment is done there's blood work done basically to test for communicable diseases and then the tissue needs to be evaluated to determine its suitability usually just with a slip lap exam and specular microscopy to look at the end of feeling and really the contraindications to transplant based on this history medical and social history and also the tissue evaluation are to prevent communicable disease that would really be the number one thing and that would include infections certain really scary things like rabies which is you know pretty much fatal if you get that neurodegenerative disorders like crutsfeld yacob disease man cow disease which are also really scary Alzheimer's which is and kind of an unknown risk in donation actually certain cancers adenocarcinoma retinoblastoma have been transmitted via i donation those are very rare and surprisingly infectious diseases like AIDS and hepatitis are really rarely transmitted if ever the structural things that would determine success with you know in our country it certainly would be previous lasik or prk surgery would be something that would have to be taken into account scarring many times there could be other criteria like lower cell counts or possible care to conus which would affect success and then in our the FDA requires us to test for these diseases although pretty much everyone agrees that syphilis cannot be transmitted with corneal transplantation but the FDA requires it so so we do it so again kind of surprisingly maybe hiv there's no documented transmission although certainly could have occurred hepatitis b has been transmitted hepatitis c no proven transmission but there are suspected cases prion disease has been transmitted there are certainly some cases of mad cow disease that are suspected i didn't put those in there and it's kind of dealing with u.s statistics but internationally there are some other things and then malignancies as i mentioned one thing that's important and you know we're learning a lot of things about corneal donation and in particular there's always been a bias in this country to use younger tissue one would think that a younger cornea is going to probably have a longer survival better outcome but that really has not been borne out in a well-designed study called corneal donor study that really the donor age at least kind of making a cut off at age 65 and looking at donors less than 65 kind of 40 through 65ish via or versus older up to about 75 really didn't make a difference in outcomes and then a current study and i've been lucky enough to be involved in both of these is looking at the length of storage of corneas which again there's always been a bias in our you know cornea surgeons and certainly in the u.s a shorter storage times would be associated with better outcomes but this is actually being studied prospective prospectively and desec patients in this cornea preservation time study and the initial results are really with with one year into the study is really showing no difference but obviously we need to finish the study we're masked but we can tell that so far the outcomes are the same so this is actually really aided international donation because if u.s surgeons don't use the tissue then it's available for international use and many international surgeons have really appreciated getting a cornea that's eight or nine days old and know that usually the outcomes are good so in the developing world corneal blindness is a huge problem and often for different reasons reasons and we have here certainly trachoma would be a leading cause of corneal blindness other infections trauma xerophthalmia vitamin a deficiency that type of thing so there's a great need for corneal transplant tissue in in the developing world and so the supply and demand is not not a matched it's not matched in terms of you know the supply is very limited in developing countries because eye banking is not well established in most places we do have surplus tissue in the united states and so a lot of tissue is actually exported for transplantation some just some of the you know some of the challenges as you could think about as i went through all of those things would be first of all just getting people to be willing to donate and there will be cultural perhaps there really aren't a lot of religious barriers to donation but there are a lot of there are a lot of lack of knowledge you know ignorance isn't really the right word but people just don't really understand the process and then there's certainly cultural barriers and then just the logistics of it is probably the biggest barrier trying to you know kind of go through that process to make sure that the tissue is as safe but it's something that we need to we need to do we need to try to improve this in the world and so the bolivia trip was basically one of the things that we want to do is kind of work on helping with eye banking in bolivia because right now they do not have an eye bank so in our country we have a lot of willing donors and we have a surplus of tissue and so 22,000 corneas were were exported for use in other other countries mostly developing countries and i looked into our own eye bank statistics and found out that this year 2013 we have had you know roughly 760 corneas that were transplanted surprisingly to me 40% of our overall volume were exported i didn't think it would be that high many places are willing to reimburse us although typically the reimbursement is lower but this amount here does cover the hard costs for the eye bank in other words there's fixed costs associated with supplies blood testing things like that so it's not necessarily a lose lose proposition in terms of the finances of it for the eye bank but as you can see there's probably some subsidized subsidization with our domestic donors and our eye bank like most eye banks is a not or non-profit entity you know it's we're looking for balance books this i also thought was interesting and again thinking about that time to transplantation and the also the cell counts because again one would think well all of the bad tissue is going internationally but our minimum criteria for transplantation is 2000 so we can see that we're actually our eye bank is exporting really good tissue and the average death to surgery is you know a little less than 10 days which is thought to be very acceptable and there certainly are barriers i mean customs would be the most common one ship it we recently had a tissue we shipped to china sat in customs for six days it was too long you know the ice melted and tissue was bad so so our bolivia trip was was great we were able to uh through our eye banks and yago eye bank and vision share eye banks have about 29 donor corneas and we used 28 or 29 um uh transplants and lots of different diagnoses one of the challenges that they have in bolivia is getting good tissues so there were a lot of failed transplants that we we operated on really high incidence of keratoconus i i found somebody's dissertation where they looked at atopic disease in bolivia and 20 percent of 13 and 14 year old kids had atopic disease so there's a lot of eye rubbing there's some thought that the high altitude and you know it's amazing i mean you go there keratoconus is just rampant and it's awful lots of corneal edema patients after cataract surgery generally the bolivian population they have kind of smaller eyes so they're prone to glaucoma so we had some patients that haven't had corneal decompensation related to glaucoma problems and then trauma corneal infections things like that things that you would expect the other a couple other notable things is that we worked at the eye institute there and i think dr. duffin and maybe claudia are going to talk a little bit more about that um i was very impressed not knowing what we would be what it was going to be like the surgeons and certainly the residents and the staff that we were working with were very well trained very competent and technically there was not an issue in my opinion really in terms of the challenges of corneal transplantation um but the tissue is definitely a challenge for them i mean they were just amazed we had you know kind of leftover corneas from the u.s and wow it's a great tissue you know 2000 cell count good stuff 10 days only 10 days old you know wonderful um the other thing is i think some of the you know different transplant techniques would also be very helpful in some of these countries for example doing anterior lamellar caritoplasty where the quality of the tissue doesn't seem to be quite as good and we were able to do some some early cases in bolivia that you know may allow them to use have a little broader use of the tissue that's available and then i maybe dr. duffin i'll talk a little bit about some groundwork that was laid for future eye banking and then of course our educational exchange that we hope to continue with the institute there and i'll pause and claudia and um if you're interested in you know helping or getting involved and certainly residents and fellows you know i think there's a lot of things that can be done um to help international eye banking efforts and um really could be something that could you could actually literally participate in our eye bank is very excited about this you can contact me or wade um i want to thank wade he's not here but i want to thank him for helping me get some of the statistics for this and that's it happy to briefly answer any questions if you have any dr. olson