 B. Dollywall is currently the director of many things at the University of Pittsburgh Medical Center, including cornea and refractive surgery, cornea and external disease, medical director of their laser center, and the Center for Integrated Eye Care. She also has some training in acupuncture. I understand she gave a great talk last night, and she was a medical student at Northwestern, was a resident at the University of Pittsburgh, came here and did a fellowship at Moran in cornea, external disease, anterior segment surgery, and was selected as our alumnus of the year. That's why she has been invited here to speak to us, and we are thrilled to have her here to talk to us today. We did have a little bit of a speed bump with the computer, but it's here to be cooperative now, so I'm going to turn things over to Dr. Dollywall. Thank you. There you go. Thank you so very much for that introduction. You'll recognize a few of these cast of characters as I go along the way here. I was here 21 years ago. Mark, Mark Mifflin, and I were co-fellows. I know he looks a lot younger than I do, but we are the same. So anyway, I'm coming from Pittsburgh, and I have to say, I really feel like I'm coming home to Utah. You guys are just a family, and it's been just a wonderful road. Instead of doing a talk on the latest in corneal transplantation, I decided to do something a little bit more fun, I think. I hope you'll tell me that is more about kind of the lessons I learned. And when I think about my life, I realize that a lot of the stuff that I still do now, it's because I learned that in fellowship. It's kind of scary, but really true. So my title is All I Really Needed to Know I Learned in Fellowship, and I'm going to go through several lessons to kind of highlight that. So these are my disclosures. And really, it all started with a visionary. Too bad Randy's not here. I saw him last night, and he had to be in Chicago because he's such a visionary. And so he had the foresight. Now think back 21 years ago. Refractive surgery was just kind of really the cowboy operation, right? I mean, very few fellowships offered refractive surgery training. You were kind of lucky if you got to run after a refractive surgeon on a certain half days, but there weren't really a lot of fellowships that said, you know what, you will learn a systematic kind of approach to it. And then Randy Olson developed this amazing fellowship where he kind of married cornea and refractive surgery. So what it was is you did refractive surgery for six months with Charles Casebeer. And this was the Casebeer Center for Character Refractive Education and Research that's in Scottsdale, Arizona. And then you would come back and spend six months with the home team. And in those days, it was Randy, Claren Aldridge, and Tom Clinch. So really incredible lessons learned. My fellowship was a life changing experience. And really it formed this broad and stable foundation upon which I built my career. So a bunch of lessons. First lesson number one, it's okay to take a risk. And when Randy started this fellowship, it was outside the match. It was brand new, and I didn't know, was it good, was it bad? So I asked everybody I knew what I should do. So all the faculty, University of Pittsburgh, when I said, should I do this fellowship in Utah? They said, no way, are you crazy? You're gonna sell your soul to the devil deep. I said, okay, I guess I shouldn't do it. And I asked Peter Leipzig when I went to interview there. He said, no, you need to come to Wills. I said, okay. And then I asked my friends, actually these friends that were a little bit more forward thinking in Pittsburgh. And he said, absolutely, what's wrong with that fellowship? That sounds amazing. So I said, all right, I followed my heart because I really wanted to come here. I just needed one person to say it was okay. And so I found that one person and I called Randy and I said, okay, I'm ready. So I took a risk and it really ended up being one of the best decisions of my life. So it's okay to take a risk, follow your heart. The other thing is life is really full of opportunities. And if you always stay guarded and kind of in the middle of the road, yet your life may not reach its full potential. And so you sometimes have to reach outside that comfort zone to experience life to the fullest. And really, no risk, no reward. And of course, they should be calculated risks. All right, lesson number two, if you are at the cutting edge, you can get cut. So Mark and I had the opportunity to spend a lot of time with Charles Casebeer. And he was a true pioneer. I mean, they would have model one of a micro keratome and Charles would be trying it. So you would do these new procedures like automated lamellar keratoplasty. ALK and we would, you know, some things worked well, some things did not. So hacks, which was hexagonal keratotomy, not so good. In hyperopic ALK, what we did is we cut 70% into the cornea to create a controlled ectasia to create a myopic shift. So it's kind of scary. Dr. Patel's shaking his head, you know, the retrospectoscope is always very clear. But at the time, when you're doing these things, you're not sure. But some of those principles of corneal and lamellar surgery are still useful today. So the basic things about incisions, really important, like astigmatic keratotomy, what we do, or LRIs, you're basically segmentally flattening a given meridian to neutralize astigmatism. You all know that the longer incisions have more effect, closer to the optical zone, you're going to have more effect. And because of coupling, the spherical equivalent does not change. So I learned that back then and it's still true now. Another super important concept that we learned by doing ALK is that there is something called the stromal structural threshold. And to prevent ectasia, you have to leave enough untouched cornea behind. And how much is that cornea? Well, the rules that we used were either 50% of the corneal thickness or at least 250 to 300 microns, whichever is greater, should be untouched. And the Lasik flap does not provide any tectonic support. So this type of equation is really important where you take the corneal thickness and you subtract the flap thickness with the ablation depth, and that should always be greater than 50% of your cornea or 250 microns. And again, in a hyper-opic ALK, so for those of you who don't know, when Mark and I did our fellowship, there was no FDA-approved eczema laser. So we basically did this procedure where we made a flap just like in Lasik, but we had no laser that was FDA-approved. We had an investigational one that was in Scottsdale, but we couldn't use it. So then to decrease the, or to change the curvature here, we would just take the same microkeratome and just slice off a little extra cornea there in the center. All right. So, but the thing that we have to remember is that we have to thank the pioneers. If it wasn't for them, we would not be doing Lasik now. So if we didn't do ALK, we really would not be doing Lasik. So really, we should just take a minute and thank those pioneers. I'm definitely not a pioneer. I follow those before me. So this is a picture for those of you who haven't seen. This was the automated corneal shaper. And I'll show you a picture of the inventor of this later on, Louis Ruiz, but this is the actual type of microkeratome we used. We didn't have femtosecond lasers. And then things could get caught on here, like lashes and drapes and things like that. Lesson number three, we learned how to be a pilot. It was really exciting. So Charles Casebure was a pilot. And as a fellow, we would be the co-pilot oftentimes. We'd have the headset on. We'd be sitting there. And it was wild. OK, so this is the type of plane that we flew in. It's a turbo commander. And his was 2-4, Charlie Charlie. I still remember. I remember flying into O'Hare Airport with Charles in the turbo commander. And there was a huge 747 next to us. And he was really amazing. So the key that he brought into ophthalmology, because he was a pilot, he brought this whole aviation framework into ophthalmology. So that whole concept of a pre-flight checklist, that came from Charles. And it's something that we even think about right now. So you want to make sure you have everything's in order. Everything's a system. And he would give courses. And he would say, you know, you have to say, well, if engine two doesn't sound right, you're not going to proceed. So that's a good way to talk to your patient. So if you have a laser that's malfunctioning, you just make this analogy to aviation, to flight. We often are in the airports and our flights get canceled, because engine two does not sound right. So they kind of get it. And they're less upset, because this is just high-tech stuff. The other thing that he taught is to have a system. The same ingredients come in. You do the same thing every time. And you'll get very predictable post-op results. And that is another critical thing, be methodical. Another lesson, lesson number four, is never let them see you sweat. And this was a lesson that we learned during our fellowship, especially in Scottsdale. So we had visitors from all over the world fly in to this case beer center. And they would watch all these cases through glass. So basically, there was glass. And then there you were using the micro-caratome, doing radio-caratotomy, doing all this stuff. And you couldn't act like an idiot, because they came from all over the world. And Charles was kind of showcasing you and him and all this, so you had to develop this kind of sense of confidence. And even if you didn't really know, you just had to kind of fake it till you make it. So this confidence is really a critical, critical thing in terms of successful doctor-patient interaction. So when you walk into a room, you got to own it. And when you're examining the patient and you don't know what they have, that's OK. Just answer your pager, exit the room, look it up, and go right back in there, OK? You don't have to say, oh my god, I have no idea. Don't be perplexed, right? The key is these patients know less than you. And you really need to, I mean, obviously you're not going to say something that's untrue, but you just have to have, if they're in the emergency room and you've never seen this before, they're going to be even more nervous if they see you being nervous, obviously. So call your, call a friend, phone a friend, whatever you need to do to get the answer that you need. So I think that's really important. And I get, we all see patients as third opinions, fourth opinions, and we don't give a different opinion necessarily, but when you say it with confidence, ma'am, you have XYZ syndrome, and then they believe you, and then they feel a little bit more comfortable that you know what you're talking about. All right, another lesson number five now was we learned how to teach in our fellowship. And part of our fellowship was helping to teach refractive courses all over the nation. And what we would do is we would finish clinic. Our clinic was in the Scottsdale Air Park. So we would finish clinic, we would go out the back door, we'd jump in the plane and get ready for this, and jet off to the next course. Okay, I was kind of excited. I learned how to do that on the airplane. Well, this, I'm like, how do you do these animations? So that was exciting. All right, and that's what it was like. We would just, it was crazy. We'd finish patients go, jet off, and then we'd have to teach. Now, teaching, you know, as we learned, and Charles was just incredibly entertaining. He would tell a story. He would keep it relatable. He would bring it home. He would have the confidence, and he really knew his stuff, but he would have fun while he was teaching. And his courses were really well attended. He taught over 7,000 ophthalmologists, incisional keratotomy. So it was really impressive. And so, you know, to teach, you really remember who your audience is. And years later, Jim Katz and I, who was also a fellow, he was a fellow after Mark and I, we would go to Scottsdale and do LASA courses, and Charles would be in the back of the room, and he would give us feedback on our lecturing style, and it was incredibly valuable critique. And that's another thing, is that when you're, you know, teaching, ask your mentors how you did, how you can improve, get feedback, because there's always room to improve. Now, in terms of how to teach surgery, I learned this here, especially in Utah. And I remember Alan Crandall saying, why is the eye moving, right? I mean, I don't know if he still says that, but he said that so much to me, and I distinctly remember that. But the key is you want to teach finesse, right? The finesse of surgery. It's not necessarily just all the little, you know, how to make an incision, how to, you get to the next step, and that's what Alan really taught so beautifully. Videotaping your cases is great because you can teach and learn from them. The cannula from the BSS bottle is a great tool to teach residents and fellows, and the careful vocabulary. We think our patients are sedated in their lullaland while we're operating. Some of them remember every single word you say and how you said it. So, you know, you can just, I remember the vocabulary, you know, that Alan used, notice how I carefully bring this, Rex's back from the zonules, you know, and he would just be very calm and just kind of notice, you know, notice how I do this and notice how this happens, and it was brilliant. So, that's another thing that was critically important. Another thing is that cowboy boots and bolo ties are really cool, and both Charles Casebeer and Alan sported them and still do, so this is just at our recent meeting. We were at ASCRS, and there's Alan with his bolo tie, and these are Alan's boots. We got a picture courtesy of Amy Lynn and one of the Guacomo fellows, I think, helped get these. And then, you know, you gotta pick your own style. You don't have to wear a black suit and, you know, be boring, you can just pick your own style and go with it. The other thing is we also learned as part of our fellowship how to learn. We learned, like our mentors in Utah and Scottsdale were incredible. To learn, you really need to watch carefully, initially emulate everything your mentors are doing, and be prepared. I remember learning with Randy Olson, we would review charts at the end of the day, and he would teach us pearls left and right. Claren, I remember, I felt like I was in the remedial PKP course because he made me, he came in on a weekend and he actually, we practiced tree finding on a rubber ball because he had that manual tree find that he used to use, and so I needed extra help and he came in and taught me how to do that and replay the video, obviously, with Alan. So here is a picture of one of the fellow reunions that we had with Charles, and our first fellow's reunion was on a cruise ship, and you can see Charles there in the middle, and there's a special guest there, Mark Mifflin. It's more. Sure, sure, sure. Nice, sure, Mark, nice, sure, it's okay. Definitely want to highlight that. All right, so, and, you know, we would just sit around in a small group and just, he would just teach, we would go over cases, it was fantastic. So the other thing is when you're learning, look for opportunities. Don't just wait for this, you know, this learning opportunity to fall in your lap. So when the glaucoma fellow would be out of town, I would operate with Alan Crandall. That was my chance to jump in there, and this was because of Peter Derienzo. He was, he just knew what was happening when, and he had been here six months already before I got here, and he really showed me the ropes, and I really owe him a lot, and so we, you know, basically take advantage of the opportunity. Alan didn't need me to be in the OR, for sure. He would have been much, he would have been done much faster if I didn't show up, but it was great for me to have that opportunity. And more recently, you know, when you're out in practice, you gotta keep on learning, keep on evolving. You can't keep on doing the same stuff. So we, you know, we transitioned to DMACC, and I personally didn't feel comfortable until I flew to my, you know, to watch my friends operate, and also, you know, watch videos and speak with people. You can't just read a book and learn surgery, obviously. So now we have a lot of resources. And the other thing is you really shouldn't be doing the exact same thing this year as you did last year. There's always gonna be something different, so always, always pay attention. Another thing is, you know, be nice. Be nice to everybody. Be nice to your patients, obviously, to your colleagues, to the surgical staff, to your techs. It goes a long way. You're part of a team. Don't ever think that there's you and them. That is not gonna last very long. So, you know, definitely in Utah and Scottsdale, you know, this kind of collegiality was wonderful. And I don't know if there's any nurses here that were here 21 years ago, but they were so wonderful. They would actually take my socks because they would get wet during Faco. I don't know, I never learned the draping thing very well. And my socks would be wet, and I hated that. And they would actually put them in the autoclave and dry them for me. It was so nice. I mean, they offered it. I hope there weren't instruments in there, but it wasn't like fabulous, right? And it was just about being nice. They were nice to me. I tried to be nice to them, and it was fun. And my feet were dry, so it was great. So, you know what, I really noticed is that when my mentors went into a room, they made every patient feel like they were the most important patient that day. They might only have spent two minutes in the room, but man, that patient felt like they had the best exam and best patient experience ever. And that's because the eye contact. They were awesome. They just looked people in the eye and said, whatever they needed to say, and it didn't have to be 15 minutes. It could have been two minutes, but it was really that quality time. So I highly encourage that. Now with EMR, it's so hard, because we're typing all the time, but make sure you take at least a minute and just look the patient in the eye and tell them exactly what you think. Lesson number nine. The more you do, the more you do. So surgery is definitely a system and you wanna develop muscle memory, okay? Practice a ton. The stuff that you couldn't practice in the wet lab. Practice and practice, when it was our day, we were practicing suture in the wet lab. Now nobody sutures anything anymore, but whatever you can do, Capsule Rex says, whatever you can practice, do it. It's the same movements every time. And really, the better you are surgically, you guys know this, the more cases you're going to end up doing. So make an awesome first impression wherever you are. Lesson number 10. Don't just follow the crowd, okay? This is something that, as ophthalmologists, we often just kinda, well, everybody else is doing it, so I guess I'll do that same thing. It's just kind of the wave, you just kind of ride the wave, don't do that. Think about what you're doing every step. Which faker machine you're using? Why are you using it? What tip you're using? Which implant you're gonna implant? Think about these things. Is this the best way you can do that procedure? And is this the best lens that's gonna, is this the best lens for that particular patient? So when I was a fellow, a new IOL was introduced to the market, the Acrosoft lens, can you imagine, in this wagon wheel type of configuration. And Randy, being the astute observer that he is, noticed that this lens had glistenings. And then because of that, he was concerned and we followed our patients and we actually did a study looking at the visual significance of glistenings. And Nick, mammalist, figured out what those glistenings were and we published this. And this was back in 1996. And this is one of the first clinical papers on the glistenings seen in the Acrosoft lens. So again, you have to do what you think is best. And the litmus test that I do is would I have that lens in my eye? Would I have that procedure done to my cornea? Would I have that chemical put on my conjunctiva? If the answer's yes, then you've probably, it's probably good. But if you say, oh no, I would never have that. But yet you do it to all your patients, then maybe there's a little disconnect there that you have to think about a little further because there are always options. So think about what you're doing. Another thing is think outside the box. So when I was here, 21 years ago, people were doing surgery kind of the old fashioned way with a block and this and that. And this concept of topical anesthesia came around. And I remember Dr. Patel was even involved with this topical anesthesia study. And so think about how to make things better. And it might not be your classic technique, but you can think outside the box. And so I thought outside the box and I became a licensed acupuncturist in 2006 to study alternative integrative complementary treatments for eye disease. I was actually having an acupuncture treatment in 2005 and I was thinking, this is crazy. I was from my back or something, I don't remember. But I was thinking, this is 2000 years old, right? And we're still doing it today. Maybe there's something to this. What about the effects on the eye? So again, I became an acupuncturist and we started the Center for Integrative Eye Care at the University of Pittsburgh. We completed a dry study and now we're performing a pilot study on dry macular degeneration. So here's a video. So let's get started with the treatment. The first needles are in the scalp. These needles are short. And the pattern has been all worked out by an MD. His name is Dr. Alston Lundgren. He's in Santa Fe, New Mexico. And his goal with acupuncture is to treat difficult to treat conditions. And luckily for us, he picked macular degeneration as one of those treatments. He's not an ophthalmologist. These points are near the back of the scalp to stimulate the occipital cortex. So there's six needles in the back and then we put two here in the front. These are longer needles. They're sometimes a little trickier to thread through. These are long and thin. And then we're gonna go ahead and check her ears. This is an optic nerve point. This is an eye point. And these needles are stimulated with a magnet for one minute, three times a day. These all look fine. So there's five in the front and then there's one stainless steel one in the back. And let's check your other ear. One, two, three, four, five. Those are in place. And this whitish stuff is actually liquid band-aid. So the indwelling needles stay there. The studs stay there longer. The next thing we do is get you connected and there's a specific way to connect these leads. So this is the pattern. Okay? So these points go in the four corners of the orbit and the idea is to connect with the orbital periosteum. And really there's no specific landmark just to have crisscrossing current. And you'll see when we put the electrodes, you'll see how we crisscross the current. So we are hoping to get more blood flow and just relax. And any pain when I do that? So I can, does it hurt when I get the needle through the skin there? No, okay. That's what everyone will want to know, how much this hurts. Yeah, there's 10 treatments. I punched her in the eye before we start. Okay? Mm-hmm. Okay, done. So we put this on so that we can stabilize the leads that are gonna be connected. Statue of Liberty, pose. Okay, very nice. Anything hurting right now? No. Okay. So we're gonna go ahead and start with E. All right, so we- Allegeable stimulation. Here's her results. Okay, I know you think I'm crazy, but just listen. I was excited about it because I was having a lot of visual problems. And I'm a professional person. So I've got a lot of reading to do. I teach, I'm dealing with new books. And the vision, it was a problem because I have a blind spots that I would miss syllables or words or numbers. Also, I couldn't keep the line straight. And so I ended up that I've been reading for the last couple of years just using one eye. And then I get tired reading because I have to go back and fill in the blank spots and so forth. So maybe I have to read the line two or three times. Then I'm frustrated because I've always been an avid reader and I don't wanna waste that much time. So the fact that my vision keeps improving is exciting to me. And I can also read longer lines or longer amounts of printed material. I can read the whole road sign instead of just seeing the right hand side of it. And I'm not using glasses at all to drive, to watch TV, to watch movies. And the image is just real sharp. So I'm very pleased. Life changing medicine. Okay, here we go. So it's an interesting concept, right? I mean, we don't have a good treatment right now for dry AMD. Who knows? I know researchers in Germany, I believe, are just doing this kind of trans-cortical stimulation for glaucoma, things like that. So you gotta think outside the box and we'll see what happens. All right, something more conventional and ophthalmitis prophylaxis. So does anyone still use a collagen shield in Utah? All right. Okay, I cannot stop because Randy Olson taught me how to do this and touch wood, I've been thrilled with our results. And honestly, I'm scared to stop. It's working, so I don't wanna mess it up. But obviously, end ophthalmitis prophylaxis is a critical thing that we all need to think about. And I'll just show you how we prep the eye. Look up, top of your head and then there's drops going down below. Close and look down. Good, and close, very nice. And now we're gonna get the beta-dyne. This is the key part. To turn your head toward me and look down first and we squirt and look up. Close and just gently. Okay, rock and roll, done. You're awesome, thanks. I love how he winks to the audience. Okay, and then I wait three minutes until the next part, which is instilling the lidocaine gel. Look down and look up and close. Perfect. Okay, and now he's ready for surgery. So I do this myself. I don't delegate this to anybody or our fellow does it or a resident. Somebody, when they're in the holding area, we do this. And you might think, you know, Daliwal, you're totally overreacting. Just put a couple of drops of povidone iodine. But I'm not overreacting, because in the literature, there's a paper that shows that irrigation of the fornicies with 5% povidone iodine was associated with significantly fewer positive conjunctival cultures at the time of surgery compared with the application of two drops on the conjunctiva. So you know, it's all about prophylaxis. There's no organisms on the eye around the surface. They're not gonna get in, right? So just, I think that if we just pay attention back to the basics, back to just preparing the patient. I mean, right now, I don't use any intracameral antibiotics. I still use topical antibiotics with a collagen shield. And, you know, we've been pretty happy. In addition to the pre-op, it's really important to look at your wound. And I know, you know, we definitely paid attention to this during the fellowship. So I thought my wound was awesome. You know, and then when you look with OCT, you can see that there's actually a little gap there. And then on the internal area, in the internal part of the wound, there was also a little gap. So these wounds, we think they're okay. They may not be all the time. You know, we hydrate the wound and it looks great. But we know the hydration's not gonna last forever, right? And we know patients are gonna go home and possibly rub their eye. So I spend a lot of time looking at the wound. And if I'm just not happy, I'll seal it. And, you know, we'll either put a suture in or put reshure sealant. And you can just see how when you put the sealant over the wound, it really is a nice barrier. So I think just prevention, you know, is critically important. So, you know, those are the old things that we did. How about beyond, right? 2016 and beyond. So it would be great to take compliance out of the equation. So we're actually studying the intervitrial antibiotics and story delivery, the imprimise formulation. We're looking at in a rabbit study to see if this is effective, the trimoxy and the trimoxybank. We're also about to do a study with Avenova. We've done some work already with it. This is the hypochlorous acid 0.01%. It's an antiseptic. And it turns out it's perhaps kinder and gentler to the surface of the eye. We did a time kill study in vitro to show that the time to kill 99.9% of the organisms with MRSA, MSSA and coag negative staff is one minute for Avenova and two minutes for povidone iodine. So it actually kills faster. So antiseptics are great because bacteria don't get resistant to them. So I really like antiseptics. Another thing, an exciting project we're doing in Pittsburgh is this micro particle hydrogel. It goes in as a drop and it turns to a gel. So there's a rabbit eye and so you put this in the lower phoenix and it turns into this kind of whitish gel which basically you should stay in there until you remove it. So we did a rabbit study with our endothelmitus model that we have in the Campbell lab and group one up here is Vigamox pre and post inoculation. Group two was the moxifloxacin hydrogel. Okay, just before the inoculation and these eyes all look very beautiful and there was no endothelmitus. Group three was a control which is the blank hydrogel and you can see that these eyes got infected. So who knows? We'll be able to maybe get rid of even drops. So enough about endothelmitus. Let's talk about some more important lessons like giving back. That's a huge philosophy here in Utah and it's awesome, right? So we need to use our talents to help our community, our country, the world. And you guys in Utah see that all the time and live it, so it's fantastic. Another thing is it's okay to make a mistake and admit it and show it to other people. Just try to learn from it. It's not, you shouldn't hide all your mistakes. And so I've been really fortunate to be part of this course at Ascarus and AO, that David Crandall, Allen Crandall, Jeff Petty, and Susan McDonald are part of. And it's basically the title is learning from our mistakes. A video kind of a complication management session. And so we show all our cases and it's cathartic and we learn. Another big lesson is how cool the Utah family is. So these are just some members of the Utah family. I mean, of course I knew Allen and Randy back in the day, but I learned Jeff Petty, Susan McDonald, Liliana, and it's been super fun. There's kind of this Utah bond that I think we all share and it's a wonderful, wonderful family to be part of. And there's also the Utah Scottsdale family. And we had fellows reunions. One was on the cruise ship where you saw Mark Mifflin and his shorts. And now this was another reunion we had. This was at Charles Ranch, the Sea Bar Sea Ranch in Montana. This was, and that's a picture from when we were out there. This is a cruise ship and there's Mark again. And his lovely wife. And this, we had our first fellows kind of summit there at the biosphere, it was interesting. Another important lesson is how to mentor. I think that as we move on in life, mentoring is really important and all of my fellowship mentors have opened doors for me. I've been very grateful. But then as you go on along in life, don't forget to mentor that medical student or college student or wherever you are, there's always somebody, there's always somebody below you if you make it to residency, right? So reach out and it was amazing. Charles introduced me to some of the world's pioneers in refractive surgery. And here we are, this is in the 90s still, I believe. This is Joseph Collin, he invited us to his home in France, it was very special. And this is Louis Ruiz as part of my fellowship in 1995, we flew down to Bogota, Columbia to watch Louis Ruiz using that new micro-caratome that automated micro-caratome and he was doing Lasik because he had a laser and watched him doing Lasik. It was Steve Slade, Charles Casebeer, Steve Upt, Graf, myself and Jeff Machot had never touched a micro-caratome by then. Another thing I learned is to be more adventurous and to enjoy nature as a part of my fellowship. So I learned how to roll a blade and I had lots of fun exploring nature with Judah Warner. We went on a road trip and it was great. So we had a blast, I had so much fun at my fellowship, just enjoying life and nature and everything. A critical thing is though, family first. I really believe in this and I think that this is truly exemplified in Utah and you can see here's Jeff, he brought his baby, his new baby and his wife to the academy meeting and there's my sister feeding Jeff's baby and here are my beautiful children, Dia and Covey and then here's my mom and nephews and here's my husband, Sanjeev. Family first and the thing is that when I had kids, I kind of took a break from the travel. For four years, I said no to pretty much every obligation that would take me away from my family because I wanted to be with them. I didn't want someone else to be there to, I wanted to be with my babies anyway. So I did and now that they're this age, nine and seven, I feel happy to travel again. So it's okay to take a break. I couldn't believe it. At ASCRS, I was moderating a symposium and there was a physician from Johns Hopkins who had a newborn at home. She flew in that day, gave her talk, which was 10 minutes and then caught a flight back that same day to go back to her baby. I would have just said, no. I would have just said, I will not be able to be there. She was kind of, it was very impressive, I have to say, but unnecessary, it's okay to say no. You can have a family and a career and do what you need to do, but just all in good time, don't kill yourself doing it. And these are just some of my final slides. This is really rings true. A teacher affects eternity. He can never tell where his influence stops. And we, this is an incredible quote that I love. And here's this incredible picture and what you see here is you see Randy Olson in the middle. You see that, okay, you recognize him. Then of course you all know Susan McDonald because I know she was giving this lecture last year. This is Lorenzo Cervantes and he was one of my fellows, one of my favorite fellows. Don't tell him I said that. And he though was inspired to go into ophthalmology by Susan McDonald. Isn't that incredible? So he was a medical student and Susan came and gave him a lecture. And so he went into ophthalmology and then we were both trained by Randy and then Lorenzo was trained by me. That was fascinating. So it's just a all big happy family. So thanks Utah for changing my life and my, of course, my family.