 It's eight o'clock. We'll go ahead and get started. So I'm Becca Gensher. I'm one of the second year residents here, first year in ophthalmology. And I'm pleased to introduce three great speakers today. We have Jeff Petty and Eric Hansen, who will be talking to us about some of their global experiences. And they're gonna kind of tag team their talks and we'll have a little Q and A afterwards. And then following them, we will have a neurology presentation from Ladan Hadarian. She's one of the fourth year neurology residents who will be talking to us about a case of interesting frozen eyes. Thank you. This is Christopher Masuano. Why don't you say that just so it's clear? Christopher Masuano. I think that's what I said. Yes. So this is a dear friend. He is one of just two ophthalmologists in the, really the second largest city, Mwanza, Tanzania. And again, as one of two doctors, he probably has a ratio of one ophthalmologist to, if you really take in the region, probably 3.5 million might be accurate. He is an absolutely delightful person. Someone who truthfully, if you guys take him home and have him for dinner, you will feel like you gained a cool experience with him. And one of our own has been to Mwanza, Brad Jacobson. So I tried to find him earlier. I explained the concept of a man bun to Christopher. It was very confusing. But that's the guy right there. So if you see the man bun, that's who you need to meet with and talk with later. And anyway, we'll get going. Christopher, welcome. We're excited to have you. Thank you very much. My pleasure. So first of all, welcome applicants. Again, we are incredibly excited to have you. It's going to be a really, really a great discussion that this is going around. So I'm really looking forward to what we're going to dive right in so that we can save some time for discussion. You can see from the title of my talk, both on the paper or here, it's interesting because it really is all about what is our potential role in academic ophthalmology. And then also really trying to understand within the landscape. I don't have any financial disclosures for this talk. So we're going to dive right in. What is global ophthalmology? It's probably the best definition I've seen. This is from the Academy. Global ophthalmology, the practice that addresses and advocates for eye health worldwide while focusing on the issues related to providing quality, practical, and sustainable care. I highlighted worldwide because that actually does include the United States. And so Brian Stagg, when he was here, he introduced us to many of us. This is the report from the National Academies of Sciences, Engineering, and Medicine. This is essentially an assessment of where we are in the United States currently. It is a policy advising document. It doesn't have any teeth and nothing potentially could be done. There's really nothing from this. This is just again the recommendation. So the one thing that I think is pertinent for this conversation, avoidable vision impairment occurs too frequently in the United States and is the logical result of a series of outdated assumptions, missed opportunities, and manifold shortfalls in public health policy and health care delivery. It's actually reasonably damning as you really kind of dig into it. And we know this. We know this certainly here. Not just the Navajo Nation, but other areas that have significant underserved populations for the applicants. Navajo Nation is a place that we've been working really for years. In addition to some other research projects we have ongoing with some other Native American nations. Our own Fourth Street Clinic. This was really the impetus for us beginning our operations site day, which will be December 2nd. Again, we'll be adding some additional patients. And here's the thing. I truthfully thought that after about, well, now going on six years of our operations site day with surgeries, almost 250 free surgeries in our community that we were probably getting on top of the homeless population at the very least until I went to this event. This was an event held at our large convention center. And in the screening with Dr. Bernheisel, we had this patient come through. He's a homeless gentleman. He did have a blind stick, but when he went to the homeless shelter, they, the, what he called security actually took it from him and told him, quote, you don't need a prop to get attention. And that was the last time he had his blind stick. And so currently he's about 2,200, 2,400. Okay. And he's bilateral cataracts. That's it. And he's in our community. And it's like, this shouldn't happen, right? So global ophthalmology is something that we are clearly invested in here, and we should be. You know, for those of you that have heard any global ophthalmology talk these numbers, you probably have memorized at this point, 90% of the world's blindness is in the developing world. It was about 40 million blind. That's kind of the estimates currently. Half of that is roughly half of that's going to be cataract. 80 to 90% can be cured or prevented. So those are kind of the numbers. And we've been quoting these actually for years, since certainly at least for the past 10 years, right up until this study came out. And so this is actually a really important study in Lancet Global Health. And this study talks about what is our best estimate? You know, in fact, the estimates right now of like 40 million blind, that's only an 80% confidence interval because we just don't have great data. But that's the best estimate we can come with. But then when they look at what we currently have, where we're actually able to provide care, even the successful places in the world, what does this mean? So this is important. Moderate investments that were made in the alleviation of impairment during this period, 1990 to 2010, have reaped considerable dividends. Such dividends include improvements in the quality of life with large economic benefits because people work rather than living with or caring for those living with unnecessary visual impairments. There are successes, pockets, very, very small pockets, but there are some successes. And that should encourage us. The kind of discouraging thing that just, I just, this is by 2050 by current estimates, currently what we are doing in the world as ophthalmologists throughout the world, we're losing. So their estimates were by 2020, there'll be about 40 million blind. And then by 2050, the amount blind in the world will be up to somewhere between 60 and 70 million. And then when, again, blindness we're gonna define as 2200 or worse, but then when you talk about significant visual impairment, I mean something between 2060 and 2200, those numbers are just, they're just off the charts. And so that's what's happening. That's the direction we're going. Okay, so what's being done? Well, let's talk about some of the successes. So first of all, this is the one that most of us in this room are really going to be familiar with. Applicants read Second Sons. It's a great, great read about successes. Dr. Sanduk Rui, obviously Jeff Taban and Sanduk, they've really, really helped to transform Nepal. Again, as the one developing country in the world where there are less blind the next year than there were the year before. And the only developing country like that. So that is a success. And really why? So they went for the low-lying fruit, which is cataract, and that makes sense. And frankly, that's, it's just, if we could eradicate cataract blindness, we would be that much further ahead. And there's a lot of work being done. So you may or may not have heard of something called Help Me See. Help Me See is a group that is kind of an offshoot of Orbus. This gentleman who essentially started Flight Simulation, that's his company. He's not doing too bad in the financial department you can imagine. He has devoted millions and millions and millions of dollars, pulled some of the best engineers from Flight Simulation to create a small incision cataract surgery simulator. I've used it when Michael Yeh and I were in New York. It's unbelievable. When you watch and you're putting the blade on the eye, the blade stops when you get to the eye and you actually get tactile feedback as you're working. It's an unbelievable piece of equipment. Millions of dollars being devoted to that resource. A lot of manual small incision training that's going on, a lot of wet labs. Again, the simulator, this is what it actually looks like. So there's a lot going on there. But cataract as lots of the doctors in this room would let us know is not the only issue. So what are these other non-cataract blindness? This is half of the world's blindness here. Non-cataract. And not only is this blindness not necessarily reversible, and again, this is permanent blindness. So for all of these, with a couple caveats, perhaps some corneal opacities if we ramp up transplants and things we can get on top of that. But then the other thing to notice about this list, this is very subspecialty heavy. This requires really to have in country someone who is really highly trained. So Christopher can tell you, it's hard to know exactly the exact number of practicing ophthalmologists in Tanzania currently. It's somewhere between 38 and 45, I don't know. How many of those are doing surgery is another question. But that's a country of about 45 million people. And so you take Christopher and just getting on top of the cataracts alone is potentially a lifeline, much less getting people who are highly subspecialty trained to be able to start preventing the permanent forms of blindness. Because part of those projections out towards 2050, they anticipate we're gonna do better with cataract. But if we eradicated all the cataract blindness in the world now, we still have permanent blindness that needs to be prevented. And that's public health work, that subspecialty work. Those are complex, that's actually a real challenge. So in this, again, you've seen this several times. This is where the ophthalmologists in the world are. This is where the blindness is. So I wanna come back to Dr. Ruit. So Dr. Ruit's important because Dr. Ruit started with cataract surgery in his country. But the interesting thing that's happened, and people like Paul Bernstein, Brad Katz, and others who have been there can tell you, his eye center, the Toganga Eye Center, is a place where I personally would feel comfortable having absolutely any surgical procedure on Earth with an ophthalmology done on me today. When I went as a fellow, I'd finished residency and I was an okay resident, not the best we've ever had, right? I was a bad. I did pretty good on OCEPs, right? You know, I wasn't the worst. So I was in a meeting with these residents and they were meeting with a community ophthalmologist who was asking them questions. It's kind of just potpourri, bring a case and he takes them through and asks these amazing, like really, really difficult questions. And I'm sitting in the back like, oh Lord, please don't call on me. Like, and I was done with residency, right? Like these people were in residency and they were just on it. They have created a true, true center of excellence with exquisite subspecialty training. And that is actually the only thing. I mean, again, just kind of reversing here. If you look at this problem, which is truly the problem facing global ophthalmology, it's not a cataract problem. It's a capacity, it's a number of doctors problem. That is only remedied by centers of excellence and we'll get to it. We'll get to the crux here. So I do just want to go through briefly who's doing the work right now in the world? So we're gonna start with governmental. Organizations really for ophthalmology, probably the biggest players are the individual ministries of health. Wherever you go in the world, there will be ministry of health. But again, they're stretched and the bandwidth for ophthalmology, depending on the country, is gonna be maybe 1% of what the minister of health is actually thinking about at any given time because they have a lot, infectious disease, maternal fetal health. And ophthalmology unfortunately is not at the top of the list, despite it being potentially one of the interventions that gives the most impact. Looking at NGOs, I'm gonna go into some detail about the major NGOs, the World Health Organization. This is an NGO, although it is essentially the United Nations health arm for NGOs. They do have some direct ophthalmology initiatives. The IAPB, International Agency for the Prevention of Blindness, this is an interesting one. And I actually wanna read this. So this is their kind of belief. So it was established in 1975 as a coordinating umbrella organization. They themselves, their membership is not physicians, it's not individuals, their membership is organizations. The Academy is a member of the IAPB. The Moran Eye Center can be a member of the IAPB. Basically, their belief is through this kind of plurality of approaches, they can kind of be the umbrella organization to help coordinate a lot of this. They play a really vital role. International Council of Ophthalmology. What I thought the ICO was, I thought it was like the International Academy of Ophthalmology. It is not, it does not have a physician membership. They do have some really, really important, kind of foci in the world. And really the three things that they will tell you, these are the things they really do well. One are the ICO exams. So as residents, we take OCAP examinations, then we take a board examination. So if you're anywhere in the world, Trinidad, Tanzania, otherwise, you're in a residency training program, these are the metrics. This is how you can go through and prove some sort of competency through these examinations. A government won't have its own examinations. What's happening is the ministries of health are now saying we're going to adopt these ICO exams as our kind of vetting of someone's medical knowledge. So they're playing an incredible, incredible vital role. So ICO does exams. They also provide residency curriculum. This is interesting. This is the actual ICO residency curriculum document. It is not a textbook. It is a 219 page document with a majority of the pages looking like the one on the right. Clinical refraction and then going through line by line detail by detail, what are the expectations for learning? They do not have a physician group that does the work for them. They are there to provide the examinations and then to provide the recommended structure. And that's why Moran Kaur and the work that Lloyd Williams and Kathleen DeGree is doing is so important because they don't have a textbook. They don't have significant amount of materials and they don't have people to teach. They have some, the final thing they do that I really, really love is they do really extensively, a very systematic teaching the teachers. So if you're a program director somewhere, you're an educator somewhere in the world, they really, really focus in on leadership development. So I'm gonna just blast through a bunch of NGOs. Volunteer eye surgeons international. Primarily cataract work in several countries around the world. International Eye Foundation, Unite for Sight, C International. This is a group that basically, if you wanted to go do surgery somewhere in the world, they can help facilitate it. If you wanted to go do surgery in the world, they can plug you into their system, they can provide materials. SEVA Foundation, Sight Savers, Himalayan Cataract Project, Helen Keller International, Fred Hollows Foundation, Charity Vision, all of those NGOs, 100% of them play an important role. A lot of them are facilitators connecting physicians with people in the world, a lot of them will connect physician teachers with people in the world. None of those NGOs do the actual work that can be done in an academic medical center. I mean, you think about what we do, like what's our, what are the three missions, right? What are the three things that we do? Research, patient care, and education. And truthfully, the only way we get on top of this problem is through places like the Marin Eye Center. And we're about 10 to 20 years ahead of the rest of academic medicine in this. I think our most important role we will have over the next 10 years is helping the rest of academic ophthalmology in the United States understand truly how to do this work to help build capacity. Jeff, can I just add that at this Academy of University, I had multiple other places come and say, this is one of the first I've had so many, what can we do to help participate and take part? Just as what you said, and I said, there's plenty of room for everything. Yeah, typically what happens, maybe a department gets a donation from someone, $500,000 to do international outreach. And this isn't a bad thing, but typically what happens is the kind of path of least resistance is going to be, oh, Dr. X and Dr. Y, they've been working in Peru with this NGO and they've been working in Mongolia with this NGO. Let's support them. And so those NGOs kind of get an infusion of energy impact and that's not a bad thing, but it completely misses the opportunity to really, really focus in on what we do uniquely as academic institutions and how if we identify academic partners in the world. Here's final example and we'll finish up in the area. This is Dr. Frank Sandy, he's been here, he's at the University of Dodoma, he is essentially the same thing as Christopher, Christopher is at a university in Monza. He's in charge of teaching, so he does all the medical student teaching for ophthalmology in this medical school. After we gave these series of lectures, we asked the students, how many of you are going into ophthalmology? And Christopher, you can tell me if this is true. They tell me that in Africa, they will tell you what they think you want to hear, not necessarily what's true, is that true? Okay. But again, it's his teaching, it's not only teaching the physicians, it's building capacity among the nurses. As far as professional organizations, I'll end here. I will give anyone in this room $100. I don't have it on me, I'll go to the ATM, but Dr. Olson might have it that I can borrow. If you can tell me what is the professional organization in the world that is focused, this is a physician professional organization that is focused on this problem of global ophthalmology. Because it's kind of a subspecialty, right? There are best practices. There are groups out there doing work that are causing a lot of collateral damage and harm in areas in the world. There are clear best practices. There is no physician group in the entire world currently that's devoted on trying to help other physicians understand how to do this work. And that's kind of the second thing that I think is gonna really be profoundly changing over the next 10 years.