 Good morning to everybody want to welcome you to our annual global ophthalmology grand rounds. It's really a pleasure to be here today to introduce our speakers to you but I'm going to turn over our introductions for our first speaker over to Dr. Emmy Hartnett. I just want to let you know that exciting things are happening in global outreach. We're just starting to gear up back again with some of our international works we're excited about that. But there'll be a flurry of activity throughout the academic year that we're just so excited to share with you all as a year progresses and there's always room for engagement and for involvement for everybody at every single level. So this time I'd like to ask Dr. Hartnett to come up and introduce our first speaker who we've been privileged to have here for the past year. Good morning everyone. Thank you for being here. So it's a great pleasure to introduce Maria Margarita Parra who is going to speak to you today and I think many of you already know her and they have helped her with her first time seeing snow and also in skiing here in Utah. So she completed a residency in ophthalmology at the Ophthalmologic Foundation of Sandhander in Bukamuranga and then a two year medical surgical fellowship in retina and vitreous at the same institution. And in about about two years ago she contacted me to ask to do a pediatric retina observership because her country wanted her to come back and start the first pediatric retina center in Columbia. And so with the support of Dr. Olson and the now late Dr. Crandall, we created an observership for her and she's done very well. She's worked here and also at Primary Children's and she's received an Academy of Ophthalmology award. She's also attended the Academy and Arvo presenting and she's submitted three papers already with several in publication. She is recruited to join the academic program as a faculty member for the residency programs in ophthalmology and retina and vitreous fellowship at the University of Val del Calco in Cali, Columbia. And her goals for future include teaching research and clinical care. So she will tell you about one of the conditions that she's been studying retinopathy prematurity and about it in Columbia. Thank you. Thank you, Dr. Harnett for that great introduction. So good morning everyone. Thank you so much. It's a honor for me to present today at Grand Rouse this project that was developed in my country. We are going to talk about a prevalence of retinopathy of prematurity in my country, Columbia. So thanks to the co-authors who collaborated with the development of this project. The presentation or the results of this project were presented at the last Arvo meeting in 2022 in Denver, Colorado. Preventivity is a problem that is has been increasing over time and affects children around the world, especially in developing countries and in Latin America and the Caribbean. Retinopathy of prematurity is one of the leading causes of childhood blindness in Latin America and the Caribbean. And when we compare the impact of retinopathy of prematurity in high income countries with the Latin America and the Caribbean. We observe that the number of the babies that survive and have ROP can in high income countries, they can have better outcomes of visual acuity compared to Latin America and the Caribbean. So in other words, in Latin America, the probability of getting blind from retinopathy of prematurity is higher compared to high income countries. This is my country, Columbia located in South America. And as we can observe in this graph, we can observe how over the time, what is the behavior of the number of light births over time since 2007 to 2016. So as we can observe in this graph, the number of light births have been decreasing. But if we observe the blue line, what we see is that the blue line that corresponds to the percentage of ROP over time. It's actually has presented a sustained increase during the last five years, which can correspond to temperature babies for every 1000 light births. In Columbia right now, or to this date, we just have two studies that have been published about the epidemiology of this disease in the country. They have reported the prevalence of ROP at 7.7% to 18.2%. Actually, little is known about the epidemiology of retinopathy of prematurity in Columbia. And that's why we want decided to do this study in order to know more about the epidemiology of this problem in my country. So the objective of this study was to report the mean gestational age, the birth weight, and the risk factors associated to development of ROP in three different centers for three different cities from my country. Columbia is a country that has 50.88 million of inhabitants. And we already have 182 new native intensive care units around the country. Those NICUs are located in 23 of the 32 states of Columbia, and they are mostly located in the center of the country and on the west coast, as we can observe in this picture. This was a retrospective study, and we collected data from charts, from babies that were screened from 2010 and 2020 in three different cities of the country, Bucaramanga, Medellin, and Bogota. And the reason we chose those programs is because we have more confidence about the quality of the data from those programs. What were the screening criteria that we took into account for this study? Infants screened at 32 weeks or less of gestational age. Infants with 1500 grams or less of birth weight. And those infants that didn't accomplish those criteria because they were more than 1500 or more than 32 weeks of gestational age, but the neonatologist that was in charge of those babies recommended to do the screening of ROP because they presented risk factors for development of ROP. The evaluation was performed using indirect ophthalmoscopy during the four and six weeks of life. And the diagnosis and severity of the disease was based on the classification of ROP second edition. We didn't use the ICROP3D1 that was published recently because this study was performed before the publication of that one study. What were the variables we took into account for this presentation for this project? The gestational age, birth weight, sex, the presence of ROP, the stage of ROP, the different risk factors associated including supplemental oxygen, pregnancy, bronchopulmonary dysplasia, sepsis, perinatal surgeries, intraventricular hemorrhage, and finally preclamps. This is the statistics we used student T test and she squared test to, sorry, to do the analysis of the data. And also, because we wanted to evaluate the association of risk factors to with the development of ROP, we adjusted the risk factors of the patients with by gestational age by birth weight and severity of ROP. In total, we screened 1691 infants from those 43% were male and 57% were females. The mean gestational age of those screen babies was 32.44 weeks and the mean birth weight was 1,536 grams. The prevalence of retinopathy or prematurity in this study was 17.5% because we found 310 infants with ROP from the whole sample. And they presented a mean gestational age of 28.66 weeks with a mean birth weight of 1,230 grams, sorry. So in this table, we can observe the distribution of infants that presented any kind of ROP according to different groups of birth weight. So what we observe is in this second column is that the number of screened infants, the most common group of patients according to the birth weight was in this row. And the infants that presenting ROP were more likely with birth weight with low birth weight that was less than 1000 grams. In this pie chart, what we can observe is the distribution of the different stages of severity of ROP. And we found that the stage two was the most common in this study. What were the risk factors associated to the development of ROP? When we tried to analyze that and we didn't do an analysis that took into account other variables, we found four different kind of risk factors. But after doing a logistic regression analysis adjusting by birth weight and gestational age, those risk factors got reduced. And finally, adjusting by birth weight, gestational age and severity of ROP, we found that the risk factors associated to the development of ROP in this study were supplemental oxygen and bronchopulmonary dysplasia. The percentage of infants that require treatment of ROP in this study was 13.2%. And in this table, we can observe the distribution of the birth weight according to the type of treatment. So what we found is that younger babies or babies with low birth weight require more treatment than the ones that had more birth weight. And what are the key points of this talk? The percentage of retinopathy or prematurity in this study was 17.5%. In patients with ROP, the mean gestational age was 28.66 weeks with a mean birth weight of 1,230 grams. And the main risk factors to the development of ROP in this study were supplemental oxygen and bronchopulmonary dysplasia. There are some studies in Latin America about the prevalence of retinopathy or ROP. And in this one, we observed that the prevalence of any stage of ROP was considered or was range from 6.6% until 82% according to the country. The requirement or the need to do treatment in ROP in this study in Latin America shows that can be as higher as 23.8%. In contrast to our results in which we found that it was 13%. Also, when we compare the results of this study to countries of high income countries like the United States, we observed that the prevalence of retinopathy or prematurity in this country is less. But also, we can find some similarities, for example, that the peak of frequency of ROP was in the group or in the range of birth weight between 750 grams and 999 grams, which agrees with the same result that we have in our study because we found in our study that small babies had more risk of ROP. On the other hand, the risk factors that can be associated to ROP can be different among the countries. The risk factors in the United States for development of ROP are not the same that occurred in Asia or in Latin America, for example. So in my country, we found that the use of supplemental oxygen and glaucoma meridia dysplasia in this study were the most important risk factors. But here in the United States, the presence of female sex, the gestational age list and 36 weeks and a birth weight less than 2000 grams were risk factors as well. Also, 8.31% of infants require treatment. In our study in Colombia, around 13% require treatment. And if we go back to the other study, the one that evaluated different countries in Latin America, we observed that the treatment warranted ROP was 23.8 cases. So what means is that, of course, there are difference between countries. And the important thing here is try to identify what we can do to act in all those differences to reduce the burden of the disease. What are the future directions? This was a retrospective study. So any kind of retrospective study has limitations. The evolution of ROP was not evaluated in this study. We didn't evaluate how many patients presented reactivation of ROP or progression to more severe stages of ROP like retinal detachment. Also, there are other risk factors that can be implied in the development of ROP or severity. And we, we, those risk factors could have taken into account, maybe in future studies we can do it. For example, the extra uterine growth restriction, fluctuations in oxygen tension and maternal factors, and many other factors that have been identified in the development of ROP and severity of the disease. Finally, this study doesn't show the whole sample of Colombia. We chose the three centers that we consider the best for us, that we consider in which we could find the best availability of information. However, is the best study, I mean, so far is the best study in my country. We just have to. So this is the third one. It's multi-centric. It's the first study multi-centric. And we hope that in the future we can have more research and more studies to understand what is the behavior of retinopathy or prematurity in Colombia and what we can do to work on all those risk factors to reduce the burden of the disease. The conclusions is that the prevalence of retinopathy in Colombia in this study was lower compared to other Latin American countries in which the prevalence is up to 80%, around 20%. The average, the gestational age and low birth weight are risk factors to ROP as reported in the United States. The supplemental oxygen and bronchopulmonary dysplasia are risk factors that can be target of modification or treatment to reduce the prevalence of ROP. So what we have to do or what we might do in our country is to understand that maybe we are using the oxygen incorrectly or maybe we can work on that or study that in order to reduce the number of babies with ROP and their severity. What other future directions do we have? This is Cali, Colombia. So after finishing my program, I'm going to be working in a university hospital, Valle del Calca, at the University of Valle Cali, Colombia, which is this building that we can observe here. This is Cali and I am from Bucaramanga, which is located right here, Bogotá is the capital city and this is the place where I am going to go. My purpose in Colombia is to teach all the things that I have been learning during this time, during this training, and to provide an specialty that we don't have in Colombia so far, which is pediatric retina. So I think that there is a lot of work to do, it's challenging, but I am very excited to provide the opportunity of other people to be trained to learn and to improve maybe in the future, or to make an important impact maybe in the future in our children's side. In addition, training in this institution that provides lots of educative clinic and research opportunity was incredible. I am very grateful for having the opportunity of staying here for almost one year. And also I have to say thank you for providing the support and guidance for me to be, for me to do or receive the best education as possible. So thanks to the outreach division, global outreach division here. Also, I had the opportunity of making new friendships. Thanks again to the residents, fellows and all people that have supported me and helping me here. And for her mentorship and for commitment to my education support and kindness. I had to be very grateful with my professor Dr. Hernet for allowing me to stay here and for being so kind to teach me all this time. All those things have contributed to my academic professional and personal growth, and I am so happy to come back to my, to go back to my country, and face this challenge of starting a new pediatric retina service there. Muchas gracias. I think that's a great question. And in my eyes, I think that is not very high right now compared to previous years. I think most of the population in Colombia is located in the center of the country which we have big cities which we have good hospitals. So, actually, less of the population is living in the jungle or in other areas that are very far from the center of the country, but I would say just 5% of the population would be in that percentage. Thank you so much. Thank you for that question. So, according to the first question. So, how or what, what is the, how easy is to get access to treatment and TVGF laser for us. We do have access to those kind of treatments because we have all those equipments and things that we need. Sometimes it's a little bit difficult because of the health system. Most of the patients are a. Most of the patients have health system insurance health insurance, and they can access to the different different treatments, but sometimes those are delayed. So that is one of the first challenge because we do have the resources we do have to choose the problem is that maybe we need more organization, more administrative work to to to provide those tools to the general population. And according to the second questions about imagine our order imagine imagine results or imagine resources or other kind of tools that I saw here in the United States. And maybe we don't have in my country. We don't have imagine but for sure the United States is leadership in research is leadership in in in innovations, you know. So, right now we are doing the way that we are doing screening of our opinion my country is to is to the clinical way is to do indirect of thermoscopy that's the way that we are doing. We do have red cams we do have imagine actually we have an optos camera in Bogota, but for sure we need more organization in order to provide the possibility of taking those images to the more amount of babies. And it's challenging. Yes. And, but I think that what I have to do is go there and to do an evaluation of the thing of the needs that we have and try to do how can we make it work. And for those 182 NICUs that we have around the country, I would say that just 10 are with a residence program. So, just 10 have a residency program in ophthalmology training there. And what don't have like a direct coverage for an ophthalmologist. So what we have to do is to send an ophthalmology to send a person that is trained in ROP to screen those places, because, because it's not like that we don't have enough time to service all the time. Yeah. Thank you. All right, we're going to transition a little bit. Many of you have not met Nate Gephard. He's our current global outreach fellow. He's currently on assignment in Mwanza, Tanzania. We're going to be we've, I think pre recorded his talk, Ethan will be bringing that up to our screen here shortly. And as he's bringing that up and they will be trying to join us for at least q amp a little bit shortly. He's currently doing a FACO training with some attendings there at Pugano Medical Center. But Nate comes to us he finishes medical school in 2012 at the University of Colorado, and went on to Brooklyn for his internship and completing his ophthalmology residency at UC Davis in 2016. Since his graduation from Davis he's been an attending staff at KCI Institute for HSU. And I asked Nate a very simple question you know you've been traveling around the world for a while now. What's your favorite dish? What's your favorite food so far? Was it the momos in Nepal? Was it the Tikka Masala in India? And Nate had a great answer. He basically said that so far his favorite food has been the chicken nuggets at Mwanza Waterpark. So you can tell Nate's a little bit homesick ready to come home. He will be joining us shortly in a week or so he'll be coming back to Utah to take some call and to do some administrative things and to get ready for the second portion of his year in Tanzania. So we're going to go ahead and play his presentation. He'll be speaking on adults for business challenges. Hello and good morning everyone. My name is Nate Gebhardt. I'm the current Moran Global Ophthalmology Fellow and a visiting instructor from KCI Institute at OHSU in Portland, Oregon where I've been on faculty for the past five years. Just to give you a little background about myself, it's been a dream of mine to pursue a global ophthalmology fellowship ever since residency but the stars never really aligned until recently when my department approved a one year sabbatical and I was able to arrange this fellowship with Moran. And I'm so grateful to be a part of the Moran family. This year has been an amazing year and it's taken a lot of planning and preparation and I am indebted to so many people at Moran for helping to make this possible. Namely, Lori McCoy, Jeff Petty, Craig Chaya, Abdul Khalid Wairar, Erika Ruiz and many others. So I just want to thank you all for helping me make my dream a reality. And once again, I'm excited to be with you all this morning in spirit. I'm pre-recording this presentation from Wanzat Tanzania where my family and I are currently residing. So, let's get started. On December 30th, our family of four packed all of our bags and left our home in Hood River, Oregon and set off for Kathmandu, Nepal. We packed everything we would need for this entire year into these six bags and we were off. This is a family photo here on the left. That's my wife Annalisa and my son Silverton who is seven years old and my daughter Louisa who is four. So I'm just going to take you on a little journey to Kathmandu. This is me and the kids sleeping on the plane. This is Kathmandu through the airplane window as we were about to land. And on the right, this is the picture of Nima House in Kathmandu where many, many Moran faculty and fellows and residents have stayed over the years. So here's our first morning in Kathmandu. Me and the kids on the roof of Nima House. And the purpose of starting off this fellowship in Kathmandu, Nepal was to begin with an SICS course at Tilganga Institute of Ophthalmology. It's been a dream of mine for many years to visit Tilganga, the Shangri-La of global ophthalmology. And I was just so grateful to have that opportunity. This is my ID badge on the left which I will probably keep forever as a souvenir. And on the right, this is a picture of me and my Mongolian ophthalmologist friend Baissa who just happened to be finishing his own SICS course as I arrived. So Tilganga is an amazing place. Many Moran faculty have visited Tilganga over the years and many Tilganga faculty have visited Moran. There's been an ongoing partnership and affiliation which has been ongoing and so many of you might recognize some of these faces. These are some of my mentors who helped me with my SICS training. This is Dr. Ben Limbu on the left and Dr. Sagar Ruit on the right who is Sandu Ruit's son. After spending about a week at Tilganga, we went on an outreach trip to Sinduli. Sinduli is a province to the south and east of Kathmandu. It's about an eight or nine hour bus ride. So our family and I joined the Tilganga outreach team, loaded up the bus and we drove over windy mountain passes, forwarded creeks and streams as you can see here in the left hand photo. And we finally made it to Sinduli, specifically a small municipality called Lampantar. And this is where we conducted our outreach. As you can see, the Tilganga team brought all of the surgical equipment and instruments that they would need for the surgical camp. It's a very basic setup with microscope table instrumentation. In the center you can see the small community hospital where we set up the surgical camp. And then on the right, this is us going into the hospital on that first day. So in Sinduli, my two mentors, Dr. Rogita and Dr. Sanjita, were able to mentor me in SICS techniques and also were able to complete over 120 SICS cases themselves. Not only were they teaching me, but they were also doing pretty high volume cataract surgery during those three days. In the pictures here you can see Dr. Rogita and Dr. Sanjita on post op day one checking patient's vision. And in the center we have a picture of the operating theater. And on the right hand side that's me and my family at the end of the camp where we're posing with some gifts that some government officials had given to all of the participants. Here's another picture of me with Dr. Rogita and Dr. Sanjita who were wonderful, wonderful mentors. And just a couple other photos of Sinduli. It's a beautiful, beautiful place, lush green fields, mountains, lots of goats. You can see me posing here with my son in a goat pen. And here's another family photo from that Sinduli trip. After we got back to Kathmandu, Annalisa, my wife, continued homeschooling the kids. You can see her homeschooling here on the roof of Neema House. And here's just a typical picture of the fair at the Tilganga canteen. We really loved our time in Kathmandu. It was very fruitful and productive time for me professionally, but also personally. I experienced a lot of growth and we as a family also got to experience a lot of culture. You can see my daughter and son here at the Swayambuna Temple or the Monkey Temple in Kathmandu. And after one month in Kathmandu, we journeyed to Hattauda, which is about a four to five hour jeep ride to the south of Kathmandu. So we loaded everything up into this jeep, drove over some more mountain passes, and then arrived in Hattauda. You can see this is Hattauda Community Eye Hospital in the center photograph. That's my son on his bike posing in front of the hospital. And on the right hand side, you can see a picture of all of the Autorikshas that zoom up and down the streets. And that's how we would get around town most of the time. So Hattauda Community Eye Hospital is an affiliated hospital of Tilganga. And so they basically operate with a similar philosophy and model. They are committed to outreach and committed to reaching patients in underserved areas. And they do a really good job of reaching those communities. As opposed to Tilganga, Hattauda Community Eye Hospital typically conducts its outreaches without doing the surgery in those locations, but rather they bring the patients by bus back to the Community Eye Hospital for surgery. In this slide, I think I'm posing here with the operating theater staff. And that's Dr. Sunil, who was my principal mentor that month on my right. As I was mentioning, Hattauda Community Eye Hospital does a lot of outreach, just like Tilganga does. This was one of our outreach trips. I'm posing here with Cecile, who is one of the outreach coordinators. And so we screened 100 plus patients and those who were eligible and good candidates for cataract surgery, we transported back to Hattauda where we performed their cataract surgeries. And this was, again, a great opportunity for me to learn from my mentors in the center photo. You can see me being mentored by Dr. Sunil in SICS techniques. And these are the atomic technicians preparing post-op medications and eye patches and taking care of the patients on post-op day one. Okay, so that concludes our journey through Nepal, both in Kathmandu and Hattauda. The next stop was Tanzania. So after spending a month in Hattauda, we took a Jeep back to Kathmandu where I left my wife and two kids at Nima House. And I flew to Tanzania to meet up with Jeff Petty, as pictured here in the center, and the rest of the Morayan global outreach team. On the left-hand side is a photo of Bugando Medical Center, the primary place where we collaborate with our Tanzanian ophthalmology partners. And on the right-hand side is a picture of the FAKO machine that we typically use on these outreach trips, the Ortley cataracts, which I found to be an amazing FAKO machine, which packs a lot of punch for such a small compact and portable machine. So here we are, the Morayan global outreach team with some of our Bugando partners. By the time I arrived in Moansa, Tanzania, where Bugando Medical Center is located, the Morayan team had already been there for a week. Dr. Hoffman had been doing pediatric ophthalmology training week with Dr. Everista, the pediatric ophthalmologist at Bugando. So I joined the rest of the Morayan team for the second week, where we primarily focused on cataract surgery. And as shown here, the Morayan team worked in collaboration with our Tanzanian ophthalmologist partners to conduct this program and to screen patients for cataract surgery and to perform their cataract surgeries this week. A couple more photos of our partners at Bugando. And this is Dr. Christopher Mwanansao. He's the head of the ophthalmology department at Bugando Medical Center in Moansa. And he's such a wonderful person and physician. He really is the person who facilitates these Morayan outreach trips to Bugando. And he's been an amazing partner for Morayan. And I now count him as a dear friend. And after the Morayan team left, I stayed behind for a few days looking for housing for my family and looking at different schools that my kids could attend for when we would return. And Dr. Christopher and his family had me over for dinner, so we are here posing outside of his house the afternoon they had me over for dinner. All of the department staff are such wonderful people and Morayan is so lucky to have such a wonderful group of people at Bugando as collaborators and partners. I felt very privileged and very honored to have had the opportunity to work with all of them. So after our Morayan outreach trip in Tanzania, I flew back to Kathmandu where my wife and kids were waiting and we bid farewell to our Nepali friends. This is Nima and Pemba, the owners and operators of Nima House, who many of you may recognize. That's my daughter posing with them. This is Krishna in the center photograph presenting me with my SICS certificate from Tilganga and then me and the kids touring some temples on the right. And then the last week of March, it was time to pack our bags again and we were off to India. So here are a few photos of my wife and kids at the airport. And here's my son Silverton learning his Indian geography. He's pointing to Madurai in the southern Indian state of Tamil Nadu where we would spend the next month at Aravind Eye Hospital, who I'm sure all of you are very familiar with. So this was where we would spend the month of April. Aravind, as I'm sure you all know, has for many decades been an epicenter of global ophthalmology and they've done pioneering and groundbreaking work in global ophthalmology outreach and in reaching underserved and marginalized communities and providing them access to high quality and affordable cataract surgery and other ophthalmic care. It's also been a dream of mine for many years to visit Aravind and I was so grateful to our Moran partners and our Aravind partners for helping to facilitate this and make it happen. On the left-hand side, I'm standing with my SICS mentor at Aravind, Dr. Avatesh and Dr. Jena, who is the current Global Ophthalmology Fellow at the Seva Foundation in San Francisco. We just happened to coincide the same month for our SICS courses and that's my daughter there as well. So Aravind is famous for its outreach as I'm sure most of you know. We had the opportunity to go on several outreach trips, visit several vision centers and to visit one of Aravind's secondary hospitals that they're building. Aravind these days is a vast network of multiple hospitals, secondary hospitals, vision centers and a very well-oiled machine of outreach programs that basically covers all of Tamil Nadu and other parts of South India. So this is one of the outreach trips where all these patients are seated on the left-hand photo, screening patients in the center photo and then that's just me standing in front of the Aravind Eye Hospital original building in Madurai. So we did have time for a few family field trips. I've never worked so hard in my life as I did at Aravind. In India they just work so hard. It's a six-day work week from dawn to dusk and so often I felt like I was neglecting my family duties and responsibilities as I was training at Aravind but we still did manage to have some family fun. This is my daughter and my wife Annalisa on the left at the Chittirai Festival which is the big festival in April in Madurai. In the center this is us I think posing in an auto rickshaw and then on the right-hand side it's my two kids in front of the famous Minakshi temple in Madurai. So the SICS course at Aravind was also just an excellent training experience. This is Dr. Madhu Shikhar presenting me my certificate at the end of the course. Aravind has SICS training down to a science. They have surgical simulators. They have goat eyes every single day in the wet lab for their trainees. They have surgical mentors and almost daily training cases. And so by the end of the four weeks at Aravind both Dr. Jen and I were feeling much more comfortable and much more confident in our SICS skill set. As you can see here on the left this is me at the Help Me See surgical simulator and a couple more random photos. That's me and Dr. Shankar at his coconut farm. He supplies coconuts for the hospital and this is on the right-hand side during the Chittirai Festival. All right so where are we now? My wife and kids and I are now back in Moonset Tanzania and I'm currently working with our Bugondo partners and Lori McCoy on enhancing the efficiency and the quality of care in the clinic and surgical theater. Lori McCoy was here for about two weeks and just recently left and did a lot of work helping to streamline their clinics and to help them prepare for moving into their new building. Now one of the other things that we have started doing is phase one of our FACO training with Dr. Wan and Sao. So Dr. Wan and Sao the head of the department does have some background in FACO. In their new building they will have a FACO machine. It's in the storage room ready to be used as soon as they move in. And so one of the primary objectives of me being here several times this year and for my extended stay later this year is to help Dr. Wan and Sao and Dr. Everista along in their FACO training. And I'm really excited about this and I'm excited about the skills exchange that will be taking place and already has taken place. I've learned so much from them surgically and clinically. They are masters of SICS and so I've been learning so much in terms of SICS. Another ophthalmic surgery and I'm happy to play a small role in helping them to become more proficient FACO surgeons. So fellowship goals and plans. So for the remainder of the seven months of my fellowship we've got quite a bit planned. I'm going to be participating in some of the Navajo Nation outreach trips I think with Dr. Chaya and Petty. We have the Global Ophthalmology Summit in Park City in August. As I said earlier from August to December I'll be going back to Mwanza with my family. And we'll be staying there for an extended stay to really work with our partners in a longitudinal FACO course and also working on different research projects and skills exchange. Also we'll be helping them facilitate the move into their new building and hopefully getting their new FACO machine and operating theater up and running. Obviously I'm excited to continue my education in global ophthalmology. I'm really interested in social determinants of health and barriers to healthcare, particularly in ophthalmology. I've already learned so much from Tilganga and Arvind and from our partners at Bugando of how healthcare systems can deliver eye care to under-resourced and under-served areas. And it's just been an amazing education and I feel so grateful to have had this opportunity to work with these partners and learn from them. Next point, I have finished two SICS courses, one at Tilganga and one at Arvind and I hope to continue to hone my SICS skills throughout this coming year working in Tanzania. And also hope to pursue some additional collaborations with some of our other partners in Mongolia and possibly American Samoa and Micronesia. And last but not least, my post fellowship goals and plans. I'll be returning to Casey in January of 2023 after I conclude my fellowship. And when I return, I plan to continue working with Mitch Brinks, who many of you probably know. He's done a lot of global ophthalmology work over the years and particularly in the South Pacific. And I hope to pursue additional collaborations and potential synergies between Casey and Moran and global ophthalmology outreach work. I would love to continue to support our Moran partners in Tanzania, Mongolia and elsewhere. It's been a pleasure being with you this morning in spirit. And if any of you have any questions, I will try to call in. And thank you very much for your time. Appreciate it. Looks like Nate just logged on. So we've just a few minutes later. Wow, that was good timing. I just barely logged in. Awesome. Perfect timing. Well, we've got just hear me. Yes. Here you date. Hear us. I'm sorry, what was that Craig? Okay, I was just wanting to making sure that you could hear us but we've got just a few minutes just finished up your presentation. I apologize. I had introduced you as talking about strobe business. I was questioning that my mind, if you're really going to be talking about strobe business, but business I heard. Maybe maybe you could just entertain if you question any questions from the audience here. Sure, happy to answer any questions. Are things going for you there so far. Great. This is my second time here in Tanzania. This year and the second time. It's been about four weeks now and we have gotten our FACO training of Dr. one and so underway. We just finished a couple of cases this evening. And so we're still in the OR. So we're going to be able to see our last patient and see if we can get discharged our last patient. Let me see if I can get some video. Maybe you can see me and Dr. one and so here. Is anyone able to see the video or no. Yeah, we can see. So there's Dr. One and so. Here's Dr. Salima. Our staff. You've had a busy earliest part of your fellowship so far. We're thrilled to have you come back for a short period of time so we can reconnect and regroup for the second half of your year. But thank you so much for presenting your tour so far and the impact that you've had in different locations. So we'll reconnect when you come back to Salt Lake. I appreciate your time. Yeah. Absolutely. Thank you. Looking forward to seeing you all in in a couple of weeks. Good. Thank you everybody for attending. Good morning. Thank you.