 All right. So many of you probably know that Dr. Crandall and Dr. Tabin and I, and one of Dr. Crandall's old, well, he's not old, but he's one of Dr. Crandall's former fellows, Roger Furlong, who's now in Montana, all went to South Sudan at the invitation of John Dau, who was the leader of the Lost Boys of Sudan, who is the subject of the movie God Grew, Tired of Us. And that was a movie that won an award at Sundance about five years ago. I'll tell a little bit more about him as we go. So if anybody saw the TV thing, the bats will make sense. We had bats in the OR. So just a little brief about South Sudan. The Carter Center did a study and found that 15% of the people in Ayod County, which was the county north of where we were, were affected by trachoma. And 3% of those were children, or 3% of children were affected by trachoma. Blindness estimates range from 2% to almost 10% depending on where you get your resources. Either way, 2% is high and 10% is ridiculous for blindness in a population. Most of the blindness, like most places in the developing world, is easily treated or prevented. Cataracts, of course, are one of the common causes. Corneal blindness from trachoma and river blindness was common, and glaucoma was very common. The Republic of South Sudan is the newest country in the world when we got our visas. Mine was visa number 672. So that's pretty early in the process. They've had a total of 15 years of peace since 1955. And peace is a word that I think can be used loosely since they're in a state of peace right now. However, roughly 1,000 people have been killed in the Jianglai state in the last two months. About 90% of the population lives on less than $1 a day. They have some of the worst maternal mortality. 2% of childbirths result in death of the mother. And 13.5% of childbirths result in death of the child. There's only three surgeons in the whole country. There's only one ophthalmologist who's Ethiopian, and he spends a significant amount of his time outside of South Sudan and Ethiopia. This is a view flying in to Juba. I think that's the Nile in the background. And then a view flying into the village of Duke Pailluel, which was John Dow's home village. And you can see the little huts here. This is the plane we flew in on. And I actually had a really exciting experience on the flight out. I think it would have been exciting for Dr. Crandall, who had he known. But I was flying the plane over the Rift Valley of Kenya for about an hour. The pilot turned to me and said, hey, you ever flown a plane? No? You want to? Yeah? All right, here it goes. It was exciting. This is refueling the plane. The pilot dropped us off. He had about three minutes to turn around and get back in the air in order to make it back home before sundown. And they originally brought him a can of automobile fuel. He said, no, no, that's the wrong stuff, jet fuel. So they went and got a different one. But I hate to think what would happen if you started putting the wrong stuff in the plane. And then the pilot took off. And then we were pretty much alone in this little village. This is the outhouse. Not everybody's favorite place. This is where we stayed. We each shared a tent. It was pretty interesting. Killed a scorpion right here one morning. So it was pretty out there. This is the village. This is the village at sundown. And this is the hospital. This is the pet antelope that they had, which was kind of interesting being that close. You could feed it in the morning with a bottle. And these are the patients coming in. Some of the patients walked as far as 80 to 100 miles to come to the clinic. One of the South Sudanese named Oger had some training that Dr. Tabin sent him to get. He had some training in Nepal. And so he went out into villages all around before we got there, did some assessments of blindness, identified blind patients, and then told them to come to clinic when we arrived. So this will just be some photos of people being led in. This is sort of how you travel when you're blind in South Sudan. You hold one end of the stick, and then people lead you along. There were so many sticks in the preoperative area that I almost put my own eye out. Just sticks everywhere. And Crocs, somebody brought a shipment of Crocs to South Sudan somewhere, so those were very common. So this was sponsored through the International Division of the Moran Eye Center. So when I first arrived, we flew in in two groups because our gear was too heavy, not ourselves, but our gear was too heavy to fly it all in, all of us, and all our gear at one time. So I, Julie Crandall, Michael Ye, and two emergency doctors we'd worked there before, and his son and a friend of his son flew in first, and Dr. Crandall and Dr. Tabin, and Dr. Furlong stayed back in Nairobi to do some training there. So setting up the clinic fell on me. And so the way we arranged it was this was the registration. A patient would come in here, and either they had a chart already made by Auger, or if they didn't have a chart, then we made a new one on a card. Then we checked their vision on the side of the building, and then they moved into the building, which was a pretty packed every day. And then we would do eye exams, sort of just going around the circle. Dave Reed helped. He's an emergency medicine doctor. He helped with the eye exams. Michael Ye is our international, one of our international people here. And so he was helping out. And Julie Crandall also helped tremendously. I can't give her enough credit for getting all the equipment together to bring and organizing things and all the work that she did. I'm probably shouting right now, Levinian, Levinian, which means open your eyes. You can see the bell's reflex. I have never met people who can squeeze harder than these people. And you can hold their lid up, and they can bells for five minutes straight. They never get tired. And the eye never comes down. So exams were pretty difficult. Thanks to Dr. Teske for loaning us his indirect. That was very, very helpful. So all patients were initially screened by Julie, Michael, and Dave Reed, the emergency medicine doctor. And then I saw every patient at the end after they'd been dilated to either confirm or change what their diagnosis was. So this is a quote that Dr. Tabin likes to say a lot. But it kind of sums up how a lot of people feel in the developing world about blindness, that a person who's blind is a mouse with no hands. Because the blind person, studies have shown when a person becomes blind in the developing world, they take an average of two to two and a half people out of the workforce. The blind person and the people to care for them. And so blindness can plunge a family that was on the edge of destitution into absolute poverty. Often, blind people are totally neglected. And the life expectancy of a blind person in the developing world is a half to a third of that of an age-matched control. So you're not just giving people their sight back, but you're changing the economic status of their family. And in some way, you're saving their life. So I have a couple quotes from blind people in the developing world about how they feel about it. This is a quote from an adult. He says, I'm nothing but a burden. I've lost many things over the years. But most of all, I've lost my dignity by being blind. Every morning, I wake up feeling hopeless and worthless inside. Each morning, I try to figure out how I can kill time for the whole day. And a child says, I'm blind and I don't deserve any friends. I'm not capable of doing anything but sitting in my home with my grandparents all the time. Nobody is willing to play with me. I can't see now, and I'm afraid I will never see again. These are some of the patients. You can see those cataracts probably from the back row, similar to business. Maybe one of the residents can try to identify this difficult diagnosis. This is a picture I just pulled off the web because I didn't have a camera. But I can't tell you how many times I saw this. Even in children as young as 15, just completely cupped out nerves. And trachoma with severe entropion, trichiasis, and corneal blindness. So this is the, as best as we know, this is the first eye surgery performed in Duke County of South Sudan. When Jeff Tabin got off the airplane, the first thing he asked me is, have you done surgery yet? I said, yes, I have. I said, but don't feel bad. You'll have the second eye surgery in South Sudan. This is the Traboo procedure. And I had discussed this with Dr. Patel before I went to South Sudan. I was taught this in Zambia by a physician when I was a medical student. But Dr. Patel said he really likes this procedure in the developing world. So it was the procedure I used. There are other procedures that can be used though. This is our encampment in the evening. And then after two days, Dr. Tabin and Dr. Crandall arrived. And this was part of the welcoming party. Just by reference, this guy is six foot seven. But that guy's just as tall. And this lady's pretty close. And this guy's about as tall. And that guy's probably six, five. Like, is the first place I've ever been where I felt short all the time. And wait till Crandall and Tabin got there, you know? This is John Dow and our illustrious surgeons. This is Mr. Marmot. He's a Marmot sponsored athlete who took a lot of our photos. This was the bowl that they gave us. And they also offered Dr. Tabin a plot of land. I was trying to convince him to become a South Sudanese farmer. But we just ate the bowl instead. This is the operating room. We had a small generator and then two operating microscopes. There's about 105 degrees. So Alan still managed to wear scrubs, but Jeff switched to shorts and a light shirt. And we had a South Sudanese person and Julie Crandall did most of the OR teching. That was our generator. This is what our charts looked like after a day. The other thing I want you to notice is how dusty and dirty it is. So we, as part of the operating room procedure, all patients had a face washing with soap prior to their retro bulbor block. Cataract surgery. IOL, that's his Roger Furlong doing surgery. Alan using the spirit lamp. He said he hadn't used one of these since the 60s. So they're pretty cool. They run on ethanol and you have a little brass ball that heats up in a point. And it's a pretty neat way of doing coterie. This is Francis Gao. He was a South Sudanese who'd been trained to do a bilimelar lid rotation. So he came and helped us with tracheosis surgery and did 18 of them bilaterally. So that was very helpful. This is what happens when the sun goes down. You can see that other than this small globe of light, the rest of the room is completely black. It's still 105 degrees and I'm pretty much dripping sweat, but when we had a couple suture packs that had sort of a bluish suture, and you couldn't even see the suture against their dark skin and that amount of light. So you'd have to sort of feel for it. So I made sure after dark I used only the white sutures. This is the last patient waiting for her cataract surgery on her last day. Now the fun stuff, post-ops. Post-op clinic was a zoo for the most part, but between Dr. Tabin, his entourage, the photographers and excited patients and family members, it was pretty wonderful to see that moment where you take the patch off and the patient, there's this lag time where they open their eye and they're not really even sure what's happening for a few minutes and then they start to realize that they can see. It's pretty wonderful. Yeah, this is the zoo. And then we eventually moved the post-ops outside because there were so many, so we would do it here. This is one of the ladies from the original pictures where you saw her cataract and Roger Furlong and Michael Ye. Even though I love these hats and stuff, it's 100 degrees and people were wearing ski caps and big fuzzy hats and North Face jackets when it got down to 80. This was one of the other patients that was in the pre-op, which was John Dow. A little bit about John Dow. John Dow started the clinic where we were and John Dow was the subject of the movie, God Grew Tired of Us, which I think I said, but when John Dow was 13 years old, he was still about six foot nine and he led 27,000 boys between the ages of three and 13 out of South Sudan on a 1,000 mile walk to Ethiopia while they were being bombed by the North Sudanese government attacked by wild animals and starving. And then after spending a year in a refugee camp in Ethiopia, they were driven out of there and walked another 1,000 miles to Kenya and he led these boys on this whole route. They started with 27,000 and about 11,000 of them died along the way. And he was essentially, they elected him their leader, so to speak, because he was the tallest. But then he was brought to the United States through a refugee program and lived in Syracuse, New York where he worked three jobs to send money home. And eventually he got on his feet enough that he decided that he wanted to go back to South Sudan and make a difference there. So he built a clinic in what had been his home village which had been burned to the ground during the Second Sudanese War. And now this clinic is the only thing that provides healthcare for this whole county. He's also involved on a relatively higher up political level in working for peace in South Sudan. Really an amazing guy and a tremendous asset to everything we did there. She's waiting for a surgery on the second eye. This lady walked 80 miles to see us to have cataract surgery and had a great result celebrating all the way home. But I didn't follow her all the way home. I don't know if I can walk 80 miles. Very tough people. That shows you how tall John is. The photographers couldn't take pictures of John and Alan in the same picture without standing on a chair. Otherwise John's head was behind the sky and then he's so dark that you either had the sky bright white and only a dark face or a bright face and everything else washed out. So this is the... And she did a really tremendous job as well. These were our guards. We had guards armed like this sort of around the periphery of the hospital. You didn't see them a whole lot but they'd wander in for dinner with their guns and wander back out one morning. They told us, don't worry unless you hear. If you hear a shot, it's not a big deal. Don't worry unless you hear shots to answer the first shot. It was laying in bed one morning and pop. And I have to run out into the bush in my underwear and hide under a tree or something. And then we found out that they were just... One of them had died from a sickness overnight and they were giving him a three-gun salute in the morning. These things suck. I hate them. They're huge. They hurt like the Dickens when they bite you. They're bleeds. They're tzitzi flies. And while you're doing surgery, you'd be doing something delicate. So it was miserable. I'm glad we don't have these in the operating room. These were nice in the operating room because they eat the flies. There were about 2,000 bats that lived in the hospital. So once the sun got down, the operating room was really kind of exciting to have four or five bats sort of swirling around the room, cleaning up the insects while you worked. Fortunately, they're pretty good at not running into you. So just a little bit of data from our trip. We saw a total of 284 patients, most of which we saw in the first two days. They ranged from age three to 89. And about two-thirds were female and one-third male. Of that, 20% had seen an eye doctor in some other area, like Kenya or in the capital city. And most of them came from Duke County, but some of them came from a far away as Boer South or Eur County, which is about 100 miles away. Of the patients we saw, 133 or 53% had no eye better than count fingers and 35% had no eye better than hand motion. So a lot of people had severe bilateral blindness. These are our top diagnoses. These are now per eye. So out of 568 eyes, and some eyes have multiple diagnoses, so that's why this number is more than 568. There were 295 cataracts out of 284 patients that were visually significant. Trichiasis was very common, 113 eyes with trichiasis from trachoma, 80 patients had corneal blindness and at least one eye, 63 eyes had end-stage glaucoma. And we actually even saw Nicolopia from vitamin A deficiency. Dr. Crandall, Dr. Tabin, and Dr. Furlong together did 181 cataract surgeries, and Dr. Gao, Dr. Tabin, and I together did 120 eyelids for trichiasis. And on post-op day two, we had 67% of patients were 2200 or better. I suspect that the final numbers, once corneal edema and everything is cleared up, that there would still be roughly 10% or so of these patients who did not get a good visual result because they either had glaucoma that we couldn't diagnose prior to taking out the cataract and then you take out the cataract and you look back at the nerve and it's completely cupped or there are a couple of patients who had a retinal detachment that was hiding behind the cataract that we didn't know about. This is the softer side of Alan Crandall. This little baby just walked up to him and grabbed his hand in one of the villages. That's it. But I do wanna thank Dr. Crandall and Dr. Tabin for taking me to South Sudan. It was a great experience and I really appreciate getting to work with those two guys. They're really amazing people. Any questions?