 I'm going to talk about global blindness past to present and then future challenges. I would first like to give an overview of global blindness over the last three decades and then spend 10 minutes talking about four future challenges to improving eye health. The number of blind people in the world has increased from 31 million in 1990 to 36 million in 2015 and all people with visual impairment from 190 million to 250 million. However if we look at the age standardized prevalence of all visually impaired people that is blindness and moderate and severe visual impairment the number has decreased by about a quarter from 4.6 per hundred to 3.4 per hundred people. The causes of blindness can be divided into very treatable like cataract, easily preventable like glaucoma, more difficult to prevent like glaucoma and then causes for which a public health intervention are not easily feasible. In 2000 about 75% of the causes of blindness were due to treatable or easily preventable causes. This led to the Vision 2020 Right to Sight Initiative with the goal to eliminate avoidable blindness from the five diseases cataract, refractive error, trachoma, oncosaciasis and avoidable causes of childhood blindness. If we look at the latest 2015 data we can see that the causes of blindness have changed with blindness from oncosaciasis, trachoma and vitamin A deficiency being reduced and glaucoma and diabetic retinopathy becoming more important. The next two slides show the actual numbers by cause with 56% of blindness being due to cataract or uncorrective refractive error and 75% of all causes of visual impairment. So to summarize the first part of the talk in the last 25 years there has been a decrease in the prevalence of blindness and vision impairment by about 25% but an increase in the number of people blind and visually impaired from 190 to 250 million due to population growth. At the same time there has been a reduction in the causes of blindness from oncosaciasis, trachoma and vitamin A deficiency with non-communicable causes like glaucoma and diabetic retinopathy becoming relatively more important. I would now like us to consider the current and future challenges to improving global eye health. The two immediate challenges from my perspective are first an inadequate number of trained eye personnel aggravated by poor distribution and second that services are inequitable with people living in poverty, rural populations and women being particularly underserved. There are also two challenges which will increase significantly in the next two decades. First an increase in the complexity of delivering eye services and second a major increase in population need. We'll now look at each of these four challenges in a little bit more detail. In 2000 minimum targets were recommended by Vision 2020 for the number of eye health trained staff. These were four ophthalmologists, 10 optometrists and 10 ophthalmic allied personnel per million population. Please note these were minimum requirements. By 2017 the human resource situation in Africa for English, French and Portuguese speaking countries is still well below this minimum target. There has been significant progress in some countries but overall there remains a major shortage of human resources for eye care. Without trained staff no amount of money will improve the eye health of the population. That is one reason why the Lynx program has an important role to play. The second current challenge is inequity. This slide shows the proportion of cataract surgery with good outcome in the vertical axis against the human development index in the horizontal axis. As one can see there is a correlation between poor outcome and poverty as shown by the HDI. This next slide is from a study in Nigeria. It looks at cataract coverage that is the number of people in a population that have received cataract surgery as a proportion of all the people that need surgery. The vertical axis shows the coverage from 0 to 60%. The horizontal axis first divides the population by literacy and then into urban and rural and the colored column show the coverage for men and women. As one can see the high coverage 30 to 50% is in urban, literate men and women and the low coverage in the literate rural population with less than 1 in 10 having received cataract services. This inequity is not just a challenge for low income countries but also occurs in high income countries. We know from the UK and USA that there are marginalised groups who do not or cannot access eye services. We now move on to the challenges which are likely to increase in the next decade. This is a diagram of the causes of visual impairment in 2015. Trachoma, oncosaciasis and vitamin A deficiency are focal diseases of poverty which are being controlled through mass drug administration programmes using ivermectin, azipamycin and vitamin A supported by primary health care activities for example water and sanitation and immunisation. Visual impairment from cataract and refractive error occur everywhere. However we have effective and low cost treatments which by and large are one-time interventions. If we want to develop public health programmes to prevent loss of vision from glaucoma and diabetic retinopathy then we need to screen the at risk population to identify cases, ensure referral pathways to obtain a correct diagnosis and then provide treatment services which require compliance and long-term follow-up. Other blinding conditions including pediatric ophthalmology require tertiary specialist services. Therefore the easier bit of reducing blindness that is the easily preventable or treatable causes is being addressed to some extent but as cataract and refractive error services improve the challenge of delivering eye care for chronic non-communicable eye diseases like glaucoma and diabetic retinopathy is more complex and definitely requires more resources. As we look to the next three decades the population is estimated to grow by about 30% from 7.3 to 9.7 billion. But the population will also age with a more than 100% increase in those aged over 60 from 1 to over 2 billion. This increasing and aging population will create a major increase in need which if not met will result in a 2 to 3 times increase in global visual impairment. I should point out these predictions do not take into account pandemics or climate change. However not all is doom and gloom. The challenges are very significant but there are also potential solutions. In particular new technology is becoming available. It can be used to screen and diagnose patients in their home. It is providing better information to plan eye services. And importantly it is being used to share knowledge and expertise among eye health professionals. So to summarize the future challenges there needs to be a significant increase in eye trained personnel. Services need to be targeted at the marginalised to address inequity. While not losing the improvements in disease control brought about by vertical programs there is a need to develop comprehensive and sustainable eye care at primary, secondary and tertiary levels. The increase in an aging population will be a significant challenge. Technology if embraced and used well can help address some of these challenges. In conclusion, Vision 2020 has been important to address avoidable blindness in the last 20 years and there have been some achievements. But as we look to the future we need to face the challenge of avoidable visual impairment realising that the numbers will be far greater and their management more complex and requiring more resources. The challenge is to make sure that all people can access good eye care to ensure good vision. The right to sight remains an important endeavor. Thank you. Thank you very much, Alan. Speaking of somebody who during the last years has become increasingly presbyopic, I now fully appreciate the concept of visual impairment and you are absolutely right in that we have to address that as well. Can we move on and invite Simon Day from IAPB to present his talk? Simon, I think I saw you there. Yes, thank you, Michael. Can you get me? Yes, I can. I'm going to share my screen with me. Has that worked? Yes, fine. Okay. Thank you, Michael. Thank you also to the Royal College of Ophthalmology and to coexit for this opportunity. The International Agency for the Prevention of Blindness is the overarching alliance for the global eye care sector. Over the past 40 years we have built a community of 160 NGOs, professional bodies, charitable eye hospitals and academic institutions spanning over 100 countries. Together we advocate for the policies and resources needed to achieve universal access to eye health. We believe that by working together we have far greater chances of achieving change than any one organization can alone. We actively seek partnerships and collaboration with others as an effective means to achieve our vision. IAPB divides its global network into seven geographical regions. Each region consists of their own subregions with a multitude of countries within. In this regard, we embrace the plurality of approaches we adopt in the pursuit of our common goals, in the belief that our strength derives from diversity rather than uniformity. IAPB sees international partnerships and alliances as instrumental in developing and strengthening effective public health responses for the prevention of visual impairment. In this regard, considerable efforts have been made during the past 30 years to address eye conditions and visual impairment which resulted in progress in many areas. The global initiative for the elimination of avoidable blindness, Vision 2020, the right to sight, was launched in 1999 by the World Health Organization to intensify and accelerate activities for the prevention of blindness with the goal of eliminating avoidable blindness by 2020. The initiative has been pivotal in achieving unified and coordinated advocacy for key priorities for action in the field of eye care at the global, regional and national level. It has been instrumental in strengthening national prevention of blindness programs, committees and focal points as well as supporting the development of national eye care plans and advocating for the stronger evidence in the field. The Universal High Health Global Action Plan 2014-19 added a further dimension around universal access to comprehensive eye care services and set an ambitious global target to reduce the prevalence of avoidable visual impairment by 25% by 2019. Last year, the World Health Organization launched its first World Report on Vision. The report seeks to generate greater awareness and increase political will and investment to strengthen eye care globally. It offers clear proposals to address significant challenges in delivering eye care through existing health systems. It builds on concerted efforts of the past 30 years to propose an integrated, people-centered eye care that strengthens health systems and meets population needs. Although significant has been made in the past years, the global need for eye care is projected to surge and in the coming years due to population growth, aging and changes in lifestyle. The major challenge in eye health remains reducing the inequality in coverage. Currently, at least 2.2 billion have a visual impairment and of these, at least 1 billion people are being left behind in eye health. Bringing together the world authorities on eye health and system strengthening, the World Report on Vision provides a major opportunity to mobilize the highest political support for eye health. This is a time for all of us to galvanize our efforts around the set of crucial political messages and as IAPV, we encourage our members and partners to call on heads of state and national governments who have committed to universal health coverage and the STGs to take action and ensure universal access to eye health. Working with our members and partners to implement the World Report on Vision action plan is the cornerstone of IAPV's global strategy. International organizations, donors and the public and private sectors must work together to provide the long-term investments and management capacity to scale up integrated, people-centered eye care. At the global level, it is necessary to monitor and influence the policies of key international and multilateral institutions such as the WHO and the United Nations to ensure a global commitment and investment in eye health. At the national level, as the movement to accomplish the ambitious goals around it, it is important to remember that policies actualized by those working on the ground. Critically, it is necessary to mobilize political will and persuade governments to adopt and implement its recommendations and provide the resources necessary to fully integrate eye care as a core part of universal coverage. Our hope, building in past efforts, is that we can all successfully take on this challenge and achieve the vision of a world in which everyone has access to the best possible standard of eye health. We're known as needlessly visually impaired and where those with irreplaceable vision loss can achieve their full potential. Thank you. Thank you very much, Simon, and thank you for all the work that you and your colleagues at the IAPB have been doing over many years. It's a global challenge and your organization is definitely contributing greatly to that challenge. I think it's all right. What I'd like to pass on now to two people that I've known for many years, Nick Asprey and Marcia Zondavan, who will be talking about the Vision 2020 Lynx program. Hopefully Marcia and or Nick, are you there? We've got a pre-recorded session coming up. If it doesn't pre-record, then we're here in the flesh. I think we better do this live, Marcia. I think you better appear live. You can't hide behind the video anymore. Marcia, can you unmute yourself? Yes, I'm unmuted. Can everyone hear me? Yes, we can hear you. Welcome, everybody. It's so good to have this opportunity to meet together, to look at what has developed over these last years, since 2004, when the Lynx program began. And just an opportunity to look at partnerships and to look at the way forward together by looking at what has happened and by even with this pandemic, looking at how we can work together as partners going forward. And I just, you know, it's just such a great opportunity to say thank you to one and all for all the work that has gone into the development of the Lynx over the years and the way teams have grown and been strengthened. Nick? Yes. In 2004, we started the Lynx program. And at that time, a number of ophthalmologists were going out to Africa and doing short-term work, operating, doing some teaching. But we felt there was a great need for an organized program. And so when it started, it was based around finding out the needs of the people we were trying to partner with and help. So we would send out a needs assessment which would be filled in. And then we would send out the needs of the other hospital and match them with an institutional hospital in the UK. And it started then in 2004. We've now got 30 Lynx. And it's based on having an activity plan for three years and being a sustainable long-term program to increase the much needed human resource capacity in Africa. As we all know, it has been eloquently described by Alan and Simon. Nick, do you have that wonderful little map of all the... Maybe you can get it as we're talking. So we have 30 Lynx, and Nick had made a really nice map just to show everyone. But there's 30 Lynx that have developed over these years. And a lot of them have over the time we've recognized that there was some themes, some very specific themes. For example, we had, I think six years ago identified that there was 15 Lynx which we're trying to develop the diabetic retinopathy services. And so through funding from the Queen Elizabeth Diamond Jubilee Trust we actually were able to pull a network to develop a network so that there could be shared learning. And I think this is one of the key areas where there has been success is that there has been an opportunity of shared learning together. And it's not just the shared learning to Africa and Africa to the UK but shared learning within the regions and also at the level. And the same way was with the development of the RB network. And we will hear later from various participants we're going to hear about the networks in more detail. But also with the RB net we looked at strengthening through links with India and the UK and Africa and again the South South in Africa to Africa and India who has already developed some in some ways they have good programs. They have excellent programs and they're also having some of the best presentations. So a real ability to learn together to share that learning and we will see a case study of that shortly. And just to add another aspect one of the rather disappointing things is that there are not links programs in other parts of the world involving other countries. But we've made a lot of progress with Ransco in Australia and New Zealand who have developed links and teaching links with the Pacific Islands which is fantastic. And recently we've been collaborating with Alliance Mondial in France who want to work with the Francophone countries because our links are understandably mainly with the Anglophone countries and with coexa. Just mentioning coexa there's going to be a lot more on this great link between coexa and the college with Mike and John talking soon. So we've got a lot to be proud of Marcia particularly you leading it for the last 16 years. I think one of the key reasons it has had success is because it has been related to what the needs are from the overseas institutions and that's why that's in Africa and the Caribbean in the Pacific but very specifically relating to what their needs are and trying to match the teams and it's about teamwork not just ophthalmologist to ophthalmologist but the entire team working together. Thanks to each and every link input that we have been able to bring about a change. It is and thinking about teams it's so important to think about optometrists and orthoptists and nurses and in particular because equipment spends most of its time being broken down part of the links team is often one of the an expert I can't think of the word in the hospital who goes out of technician and who fixes equipment and that's another aspect which makes this a really practical program. So we're going to have a good day everyone and thank you so much for joining. Thank you. Thank you very much Marcia and Nick I think as Nick has alluded to Marcia as usual has been somewhat modest in her assessment of her role she has been instrumental in the driving forward of the links program to the success that it is today and that was recommended by the award of an honorary fellowship by the College of Ophthalmologists which was one of my great successes as president and congratulations on that again Marcia well deserved and what I'd like to do now is pass on to our coexa colleagues John and Josiah to review their, to give us their thoughts on the coexa I think with the College of Ophthalmologists so hopefully the John or Josiah will pick up now. Thank you very much Mike and thank you Nick and Marcia for a very good presentation As you know coexa is the College of Ophthalmology of Eastern, Central and Southern Africa and under that umbrella we cover 12 countries and very soon we are looking at 15 countries in the near future among the 30 institutions that Nick and Marcia talked about a good number is within our region under those 12 countries in this presentation we are not going to talk about those individual institutions that had links links from 2007 onwards we are going to talk about coexa as a college as you all heard from Professor Alan Foster without developing the human resources no amount of money will solve our problem in eye care so in our links with the Royal College of Ophthalmologists is mainly focused on developing high level well-trend ophthalmologists and other teams of the eye care team without going into much detail I will invite Josiah our CEO to present our experience as coexa over the last 12 years from 2008 Josiah are you there yes John thank you very much and it's a great privilege to join this online community today from all over the world celebrating international partnerships and I present on outcomes of our partnership with the Royal College of Ophthalmologists spanning a period of 12 years from 2008 back then when we had the east Central and East Africa College of Ophthalmologists that later merged with the society that was bringing together all the ophthalmology fraternity so I have a brief PowerPoint for slides that I want to share and I may just shoot it on the screen for our purposes can we all see the screen yes so today presenting on the impact of our partnership we've had with the Royal College of Ophthalmologists coexas you've had stands for Ophthalmology of Eastern Central and Southern Africa with a vision of high health for all in Eastern Central and Southern Africa that's the region in which you operate in 12 member countries each of them having a society of its own and our mission is to improve the quality of eye care through training research in advocacy as well as provide leadership in eye care and creating a platform for exchange of palmyx skills and knowledge as well as resources and they say pictures speak a thousand words and part of the journey we have had begins here in this photo this was way back in 2014 in Naivasha Kenya and I'm sure a few of us who are participating in this workshop today can see way back where we've come from this was a curriculum review workshop in 2014 and this was to help in standardizing the training curriculum Ophthalmology course within the region so you can see all the faces are all smiles there way back then we started together a happy journey together as RCO curriculum development lead and the team from the college visiting over in Nairobi in Naivasha and we all had a wonderful time okay over to the broad areas of collaboration we have had between coex and RCO that covered areas of curriculum development examination in terms of marking and grading we've had a few exchange visits to the UK as observers our examiners go to participate in the Royal College of Exams Royal College of Ophthalmologist Exams sorry train the trainers program the clinical guideline development training CPD exchange and also lately the networks that developed over time the retinoblastoma network diabetic retinopathy network and just speaking of some of the outcomes that we celebrate today we have a harmonized curricula one for residency and the universities that are still training under the MMed system and we also did one for mid-level curriculum that is for ophthalmology ophthalmic clinical officers and nurses and currently we have this curriculum for a residency in use at Rwanda International Institute of Ophthalmology and it has largely influenced training of MMed program and the universities that are under coexa we've had over 138 trainers who have undergone the train the trainers course and have been able to cascade the same that is being able to advance ophthalmic education in the region and because our exams fellowship exams is done in a rotational basis we've had an impact we've had is one of the universities had been doing long and short cases in the examination process but they changed to Viva and Oskis in the process so we're happy to be associated with that kind of positive change at the institutional level regionally we've had development of evidence-based guidelines which have led to improved clinical practice and care for example we have the glaucoma guidelines that has been adopted by various ministries of health Kenya and Tanzania have developed retinoplastoma guidelines Kenya has also led in developing the retinopathy of prematurity guidelines Tanzania and Kenya both have developed diabetic retinopathy guidelines with of course impressive outcomes I remember sitting in one workshop one time and I remember it was during an exam time and I was shocked to see this child with an eye popping out but over time over four years as we fear clinicians share during CME sessions that there has been a reversal that nurses are able to quite knob cases of retinoplastoma in the early stages and refined appropriate action is taken and also through the CPD exchanges there's been an improvement in the clinical practice through the CPDs and mentorship sessions so these are some of the outcomes we say we are celebrating today of course not all is captured here we will hear in the individual institutional link-to-link programs at the individual consultant level and at the institutional level in terms of looking forward for us even as we see the slide that was shared by Professor Allen was quite interesting in terms of the shift now from the preventable courses and we are now moving towards more lifestyle and light eye health problems so we are looking for coexa in terms of the partnership moving forward because these outcomes we are talking about would have not been possible without the partnership we have had with the global north so the areas we are looking at in terms of partnership moving forward is in the area of examination coexa is still working towards setting up the coverage, train the train-up program the exchange visits we have had they have helped us improve in so many areas and also the aspect of institutional development moving forward so for us really that has been our experience and we are truly grateful that the partnership has been based on a mutual agreement and understanding and cooperation and we can do more together indeed with the partnerships thank you Thank you Josiah I think you went through on a comprehensive presentation of what is our impact of the links without delay I think we are going to invite now Mike to tell us how painful it has been for the Royal College to partner with coexa was it painful or was it delightful I think if it is about how painful it has been John it will be a very, very short talk because there has been no pain at all I would like to thank you your predecessors and Josiah in particular for facilitating so much this I think very successful link so it has been a joy and a pleasure in my career to be part of this I have now got to the age where people start asking me could you tell us about your career and you start reflecting on key point decisions and it was an element of randomness and luck involved and a lot of decisions we make that lead to where we are today I think one of the key decisions that I will always be glad I made was when with Marcia and colleagues from Birmingham we were setting up a link with our colleagues in KCMC and that time Anthony was the lead clinician at KCMC and I note that he is on the line now presumably from Australia welcome Anthony whilst we were setting up the link Anthony told me about an organisation called East African College of Ophthalmology and this caught my imagination because it was going to be at that stage an attempt just being set up to link ophthalmologists across I think it was that stage three countries Kenya, Tanzania and Uganda to provide a cross-border cooperation to improve the standard of eye care in sub-Saharan Africa and I thought that this was in itself a stunning idea one that I think in Europe we would struggle with our very partisan approach to our eye colleges we would struggle to replicate in Europe and I said to Marcia at that time that's the there's an initial process by which the each party visits the other so on the return visit when Anthony came to England so in my team who was then I think chief executive to come and meet with our president of the Royal College of Ophthalmology Brenda Billington and at that stage the link was started and in 2008 a formal link was established with the ARCO with the goals of developing fellowship examinations standardizing training across those three countries to provide CPD and to develop sub-speciality training in the region I think a few months after that link was formally inaugurated a colleague and I went to Nairobi that was Peter Tiffin who at that stage was heading our exams and he and I went to Nairobi with Marcia and we led the first training program on how to deliver examinations and I can still record eating in a home in Nairobi and said to each of the universities represented there could you tell me how you train and they listed their training program and their curriculum and it was quite clear that there were significant differences at that time both in how ophthalmologists were being trained in the three countries and how they were being assessed and there was mutual recognition that there would have to be some degree of convergence if we were going to have a successful coexa examination and I have to say that one of the great pleasures I had was in 2015 to visit Ethiopia as external examiner at that time I think there were about nine or ten candidates taking the exam and the two things that really struck me were the quality of the trainees the candidates there were very good indeed but equally so were the examiners I genuinely left there thinking that the examiners could easily slot into the College of Ophthalmology exam and be completely in place and look like they've been doing exams for years alone was a very successful story that I think this cooperation this link has produced over the years we've worked together and helped to develop the curriculum for coexa that is appropriate for Sub-Saharan Africa Melanie has as everybody knows delivered a huge amount of the trainers training we've been helping with CPD and we're working with joexa to help them to develop the very important regional journal that will provide the scientific platform for research in Africa and I think also over the years I've observed I've had the privilege of being invited to join your congress and I have seen it grow immensely I'm very pleased to say that I'm joining our colleagues in Rwanda a huge amount, genuinely I'd like to thank you and your colleagues for a very successful meeting in Rwanda I hope that we can see you all in Malawi but that I presume is still up in the air The other thing I would like to just highlight is something that John said I think in the coexa meeting in Ethiopia I don't know if you recall this John but at that time you put a very strong marker down to say we want to be independent and self-sufficient if we are relying on NGOs to develop ophthalmology and deliver ophthalmology services we can never develop our own ophthalmology services appropriately and I said absolutely right John that is exactly the aim that you must have and hopefully that is the aim that the link will help you deliver so at that point I think I'll stop talking I'd like to thank you so much for allowing us time to clearly work to be done it's a great pleasure for my colleagues they've all contributed to the program and I think I'll stop talking there and us on to either John for the last or Melanie to the participant part Thank you Mike, this is an excellent report on the journey we have had together and we look forward to continuing with the new president and the whole of the Royal College and we still have a long way to go we appreciate where we came from but the way ahead is also a very long way and we hope to continue to work with you I think we can hand over back to Melanie for the poll Are you there Melanie? Sorry thank you very much Mike and John so as well as this day being a great celebration it's also an opportunity to share a lot of the learning that we've gained from that and this sharing of learning isn't only from the speakers to all the delegates but we definitely want all the delegates to participate in that sharing of information as well so we've built in a couple of small group discussions so you can talk amongst yourselves and also some large group discussions for the whole group and also some questions and answers as well so if you'd like to submit questions to the chairs or to those discussions you can please enter them in the chat please try and reserve the chat to everybody purely for the questions to the chairs because it makes it much easier for us to sift those out but also what we'd like to do is for you to share everyone's opinions with each other to find out who we are what we think and how we can share ideas about moving forward so I'm going to move on to Graham and ask him to please put up the first poll so what you need to do is use your keypad to select the answers so it's where do you work and then you just need to select the option so it's either Europe, Africa Asia Pacific Islands and Caribbean and then the rest of the world which might be the states, Australia and anywhere else right I think the bars have stopped moving so we will end the poll there and we can share the results so John I don't know if you've got any comments on that but I wonder whether we should rerun it because only 28% voted I wonder whether it might be worth running it longer okay so with trial run let's do that again I'll relaunch the poll so there's a lot of new things that we're doing here some of you might be familiar others might not so we'll give you the opportunity to do that poll again so I'm just going to relaunch that and we're going to continue now to vote even if you voted last time please vote again and we'll just see if we can get everyone included on the voting well we're up to over 300 attendees on the line and that looks at the polls stop moving there so I'll end that and share the results so John any comments on that John can you unmute please Africa 23% only 48 voted from Africa maybe it was a challenge to know where to vote I couldn't vote myself for example so and then Asia Pacific 6% and others US Australia 1% so we are covering the whole world as you can see lovely right so we've got a second question for you at this stage so if we can just go on to the second one please Graham so have you been involved in international ophthalmology so there are various ways you might have been involved have you held a post in a different country or a different continent rather have you performed clinical work while visiting another continent have you supported and learnt through an organisation partnership with another country or are you just hopeful that you might be able to be involved at some point in the future in some way or other so there we go the bars are still rising so keep voting there we go Mike perhaps I can ask you to comment on this one I hope you can can you hear me yes we can thank you I've known for years yes there's clearly there is a risk that we may be talking to the converted but it is really very nice to see that so many people have been involved in overseas and along this is a reason why we are committed to the college and why link to I think probably going to pass back if that's alright provided a serious challenge to our next chairs of controlling people's enthusiasm to talk about the links in five years stints so I think if we start a couple of minutes that might help Simon and Will to get through the next session more or less on time