 Good morning everybody Thank you all so much for coming this morning and it gives me great pleasure to introduce my partner of Almost 20 years now Sonduk Ruit and Medicine is really a bastion for risk averse overachievers and people who fall into a a small safe zone and try and stay with it And there are just a few innovators. I've had the privilege of meeting in my life Who always strive to do better who think how can we do something a little bit better? How can we change things? How can we improve things? And they're also just a few people I've met in my life who really look at the world in a large perspective From all different religious perspectives Philosophical perspectives and think how can I make our world a better place and to have that combination of the philosophic thought of how can I make our world a better place and Never being satisfied that what I'm doing now is good enough I can do something better. How can we make things better? How can we improve our world and if anyone I've ever met at any university? Any place anyone in medicine? There's no one I've met who's changed our world more than the person. I'm very very proud to introduce Sonduk Ruit There's you know govindapa Venkantan Swami the founder of Aravind Eye Hospital there's Maybe nag Rao in Hyderabad, but next to that There's no one in the world of international medicine that I can think of that has changed our world The way Sonduk Ruit has and it's a great honor for me to save Professor dr. Sonduk Ruit from Nepal here with us this morning. Thank you all so much for coming Thank you very much Jeff and Jeff as he had pointed out We have now together Been working for almost a little more than 25 years in this wonderful Journey that we had you know and this morning. I like to Say a very nice. Good morning to This wonderful group of people here at the moran's eye center some faculty members some managers some residents some students and You know quite a few of you have come and visited us in Nepal and We take great pride in saying in Nepal and elsewhere that We have a great Collaboration with the University of Utah moran's eye center and this morning. I like to take you And so you some of the works that we started bit by bit in the early phases and how we have come and mostly on cataract surgery and Our Jill right from the beginning has been how Could we provide the state-of-the-art cataract surgery? To the community in a country like Nepal and elsewhere if you look at the cataract blindness worldwide You know, we don't really have a the World Health Organization doesn't have You know specific data's but we have some data's which are available to us and according to this data's We believe that about 18 million people of The 39 people 39 million are blind with cataract So almost 50% of the of the blinds are mostly with cataract and if you look at The other category of visually impaired with cataract if you take 660 which is 20 by 20 by 200 then the number of you know Visually impaired with cataract becomes about a little more than three times and if you take it with 618 it becomes little more than eight times So it's very important for me to let you know that this category of Visually impaired with cataract is important because most of the surgeries done globally right now are on these patients Not so much on these patients. So I always say that the real Blind cataract patients are cocooned By patients who are seeing better So these patients who are outside sick surgical services and we who can provide them surgical services Faco emulsification we've become so good now that we tend to take up patients with little cataracts and We know vision is very it's very predictable So a lot of these patients get surgery quite early but again, you know the the ones who are really blind really gets Stayed away and some of the reasons for this blind patients to stay away is with the severe advanced cataract is because they are deprived socially and economically and Because it's very difficult to reach them through transportation and other amenities and again. I say it's you know cocooned now it is estimated that Globally in 2011 About again, we don't have specific data, but I may be correct one million plus and minus that we have about 23 million surgeries per year globally yeah, but unfortunately the iniquity is so much that in some countries you have the Luxury of having about 8,000 Attracts surgical rates per year per million population But there are some countries in the world in the same world Where the CSR is less than 500? And we still have lots of large countries where the CSR is less than 500 and About 33% of the countries have CSR less than thousand And just about 6% has more than 4,000 of course this is increasing now and I try to get into this figure and Let you know let you present this and if you look at this is The number of people who are blind with cataract and these are the category of patients who are visually impaired but operable cataracts and since The 23 million of people were doing globally surgery Most of the patients fall in this category you know and We have done only 23 million, so we're still left with hundred twenty twenty one million per year to do surgery If we continue to operate like this, I hope I'm making my point clear, you know see if 18 million is the one which is truly blind and then there are categories of Cataracts with visual impairment not so mature, but in this category of vision and As you know that in most developed countries and a lot of urban urban cities and developing countries Most of the cataracts done are in this category You know because now we are able to do it because the results are so predictable and that's why I Think if we continue to do like this then I believe we still have About hundred twenty one million to do every year. We need to do more surgeries and This is to look at the challenges of cat doing cataract surgery in a community particularly in developing country and I'm looking at a broad challenges and again inequity in terms of quantity in terms of quality There are only very few countries where intercap is being done now Fortunately intercaps almost now Going away from most of the countries, but still plan extra cap with sutures are done quite in many places the world and A lot of small incision surgery is coming up and of course Faco, so There's a you know so much in quality But it's again important that you address the cat right mind and As I said the magnitude of the operable cat right much much higher And there are geographical challenges and there are government and bureaucratic challenges people You know like Jeff me and Alan and many of your friends, you know Hoping the Bob there we all face this problem when we go to work in other countries And although I put it down here the government and bureaucratic, but it's a very important challenge that we face when we go and do charity work now trying to Limit the challenges a little bit more specifically to the cataract surgery. Yeah now working conditions are different and The Suboptimal the microscope may not be like you want The surgical instruments may not be like you want the power supply may not be like you want There are many other things and of course the very important thing is team team is so important and team building is so important for work in our part of the world and Finding cataracts in its various stages from early Immature PSCC to very advanced and different types of cataracts and mature different maturity cataracts and again equipments and instrumentation and Then the large volume of cases that you have to encounter so these are more specific challenges we face and This is something that I like to particularly Have our young Future of terminologies to look at something that I had my in my mind, you know, we started from here with actually micro in season if you look if many of you some of you who know about couching Couching is actually a micro in season We just put a small Nick there and then push the lens backwards. You don't need to give stitches and it's so small It's probably about less than one millimeter So we started with couching with micro in season and we were quite happy to have a vision of finger counting So that was many years ago, you know in the early 19th century and late 18th century and then you had different forms of plan, you know different forms of crude extra caps the devils linear expression and Extra caps where we went in with a force up like this and and you know Bite the anterior capsule and takes the material out But still a lot of things are left behind, you know, the eye is very strongly reacting and then After extra cap with the problems with the extra cap people shifted to intercaps And because intercaps you take the lens out there isn't much reaction those days There were no microscopes people are either operating with bare eyes or with simple loose so it was Harold Ridley who I think Just feel I you know He was I think he was practicing in St. Thomas's Hospital, isn't it Alan? Yeah, and He got this idea from a resident Who was watching his surgery from the back when he did an intra cap surgery Once he took out the lens and the resident asked him, so are you not going to put another lens be back? So that's how he got the idea of putting an intro or lens and of course the rest is history and but that time They were using very large lenses and the extra cap was very crude Still being done with loops and left behind a lot of cortex a lot of other materials so, you know He faced his own Challenges in the beginning among colleagues in other place other people then slowly People started doing Intercaps and anterior chamber lenses and iris fixated lenses and the scene actually shifted for a short time from England to Netherlands Where CD being cost started doing the? the wonderful iris clip lenses and and then from intercap again went into finer extra caps and Then came to states and I think shearing started the the first posterior chamber lenses and About that time Little bit later, you know, Blumenthal was starting his Small incision surgery office based using the entire chamber maintainer in Israel Yeah, a little bit later, but about the same time or a little bit earlier Helman was using his fake emulsification and The machine was very big. There were a lot of problems, but there's a wonderful idea and So the machine was put aside and we moved ahead the mission didn't work for five six seven years And that's how things sort of you know come forward and then We had a challenge of taking the extra cap IOL into communities in a country like Nepal Well, I'll tell you a little bit later and then we started modifying the small incision surgery to suit for non-office in Community in large number of patients and hundreds and thousands of patients How could we do this in a more efficient way? And of course you had You know then fine-tuned fake or emulsification and became a stand-up surgery for a cat racks in the West and then now coming back To rollable lens and micro incision you say again So you're finally started with micro incision you're back to micro incision and that's why I like to call it as a movement Backwards to forwards now catrack surgical techniques the Simple extra caps IOLs with suture. It is safe, but there are better options available now and Faco's it is very safe great outcome training and text and cost complexity is still there Although the cost complexity is getting better and training is also getting better manual small incision catrack surgery More refined modern version. It's safe cost effective great outcomes, but training complexity this is how we started way back in mid 80s or late 80s when you had You were doing switched extra gaps in this part of the world and you were taking about 45 minutes per case and using the big disposable sets and We were trying to find out appropriate microscopes appropriate techniques to use in the large volume of patients and this is actually a laboratory microscope which has been sort of you know put together and Gives a pseudo coaxial and we started putting in a lot of secondary light sources from other parts, you know So that you could see the red reflex a little bit better And sometimes you could not see the red reflex so you have to turn the eyeball around to see the red reflex properly so that's how we started many years ago and This is starting with a little better version of Conan microscope now Conan has stopped producing microscopes and we wanted to develop a simple effective technique Where we could do cost effectively very good quality surgery in that part of the world So we started working in the bush to develop the system and this is actually operating in a in a veterinary clinic up in the mountains and The person who is assisting me is now one of our senior managers and Naveen most of some of you may have trouble to Nepal probably know him That's The extra caps we used to we were operating with bare hands those days, you know no gloves then we had to wash the infarcular lens Those days because we were worried about the ethylene oxide But we don't have to do that now, so we had to wash that now So finally You know it took us nearly five years. We simplified adapted and tested and and then started Taking the system globally and through a standard operating procedures the Fred Holler's Foundation and the emerald and cataract project Under their platforms. We took it around the world You can see how several nurses stay in the station. We started in 1994 ambulatory surgery and We believe this was one of the first setups in the developing country to start ambulatory surgery and we off and Then we you know Got the idea of cost recovery where the cost was subsidized through cross subsidy And the surgical modification on a production line approach Again, I was I was talking about geographical challenges, you know, these are the Some of the places that we need to And team is very important building team is so important if you're working in a country like ours and many other countries in the world and team again, you know It's interesting because this is a patient with a 90-degree catharsis And we're trying to operate the patient on the microscope and one of the ways we found it's effective is lifting the patient's leg up for some time till we finish the surgery and But I'm just trying to say that team work is so important Yeah, this is again team, you know, a lot of our team members are you know used in different And again number I said number because the number of patients we have to do is really large numbers and logistics, you know logistics of Electrical supply logistical surgical instruments logistics of medical consumables and quality medical consumables and of course cataract, you know, you face cataracts like this and Then sometimes I'm even this, you know and look at this this is a this is a brown cataract and I Called this is a pregnant nucleus Yeah, you have a very large anterior posterior diameter and you try to do a fake or and you really land up in problem in these cases and Like I was doing a big surgical workshop in Indonesia recently and We found nearly Three-fourth of the cases were coming to the table where very mature cats mature cataracts You can see Why an alternate to Faco is necessary? You know, I think using a Faco for in a In a case like that is really difficult. I believe cataract surgical delivery system I said right now now we're coming from, you know cataract surgery to make it into a system which is very important and Because when we are delivering cataract surgery in the developing country, it has to be a system There are so many things that we need to consider It has to be safe and technically straightforward Rapid and sustained visual outcome with very low complications and should be able to address all steers of cataract Incorporate in a high-volume ambulatory setup If needed be and has to be cost-effective and address a very large target group It's very important because your target group is very large. Now. I'll just I'm sure you have seen this this video before but I'll Go through the technique a little bit Is that open like that? look at the anatomy of the anterior capsule where you have done a capsule like to me and The the the triangle the apex of the triangle here. See That's the production line approach that I was talking about and now Let me explain to you a little bit length different steps of the surgery and You know the most important thing of course every step is important, but the wound construction is very important and Capsulatomy, Nucleus delivery, Lens implantation and Capsulectomy finally The wound construction again, you know the external and internal openings at two different planes and it's important, you know When you become really good you can You know sort of manage between the two but sometimes you have to go and in some of the nucleuses you may have to go as much as 10 millimeters and It has to be a smooth bed and uniform width internal opening larger than the external opening and The anterior capsulatomy I was talking about Generally done in closed chamber. So all types of cataracts can be addressed with this Nucleus delineation and easy delivery and there is very little pressure on the pressure on the capsule journals and Some people fear of this tearing out doesn't happen if you do it properly The Nucleus management has to be done in two steps delineation, dissection and delivery to the anterior chamber, final Nucleus delivery, and we use a Corrigated Simco Canola with the 21 Gauss infusion infusion This is the table and This is you know some of our we did an early study on Looking at temporal section and that superior section. We found that about 50% of the patients had an Uncorrected vision of 680 no better with the superior while with the temporal section about 82% had better than 680 and uncorrected vision and Again the uncorrected vision with a superior and temporal section here and This is the same patient having Superior section in the right eye and a temporal section in the left eye see in the same person having so much of against the rule of stigmatism another person having Temporal having a superior and a temporal section so finally we did a randomized clinical trial comparing small insistence surgery with modern bagel and We found the visual results were comparable and Of course a lot of you know, there are individual surgeons who can do a lot of number of cases But generally we would say that two surgeons can do about 150 cases per day But we have surgeons in Nepal who does more than 200 cases a day, of course a younger group of people, you know Uncorrected visual equity in week six following the visual outcome of clinical trial that Jeff David and we did and you see uncorrected visual I could do week six month six one year and corrected visual I could do one year now just to tell you a little bit about till Ganga and The Institute has actually a intraocular lens manufacturing facility has a clinical hospital and a very strong community outreach program and an eye bank We also have academics and training and research And this is Actually some of the surgical demonstration on a 3d Video Provided to us by David Chang isn't it there and this is the intraocular lens manufacturing facility and which manufactures single-piece PMMA and Hydrophilic acrylic lenses and also capsule attention rings These are single-piece lenses We have till now distributed close to about 4.5 million lenses in over 80 countries This is our outreach program The eye bank The cornea retrieval area is of the crematorium. This is an interesting thing about our eye bank This is just next to the crematorium that they get to treat the cornea These are community eye centers that we we have established outside Kathmandu and one hospital Community eye hospital where and if you look at this is the total number of patients Going up and our target and next to is To take it to 0.5 million per year. This is the surgery floor. Our target is to take it to 30,000 But then again, there are different types of sub-specialty surgeries and I just wanted to share with you That temporal section small incision manual is great, but still training is not easy and not that easy and If you look at the causes of blindness comparing Nepal in 1981 in 2010 You'll find that the cataract is actually becoming less now There are other diseases which are coming out And interestingly the blindness prevalence in Nepal has halved in the last 20 years from 0.84 Privilege rate to 0.39 now. We are trying to address visual impairment rather than blindness now this is the total number of cataracts done in 1990 and 2000 and 2010 You can see how it has increased for a population increment and our CSR has increased from about 1500 to Capacity CSR of 7500 here. A lot of patients are from India. Of course, yeah for Nepalese patients CSR would be about 3500 I think you can see that the small incision surgery is You know coming down and I think it's going to stay around that But small incision surgery has been the main straight, you know factor for Keeping up the cataract surgical volume and now feku is coming up feku with Oldable lenses. It's great, but cost training and equipment. I think all the all the things we need to consider and Jeff Has been really instrumental in taking Tilganga to the label we have right now and through him Through our partnership with the moran's eye center We have been able to establish sub-speciality facilities in in in Nepal And it has been a working fantastic working relationship with the moran's eye center on a win-win basis and Jeff and I have some great plans on the future and I'm sure we'll sit down and discuss more about it But we have of course we face challenges But we are excited about some of the things that we're getting through and this is the great team that we have back in Nepal and I don't know. I don't think we can work without such a wonderful team and that's Dr. Rita She's now officiating back in the center and The team is you know, I just wanted to let you know that the team is so important Yeah, now just just a viewpoint that I have about Faco is You know Faco is going to come definitely but low cost and good quality. It has to be user-friendly machine lower consumable cost Intensive in a standardized training programs and it has to be able to address large target group How are we going to do that still? I mean, you know, it may finally land up to a level that it's like a laptop You know, but I don't know I don't know. I think something's going to come really now What I really wanted to share with you is What's what's really important is the safety for the patient? The patient safety is so important and whether what technique you use it doesn't matter This is a very short video that Jeff and I have Is just two minutes two minutes I think the the most important thing for doing surgery in a set of like this is the safety for the patients That's it. Well, thank you very much. Thank you Nice like this Bye