 We'll get started with Grand Rounds. So today for our first presentation, we're hearing from Dr. Harry. And Dr. Harry is, as you all know, works a lot with ultrasounds. Then lately, he's also been coming to the DA for about the past. We've gone on two years in July. We've gone on two years, yeah. And that's, for us as residents, been really nice to have a chance to work with Dr. Harry, especially the interns work with him. And I know that I think that's a huge advantage to us. We all really like working with Dr. Harry and really respect him. And today, we're going to be hearing about some of his work at a juvenile detention center. And then following Dr. Harry, we'll have a second presentation. I'll introduce the speaker at that point. So thanks very much. You know, we're very fortunate to belong to a very high-impact, time-intensive profession. You think about ophthalmology. You think of the time spent per patient, what we can achieve as far as helping patients see better. And I thought about this a lot lately. As I reflected on my career, I'm sort of in a transition year this year, I'm going from comprehensive practice into more just strictly ultrasound. And my last surgery day was a couple of weeks ago. And I sort of thought as I did my last case, my last surgery patient reflected back to 40 years ago when I was first training. And in these days, we had intracapsar surgery. So we'd bring the patient to the operating room. We'd give him retral bulbar, give him lid blocks. We'd make a big incision, 140-degree incision. Then we'd go with a cryoprobe, liquid nitrogen. We'd freeze the tip of the probe to the lens, kind of rotate it out. And before that, we would put alpha chymotrypsin in to soften the zonules up. And what a paradigm shift. We used to not like zonules. Now we love zonules. We treat them with tender-loving care. But in those days, those pesky zonules get rid of them so they could get the lens out. We'd bring the lens out and put five to 10 stitches in to close the eye up. I think my first case took an hour and a half. And finally, the next day after surgery, the patient looks like that. Afakik, I couldn't really see much because they didn't have a lens in the eye. After about three months, we'd put them in Afakik spectacles. So that was how I trained in surgery. And my last case two weeks ago was 20 minutes. You know, the next day, 20-20 vision on the eye chart. If I could get a time machine and transport a professor that I trained under at UCLA and have him sit there and look at that patient, he'd had no idea what we did. He'd say, this is magic. Like there's no stitches in the eye. The patient's saying, 20-20 on the eye chart. Well, how did you do this? What miracle had occurred? Well, along the way, there was a lot of things that had to occur to have that miracle happen. This was Kohler, back in the 1800s, who first got the idea about using cocaine anesthesia from a classmate named Sigmund Freud. And that revolutionized eye surgery rapidly. One of those things that just have a high impact. The world was ready for that. When he announced this, within about a year, it was widespread throughout the world. And that became the standard of care to numb the eye with cocaine drops instead of having to hold the patient down and have lightning fast surgery and almost couch the lens to get rid of it. So major innovation. Helmholtz ophthalmoscope, be able to see inside the eye, see pathology, glaucoma, diabetic retinopathy, all these things that we see now so easily couldn't be seen before that time. And of course, the innovators, the modern ones, we have Ridley with the intraocular lens. We have Kelman with Faco, which is standard of care now. Yet, they had to go through a lot to bring these things along. There was a lot of resistance, a lot of derision of them. When they first announced this, had to fight the establishment, but finally prevailed. And what we have now with our modern surgery and machimer with vitrectomy, I remember days at UCLA with diabetic retinoclinic. I used to dread that day because diabetics with hemorrhage, anything complication with hemorrhage inside the eye, we had nothing to do. Ridley, we couldn't get the blood out. There's no way to do it. So we'd say go to bed for a couple of months, keep your head down, don't move, try to get the blood to settle down. That was our approach to hemorrhage inside the eye. And that was just an easy 20 minute procedure with modern vitrectomy techniques that residents can do. So these innovations, these things that have occurred are so amazing in my career that I reflected back on that first case and last case of surgery. A lot of this translates too to underserved areas of the world. A lot of our modern technology parts of what we can take with us and do amazing things in countries that don't have access to care. We have Randy's vision to be able to see this and to create a department here of international outreach and community outreach. We have a boundless energy of Alan and Jeff who lead us in how to go and help people and do things that make such a difference. So we're very privileged to be able to be part of this and see this as part of the residency training program here to have residents have this experience to be able to be part of this and have that planted inside of them. Again, thinking back to my earlier days, this in fact was our residency program at UCLA at Jules Stein back in 1976. Randy was supposed to be there. He was, I guess, out that day, probably doing at a meeting or something, but anyway, this guy here, I did have hair then, more hair and less gray than I have now, but that was our program at UCLA, but it kind of planted the seed for me. They had an outreach program, both the mobile eye clinic that we used to go on and see local populations. And also as part of senior residence, we would go down to Tegucigopa Honduras, the big charity hospital called San Felipe in Tegucigopa and spend three or four months there as a senior residence and work at this big eye hospital. And it was quite an experience. I remember as I arrived in Tegucigopa that same night, the resident I replaced for the next rotation took me on a tour. He went to the hospital and we went in the ward and saw the eye patients. There were 20 beds of eye patients and I was taking notes that she was going through each patient, but there were 20 beds with their 40 patients because they had two patients per bed, one head at one end, one head at the other. That was our eye patient ward. And that was, I finally said, well, that's a lot of patients. I was writing out these notes. She says, that's the male ward. Let's go to the female ward. 20 more beds in the female ward with 40 more patients. So 80 eye patients in these beds. The next morning was eye clinic. I got there early. They were lined up down the block to get into the clinic. I spoke a little bit of Spanish, not much. And just these Roger patients just coming and coming and triaging and trying to decide who got surgery, who didn't, what to do with them. And the price of admission for surgery was a pair of glasses from a hardware store. Plus 10 lenses. They had to go buy a pair of plus 10 lenses for $4 or $5 and a bottle of eye drops. That was how they got into eye surgery. They didn't have that. They couldn't have the surgery, so that was required. And to many patients, that was probably a month's wages or more for them to have that. So anyway, under the International Eye Foundation, their auspices, we went down and did that as senior residents. And that experience of seeing these patients, and seeing what can be done even with those earlier techniques, the difference you could make with blind patients, kind of planted that seed in me that has persisted throughout my career. I've had the opportunity many times to go with different groups. I've gone with Orbis. I've gone with See International, LDS Charities, and been able to go to different parts of the world and do teaching, training, working with patients. So that kind of foundation has been laid as part of my residency training. And that's the neat thing about Moran Eye Center. That's a very strong emphasis as part of the program. And being able to have residents have that experience. And it's not just internationally. It's actually even more locally. We have that experience to be able to go here to the reservations. And there's a picture of Jeff here pulled from the internet. That's a very good likeness of Jeff, a very nice picture. And I saw Jeff in the hall yesterday and just asked about programs in general. My sense is that many ophthalmology programs probably do have outreach kinds of efforts. And Jeff, would you just maybe spend a second and just say what you told me about your paper that you've done on that? Yeah, yeah. So he did a survey of all ophthalmology residents. He's asking specifically about international involvement. And depending on whether they allowed it or not, whether they allowed two weeks or four weeks, whether they financially supported it and a number of other things, he came up with sort of a ranking with residency programs based kind of international outreach efforts or commitment. And Moran was actually not surprisingly the clear outlier. I mean the clear outlier on what for us is the good end. It's rare in academic programs to have an actual outreach division, I don't know if Michael Yake can comment on that or not. It's incredibly rare for that. Oftentimes, a residency may have a free clinic that a resident can go to or sometimes don't require it. But that typically is the end of the involvement. However, there's a massive move over the past 10 years. At least 50% of residency programs are now trying to offer some sort of international ophthalmology opportunity for a number of reasons. But one is, residents just want to do it, it's an interest and they're coming in asking, how can I do it, where can I go? And so it's definitely changing. Okay. Any rough idea? I want to point out too that part of our service we have Jeff Petty literally carrying patients from the doctor. Well, that's right. Only a little, little ones. Alan carries the heavy. And Randy, you missed this picture, but I had to show it to you that go back in your time machine here. Oops. There we go. Oops. Right here. No, you weren't in there. Somehow you were gone that day. That was our residency picture at Jules Steinback in 1976. Remember that? They had absent members and you weren't there. You were probably at a meeting or something. Probably planning the future. Anyway, so. Well, thanks, Jeff, for that. And I think that's, you know, a lot of residency programs are certainly aware of that and the impact you can have on residents. Again, local community. The Moran also is involved with the Fort Street Clinic. I think a lot of you have done that. The Malahe Clinic, kind of the working poor. These kinds of efforts to reach out locally and to help people have the Operation Site Day where we have free surgery several times a year and many people involved in that. So a lot of opportunities to serve. And I know even in general practice, I know sometimes young ophthalmologists say first art practice is kind of hard to take off on these trips. You know, you got to kind of build a practice. You have a young family to take the time. But the neat thing about our specialty is you can do things just on a daily basis in your office. I mean patients with that insurance, you know, that you can help. The Academy of Ophthalmology has the I Care America program. You sign up for that and you commit to a certain number of patients per year that you'll see that can't pay. Health Access, Assault Lake County Medical Society has a program similar to that where you agree to see certain patients per year. So just many opportunities for us to do that. And that's the neat thing about our specialty. We can do that almost on a daily basis and be able to have this opportunity to help and to be part of that. Well, this leads up to what I'm talking about today. This is Assault Lake County Youth Attention Center. This is about 9th West and 34th South. It's down by the right across in the gel. This is for young people kind of 12 to 18 years old if they're committed a crime and they're picked up. This is where they're taken immediately. So if you're reading the paper about somebody that was involved in a crime, they're often not named because of laws about juveniles, but they're taken to this facility and they're placed there. And this is kind of a triage holding facility that I've been involved with for a number of years. It's actually through a church assignment that we were actually called on there initially to help these kids with kind of spiritual principles and life skill things. But while being there, I realized how many of these kids can't see very well. As I taught classes, I would see them squinting and they couldn't read the words on the board. So I kind of got the idea to maybe do some visual screening while I was down there and just kind of set a program to do that. Just a bit about the detention center. This provides again short term lockdown for kids. So they're picked up for a crime they're taken there night or day anytime of the day. And they're placed into a holding facility. And they have eight different units. They have six boys units and two girls units. And each unit has a number of rooms inside with secure doors. And it's a triple lockdown facility. As you go in the front, you go through the three lockdown facility and there's a control tower to kind of direct all that traffic. But these kids is a typical room that the kids are in very stripped down, very basic. And they have to watch these kids. There's sometimes suicide attempts and other self harm things. They have to kind of really keep a close eye on them. The statewide admission guidelines are what are the reason the kids are sent there. A juvenile judge has the ability to sentence a kid to go there or to stay there for a certain length of time. And these are offenses these kids commit. So it's a much more than just shoplifting or smoking a joint. These are major crimes. And these kids are just amazing sometimes to look at these kids. They seem so innocent, so young, one on one, but yet there's some pretty terrible crimes that are committed. And so often just poor choices, kids that are impulsive and very bad home situations and the reasons for this, but still there's some pretty serious stuff going on out there. And these kids are sent here for these reasons. They are entitled to hearings. When they're first placed there, they have within 40 hours, they have to have a hearing. There's kind of a room with a closed circuit television that juvenile court judge can actually see the kids without having to come to court when they first get there to determine how severe the crime was, what the deposition is gonna be, if they're gonna stay there for a while, they're gonna go to another program, go to long-term lockdown, different things. This is Judge Valdez, one of the famous juvenile court justices that just retired a year or so ago. And he has quite a history. He himself as a child grew up in kind of a poor area in the city and sold newspapers, ran around, got close to gang activity, but he turned it around. He had a mentor that sort of singled him out and started working with him, taught him how to play tennis, taught him how to work in school. He actually got a tennis scholarship to the U and went to law school to U on a tennis scholarship. So, and he's became a juvenile court judge. So he can relate to these kids and empathize with them and counsel them and advise them about things to do to help them improve their lives. Some kids aren't placed in this facility for different reasons. If they're runaways or truancy issues, things like that, they're placed in other facilities. They have foster care. They have group homes. They have proctor homes and other things that these kids could be put in that don't require a lockdown. There was a story in the paper recently about an eight-year-old boy that was dropped off at a hospital just by the mother because she couldn't handle him. So she just kind of dumped him there in the front door of the hospital. They didn't know what to do with him. They liked to place him in, I think, a proctor home, but there are facilities that kids can go to that don't require being locked down in this facility. They can also be confined to home confinement and they monitored there, again, feeling that the level of danger to themselves and to society. Well, while I was there, I just sort of out of curiosity wondered about the number of kids here versus outside detention that had refractive errors. Again, I've seen these kids. We began this program of screening kids. We have an auto-refractor, a handheld auto-refractor that we go around and check their eyes with and we have different powers of glasses. I used to try to order glasses and get into the kids, but these kids were so transient that they'd come and go so fast. The time I got the glasses made and went back, they were gone somewhere and I couldn't track them down. So I just go to zinni.com. I'm their best customer and I order many glasses a month, different powers, different strengths. I just take those with me. I have a little box of the glasses. I pull them around and right there on the spot, we can fit glasses on these kids. So that's worked the best. Some kids that we can't fit, we do try to get glasses for other sources, but it is a problem with their transiency. So worldwide, refractive error is actually the largest cause of visual impairment in the world. We always think of cataracts, glaucoma, the more dramatic things, but actually simple refractive errors really are a major cause of disability and many countries can't really afford glasses. Estimating almost a billion people don't have access to corrective lens as something as simple as a pair of readers to be able to read after you're Presbyopic. Visual disorders are the fourth most common disability of children and the leading cause of handicapping conditions in childhood. So it's a really big problem among kids. Again, we think of third world thing of developing countries, but right here in Salt Lake City, we have kids that don't have access to glasses that could really be helped by them. As I looked different studies, the numbers around 20% or so in different countries, more developed countries, you get more remote areas, you get higher instances, India as high as 50%, Asia probably that is higher, higher. United States studies showed around 15% by the end of grade school that need glasses for myopia. So the study that we did, we looked at over two years, about 1,600 kids that were screened, and we gave glasses to 569 of these kids and referred 22 of them for problems such as amblyopia or other problems that couldn't be corrected by glasses. One of our texts from the Moran that helps me out, we have about six of them rotate on every week and go with me and help screen these kids. So we simply checked their vision on an eye chart. We have charts in each unit and have them read the eye chart. And just based on that, we sort of do an initial triage screening that they can't see better than 2040 will then auto-refract them and then determine the refractive error from that. If they're 24 year better than we usually don't unless there's some major problem that they can't see. And I compare this to a junior high school population. I got some numbers from the PTA that does a lot of the screening for kids in junior highs. I tried to get a kind of a comparable population and determined from that that almost 400 refractive errors had enough to require glasses for us or about 22% of these kids. So if you compare the numbers in the DDT population, 34% need glasses or refractive errors enough to merit getting glasses compared to the junior high school population, about half, just almost half that. So a very significant P value and odd ratio, obviously very different in these two populations. So my texts again that go around with me, you probably work with some of these, Marcella and Riley and Marissa and Elizabeth that are helping me out. So very faithful in doing that. And every week they just take turns coming and make the rounds with me and see these kids and give glasses to them. Types of refractive error. We saw a lot of variation. Anisotropy, astigmatism, again, these require special glasses. We have to special order. So that's always kind of a challenge but we do the best we can. But these are glasses that we give. We can give to kids right on the spot. And amazingly I've had kids as high as minus nine, minus eight that never had glasses or contacts. Imagine a 16 year old, just how does that happen? Well often it's dads in prison, moms under rugs, brothers in a gang, they're foster cares, homeless, bounced around, they just don't get, they just fall through the cracks in the social net. So right here in Salt Lake City, we got this kind of a problem. We got minus nine, how blind can that be? That's worse than sometimes a dense cataract. So anyway it shows around us everywhere there's a chance to help and to serve, to use our skills and knowledge to be able to help people. And again the auto refractive, we just use this Nikon unit that works quite well to be able to determine refractive errors. Also just as a side interest, I kind of wondered the correlation between visual acuity on the eye chart and refractive error. Does a minus one always mean 2040? Does it mean 2050? What actually does it mean? And there actually there's quite a spread. I just kind of get a little graph of this just to show there's a lot of variants. The 2040 can be minus one, minus 125, even up to 2050. So there's a lot of up and down. So one person's minus one could be 2040 and other person's could be minus 150. So it's funny how the visual system is not just the eyes and the refractive error, it's other perception issues that make your vision worse or better than it really is. It's pretty obvious this isn't rocket science but when kids don't see very well they don't do very well in school. I think that's part of the problem in this population that there are a lot of challenges for them of course. They have a lot going against them with their home situations, but school performance, I always ask about that as I give glasses. I say, okay, now we're gonna give glasses to you. What are you gonna do? What are you gonna pay back for the glasses? And they say, well, try to do better. I say, well, do better in what? I always stress school. I say, what grade are you in? What grade in school? Well, I think eighth grade I'm not sure because a lot of them don't go to school. You know, they haven't gone for a while. The DT does try to provide that. They actually have a school during the day. They have school teachers from the district that come in and arrive school. But a lot of these kids are transient again. They're there for a short time and they go somewhere else. So school is really tough for these kids. But if they can do better, I stress that, that your one key to the future is to do better in school and try to focus on school. And these glasses will help you do that. And they really, they understand that. They can see better. They appreciate that. And I challenge them to use those glasses to try to do better and make better choices. So hopefully it sticks. And it's hard to get follow up. We don't have the resources to really follow these kids. I'm guessing about maybe 80% do keep their glasses and do use them and take care of them. But about 20% probably don't. They just kind of a transient thing with them and they don't take care of them. So again, Helen Keller, I started with a quote from her and I like this quote, although the world is full of suffering, it's also full of the overcoming of it. And again, we have this unique privilege of being ophthalmologists. It's incredible, especially. That's what the impact we can have just from a simple pair of glasses to advanced surgery, vitrectomy or cataract surgery, being able to help. All of us probably have friends that want to help. They say, can I go and campaign with you? Can I do this? But we say, oh, I'm sorry, we can't. You really need special skills to do this. The things that we do really can't translate to the general lay population. They want to help. They just don't see a way to do that. But we have that unique gift. So I'm just very appreciative of that. Again, this part of my career, I'm sort of phasing out that part of it, being able to look back and see the changes that have occurred, the progress, the innovations of pioneers that have laid the ground for us. So anyway, it's just a humbling, very appreciative sense that I have of what I've been able to do. So anyway, thank you for that privilege. I've asked a few residents to at least send a thing out about any residents that have had experience in an outreach program to share just a brief experience or how it impacted them. Anybody have a chance to think about that? And Julia, personally for you for the future, has that done anything for you? Has that impacted you? Great, thank you. Anybody else? Yeah. It's interesting as you talk about this problem with not wearing glasses. The other side that I personally couldn't relate is the stigma sometimes associated with glasses. So before I lasked, a lot of you remember me, Roger, when I had to put on these glasses, I was quite excited. And in high school, I always had a reputation to go door key, they made me look door key. So I go around without glasses and I know I was legally blind. The sense related to people is that you were so stuck up in high school because you wouldn't walk by and wave. I didn't wave, I didn't know who the heck I was saying. Right. So it is interesting that we may provide them, but I can think of a fair number I know who wouldn't wear them just because they don't look good. We gotta think about that. If they're not using them, then they're still essentially legally blind at what they're doing and where they are. And then the other one is that there's some interesting new work that just come along about the incredible increase of my organization, which is considered part of people so involved in not being outside and outdoors and so involved in video gaming and smartphones and the rest and some evidence that we're about ready to see a tsunami change both of my own people, particularly pathological ones. So both of you were just training, I think you're gonna see all of them when we did. And even to the point now where they're starting to recommend the kids at least should go outside for one hour and try to get them outside for one hour a day because that seems to correlate, but there's a big body of information on this. Just sitting on the video game all the time and the societies that have done that where there are some groups now where they're, myopia rate by the age of 50 is getting up to 80%. Asian populations especially in them. Yeah. And that's what it correlates with. Now atropine I know at one point, actually you did a paper on that years ago, I think you did with one of the local doctors here about atropine, does that anything come with that? So the latest is a study that came out of Singapore and actually the first serious long-term longitudinal study looking at myopia prevention with atropine is a paper that we published with an ophthalmologist up out of Ogden that came out of here, oh my gosh, 25 years ago. And the latest is that you can avoid a lot of the side effects by going down to a dose of 201% atropine and yet still have some prevention of the axially elongation. And there's debate about whether or not that should be a routine that if you're showing a myopia of progression or coming on an early age and the kid should be routinely put on that and that's a big battle inside the field. But I wouldn't, the data looks pretty good. I wouldn't be surprised if we're gonna start actually that's if they're showing that myopia of progression is coming on early and that there's gonna be a product out that is gonna be a very low dose atropine once a day for those people. So it's pretty good study, but it's a Singapore just I don't know, it did find a comment in the current but it just was a recent one in which they showed you could get a lot of the effect with not many of the side effects of that very low dose. Right. You think the Asian populations with such a high incidence might, that might be a major thing that they consider doing too. But they have societies there in which people were largely looking at distance where a lot of people were illiterate, not messed up reading in which none of them are nearsighted and then their kids who all have smartphones and the rest is some of the rural areas in China and 90% of the breeds of myopia. Right, right. So clearly the correlation is very strong. Genetic predisposition obviously varies from place to place but the feeling is is that this idea that you don't go outside and you video game all the time is just really starting to become a pretty important player in after threats of the world and we're just beginning to see a type of huge change into this problem where it's gonna become predominant. So many people are in a very immediate position. Exactly, yep. You can get that by being through lighters or other low-priced devices, the lighters they're aware of. So the low dose, you can get real low concentration. There was a counterpoint recently and they're talking about getting an editorial I know in AGO about this, about where we are. But they're still controversial, they're not, but I think the evidence is strong enough. I think it'll become, I predict within five to 10 years this will be standard practice here. Quite, yep. So about your comment that it's hard to get follow-up after this intervention. I wonder and have wondered for quite a long time if as a result of the intervention that you and that Dr. Olson has also discussed here, if one could get follow-up and it may be hard but I don't think it's impossible if we would then see a decrease in future criminal activity because of these interventions. We're actually doing kind of a sub-study now in the same population. We're looking first of all at racial tendencies towards refractive errors and also crime, violent crime versus less violent if there's a correlation to that with degree of refractive error and then follow-up with that maybe to see if it makes an impact. So that's a very good point. That'd be a long-term study and require some effort but I think that's doable. So I agree, that will make a difference hopefully. I know I was called in one time, I was like Sunday night, they called me from the DTA and said, I got, did you come down? I said, okay, there's a kid transfer from California. He was like 12 years old, just totally out of control, just combative, fighting, just couldn't handle him. I had to put him in an isolation cell. So I came down and they got the sense he couldn't see very well as part of the problem. So I refracted him, you know, minus seven and a half or something, no glasses. I gave him a pair and like, it was like valing at this calming down, like he immediately could, you know, he was, he calmed down, he could go back in the general population because he was combative, because he couldn't see, he was afraid of being attacked from the side, he couldn't see what was coming at him. So, you know, that's an example of just, you know, what I can do to somebody that's kind of out of control, just to be able to see better when they can't focus, they can't see, they're afraid, they're scared, don't know what's coming. So, any more questions or comments? Okay, thank you.