Proceedings from the First United States–Mexico Symposium on Visual Health: Priorities and Opportunities for Bilateral and Regional Engagement in Scientific, Public Health, and Health Research.
- Over 1.1 billion people in the world have vision loss, 43.3 million of whom are blind and 295 million of whom have moderate and severe visual impairment (MSVI).1 Most strikingly, 90% of vision loss is treatable or preventable and affects people living in developing countries without access to basic eye care (i.e., glasses, low-cost surgery, and regular doctor visits).2 Vision impairment and blindness have strong economic impact on the global labor workforce and the socioeconomic development of countries, regardless of income level.3
Hispanic populations are disproportionately affected by vision loss, particularly with diabetic eye disease. Among all Hispanics in the world, diabetic retinopathy (DR) prevalence is 34.6% and vision-threatening DR [defined as severe non-proliferative diabetic retinopathy, proliferative diabetic retinopathy (PDR), and/or diabetic macular edema (DME)] prevalence is 10.9%.4,5 In a recent Rapid Assessment of Avoidable Blindness (RAAB) in the northern Mexican state of Nuevo Leon, DR contributed to 29.1% of blindness; nearly one-third of the population over 50 had diabetes, 15.7% of whom had vision-threatening DR.6 In the central Mexican state of Queretaro, a recent RAAB found DR contributed to 17.5% of blindness, with 22.5% of patients with diabetes having any type of DR and 3.6% having vision-threatening DR.7
Given the visual health inequities observed in Hispanic populations in the United States (US) and in Mexico, the US and Mexico hosted on January 29, 2021, the first United States–Mexico Symposium on Visual Health: Priorities and Opportunities for Bilateral and Regional Engagement in Scientific and Public Health. Health Research.
- Over 1.1 billion people in the world have vision loss, 43.3 million of whom are blind and 295 million of whom have moderate and severe visual impairment (MSVI).1 Most strikingly, 90% of vision loss is treatable or preventable and affects people living in developing countries without access to basic eye care (i.e., glasses, low-cost surgery, and regular doctor visits).2 Vision impairment and blindness have strong economic impact on the global labor workforce and the socioeconomic development of countries, regardless of income level.3
- Goal: Discuss key areas of mutual interest in visual health’s Scientific and Public Health Research and explore opportunities to straighten binational collaborations and joint training to address bilateral and regional eye disease burden focusing on innovative, low-cost scientific, technological, and public health approaches.
- National Eye Institute/National Institutes of Health
- US Embassy Mexico City, Office of the Health Attaché – Department of Health and Human Services
- Mexican Society for Ophthalmology /Mexican Center for Preventive Visual Health
- Mexican Institute of Ophthalmology
Objectives & Conclusions
The US and Mexico have a long-standing history of scientific collaborations. However, despite the burden of eye disease in both countries and around the world, joint scientific and public health research on visual health has been done bilaterally on only an informal basis. Thus, with support from the US Embassy in Mexico City, this symposium brought together key experts from the National Eye Institute (NEI) of the US National Institutes of Health (NIH), Mexican Society for Ophthalmology/Mexican Center for Preventive Visual Health (referred to by its Spanish abbreviation, CMSVP), and Mexican Institute of Ophthalmology (referred to by its Spanish abbreviation, IMO). These partners, along with the attendees, explored key areas of mutual interest, described grant mechanisms in the US potentially available to Mexican and regional researchers and practitioners, and discussed visual health and other models of binational scientific collaboration, including training opportunities.
- Dr. John Prakash, Director, Office International Program Activities, NIH/NEI.
- Dr. Maria Julia Marinissen, US Health Attaché, US Embassy Mexico City.
- Dr. Van C. Lansingh, Director of International Affairs, IMO and Chief Medical officer of Help-Me-See.
- Dr. Jésus Jimenez-Román, President of the CMVSP.
Dr. Marinissen provided the final closing remarks, referencing the consensus among all stakeholders to recommend that the US and Mexico can benefit from creating a formal basic and applied research agenda targeting public health ophthalmology that creates innovative, affordable solutions to reach the wider population and resolve problems due to access to eye care, in particular diabetic eye disease. Existing binational scientific collaboration like the ongoing US-Mexican Network for Clinical Research on Emerging Infectious Diseases (La Red) serve as an example of successful scientific collaboration. This can work as a model to establish a novel bilateral, sustainable visual health research and public health agenda for mutual and regional benefit.
Symposium Policy, Scientific and Public Health Highlights:
- The COVID-19 pandemic has revealed how science, medicine, and public health are inherently international enterprises that are not constrained by national borders.
- Without a doubt, the COVID-19 pandemic has transformed the role of telemedicine and artificial intelligence in eye care, accelerating the adoption of a hybrid model of care in clinical practice to mitigate the risk of transmission and infection of COVID-19, while ensuring that eye care services could continue uninterrupted in the patients’ home and, when urgent, in-person. In the near future, the implementation of telemedicine in visual health should be given ample consideration.
- The US NIH/NEI is interested in bilateral collaboration supporting potential best practices in Mexico vis-à-vis telemedicine, diabetic eye care, and training, which could provide mutual benefit to the Americas region.
- The US and Mexico can benefit from creating a formal research agenda targeting public health ophthalmology that creates innovative, affordable solutions to reach the wider population and resolve problems due to access to eye care, in particular diabetic eye care.
- The US and Mexico have a long-standing and successful tradition of scientific collaboration with NIH scientists. The US-Mexican Network for Clinical Research on Emerging Infectious Diseases (La Red) is an example of a semi-formal bilateral collaboration established in 2010 after the H1N1 (2009) Influenza Pandemic that showed the criticality of long-term, sustainable collaboration at the onset of COVID-19 through rapidly launched clinical therapeutic trials. This is a model that could be followed to establish a bilateral, sustainable visual health research and public health agenda.
Scientific and Public Health Highlights
- Anti-VEGF therapy as an adjunct to panretinal photocoagulation is the recommended treatment paradigm for proliferative diabetic retinopathy, but patient follow-up is critical to prevent recurring neovascularization and vision loss.
- A hybrid remote retina screening model that combines human graders with artificial intelligence is an emerging best practice proven to be less costly to reduce unnecessary referrals.
- The real-world application of artificial intelligence in clinical practice requires further development, integration, and validation of these technologies, and connectivity barriers among lower-income patient populations need to be addressed.
Reunión bilateral de colaboración e investigación de sa
Reunión bilateral de colaboración e investigación de salud ocular
Dr. Marinissen 00:01
Doctor Maria Julia Marinissen the health attache here at the US Embassy in Mexico City. I would like my co-chairs to please introduce yourself.
Dr. Jimenez-Roman 00:16
Dr. Jimenez-Roman 00:18
Hello, my name is Jesús Jimenez-Roman. I am a chairman of the Center of Visual Health in Mexico. Thank you.
Dr. Prakash 00:28
I’m John Prakash, director of international program activities at the National Eye Institute at NIH in Bethesda, Maryland and it’s a pleasure to be welcoming all of you on this in this in this symposium in the program and looking forward to learning from all of you. Thank you.
Dr. Lansingh 00:47
Thank you John and I’m doctor Van Lansing. I’m based in Queretero. I’m the chief medical officer, Helpe-Me-See international and also the director for International Affairs for the Mexican Institute of Ophthalmology. Welcome everyone.
Dr. Marinissen 01:03
And thank you so much. We have a very busy agenda today and a set of very distinguished speakers and senior leaders that will welcome all the participants. So once again, welcome everyone to this first bilateral US Mexico Symposium on Vision Health. We think that this is a great opportunity to share notes about what the two countries are doing in the field. Although there is a hot collaboration and collaboration among our researchers we don’t have a formal agenda in between the two countries, similarly to other areas of scientific research and public health. So we came together with the support of our leadership here at the US Embassy in Mexico and my co-chairs and of course the Ministry of Health here in Mexico to see how we can advance this dialogue and find areas of interest and opportunities for joint research and joint training. So this is what we hope to achieve today during the meeting. Have an idea from our keynote speakers that will speak about the scientific areas and the new technologies that are being developed in the field and then we will learn very closely from our NIH colleagues about the entire grant application and review process. How Mexican scientists and scientists all over the world actually can apply to NIH funding and to start research collaboration with our own Institutes in the United States. With that, we as I said, you know we have a great amount of support from leadership in the two countries, so we wanna give the opportunity to some of them to welcome you all to this meeting and we are gonna start with mister. John Cremer who’s my boss and he’s the Chargé d’ affairs. I mean acting as the ambassador right now at the US Embassy in Mexico. So, Chargé, over to you, if you would like to say a few words for our attendees.
John Creamer 03:22
Thank you Maria, Julia and good afternoon to all of you and thank you very much for this, giving me the opportunity to welcome you to this Vision Health Symposium. Our embassy in Mexico City is extremely pleased to host this first bilateral meeting together with the National Eye Institute and NIH, the Mexican Institute of Ophthalmology and the Mexican Society of Ophthalmology. Of course, with the support of many distinguished institutions, including the Ministry of Health of Mexico. I think one of the things that certainly has come out of the whole COVID experience is really the importance for international collaboration in the health field. All of you, of course, knew that before the pandemic, but for people who work at the State Department and others who might not be involved in the health sector on a day-to-day or week to week basis, this has really been an eye opener to underscore the importance of building these links across the board. Because as you know. One can never be sure where a health emergency will suddenly appear, and I think that’s one of the good things which we will take out of this. Certainly at the embassy we were always blessed to have a health attache, and particularly doctor Marison, but it’s something we want to build on and expand moving forward. I give my special thanks to all the attendees, especially to licenciada Martha Caballero, my doctor Irma Zamudio and Doctor Michael Chang for the leadership and support on this initiative. While preparing for this virtual event, I was stunned to learn that more than two billion people around the world suffer from vision impairment and blindness. And yet, for more than 1 billion of them, the visual impairment could have been prevented if they had access to the care they need. It was even more striking to know that women, the elderly, people with disabilities, ethnic minorities and indigenous populations are among the most vulnerable groups. That many of these conditions could be solved or could have been solved by simply having access to glasses, low cost surgery or the chance to see an eye doctor on a regular basis. Unfortunately, our countries are not an exception to these conditions and that is why I’m particularly pleased. We can host this group of world renowned scientists and experts to explore how we can join efforts through bilateral action to address our common challenges and to support global efforts and vision health. The Biden administration has made clear from day one that international collaboration to advance global health and science based decision making are top priorities. With this decision, the United States reaffirmed his commitment to work with our friends and allies around the world to promote health and advance a global agenda that promotes health security. Clear signal that commitment was a US State. United States prompt return to the World Health Organization as a member. As neighbors, partners and friends, our bilateral relationship goes far beyond our common border. As we share a long and solid cultural, social, economic and people to people ties. As such, the security and prosperity of our two great countries are intrinsically linked. Last week’s phone call between President Biden and President Lopez Obrador underscored the importance of our cooperation on a range of bilateral and regional issues, and underscored the importance with the United States, attaches to its relationship with Mexico. We know health is essential component of our shared security and prosperity. The ongoing pandemic has showed US diseases know no borders and we need to tackle health threats through joint action to ensure the health and well-being of our citizens and that of our region. Pandemics create acute crises, but the impacts of chronic health issues caused by lack of investment in science and modern technologies, as well as inequality and access to healthcare. Our long term problems. The only way to address them is if our governments. Academia and civil society work together to find scientific solutions, provide treatment options, and ensure access to healthcare. I applaud your joint efforts to find ways to address the common challenges and vision health of our countries and to serve as a model of collaboration and science diplomacy for the rest of the world. Would also like to thank the Chairs of this symposium. Doctors, Marinissen, Prakash, Lansing, and Jimenez-Roman for promoting this important bilateral engagement. Brad, our embassy can support this bilateral effort, and I must confess I had a personal mode of participating as well. My wife is an optometrist who has worked throughout the region and actually is a graduate of the polytechnical here in Mexico City. Even though she’s from Nicaragua. Anyway, again I’m proud our Embassy can support this bilateral effort. Cannot wait to learn more about the outcome of this meeting, les deseo exito. Por se que se de aquísus grandesy excelentes initiatives, para contribuir a la salud visual de nuestros pueblos. Muchas gracias y éxito.
Dr. Marinissen 08:36
And I didn’t know that detail about your wife, so I’m so glad to hear that. Thanks again for your time and before we move forward I wanna introduce Doctor Paola de la Parra. She’s the coordinator, coordinator of Corneal transplant here at the Mexican Institute of Rehabilitation. She is an expert in vision health and she will be helping me moderate the session. So doctor Paula de la Parra back to you over to you to introduce our next speaker. I think we have you on mute.
Dr. De la Parra 09:14
Thank you very much. So yeah it is a great honor to have been invited as a co chair to these great meeting and hopefully we will have a good collaboration between countries with the NIH. This sounds really exciting so. The next person who will be talking to us is Licenciada Martha Caballero, who is director of International affairs at the Ministry of Health in Mexico. Licenciada, Martha.
Muchas gracias. Good afternoon to everybody. Let me start thanking the Mexican Society for Ophtalmology, the National Institutes of Health are colleagues of the US Department of Health and Human Services, and of course our dear friends of the American Embassy here in Mexico. For having the opportunity to be here, and I hope that everybody is well and their family is fine in this pandemic situation. I would like to recognize this initiative and the enthusiasm that the US Embassy had four promoting these dialogue in having this symposium that without doubt give us the opportunity to continue to address relevant public health issues as well as to take into consideration the importance that visual health has in today’s world. Mexico and the United States have a longstanding cooperation relationship that I might say that is vigorous and an ever growing bond. Being health, one of the longstanding periods in our relationship.
And even at a very early stage of our National History, both countries identified health as a cornerstone of our collaborative efforts. Throughout the years this relationship has evolved not only to include traditional topics like epidemic diseases, but also to include new challenges that both countries face regarding epidemiological and demographic transitions. It is importance of this symposium to have a nurturing dialogue that would allow us to build together new bridges of cooperation on public health. The relevance of visual health is undeniable, according to the World Health Organization data from 2020 an estimate of 2 2 billion people globally live with some form of visual impairment. On the other hand, in Latin America and the Caribbean. There are approximately 4 million people with visual impairments that could not have been prevented, and 6 million people with visual impairments that could have been prevented or have not been treated properly. Moreover, visual impairments are by product of unhealthy habits and an ever growing number of non communicable diseases is also part of the importance of having a wholesome approach of health. In that sense, Mexico strongly believes that with the complementary efforts that international cooperation provides ophthalmology, innovations can be offered and received. We are also sure that through joint efforts such as this symposium between also having the opportunities to identify research and clinical practice, we can improve health vision services benefiting many countries in the region, not only Mexico. We are convinced that through dialogue, argument and strategic partnership for cooperation also with international organizations, institutions, governments, and civil society, we’re going to achieve the full well-being of our communities. Finally, I want to wish the greatest success for this symposium, as well as to reiterate that from the Mexican Ministry of Health. There is an ever growing and continuous interest of sharing experiences between our two countries. And to give continuity to dialogue spaces such as this forum that will define the actions to meet the common challenges of our people, and especially in this very important transition moment in the US, we are really hopeful to keep strengthening our friendship bonds and obviously with the help of the embassy and our colleagues in the US to provide new opportunities to our very professional and nurturing specialist for visual health. Thank you so much. Muchas gracias, a todos.
Dr. Marinissen 13:59
Excellent, thank you so much. Martha is a very close collaborator of us here, so I really appreciate the kindness of your words and the support for this collaboration. So we’re going to move out to our next speaker. This is Doctor Irma Zamudio, the president of the Mexican Society of Ophthalmology. Doctor Zamudio is talking to us from Tijuana and really, her support has been essential for this meeting to happen. So Doctor Samudio over to you.
Dr. Zamudio 14:28
Nothing substitute work, no luck or professional title, when it comes to complicity of health. Teamwork is fundamental. Good afternoon. It’s an honor for me to welcome you all for this forum. We are grateful for the presence of each one of you. It is very important for us. Especially for those who don’t figures in the role or the emergencies that find themselves present here today. The medical community, including for private and public hospital, should unite and coordinate to develop or projects, and her or all. That’s a medical professional and presidents of society on Mexican ophthalmology, I and a persons to passionately beliefs and her work, especially when it’s done, has a team. For that reason. It is great honor to pleasure to see that we are restless in the need for preventative, for care, individual health. It is both powerful and exciting to weaken, unite forces and honest professional for different countries to us as one and reach our goals. And it would be for the benefits of is fundamental for all of us. As healthcare professional passionate. Welcome to all and wish all the best success. Thank you so much.
Dr. De la Parra 15:52
Ok, thank you very much Dra. Irma Zamudio. It’s a great honor having you here and our next presenter is Doctor Michael Chang, director from the National Eye Institute from the National Institutes of Health.
Dr. Chang 16:07
Well Paula, thank you very much. There are several of us from the National Institutes of Health on this panel, and obviously one is John Prakash. There’s Santa Tumminia, who’s the deputy director? There’s Mike Steinmetz, who directs the extramural activities, and there’s Lisa New Hold. Who’s a program director? And really on behalf of all of us at the NEI, I want to help welcome everyone to this conference. Yeah, I know a few of the people on the panel. Are what I would consider old friends. And yeah, I’m looking forward to getting to know the you know the rest of you know just, a, couple introductory remarks if that’s if that’s Ok. One of them is that we, at the National Institutes are interested in supporting the best science. And you know, I hope that today is a step toward discussing the potential of what we could do with Mexico. You know, the promises, and also. You know how we could overcome the potential barriers for doing that, number two, is that umm, early in my career I learned about the there’s an African proverb that goes something like, you know, if you want to go fast, go alone. If you want to go far, go together and that I’ve really found that to be true in my career that you know it would be good to find ways that we can collaborate between investigators across borders. And you know. This means Mexico Latin America programs that are of mutual benefit, and I know some things on the program here are things like telehealth and diabetic retinopathy. And, you know the third thing I would like to say is that training is an important part of the NEI portfolio, and maybe we can use today as a way to discuss how the National Institutes international training programs can be part of some of those future collaborations. So just beyond that, just a few words of thanks. You know, obviously I want to thank John Creamer, you know, from the US Embassy, you know, for your participation, you know, Doctor Caballero, Martha Caballero from the Mexican Ministry of Health, doctor Irma Zamudio. Thank you know, for your remarks, and you know, for being here on behalf of the Mexican Society of opthalmology, I see a doctor, Jesus Jimenez-Roman, you know, from the Mexican society of ophthalmology also, Doctor Miguel Burnier I know is from the Pan American Association and thank you Doctor Ellery Lopez from the Mexican Intitute of ophtalmoglogy, and you know, really, the people who put this together. I you, you’ve all spoken here, you know obviously John Prakash. Thanks for all the work that you’ve done and helping to prepare. Santa and me, you know, for this doctor Maria Julia Morrison. Thank you and you know, of course Doctor Van Lansing. Thank you. Thank you van. Let me just finish on a personal note that, Umm, you know I’ve had some. Had the chance to meet with collaborators in Mexico before and had a chance to visit Mexico City a number of times to meet with those collaborators. I’ve spoken at a few meetings in Mexico and during that time have made some you know, good friends. They they’ve taught me about things like science and Mexico and Medicine and Mexico. And you know also things like tequila in Mexico, but. You know I found. I’ve really appreciated all that and you know, I think it’s all those experiences that help shape you know our world views and you know I’m really looking forward to listening today and see what comes with it. So thank you, Paul.
Dr. Marinissen 20:09
Thank you so much. Doctor Chang is such a great honor to have you here and especially you know one of your big first meetings as the as director. We are very honored and really thank you and John and everyone in your team for the support for this meeting. So we’re going to go move to our next speaker. We’re going to start with our scientific presentations and it’s such a great honor to present Doctor Fernando Arevalo. He is the chair elect of the board of the Pan American ophtalmological Foundation and also the head of the John Hopkins Department of Ophthalmology. Doctor Arevalo is such a great honor, so please go ahead and. We ask you if you can share the slides on your screen and start the presentation, and while you do so, we will. We wanna thank a lot our senior leaders here that took the time to give us some opening and welcoming remarks to the meeting to us and to all the participants. Thank you very much everyone. So Doctor Arevalo the floor is yours. I don’t think we can hear you, but we can see the screen.
Dr. Arevalo 21:34
How about now?
Dr. Lansingh 21:35
There you go.
Dr. Arevalo 21:36
Ok, now all right, sorry about that. I’d like to thank the organizers for the kind invitation. I just want to clarify that I’m chairman of ophtalmology, Johns Hopkins Bayview Medical Center. I think this is a great initiative and I feel lucky to be part of it and having the opportunity to speak a little bit about advances in diabetic retinopathy clinical research, I’m going to emphasize management of proliferative diabetic retinopathy. Being this such an a very extent topic but also want to emphasize that some of the studies are have been supported by the National Eye Institute, but some of them are studies from the Pan American Collaborative Retina Study Group, where Mexico has a very important part with the two top institutions participating the APEC. The prevention of blindness association and Conde Valenciana as well. These are my financial disclosures which have no relevance to this presentation. I will disclose the or I disclose the off label use of intravitreal bevacizumab. So let’s talk a little bit about intravitreal antiangiogenic for proliferative diabetic retinopathy we know remains one of the most important causes for visual loss in the working population, both in developed and developing countries and currently proliferative diabetic retinopathy is becoming a major cause of lightness in many countries and one of the main reasons is because of lack of screening. Many patients get to us to the retina specialist very late and when it is really. Not very complicated to help them because of the advanced disease. There are severance that indicates that the growth of new vessels from the retina and the optic disc is a probably the result of the release of VF into the vitreous cavity as a response to schema. This is a study by Nicoletti at all demonstrating the increase of PDF individuals recovery in patients with PDR compared to other diseases. And this is another study by Lawyer Gallero at all. A classical study on active proliferative diabetic retinopathy demonstrating the same thing VEGF levels elevated compared to other patients that had inactive diabetic retinopathy. Studies have also shown a correlation of VDF levels with the severity of PDR and how there is a reduction in DF after successful laser therapy. Many patients, however, still require supplemental laser therapy and about 4.5 % of patients show disease progression that eventually will require a pars plana vitrectomy. All these difficulties and complications have stimulated a search for new therapies for treating proliferative diabetic retinopathy, such as anti VEGF compounds, but also multiple target molecules. Several randomized non placebo-controlled trials of intravitreal bevacizumab for the treatment of PDR have been published. This is when the what the studies from our Pan American Group on bevacizumab for PDR at six months of follow up, and we demonstrated a mark regression of retinal, re-vascularization, especially in those patients with PDR and a history of PRP at six months of follow up. This is another study by Mai et all vascular endothelial growth factor in plasma and vitreous fluid of patients with PDR. This is after intravitreal injection of bevacizumab and demonstrated that VDF concentrations, individuals, and plasma decreased significantly after the intravitreal injection of bevacizumab. Then comes the clinical trials. This is alarm market study that compared upon retinal photocoagulation versus intravitreous ranibizumab for proliferative diabetic retinopathy. Here it was demonstrated that treating with ranibizumab resulted in visual acuity that was non inferior to panretinal photocoagulation treatment at two years of follow up. In addition, main peripheral visual field sensitivity loss was worse. Vitrectomy was more frequent and diabetic. Macular edema development was more frequent in the laser group compared to intravitreal anti VEGF therapy. E yes with active or regressed vascularization in two years were very similar between both groups. Laser and anti VDF therapy. This demonstrates the visual acuity of patients that there was a not a significant difference, so visual acuity was non inferior in the patients that were treated with anti VEGF therapy compared to panretinal photocoagulation. If we look at the area under the curve there was even better visual acuity in patients treated with anti VEGF therapy compared to panretinal photocoagulation. So in summary, for this study treatment with a 0.5 milligrams of ranibizumab met the primary non inferiority outcome for visual acuity being no worse than panretinal photocoagulation, which is the treatment proven for more than 20 years for the management of PDR. The main change in visual acuity from baseline to two years with ranibizumab was no worse than with PRP. A superior mean visual acuity at two years. The area under the curve analysis, superior mean visual field outcomes decrease occurrence of vitrectomy were seen with anti VEGF therapies. There was decreased development of central involved diabetic macular edema as well with anti VEGF therapy and PRP was on, It was rarely given for failure of ranibizumab therapy. In addition, rates of endophthalmitis or other injection related serious adverse events were very low. So when we decide about treatment of patients with PDR with anti VEGF it’s very important to think in terms of if a patient has diabetic macular edema present as well when there is diabetic macular edema present and treatment with an anti VEGF agent is planned and we usually give six monthly injections then PRP may be unnecessary as most cases. Are most cases are treated that way and there was clarization will disappear with anti VEGF therapy? Will regressed? And if patients are compliant with that kind of therapy this is a good option. When betting, macular edema is not present, then we have to think about running with sumac being more effective than PRP and preserving central vision and peripheral vision function. But at the same time we have to take into account cost, follow up compliance and patient preference. Those things need to be considered before deciding if we’re going to create with anti VEGF therapy and laser photocoagulation and we understand that reality in the U.S. is very different than reality in Latin America, in terms of how these patients can be treated. The five year results of the of this study have been published and one important thing that came out of the study is that there was a significant number of patients that were lost to follow up. For more than about 66 % of the patients were able to be followed at five years, visual acuity in most of the study eyes that completed follow up was very good and similar in both groups. Severe visual loss or serious PDR complications were uncommon both with PRP or Ranibizumab. However, the ranibizumab group again had lower rates of developing vision impairing diabetic. Macro theme, unless we should feel lost. Again, patient and specific factors including compliance cost and frequency of visits should be considered when choosing treatment. For patients with PDR. So real world data is something different that than what happens in clinical trials and what happens if patients are lost to follow up. And there are a couple of studies looking at this. For example, this is a study on anti VEGF therapy for diabetic retinopathy and consequences of inadvertent treatment interruptions. And here they look at 13 eyes of 12 patients with type 2 diabetes that were identified. Reasons for treatment interruption including included interrupt intercurrent illness, noncompliance and financial issues. Things that are very common to or diabetic patients. Complications upon follow-up included with those hemorrhage, neovascular, glaucoma and tractional retinal detachment. Those were severe complications and despite treatment of these complications, 77 % of eyes lost three lines or more of visual acuity with 46 % of eyes having a final visual acuity of hand motions of worse. So those were very severe complications. There is another study from Will’s that studied comparison between Panretinal photocoagulation versus anti VEGF therapy that in patients that were lost to follow up. And they found 59 patients lost to follow up. There was a significantly greater number of eyes with tractional retinal detachment in the intravitreal injection group compared with PRP. There was a significant greater incidence of revascularization of the iris in the intravitreal injection arm compared to with PRP and eyes with PDR that received only intravitreal anti VEGF demonstrated worse anatomic and functional outcomes after being lost to follow up compared with eyes that received panretinal photocoagulation something to keep in mind. So continuing the theme of real-world data, the Pan American Collaborative Retina Study Group and again including 20 institutions in Latin America, two of them in Mexico, decided to look at this, and we perform a study to evaluate the effectiveness of intravitreal Ranibizumab on retinal re- vascularization in patients with PDR. Two years of follow up and this was a retrospective analysis, 81 patients, 97 eyes with retinal re-vasculariz ation participated 5 institutions from Venezuela, Costa Rica, Brazil, Argentina and Spain participated. The patients receive a complete ophthalmic examination, including fluorescein angiography and OCT, and changing vitreous leakage from retina re-vascularization on FA was our primary outcome. An assessment for retreatment with intravitreal Bevacizumab, retreatment with laser or initiation of laser treatment was performed at each visit. Recurrence was defined as an increased size of the new vascular area associated with an increase and diffuse fluorescein leakage on FA after complete or partial resolution in previous follow-up visits. We found that the mean duration of follow-up was 29 months. The mean number of injections was per eye was month for four injections the mean interval between intervisual Bevacizumab applications was three months. This is a table that shows that about 45 % of our patients needed a combination between insulin and oral hypoglycemic agents to control their glycemia and the hemoglobin A1C had a mean of 9%, so they were poorly controlled. In terms of visual acuity in our patients, we found at 24 months of follow-up that 42 % improved visual acuity significantly. 2 or more lines and 50 % remain stable. This graph demonstrates that the number of intravitreal injections that patients received there was a higher number of injections on patients that were treatment naive compared to patients that had a prior PRP. Those were the two main groups that we analyzed. In this patients we saw that about 60 % of the patients had a complete regression of neovascularization with intravitreal bevacizumab and a 17 % partial regression. But when we looked and divided into patients that had a prior PRP and those that had no previous therapy, 73 % of patients with a prior upon retinal PHOTOCOAGULATION had a complete regression of neovascularisation. And 15 % out of partial regression and compare this to only a 38 % of eyes that were treatment naive had a complete regression of neurovascularization and partial regression was 21 % in treatment naive eyes demonstrating a much robust response on patients that had a prior panretinal photocoagulation. Here we can see on this table how patients that had a prior panretinal photocoagulation had about 68 % of patients that were treated with only with anti VEGF therapy, while patients that were treatment naive in about a similar percentage needed a combination of intravitreal, bevacizumab and laser. Visual acuity improved in our patients. That’s correct, the visual acuity and OCT improved significantly. It was statistically significant. Three eyes without previous from retinal photocoagulation naive eyes and with vitreous hemorrhage did not require vitreoretinal surgery. Pars Plana Vitrectomy was however, necessary in 8.2 % of eyes. It was performed because of one eye that had an epiretinal membrane, 2 eyes presented with vitreous hemorrhage, and five eyes had developed tractional retinal detachment. In conclusion from this study, this was a retrospective multicenter study, 81 patients, 87 eyes with PDR who were treated with at least one primary intravitreal bevacizumab injection. Here, we found that 75 % of eyes with PDR that had been treated with prior panretinal photocoagulation had a good response to intravitreal bevacizumab therapy alone. However, on treatment naive eyes, 42 % of eyes had a very good response, and regression on revascularization, meaning that 58 % of eyes needed PRP or vitrectomy at the end of the two years. In patients with PDR treated with only intravitreal bevacizumab, a very regular follow up is critical. In treatment, naive eyes, intravitreal bevacizumab alone for PDR. If there is not good follow up for continued care, they may develop recurrent devascularization and potential visual loss, especially when they are lost. To follow up, they can come back with significant complications our study demonstrates that intravitreal. Well, there was bevacizumab can generate mark regression of retinal localization in patients with PDR, especially in those patients with previous PRP and recurrence of neovascular activity. When we looked at on patients in protocol as that I mentioned before, about 40 % of patients had at five years of follow-up. Still some vitreous hemorrhage. I would say that a combined treatment paradigm with anti VEGF therapy and panretinal photocoagulation is probably a better answer for this group of patients. And this has been already published. And lastly, I want to turn to preparative intravitreal bevacizumab for traction and retinal detachment secondary to PDR. This is a prospective randomized clinical trial of the Pan American Collaborative Retina Study Group. A meta analysis supports the use of preoperative intravitreal. Bevacizumab in diabetic vitrectomy is, however, our Pan American group was also the first to report that traction of retinal detachment may occur or progress shortly following the administration of intravitreal bevacizumab in patients with severe PDR that has scared some of the retina community and there is no consensus in terms of the use of preoperative intravitreal bevacizumab before vitrectomy. So the objective of this study was to evaluate the effectiveness and safety of an intravitreal injection of 1.25 milligrams of bevacizumab as a preoperative action to smaller gastrosplenic retractor minimize with traction and retinal detachment secondary to PDR. This is again a prospective, multicenter, randomized clinical trial conducted by the Pan American Collaborative Retinal Study Group. Nine countries and 13 clinical sites in Latin America. The US, Saudi Arabia and Spain with 224 patients participated. Patients were enrolled and randomized to with a 1 to one ratio to small gauge for Spanner vitrectomy, plus Sean at the control arm or a small gauge for span of tractotomy plus intravitreal bevacizumab. The study arm, three to five days before surgery. Patients were randomized 102 patients to the study group and 112 patients to the control group. All patients were accounted for at one year of follow up. This is one of the primary outcome comparisons, interpretative bleeding and postoperative vitreous hemorrhage. And secondary outcome comparisons included number of endothermy applications and intraoperative breaks. Patients were examined at day one week, two-month 1-3-6 and 12. Each visit patients had a complete of ophtalmic examination, including imaging. And we found that 80 % of our patients had a personal vitrectomy with 23 gauge instrumentation, although my personal prefer caliber is 25 and 27 gauge. These are the baseline characteristics that show no significant difference between both groups. In terms of intraoperative complications, we saw significantly more intraoperative bleeding in the control group compared to the study group. The difference was statistically significant, including grade 2 intraoperative bleeding, which is the one that is associated to endothermy applications. The use of endothermy was seen more frequently in the control group than in the study Group A difference that was statistically significant. Iatrogenic retinal breaks were present or found more frequently in the control group than in the study group at the difference that was statistically significant? In terms of visual acuity, we find that there was a trend toward a better visual acuities in the study group with an improvement of two or more lines in 73 % of eyes in the study group. The difference was not statistically significant, but we see the trend here. We wanted to compare if there was a difference if patients had a vitreous hemorrhage at baseline, and here we see the comparison between hemorrhage at baseline. Without vitreous hemorrhage and baseline, and there was no significant difference. In terms of the attachment rate, that’s where there was a high rate of rattachement in the study group compared to the control group. There was a trend, but there it was not statistically significant. In terms of adverse events, we found only 2.9 % of eyes, three eyes that develop tractional retinal detachment progression 3 days after the injection. However, best corrected visual acuity improve after responder vitrectomy in all those cases, which is similar to what we had found in our retrospective studies. I’d like to show a couple of selected cases. This is a 27 year old patient at twenty four hundred visual acuity you can see the fibrovascular membrane here three days after intravitreal bevacizumab, you see a significant reduction on the vascular component and after surgery, reattachment of the retina with silicone oil, and vision improved to 20/80. This is another patient, a 54 year old patient twenty eight hundred visual acuity. You can see attraction of retinal detachment, significant fibrovascular component and the after intravitreal bevacizumab. There is a significant reduction in the vascular component and after surgery reattachment of the retina we use gas and visual acuity improved significantly to twenty one hundred. S o in summary, this randomized study demonstrates that preoperative intravitreal injection of bevacizumab might be helpful to facilitate vitrectomy in cases of traction of retinal detachment. Secondary to advanced PDR. Preoperative intravitreal bevacizumab seams to reduce intraoperative bleeding improving surgical field visualization and reducing intraoperative and postoperative complications including iatrogenic retinal breaks and postoperative hemorrhage. This has been published in the American Journal of Ophthalmology. And I’d like to thank the Pan American Collaborative Breton Study Group at 20 centers from 13 countries in Latin America and Spain for the opportunity to present the status to you. And I also like to thank you all for this great honor to share this information with you. Thank you so much.
Dr. Marinissen 46:25
Excellent doctor Evano Paula over to you. I think that we’re gonna do all the questions at the end, correct?
Dr. De la Parra 46:32
Perfect Ok. So thank you very much for such an interesting presentation for a very important public health visual issue. And without further ado, it’s a great pleasure to introduce Doctor Guillermo Amescua, which is an associate professor of clinical ophthalmology and director of the Ocular Surface Program at Bascom Palmer Eye institute at University of Miami. Doctor Amescua, we are ready when you are.
Dr. Amezcua 47:04
Thank you very much. It is a real honor and a privilege to be invited for this I normally lecturing about cornea and ocular surface diseases. I am not a public health expert, but I’m trying my best to do something for my country. I am originally from Mexico and grew up there and still have my family there and it’s always one of my favorite things to do to collaborate with my colleagues over there. I was asked to give a perspective of the eye held in the US Mexico border and we want to share with you today a project that I’ve been involved is called “Con Visión”. I’m founder and part owner of the clinic. I received no salary and all my surgeries there that I do are pro bono I and this is a project that’s outside the my obligations and responsibilities of the Bascom Palmer Eye Institute. But I do have the support of our President, doctor Julio Frank and our Chairman, doctor Eduardo Alfonso. Which I really appreciate their support so. The US Mexico border is it’s a 2000 almost 2000 mile border. And that extends over 4 states in the United States and six States and in Mexico that the Treaty that was signed and the fines the border it it’s it defines it as 100 a hundred miles from each border. And with that we have a very active and the second most active border in the world. It is a very dynamic place. With very dynamic social, cultural and economic activities that you really have to spend some time there to understand the micro and macro and microeconomic challenges that exist in that area. Most I grew up in the City of Obregon, which is in the state of Sonora, which is the second largest state in Mexico and borders with Arizona. I was actually born in Phoenix. I tell my patients that I crossed the border the other way and eventually came back, but I’m originally from Obregon. I did my medical training at the TEC of Monterey and I’m married to. My wife from Chihuahua. So I, you know, have contact with the border all my life and had presence in Nogales. But currently most of what I’ve been going to be talking about is in El Paso. Ciudad Juarez border is the second busiest port of entry of the border being Tijuana, the busiest one so. Just to give you some background, I been in the US since 2003 when I came for my ophthalmic training in Cleveland and in Pittsburgh. But since my training in Pittsburgh and my fellowship in Miami, I’ve been traveling to Mexico almost on a yearly basis, and maybe sometimes twice a day to help with the cataract surgery. Cataract surgery is really my passion. I am according to specialist, but I do enjoy and there’s nothing that I enjoy the most that removing that patch on patients that have severe blindness from cataract and I was always impressed that every time that I was going to plan a mission trip, you know I would. It would be two three days when the schedule will be full with patients and my requirement was that the patients will have will have a visual acuity of camping configures or worse because going there and doing surgery and coming back. And my biggest fear is causing problems. So i wanted to help patients. And it was always very impressive to see how much need it was. And this is all in the in the border region so. Because of those strips and my collaboration. I have a formal collaboration with the LB Prasada Institute. I’ve been participating in a research project in ocular surface with them since 2011 and it was always to me. Very impressive what Doctor Rao and his team have achieved with his system of eye care delivery and always wanted to come back and try to do something. Of course what I’m doing right now is at a very small level, but hopefully you know in the future we could reach something that we impacting the region. So doctor Rao. And also with support from Doctor Lansing, you know we were able to open this clinic in the border our clinic is 2 kilometers from the US Mexico border. And it’s this is our third year of operations. We have a social backbone where we do surgery at no cost or minimal cost and we have a private branch that funds the projects and we do go outside and look for funding. This is to show you some of our partners. This is the Medical Center of the Americas in El Paso which is a biotechnology hub that has been helping us. With our efforts in the area and the team from LB Prasad that been present at three in three occasions to train our team, we have a Nice private area and we have a bigger space for our social area. But we all share the same equipment and we provide the care at the highest standard meeting all the requirements from the law from Mexico. So going back to this map, I do want to emphasize that one of the biggest problems we had is manpower. There is bad reputation for the border and there are no academic training programs in ophthalmology in the whole border. So Tijuana Mexicali Nogales Juarez there’s nothing. Nuevo Leon has many very good teaching centers, but they’re not in what is considered the US Mexico border, so that’s a problem and lack of physicians just to give you an example in Ciudad Juarez wires, there’s only one Pediatric Ophthalmologist. There’s only one fellowship, trained glaucoma specialist, and there are only about three or four fellowship trained retina specialist. So with this population of about 18 million people in this in this border, this is not enough, and this is one of our biggest problems that we’ve had, you know, access of care and care at the late stages. The border, like I was saying, is a very dynamic. A dynamic place you can see how independent both countries are from each other and they there is a significant amount of trading from goods from the United States to Mexico. But there’s also a significant amount of trading from Mexico to the United States and through Canada, that’s been growingly steadily since 1994 when NAFTA was signed. Because of this, the economy, the economy and the resources for the for the people in the north of Mexico have increased. People have jobs, high paying or good paying jobs with access to some of the public health hospitals and that’s good. But one of the problems that we have identified is that the main social economic problem we we’ve seen is that even in a household there’s a father and a mother. Both of them are usually working and there is a problem with nutrition with access to physical activity on the on everyone in their family, so there’s easy access for a highly processed and high highly carbohydrate diet and high carbohydrates in the area. So the problems such as diabetes it’s becoming a severe problem. You can see here how dynamic the border is. You can see on all the crossings. So if we look at if we look at El Paso, Texas, so it had a crossing of more than 7 million peoples in 2019 just by walking the border, not by entry by car or bus just by walking. And if we if we see what exactly happened and now 2019 and then we compare when the United States decided to close the borders and Mexico and Canada after March twenty first, well still you know, look at the amount of people that are constantly crossing the border. Even with the restrictions that we’re seeing right now because of the current pandemic. So this shows you how interconnected this region is currently. Areas of opportunity for us in the Mexico side are at this one, so you can see here what happened in El Paso, Texas el paso Texas. If you remember in November was one of the epicenters of COVID, and you can see all the data that was very easy for me to find and you can see how the hospitals were overwhelmed in November. Well the same thing happened, you know, in Juarez because of the movement back and forward, except that access to data in Mexico side is a, it’s a it’s a problem and it’s an area of opportunity and these two cities were suffering from the same problem around and around the same time. The hospitals in Mexico in what in Juarez got were overwhelmed. The city had to completely shut down. Our clinic had to stop doing surgery for two months because of the problems in the pandemia so. But you know, not it’s not all bad news. The economy in the region is vibrant. There is a significant amount of employment in Juarez, even with the current pandemia you the recovery has been very good and the rate of unemployment and fires is very low. There’s about 350,000 thousand manufacturing jobs currently and these are all formal jobs that people can. Have access so some of the improvements have caused problems and this is what we are seeing. You know there is not enough access because of the hospitals are overwhelmed. This is just to show you the connection between the two cities connected by the border and how this is basically just one big city. The main problem that we wanted to, help. When we started the clinic was the cataract problem and you can see here the most recent publication from Doctor Lansing and colleagues that just shows what we’ve known that cataract surgery is one of the leading or remains the leading cause of blindness. Preventable blindness in Latin America, and there are many issues with this. One is difficult access to care. Patients have fear. Of going for care. Because of complications that may happen in family members or friends, etcetera. So there is still even though we are doing more surgery than 20 years ago. Still the access of care is difficult and we are not doing enough surgery and not enough surgery with the highest quality standards. So there’s not. I really tried to. I get data from the border, but there’s not a very good data. I promise that once our clinic is functioning for more years, we will be able to share data. We do have an electronic medical record system and we are able to do that, but I think the one that we can look more is the one from Nuevo Leon. They are close to the border and we can kind of see how severe the problem is with cataract surgery. So what are we doing in Ciudad Juarez? With cataract surgery, what we’ve been doing is, well, we’re doing cataract surgery in the private setting, but we have established partnerships with Rotary Club for the first year. We did about 350 surgeries for patients with low income that at no cost thanks to the support of Rotary Club. But in the past two years we apply for a grant for NGO called FECHAC, FECHAC is a big NGO from the state of Chihuahua that was born in the eighties after severe hurricane hit the area. It’s an outstanding organization that funds projects for economic, cultural, health or social benefits for the community. So we apply for a grant in 2018 and we were able to secure a grant, and with this grant we were able to screen eighteen hundred patients related to the manufacturing business and provided surgery for 625 of these patients. These patients were. Patients that had significant decrease in visual acuity, secondary to cataracts, and we were able to. We were able to help those you can see here. What we did is through this NGO we partner with them and with the foundation. So the money was received by the foundation and the Foundation will secure the monies for each of the patients. And here you can see that every patient will be sponsored but one manufacturing industry and a within a year we were able to complete surgery for 625 We completed 625 cataract surgeries. I am happy to say that last year we were voted the best project and secure the funding to start this year for a thousand cataract surgeries. For patients that have no access to this to this procedure and you know Doctor Arevalo gave act an excellent data for the management of diabetes. So I didn’t want to get into the diabetes, but the main problem that we see in the border is obesity and diabetes and the problem is and one of the main problems we’ve had is that was really hard to get to the number of these surgeries because we will schedule the patient and we had about a 20 % cancellation rate in our operating rooms because the day of the surgery. These patients will show up with hyperglycemia. So 3 sugars of more than 300 and. You know our anesthesia thing? We’ll have to cancel the procedure so we also identified many patients that will benefit that we thought it would benefit from cataract surgery, but when we did a careful examination they had advanced diabetic retinopathy so we were unable to provide the cataract surgery. So it is the leading cause of death in that region of the of Mexico and is a leading cause of death in Mexico. It’s is highly prevalent in all the areas of the of the border and you can see here you know data that we’re all very familiar with, but it is just a very significant problem and in a clinic in a clinical point of view, when I when I’m there seeing these patients that the main problem is not. They’re not just patients with severe problems secondary to diabetes, but the combination of obesity and a chronic hypertension, chronic systemic hypertension. Makes it a recipe for bad problems in the posterior and in the anterior segment, so it’s very difficult. These patients are arriving late for care, and it’s very difficult to restore or preserve. Vision is, and in some of the spaces you can see that very. Not all of these patients, and in fact the very rarely in the Mexico side. These patients have access to diabetic retinal exams in the public and in the private sectors. It is very rare that we will receive a patient was referred from an internal medicine practitioner or a General practitioner for preventive measurements. Usually when the patient already has a decrease in visual in visual acuity. So if I have to say you know cataract surgery, it is a major. Sorry blindness from cataract is a major problem, but diabetic related eye problems such as diabetic retinopathy and neovascular glaucoma are probably the most severe problems that we see on our clinic on a daily basis. And the problems that we see in Ciudad Juarez are exemplified in this nice paper from the Group of Doctor Arturo Chayet, where they looked retrospectively at 500 of their charts. From a period of five years and their conclusion was, you know that. Most of these patients will come in when they’re already is a significant vision loss, and there was only 10 %, 11 % of the patients that came referred as a preventive measure, and half of these patients required a surgical intervention in order to help prevent or restore a vision. And most of the patients were already. Dealing, chronically with the with the diabetes. So what are we doing with this? I think if we really want to make an impact in this area. We can treat only diabetics possible, but I don’t think we’re gonna be able to do that because we don’t have the human power and the financial power. But if we really want to create an impact, we think we. I think we need to invest in education and in the in the pediatric level. So we need to teach the kids how to eat, what to eat, and the importance of physical activity and help secure an environment for them to be able to have access to this nutrition, the diet is. The kids were having the are having in the past 20 years is highly in carbohydrates and very low in protein. So with the collaboration of this foundation from Group of offer. We’re starting to. We’re going to start trying to help these kids to eat better, and they’ve done that in 2018 This project will start with us as soon as we are able to. Proceed because of COVID related issues, but you show you some data of what they’re there. The results of almost there intervention, so they are especially in the city of Chihuahua, which is 3 and a half four hours driving from the border. They’ve done a significant impact in pediatric obesity and overweight. These kids are eating better. They’re teaching them how to how to proceed, and they’re providing a high quality nutrition and also improving their academic achievements. So that’s one of the things that we’re doing, and we hope that. In next three to five years we can see even a higher impact in this pediatric populations. So COVID affected us significantly. We had to stop our cataract surgeries funding for the clinic was affected like in many of our businesses and it was difficult to keep the clinic open and we were able to do it. We split the clinic in half. We changed the entrance for ophthalmology and through the funding from the Group of FECHAC from the NGO we created a first contact clinic where patients could come in, get educated, get some of the medications and more important, I get the proper testing for diagnosis. So we started this clinic with the funding from FECHAC in early in December and it’s been extremely successful and it’s helped us keep the doors open of our of Dominic practice. Of course, this has been done with the highest standards of safety and. In conclusion, you know it’s a very dynamic region. I invite you to come and visit the clinic. I will be more than happy to collaborate and find ways that we can impact and improve eye care in the region. It’s a very complex region of the Mexico and United States, and there’s a lot of areas of opportunities and access of care is the main problem. The patients don’t have enough access of care. When we started, we went to the three largest public hospitals. And in all of them, the average waiting list for cataract surgery was about 500 to 700 patients. And that’s still the same number in the past three years. Medical education is a problem there are there are no training programs in the area. Some of the cities are bad reputation about safety, which is something that did happen in 2009. But safety is the indicators of how safe these cities are. Even better in this region than other cities of Mexico currently. And prevention, I think if we are going to have an impact here, we can treat all the diabetics with surgery medications. But we’re not going to make an impact if we don’t start educating the new generations and how to eat and provide an access to this to the and one of those special thanks to everyone that supporting this project, especially the doctor. Lansing for Academy involved in public health. This is something that is new for me, but I did enjoy the last meeting that we had in Queretaro and hopefully in 5, 10 years Con Vision is looking something like the place he has in Queretro so thank you very much and you’re all welcome to visit the clinic.
Dr. Marinissen 01:10:33
Doctor Amezcua. Esa fue una presentación increíble, sobre todo para los que trabajamos. I’m sorry I want to switch to English. I’m saying Doctor Amezquita that was an amazing presentation, especially for many of us that work on border issues. It was amazing to see what you’re doing and the statistics that you presented, so I hope that we can continue supporting your efforts. So we’ll i’m sure we’ll have a lot of questions at the end of the session, I’ll I’d like to introduce our next speaker in the essence of time. We’re going to have Doctor Gavin Tan. With a senior consultant at the Singapore National Eye Center and he’s gonna talk to us about integrating artificial intelligence and telemedicine in the care of the eye care in clinical practice. So Doctor Gavin Tan and an honor to have you here. Thank you so much. I’m not sure what time is now for you, but thank you so much for doing this.
Dr. Lansingh 01:11:32
It’s three AM so I thank him as well.
Dr. Marinissen 01:11:36
Thank you so much for this effort.
Dr. Tan 01:11:39
Well, it’s a pleasure to be invited to speak at this forum, so I mean thanks to Doctor Lansing for inviting me, and because we’ve had some collaborations in the past and so I’ll get started because I think time is limited. So today I’m going to talk a little bit about our experience in integrating telemedicine and artificial intelligence into our clinical practice, and I think this that’s this has a lot of validity when you talk about trying to provide access in developing regions as well as the fact that we are in the middle of a COVID pandemic. So these are my financial disclosures and is relevant that I have equity in EYRIS, which is in a company that provides AI solutions. So I think Kelly Metson is an important and emerging modality in medicine and essentially it is the provision of healthcare remotely by means of various telecommunication tools. Whether it may be in the old days used to be telephones. Now we have smartphones, mobile devices, Internet connection etcetera and these this provides availability of expertise it improves the access to care as well. It improves the efficiency of our healthcare systems. There are many ways you can deliver telemedicine. The most basic thing is what we do every day when we call another specialist to try and discuss a case, get more information, and provide better care for our patients. And there may be a patient to provider kind of telecommunication, which for example we call our patients up to find out how they’re doing or they call us up to get advice and allow us to try out provide support and diagnosis. And of course, as we move forward with more. Digital and Internet connectivity. More and more of these relationship or interaction is going to be asynchronous, and it’s also important that we also need more and more tools that allows us to. Perform better assessment of these patients through these telecare telemedicine platforms, because just speaking to the patients about symptoms is often not enough, and that allows us to provide where we have a patient going to provider that performs tests, whether it’s imaging blood tests or something else in the Community and then providing a telecommunication with a specialist remote leader at the end of words them to provide diagnosis, effect management, and so on and so forth. So where did what has happened? A lot in telemedicine is artificial intelligence has been able to ride on these essentially digital platforms in order to assist the doctor or replace the doctor in certain parts of this patient provider interaction and ophthalmology. The major enabler of all of this has been multimodal digital imaging, and we know that imaging has really replaced the way we interact with our patients, and it allows us to replace much of the physical examination. And in fact they do better than our physical examination in order to understand the disease condition that what kinds of treatment are needed as well as to monitor progress. And this allows us then to integrate telemedicine into our clinical practice, where we’ve replaced physical examination with imaging. We allow a communication with a remote site that allows us to interpret this imaging and it allows us to affect management, perform home monitoring or other kinds of. Patient provider interaction. So what’s happening in telehealth? I think there is a trend towards a providing greater availability of expertise and access in terms of increasing convenience and reducing costs it has allowed and expansion from acute episodic care to monitoring or more chronic conditions and the migration of telehealth from hospital satellite clinics to the home has really been enabled. With the increasing availability of Internet and home. Devices and home monitoring and mobile devices. What’s really, I think catalyze a lot of change in the past year is COVID, so it’s become. It’s created an opportunity for all of us to perhaps implement things that may not have been acceptable in the past because there’s always resistance to change. So telehealth and telemedicine is not the same as artificial intelligence. But I think they’re really synergistic and complementary. Digital technologies and telehealth in a lot of instances. And in the examples I’ll show later, really enables AI to be implemented as well. And all the emerging technologies is going to really create this virtual cycle. That’s going to make us better at doing the things that we want to do. And one of the big catalysts towards better or increased use of artificial intelligence is the emergence of deep learning, where the use of things like convoluted neural network has enabled the performance of machine learning not to plateau, and it’s allowed us to be able to get better, squeeze better and better performance as long as we have larger and larger amounts of good data to the point where we’re actually equating or maybe even exceeding human performance. And as I mentioned, it’s really been a unique opportunity and in the Asia Pacific, really what we found and what many people have found is the COVID-19 pandemic has really accelerated the adoption of telemedicine because, as the previous speaker mentioned, when COVID happened, we were forced to close our clinics to a lot of things except for emergency conditions and telemedicine still allowed us to keep in touch with our patients and ensure they were provided with some form of care. So this is a real unique opportunity that we really need to leverage on. And it’s not going to be easy, but really we really need to take advantage of this and understand what we want to do and what we can do moving forward. So again, it’s the perfect ecosystem for Kelly ophthalmology and AI. There’s a lot of media interest, and there’s increasing physician and patient acceptance in the past. If you told if I told my patient I’m going to give you a video consult, I don’t think they would have been very happy if that would have replaced that face to face interaction. But in today’s age, that has become completely acceptable. And also very importantly, this has forced regulators, providers and funders to support these new models. I think in the past if you wanted to get a subvention for telemedicine care, it would have been very difficult by increasingly around the world governments and insurance companies are willing to pay for this, which is really important. So what are the lessons that we have had from Kelly Optomology and AI implementation in our own clinical setting? And I think Dr Diabetic retinopathy screening is an important example, and diabetic retinopathy is a major problem in both developed and developing countries and I think the last two speakers has alluded to how that is a problem in Mexico as well. So what we have here is teleology, artificial intelligence, the availability of simply all you need is simple IT infrastructure and a very basic imaging advice at device for which the cost has come down greatly. And in diabetic retinopathy, there’s a clearly defined public health problem. It’s easy, as I mentioned, the imaging modalities has become much more accessible. They are portable cameras. The cost of these cameras have really come down, and coupled with greater image quality. And diagnosis of diabetic retinopathy is easy. It often requires it doesn’t require a huge amount of clinical data, which makes the whole processing or platform look much simpler. And we know they have been robust outcome and cost effectiveness studies that shows that this screening can improve the outcomes of our diabetic patients and improve their long term well-being health and economic productivity. At the same time, the impact of change tends not to be dramatic, and it affects the primary care practitioners providing them with additional tool, and it doesn’t have a lot of that bigger impact on the ophthalmologist practice in a lot of ways, so that’s that, reduces the resistance to change, and it really when we decided to apply AI into our tailor optomology it became an incremental technology. The single modality make all these data transfer easy, and because screening has been done. In all over the world, for years, there were a lot of existing data sets for you which you could use to train and then test your artificial intelligence. And there was a clear path towards some form of regulatory approval. So in our own telemedicine experience we developed the national screening program for diabetic retinopathy started in 2010 and eventually scaled up to cover more than a hundred and fifty thousand people across all our government primary care clinics and Singapore. Like any other system, it’s digital retinal. For photographs, we had a custom tally ophthalmology platform. We use non physician graders to interpret our image. Because you don’t want physicians to be the bottleneck because they are very valuable and limited resource and it allows us to provide almost immediate feedback to our clinics on the same day which made the general practitioners and the patients very happy. And what we learned in establishing this program, and we will be very happy to share with any of you who are interested. We have worked with Doctor Lansing with developing their own screening program is the first thing you need to establish communication with the Community. Because if you don’t involve them, it won’t work. You need to be able to deploy imaging devices in the community. You need some form of it program. You really need to train physician graders because we think it’s the force multiplier until you have artificial intelligence available and you need to establish some cost effectiveness. Funders and you have to also ensure, after all, the screening, there’s a process to ensure those who are identified to have disease have access to treatment. They’re not screening does not result in a positive outcome, and at the end of the day, i think the previous speaker also alluded to. Providing patient education is very important when you’re dealing with disease and that encourages compliance as well as a self-care and self management. So what we really did was then take all this data we had from our screening program to then develop a deep learning system that will be able to assist or replace out the work that our humans are have to do. And using the hundreds of thousands of images that we had from years of screening, we developed an AI that had good accuracy for identifying referable diabetic retinopathy. And what’s important, when you develop artificial intelligence systems is you do need to up to evaluate it in a diverse date and in multiple datasets to really ensure that your AI doesn’t only work or is only trained to work in or over trained to work in a very specific population for which you have a data set for your initial training. And here we evaluated it in multiple ethnic groups, studies in various countries, including Mexico. Again, thanks to Doctor Valentine’s help. And we’ve shown that it has a consistent performance across barriers. Diverse cohorts, ethnic groups, and populations. And of course, in AI it’s also very important for you as a force as doctors to be able to understand what the AI is doing, and one of the key methods is visualization, where you get the AI to show the areas from, which, it is making its decision or the increasing the probability of the decision that a particular image has a disease or does not have a disease. Then the next step we did, we took. Once we had this AI was to integrate it into our actual screening system. We had a screening system with both with a tool dual grader system in order to reduce errors and to maintain as high as standard as possible. And we did evaluate if the AI would be better suited to replace only one stage of the screening system or the whole screening system altogether, and we did a study in order to evaluate this as the efficacy and cost effectiveness. In this study, we compared the AI with a retinal specialist in again, a real life live perspective grading. And we found the AI was very sensitive and specific for referable diabetic retinopathy and. In particular, we found it actually outperformed our graders when it came to detecting vision tracking retinopathy. And we think we believe it’s a fine neovascularisation and that the AI sometimes is better positioned to detect because a grader looking at hundreds of images a day is more prone to variability as well as fatigue. But what we also found was that in terms of specificity, humans still had some of an age, and there was some value. Maybe in keeping humans in a system. Once you have already a true a trained pool of available manpower to implement, and when we did our further evaluation and cost effectiveness evaluation, we actually did find that having a 2 tier model in our specific instance, it may not apply for every country was actually lost costly because the specificity reduced referral to ophthalmologist. Or a hybrid model in our case was effective, but in many countries I think where you don’t have available manpower, a pure AI model would be a boon because it would provide a screening capability that one was where that was not previously available at all. So the real challenges here in implementing AI for screening, or in fact any medical applications is always there are complications in defining gold standards. Dr is maybe a simple disease that we have a very simple clear cut and diabetic screening and classification standards, maybe diseases like glaucoma diagnosis is less clear and that makes it more challenging and difficult. You really want this high sensitivity to detect side tracking disease. You want specificity to limit false positives. And at the end of the day, you need a lot of validation and clinical trial to make sure your software works. You need to figure out how to implement it without rocking the boat of clinician. So there’s acceptance. And of course there are a lot of other issues, including regulatory clearance and the variation of performance that you need to deal with. So beyond your screening, we’re of course working at various AI’s to address other problems, we found that the AI can be used to opportunistically screen for kidney disease, for example when you do a diabetic retinopathy screen that might be useful where in instances where immediate. That tests or albuminuria screening may not be easily available. We’ve been trying to train AI to be vet to detect other diseases so it’s no longer an AI which is a one trick pony and in this instance we developed an AI that could be developed papilledema. And of course we’ve been trying to see whether we could use the retinal images that we have so readily available to better understand whether there’s presence of other systemic diseases. And of course in the long term to predict the risk for these systemic diseases that are will allow us to. Infected early intervention. So taking a step back and away from a, I’m going back to telepathology, so we’ve talked with technology in the most basic means, which is screening for a disease. How does Teddy ophthalmology actually apply when you want to do it in our clinic, in our tertiary specialist practices itself, there are various models you can use this. You can use video consultation. That’s something that has been popularized. During COVID you can have a less. Interactive teller optomology system where you create virtual clinics where instead of having a live interaction, you send reports as a way of communication. Because you may not be able to afford time or easy implement video from software, everybody and of course at the end of the day telemedicine is just not doctor providing information to the patient and vice versa. There are a lot of availability and now of home monitoring that can really change the way we enable patients or empower patients to take care of their own disease. Our example that we have implemented recently is Tele ophthalmology, or developing a virtual imaging type clinic for our stable retinal diseases where in the past patients had to come to the clinic, have an examination at the slit lamp at their VA taken, had their OC, saw the doctor, got management, went back and what happened with COVID is we found that a significant proportion of our patients could have imaging done perhaps at Community sites or at peripheral sites. These images did not have to be reviewed by the. Opthamologist straight away. We are allowed to. We could get a asynchronous delay review and allows the patient to go home and in most cases since a lot of these patients are stable, they may not require active intervention and you could then conduct all this management remotely, and of course in the minority that had reactivation of disease. Then you brought them back to get their injection, or laser or any other treatment that’s required. And of course, because you can do a lot of this in the Community, that creates a lot of convenience and in terms of COVID it reduces the risk from patients traveling to a tertiary care clinic in a hospital setting where the hospitals tend to be inundated with patients with COVID and puts them at higher risks. A lot of our ophthalmology patients are healthy and our diabetic patients obviously have a lower immune system that makes them at high risk. And in other model that we have implemented we have patients are being registered at a investigation unit and they had their OTC scan, Oct scan and wide field imaging. We had a greater again. We leveraged our greater resources from our screening system to do an immediate review of these images and there was asynchronous review with our ophthalmologist and of course the whole thing that I explained earlier about telling Optomology providing this virtual cycles. All this data we are then using and collecting to eventually develop artificial intelligence. To replace some of the human work of interpreting all these images. When we’ve compared our multimodal imaging remote clinics with our sitam examination of clinicians, we actually find it was more efficacious and there were diseases that are, for example, peripheral PDR and very subtle DME that was identified on these screening clinics that were missed by a clinician examining honest land and only ordering an Oct. Based on his findings at this lamp and at the same time we found out the atomic radius to be very effective at as we did intermediary and identifying. Active retinal disease that may require urgent or. Expedient treatment so, of course. We’ve also added Taylor, ophthalmology, and a video consult into this whole process, and this is important in patients that may require treatment and for diseases like glaucoma, where you can effect, you don’t need to bring the treatment the patient back to have a laser or an injection, we can actually communicate with patients and then send the medication to the patients via mail. We have also tried to promote more home monitoring and home self actuation of certain functions. We have developed a home visual equity app that we’re still validating and piloting, and we’ve also leveraged with existing home monitoring devices that have been regularly that have regulatory approval to improve our care. In this example of a pilot program that we had and we are extending, we used an app that uses that measures vernier hyperacuity in patients where they perform. I self monitoring tests regularly and that allows us to identify disease occurrence within these patient groups who can’t come back to the clinic during COVID. Without having to perform that imaging, and when they have a detect a signal of a drop in visual function, they can be red flagged to both the patient as well as the clinic staff that allows them to be brought back in this pilot study that we implemented. We had sorry. Two thousand seven hundred patients who couldn’t come back to see us during our COVID lockdown and 32 % signed up for use of this app, and they had a wide variety of diseases present. The app identifies, as I mentioned earlier, patients with abnormal tests and when we review the home monitoring triggers, we did a telephone call to identify why there might have been dropped in function and in seven patients we deemed the drop in function to be significant. We called them, got them an early review. Doing even during lockdown and we found that of these 7-5 so significant proportion had a trigger where there was a reactivation of diabetic macular edema. Rdo macular edema recurrence of shroom in our AMD patients that require treatment, and we were able to then leave these patients at home and only recall them when disease recurred. 4 injections in order to maintain good vision. And, of course, there are many other options available and being developed that allows more and more home monitoring to be performed for our. Patients, of course there remains many significant barriers to implementation. There are technical factors that are still inhibiting our. What we can or cannot do, and there are many non-technical factors that still inhibit from things from lack of compelling narrative, lack of support from professional bodies and how these technologies can fit in our existing workflows. And of course, at the end of everything what we’re trying to do is to provide the best care for our patients in spite of everything, and we really need to understand our patients concerns and be able to react and adapt to them to ensure that they feel comfortable with these new models of care and happy that’s providing them the same. Book service. And so, in conclusion, I think telehealth, telemedicine, AI will really transform eye care. These are both highly connected synergistic technology platforms in telepathology. There’s already been great success in Dr screening, but there will be significant progress and application of this to enhance actually specialist care management. Ai has already shown great performance again at performing at doing very specific tasks and but the real world application will require further development, integration and validation of these technologies. And I think mobile devices and home monitoring is really the future. It will enable us to really enact the telemedicine from home, and there’s a lot of devices that are coming up that can replace what we do in the clinic, and it really has a great long term potential to change the way we deliver ophthalmology care for our patients. And again, really, the COVID-19 has provided a new normal that, as with lots of opportunities for us to leverage in order to implement these kind of technologies that can improve care and. Access for patients. Of course, I’d like to acknowledge all the various people that have worked with us on all this data and projects and, thank you again for the organization organizers for inviting me, and once this pandemic is over, you’re all very welcome to visit us in Singapore. Thank you very much for your time and attention.
Dr. Prakash 01:34:46
So Doctor 10, thank you, thank you very much. First of all for staying ready and up at three AM in the morning, and secondly for the state of the art topic that you have given us. So thank you and now there are not many questions from the panel but. There’s got the other Rio who congratulates doctor Amescua for his amazing work in Mexico, and there is a question how to deal with high cost of anti BGF and screening equipment so.
Dr. Lansingh 01:35:23
I don’t know.
Dr. Jimenez-Roman 01:35:24
If the presenters would like to answer.
Dr. Marinissen 01:35:32
I think in terms of the cost of screening equipment cost is coming down. I think I remember just as recently as maybe 10 years ago, you really couldn’t get a fundus camera for less than I don’t know. In our my local contacts would be even 20.000 thousand. Us dollars. Now you have handheld devices that are coming down to 3 to 4000$ and I think it’s impossible in a few years. These will come down to less than a thousand dollars and we know there are various groups even trying to develop. Handheld Oct device low cost OTC devices that you may be able to deliver in a mobile clinics or mobile screening setups into the community. So I think technology will eventually catch up with this high cost when it comes to anti veg Jeff, i still think we don’t have a great answer. I mean i don’t know about in Mexico but in our own context we tend to use a better system map. A lot of label because the reality is causes a great concern for our patients and just the availability. Allows us to really and we split that vowel in lower cost for each individual dose and compared to the unlabeled medications and also starting to know that. If I’m not wrong, the patents for both of the initial drugs ranibizumab and it flips are coming are expiring soon, so maybe there will be the advent of biological similars that will provide a lower cost on label options for our patients in the near future.
Dr. Marinissen 01:37:02
I agree with gavin grey talk by the way, Guillermo. Fantastic, it’s a great honor to share this session with you guys. Anti big if therapy with bevacizumab with Avastin continues to be no question. The cheapest way to deal with our patients if you’re going to treat with anti VEGF therapy. It if you aliquot the different dosages it may come down to 50$ per aliquot, and although that’s still a lot of money. It’s much cheaper than running with some mob or a flavor Sept, and the biosimilars are going to be, although cheaper than ranibizumab and aflibercept are still going to be much more expensive than Avastin. So I think Avastin for anti VF therapy is the best option now keep in mind for example for proliferative diabetic retinopathy that pan retinal photocoagulation is still a great option. And there was a question on the Q and A. Section there on zoom about Twitter with laser photocoagulation, especially in COVID times and I think it’s a great option for retinal for a couple photocoagulation have is has been proven for more than 20 years to be effective and patients don’t have to come back that often so it’s certainly in Latin America is a great option. I think that if there is the availability of an. Indirect laser is even better because you can keep the distance to from the patient while you’re doing laser and that will avoid a possibility of contamination. Taking advantage of the great session, I wanted to say that we’re also doing something similar in terms of helping. Poor populations in Bolivia with that, better with an apathy project. This is from retina. Global Rajesh Agarwal is the lead of the of Retina Global and we had we have gone to Bolivia several times to do diabetic retinopathy cases both clinically and surgically. And the leader of that particular project and one of the most important things. Guillermo I don’t know if you want to comment. Part of it is to really be able to go there, see patients and treat them, but have somebody there that can follow those patients longer term and we’re training people in Bolivia so that they can do that. Yeah, we don’t want to. I don’t know if you want to comment on that.
Dr. Marinissen 01:40:07
No, yeah, thank you Fernando, i agree completely so that that’s one of the main motivations to open a freestanding clinic to have long term follow-up, especially for diseases such as diabetic retinopathy and glaucoma. You know a well done cataract surgery, you know.
Dr. Marinissen 01:40:26
Dr. Marinissen 01:40:27
The time the patient is going to do well, but it still needs follow up so you know it’s extremely important to have that and to offer that to the patient. And all you know, and one of the. Things that was mentioned in the paper from the recent paper from Doctor Lansing in cataract surgery. So fear is one of the main problems for patients to come in for access. So if you if you show that you’re doing this surgeries and you are delivering results and then you’re going to have a more patients coming for care, so it is something that we have to take into consideration.
Dr. Jimenez-Roman 01:41:06
So something if I may to continue the conversation, I don’t know how long time we have and please feel free to stop me anytime Gavin when you mention and showed wonderful images for telemedicine. Who takes those images because one of the things that we have difficulties is getting great images so that we can grade them well and we are, you know what we get if we get great people that are taking the images and we get you know what you get is easier to you know grade them and help them. And telemedicine is quite important in every way and I think but I think that’s key.
Dr. Marinissen 01:41:57
So in our experience we have a variety of people who take the images from technicians to nurses and. As well as to us, we do have progress. Our non physician graders actually go down and take images and I think the key here again is training. If you if you. We know like anything else, there’s a learning curve in the initial period at the level of imaging is going to be quite poor, but if you are consistent enough to be able to provide feedback to these people who are on the ground taking these images, then you allow them to you create a cycle or a loop that allows them to improve their skill set and in our own experience we find that. Even though most of the devices are non mydriatic dilation is very helpful and I think in most of our screening programs, especially in underserved populations where you know the incidence of significant cataract can be higher, we dilate, we dilate all of them. Yeah, because that improves the image quality and improves the ease of getting these images.
Dr. Jimenez-Roman 01:42:58
In terms of the home devices, Gavin cost and connectivity, can you comment on those?
Dr. Marinissen 01:43:08
The device that we piloted. What was one that ran on a mobile phone? So as long as there is a smartphone. The cost. In effect, the cost of providing access was low. Of course there is still cost you need to buy to subscribe for that particular software because it’s regulatory approved and that that’s not cheap. I mean, we’ve negotiated something with the company that’s made it palatable for us and our patients, but. I think these things are gonna be democratized because it’s not. It’s not the fanciest technology that you need to get this to work. So I think costs will come down and of course at the end of the day it depends who’s willing to pay for it and the US for example because there may be willingness for insurers to pay for this the cost modeling of a lot of these services tends to be a lot higher, but I think as they proliferate become more validated acceptable. I think it’s not. It may not be difficult. Four groups and NGO’s to develop their own alternatives that may not be able to. They may not be at the funding to get it through regulatory muster, but they can do something that can provide, maybe non inferior results to these more developed or more refined tools.
Dr. Jimenez-Roman 01:44:27
How about the lack of connectivity for the vaccines? For example, we have found in the US that about 40 % of all their people don’t have Internet or access to Internet and we have a hard time getting them in, and those are for example the target of. Home devices for age-related macular degeneration, which is another big you know, target.
Dr. Marinissen 01:44:56
Yeah, that will be challenging. I mean, I’m very fortunate in Singapore. We have one of the highest internet connectivity and smartphone rates in the world, but I know colleagues and in areas like in the Philippines they may not have live connections, but usually they may be a local center that has at least wifi. It may not be high finality wifi, but there’s some form of wifi. And if patients could visit that center even once every few weeks, then that there may still be able to provide. That connectivity that needs some bare requirement standards, but that is a challenge really.
Dr. Lansingh 01:45:33
Maybe somebody else can comment about connectivity in Mexico. I have no idea.
Dr. Bhagwan 01:45:39
Ok sorry, but we are out of time now, but probably we could, you know, get into the questions and reply to them afterwards. Thank you. Thank you very much. I just want to thank each one of our presenters for such an eye opening topics for your hard work and compromise for the ultimate goal of visual health in Latin America, Singapore and around the world and also for showing us the areas of opportunity to collaborative research. Thank you. Thank you very much so.
Dr. Lansingh 01:46:10
If you could.
Dr. Jimenez-Roman 01:46:11
All please share your slides so that we could also share with the participants and people who are asking more questions. Thank you. Thank you very much.
Dr. Jimenez-Roman 01:46:23
You will put them in PDF if you’re Ok with that so that they’re shared and nobody can obviously make misuse of that. And the questions that are not answered, we will be copying them and then putting them to the presenters so we can respond together later on with the link with the recording and if the presentations are available, we’ll also make them available. Thank you very much and we have what a 5 minute break and, then, three minute break and then we reconnect and I really appreciate everyone for the hard work. And everyone especially Gavin go to sleep please.
Dr. Marinissen 01:47:08
Excellent, we see everyone in three minutes then thank you.
Dr. Marinissen 01:51:10
Hey John, doctor Prakash, I think there is one fifty one so we can get started.
Dr. Prakash 01:51:18
That doctor sent it to many years. She’s the deputy director of National Eye Institute, NIH, and she’s going to be leading the the session I’m also working with her, so Doctor Tumminia please.
Dr. Tuminia 01:51:35
Thank you John. So good afternoon everyone. I’d also like to welcome everyone to today’s session on research programs and funding opportunities through the National Institutes of Health and the National Eye Institute in the United States. First, before we get started, I’d like to add my thanks to all of the organizers for today’s program, as well as to the embassies for their support. So one thing I’d like to think about is that today offers us an opportunity to explore ways that we can conduct and support successful international collaborations. So what we hope that you take away from today’s session is that there are several ways to successfully navigate funding opportunities with the NIH and the NEI, both through collaboration and through unique research projects. So now I’d like to welcome my co chair doctor John Prakash, who’s director of our Office of International program. Activities at the National Eye Institute and Doctor Prakash will be telling you about opportunities for global research and training at the NIH and the NIH, John.
Dr. Prakash 01:52:42
Ok, so I’m sharing my slides. Can you all see the slides?
Dr. Jimenez-Roman 01:52:51
Yes one yes.
Dr. Prakash 01:52:52
Ok, so thank you very much. Again, Doctor, Tumminia it’s really an honor to be part of this team who has worked very hard. Doctor Maria Julia Marinissen, and Doctor Van Lansing, and what I’m going to do is to open this and NIH session and talk about the opportunities for international collaboration in research and training. And I always like to put this slide, in my presentation that you know some of the opinions may be expressed in this presentation are my own and not of the government of the United States. So the government doesn’t bear all the direct and any implied responsibility for information presented herein. And many of you know this is the NIH campus in Bethesda, maryland, and I like to, you know, when international visitors show up. And then I guess I like to take them for a 10 cent tour of the NIH and show them this that there’s a plaque there in the building. This building 10 we affectionately call it, and there’s a plaque there that says that you know the agency of the United States government and for conducting and supporting medical research. But here’s something really important that’s written on there is that, we, work to improve the knowledge for all Americans and the human conditions throughout the world. So we are really. It’s very connected and committed to supporting. And as our director of National Eye Institute just mentioned that if you want to go far, go together so we all support that definitely the theme that you know working together and for the for improving the human condition throughout the world is essentially the goal. So National Eye Institute is one of the 27 institutes and centers in the within the NIH that really is supporting the program either. Dedicating to organ systems or the ideas and you know, and the disease systems so. In terms of mission, the National Institute conducts and supports research, training and health information dissemination and other programs that essentially all related to blinding eye diseases, visual disorders, mechanism of visual function, preservation of sites and you know, and the special health problem, but all relates to the blinding condition and eye related diseases. And as you can see here, that you know, again, we’ve completed our 50 years just a couple years ago. Advanced in supporting the advanced knowledge of the visual system and helping in prevention and treating eye diseases and other disorders. Supervision, and thereby improving the quality of life of people of all ages. So just to give you a number here and there’s going to be a quiz on this that this is our appropriation budget for this year in the tune of about 835 million dollars per year so just think about you know when I talked to in the international audience in my job people just have a difficult time conceiving this idea of the enormous amount of this budget that supports the eye research. And essentially it leads to, you know many new ideas, new science and support of treating and helping to prevent the blindness. So it’s a big number. And this is a just, you know, sometime you know i’m in a situation and various parts of the world and they say, you know NIH is so big. And what are you guys? And how do you guys do? Can you just give me and then this? Usually these conversations take place. Let’s say you know dinner table or somewhere in the site that I have access to either a small piece of paper or napkins. And you know instead of giving you a picture of them, you know things that I draw in the napkin and said, I thought I would just give you this thing. In the bigger picture, think of NIH as a. You know, we support research programs. We support training, and there are other. You know in many areas of communication, health services and Health Communication, and you know if we have national and international science crisis and public health such as you know, NIH is playing very key and important role in this whole worldwide pandemic. So in terms of research program, the simple way to think about it is extramural. Research program and the intramural research program and the next several research program is essentially what NIH grants that go out and close to about 85 % of the budget. So think of the number that I gave you earlier than 85 % of the budget essentially amounts to somewhere close to six hundred and fifty million dollars or so just goes outside to support the research, and I research ideas and research programs around the country and around the world. And then of course, we have intramural, internal research programs that we support. Very high quality science on our campus within the NIH and in terms of training. We have long term training short term training. All kinds of training program. Very short term. You know a month long training to a year long training and then long term training that you know programs that we have. Thousands of research scholars, postdoctoral fellows who are working, and essentially they shape the future of science. Moving forward and make the next generation of scientists. So again, this number was presented here. That global blindness is a serious problem as our acting Ambassador, mister. John Kremer, just spoke and said that you know that at least or more than two billion people around the world they have vision and impairment, and a billion have a vision impairment that could have been prevented. So it’s a large number, no matter how you look at it. This was a report came from WHO about a year ago and it’s this pretty pretty much the figure that is however you look at it. It’s a very large number. A lot can be needs to be done and can be done and should be done so and 90 % of. Unfortunately the global burden of eye disease is shouldered by developing countries, and of course the region that we are addressing here. Mexico and Latin American country, you know, bear a very large burden that also was. You know, mentioned by our acting Ambassador, mister Creamer so, and therefore, you know if you look at it, no matter how we do it, a comprehensive research strategy and international collaboration is essentially, you know, really one of the leading way to really work together. So therefore the wider collaboration of researcher is needed to advance the high quality of science and the standard of care and a coordinated research strategy for basic and clinical science. Among the health services teams will help in reducing and meeting our goals. So how do we look at it? National Eye institute. We look at international Iris international research as. Global science is very interconnected and we are very active in the global research. We seek scientific opportunities, we identify shared priorities, support unique programs, and so on. We support the US. As you know, we are supported by US taxpayer and therefore, won’t you know our important mandate is we support the US domestic grantees scientists to expand their international collaboration, which has a lot of bearing on the what we are talking today and we form. Partnership among scientists, governments, companies, NGO’s and so on to leverage our NIH funds and for asking important questions. And we look. We collaborate in many areas which you’ll hear in the in the next talk and the next few talks. Actually, how do we do that? And one thing I like to point out that anyone from any country around the world can apply for an NIH grant, and there is a link here which will be sent to you. And this is again I like to throw this slide in here. That’s essentially over the years. It has shown that in a number of international collaboration I have increased our increasing and it’s even higher now and again. We are all scientists and we like to think in citation impacts and so on. So therefore, in the fourth age of research, people look at international collaboration essentially increases typically greater in terms of scientific impact, so. If you look at this in the last just a few years since 2014 this our own national Eye Institute, you know collaborations have grown quite, you know, from somewhere from around, you know a dozen countries to now our footprints go into somewhere in about 45 + 49 countries or so. And in terms of projects from about 30 plus projects to close to, you know, over 500 Project, so that’s actually also shows you that how our own international collaboration has grown. Being even a small institute, we have expanded our programs. Really you know, in a bigger way. And here is just some more breakdown here that you know we do direct grants and we have foreign institutions number of US PI’s that have foreign collaboration in some contracts and so on. But look at this number. This is about you know 10 plus. Direct grants or direct grants are also possible, as well as coming in as a collaborator as subcontract who’s working with the NEI that’s a large number, but again, you know this is. These numbers can vary and change in plus minus four five points or so. Our numbers are, so just given. You know when you are actually taking this sample, but you know in terms of a concept, this is, this really shows that direct grants are possible and many people are doing it as well as collaborations possible and a lot. Many people are doing it. So here are some examples I like to put. You know, there are some government programs, there are some you know, direct, extramural, and intramural collaboration programs, such as one with China, one with we have a large program with India for a number of years we have had and that has produced. You know they’ve got gone through its own ups and downs in the several rounds, but is produced. You know, many good for you, know, fruitful collaborations. We have some programs that are still waiting. To be functional in terms of an ideas programs in Brazil and so on. And then you know there are fellowships training programs that you know there are. Genomics training program. You know one we recently started with International Council of our thermology one we’ve we have with a globalized genetics consortium, we are working with them about 35 or so countries are participating and that is a multi level collaboration in terms of you know, intramural extramural in many different ways that actually people work together. We have brought them together. That’s the our was were main goal objective and then unite. Is a UK program which we have running for almost you know close to 10 years or so, and then the next one, which is a postdoctoral training program. As you know, we have a large number of postdoctoral presents. Visiting Fellows we have, you know, many of those, and this is actually, you know, close to 90 plus fellows are working in our own intramural labs, and they make the future scientists the next generation or so, and many of many of them. Actually, they’re not only. You know they go back and they become, you know next generation key opinion leaders and continue to connect in very high quality science and give their, input and so in terms of final thought, I would like to put this as a you know, as any NEI and NIH we support the entire research continuum from basic discovery to translation into clinical trials and affecting clinical practice and health services and so on. There are many opportunities that. Exists to explore, you know, vision related mechanistic based treatments that through concerted and focus efforts from basic discovery into clinical application, and that could be utilized here in supporting the Mexico, US collaboration or Latin America US collaboration in many areas of high health programs and that I speak for both, you know, extramural and intramural research collaboration, as well as short term and long term training and NEI team is very committed and you just heard from our director and we’re looking forward to working with the you know opportunities with all of you. So at the end I like to put it that good eye research anywhere is good eye research everywhere. If you producing good quality science, we want to work with you and we want to go far working with you. So I’m going to stop here and introduce. Take this opportunity I guess doctor Taminia of that I’m introducing the next speaker who is our colleague. Mister Michael Cheatham and. Michael is a let’s see. Let me stop sharing this thing. So stop share. And I can see Michael Cheatham here on the screen, so it’s a great pleasure to introduce Michael Cheatham, who is the manager of World Report, and you will hear that how Mexican and Latin American data fits in the NIH and NEI continuum here. What we do and what we can learn from Michael, he’s been just a great colleague working with me and with my team. So Michael Cheatham, please. Take it away.
Dr. Cheatham 02:07:42
Thank you very much John. Let me just pass around a bit until I can share my screen. Thank you and thank you to the organizers for this very important conference right there. With sharing, yeah. Bear with me. I want to share with you a couple of illustrations made through a platform called World Report that John mentioned that I managed at NIH is a heavily data-driven organization and transparency with regard to research funding is extremely important to the organization. The definitive source of public information on all NIH investments. All NIH research investments is, of course, the NIH reporter, and that is a public facing portal that is open to anyone with an Internet connection. Nih reporter contains copious details of all awards made by NIH, as well as some sister agencies within the Department of Health and Human Services World Report the program I manage at the Fogarty International Center is a little bit different, it, contains all of the same records that are listed in NIH reporter, which is to say all of the direct grant awards made by NIH institutes, centers and offices, but it also contains records of research collaborations and those research collaborations are very broadly defined to encompass. Such things as performance sites, jointly funded research programs, or even simply collaborators with material participation in another country. Everything in World Report is linked back to that definitive source of information on NIH investment. Nih reporter. So additional information that you don’t see and will report is easily obtained by just simply clicking through. So with that, I will just show you a couple of visualizations that I made. Taking a look at NIH grant records in the Western Hemisphere, North Central, and South America over the period of 2016 to 2019 The map on the right gives you an idea of the, global footprint of NIH funded research. The numbers in the circles correspond to the numbers of unique research organizations in that particular country. They do not refer to the number of research activities their organizations, and they’re scaled for size. So obviously, as you can see, the United States enjoys forty four hundred or so organizations enjoy support. Looking at North Central, and South America, we see in the pie chart on the left Mexico accounts for about 15 % of the NIH activity in this region. We’re drilling down a little bit closer to look at Wall. What are the NIH grant records in Mexico? Again, these, detail, direct awards and research collaborations. As you can see on that scale on this slide, there are 605 research records. That cover collaborations and research performed at over 130 Mexican research organizations. Likewise, there are over 220 unique Mexican investigators engaged in NIH funded research. I should add that you’ll see periodically the URL at the bottom on in red world report dot NIH dot gov, you’re welcome to play along at home, it is now a site that is mobile friendly, so if any of you who are on your phones in addition to your computers should also be able to play around with the site. So looking at who are the organizations in Mexico? Who are the most frequent collaborators with NIH funded researchers? And for this I just looked at 2019 just a snapshot, and you can see also scaled for size is a visualization of these organizations. This is A. This is the top 100 It is not. Finally, I want to show you the breakdown within NIH, of which institutes, centers and offices are most active. And I chose a snapshot from 2019 and as you would expect, the, institute of Allergy and Infectious diseases. Accounts for about a quarter of all NIH activity in mexico, that that’s a pattern, incidentally, that holds true globally as well. NIAID is a quite a large institute and has extensive international collaborations. You can, for those of you who are familiar with NIH, you can decipher some of the acronyms. But I would call your attention to NEI’s slice of the pie at the top, at 1 %, it may not look like much, but remember we’re looking at 1 % of an eight hundred and thirty million dollar annual appropriation. So this is a significant research investment. Even at the 1 % level, and perhaps more importantly, I would flash another slide which John showed you earlier, which is the trajectory of NEI’s international footprint, these are NEI international programs, grants and countries over the last five years. Again using data generated in World Report. Numbers are more than, individual research. All collaborations you can see a remarkable trend over the past. And I think we can safely say we know where this graph is going in the future so with that I would like to just end on why is it that NIH maintains this parallel system of reporting for the public, and it’s precisely because we provide this illustration, this mapping of the NIH Global research Network we do so in conjunction with about a dozen of our partner organizations, so for NIH, part of the utility of World Report is that we can put information in context. This is a screenshot taken from the World Report site again the URL is in red and you can see in that pie chart in the in the lower left of that screen shot that those are some of the other funding organizations that provide records, and again there are more of these little applets that are built into the site. Have a little over half a million grant records, 25,000 thousand research organizations over a hundred and ninety five countries. So with the partnership of NIH and its and its dozen or so data collaborators, we really do cover the world. And with that with the system, we do try and understand the institutional landscape of who is performing world class research. We use the platform potentially to identify collaborating institutions or other institutions who are engaged in similar research. Users and researchers can use the platform to find funding opportunities or collaborators. And finally, in the science policy world where I sit most of the time. We can use World Report to really take a deep dive into trends and issues and in health. So with that I would show you just one more thing. My email is at the bottom of the screen. It’s in the standard NIH format and on the bottom right you will see who are those twelve data sharing partners. I’m always on the lookout for another partner who’s interested in sharing data. We’d love to welcome you to the World Report Club. Please contact me if you have any comments or suggestions, and let me know what you think. Thanks very much. And with that I will go back on mute.
Dr. Prakash 02:16:24
Ok, thank you very much. Michael really appreciate it. And I you know, I apologies for a really quick change in schedule here. I would like to invite Professor Michael Bernier here is an old friend and a luminous and distinguished alumnus of National Eye Institute and it’s great to see you and my pleasure to welcome you, Miguel. You’re the president of the Pan American. Associated ophthalmology and the professor chair, former chair of McGill, so professor Michael Bernier, please.
Dr. Bernier 02:17:03
Thank you very much. Great pleasure to be here. I’m going to try to share my screen first. Which I hope. I’m going to succeed. I think I did. Can you all see this? This is of course is not what I want. I want this. Can you see this? They’re all good.
Dr. Prakash 02:17:24
Yes please yes.
Dr. Bernier 02:17:25
Thank you, can you hear me well?
Dr. Prakash 02:17:27
Dr. Bernier 02:17:28
First and foremost. Great thanks to the organizers of this wonderful symposium, International Symposium. I would like to thank my very good friend John Prakash and John has been in this position for now many years and I visit John in his first year. Amazes me the success and the wonderful job that John has done and we’re all very grateful to you. Very grateful. I don’t think anybody would do better than you and I’m very honored to be your colleague and friend, my good friend. Charles, don’t think also one of the organizers, Maria Julia Marinissen and I don’t know her. However, going to tell something to Maria Julia, I call her Maria Julia or Maria Julia because I have a daughter. That’s name is also Julia and this is an unbiased opinion. I think is one of the prettiest names in the, world, then Maria Julia, thank you very much and finally to Jesus Gimenez, Roman for organizing this. Also another. There that John has today sent the dominia my sincere gratitude for being here with you, I speak to you, not from McGill, but from the Pan American Association of Ophthalmology that I have the honor and the privilege of being the President and has been a great ride, has been a wonderful. Time of my life. I really believe that the associations and institutions are the best we have and we should always associated with them and try to help as much as possible. As John mentioned, I am NIH NEI educated person. I spend five years of my life in Bethesda, maryland and I enjoyed very much. It was a wonderful training and opportunity of collaborating and then I came back to McGill. In that, McGill is my home and I’m very happy of doing what I have to do. Although I like to switch languages for a minute.
Dr. Bernier 02:19:36
Ahora voy a agradecer, a mis amigos de Mexico por la oportunidad de estar aca. I toda parte de Panamericana de habla Española toda la sur América the Central America por esta gran oportunidad de hablar de una sociedad than importante para nosotros. Por las oportunidades d e education y de entrenamiento que tenemos.
Dr. Bernier 02:19:59
To the Portuguese-speaking friends, Brazil and Portugal. I would like to say that we are always committed to improving our relations and a very affectionate embrace to the Portuguese and Brazilian ophtalmological societies.
Dr. Bernier 02:20:13
Latest Ok, let’s go back to English and what I would like to share with you is what’s the Pan American? What the Pan American does? What type of programs we have, and how we have to of course accommodate ourselves, particularly after March 2010 with COVID. We’re much more virtual, of course, than we were before. However, we never step away from our obligations to our Members, and particularly, to trying to create more opportunities. Even in this very extraordinary times that we’re living in. First thing is that an American Association of Ophthalmology is dedicated to the prevention of blindness throughout lifelong education and education is a keyword and cultural exchange. Another keyword among ophthalmologists in the Americas in the world, they Pan American Foundation, which part intrinsic part of the Pan American Association of Ophthalmology serves to support the educational programs of the PAAO. If I’m going to define the Pan American Association ophthalmology with one single word, I would say diversity and also going to give a personal opinion. Diversity is not something that we should just. Only embrace it’s more than embrace. We should pursue. The university probably is the best characteristic our world can give to us human beings and diversity is intrinsic part of our Pan American sociation of ophthalmology. Was found 81 years ago and was in Chicago and Doctor Gradel was from Chicago. Doctor Behrens was from New York and Doctor Alvaro was from San Paulo, Brazil my University of Sao Paulo School of Medicine you can see in this picture on the right hand side is Doctor Grado in the middle Doctor Barons in the left hand side is Doctor Alvaro and that was the origin of the Pan American Association of Ophthalmology since 1939 particularly since 1940 we had organized the Pan American Congresses and regional courses around the world. The American Congress as a tradition is always an odd year. And is every two years and just move around the South America, North America, or the parts of the world and the last one in 2019 was particularly in Mexico and was a phenomenal Congress and was in Cancun and was extremely success. We partnered with 26 affiliated National Societies and 19 affiliated subspecialty societies, and that includes all the Americans. And particularly Spain and Portugal and Europe. But we have Members from totally different countries that are not even associated to us by language or by geographic location. It’s always a pleasure to have members from different places with us. We decided to invest in this is we have done this before and now more than ever in our campus PAAO this online learning. We offer courses, webinars and virtual symposium to thousands of ophthalmologists and that’s what we did in 2010 Although I just to mention two incredible things that we have an opportunity to participate it in 2010 one was our first Virtual International symposium. We call this PIS We did 9 webinars every Monday for 9 long weeks from the cornea to the retina and that was a great success with a average of thirteen hundred participants by each web and then about. Two or three months ago, Fernando Ravelo. That’s here with us. Former president of the Pan American Association of Optomology, a very dear friend, did something absolutely unbelievable. There is a traditional El mejor de la academia in Espanol, which means the best of America of the Academy in Spanish that we always the Pan American always put together at the end of the American Academy for the people of the Spanish language, Fernando then decided to do a virtual symposium. Virtual Webinar Half day virtual webinar this year and had a phenomenal number of four thousand four hundred attendees. That was beyond expectation, and we’re very happy that with the response of the Members and the ophthalmologist that are partners with the Pan American, then education is extremely important to us. We offer education and for education also we need to have other combined activities that are around education. One of them is the Pan American Journal of Ophthalmology that was founded 20 years ago. Now it’s completely digital. The editor is Paulo Dentes from Brazil, who is the president-elect and will be the next president of the Pan American Association of Ophthalmology. The Pan American Journal is getting better by the week and the scientific work that has been published is really very good and we want to offer this opportunity to everyone. If you like to publish with us, it’s a pleasure and it’s a peer review system like any other journal. And we’re totally digital, which makes this much easier for. All of us. Here’s the news initiative that actually was Fernandez, and then of course I continue. Was Fernando Ravelos great idea which is the PAAO and American Association of Ophthalmology, Young Ophthalmologists and this is has been a pleasure and a delight to see growing those are young ophthalmologists from around the world. Networking via social media publishing, scientific works, seeking advanced training, talking to each other and this is many thanks to particularly. I mean lots of individuals, but particularly to Camila Ventura from Brazil and Jorge Fortun from Argentina. They coordinated the activity, it is incredible. The work that they have put together, particularly in the time of COVID in the time that we have to go virtual, we did. They did extremely well and the Pan American Association of Ophthalmology Young ophthalmologist is really flourishing and this is important to us because those are the people that are going to be taken over and with the understanding that the Pan American is very important in the associations, institutions are very important to concentrate our work, in, there’s another great development that has been going on for many years, and Zeller, Korea is responsible for this is Zella, Korea is right now at the Bascom Palmer, is the leadership development course. We partner with the American Academy of Ophthalmology and that excite young leaders from around the world to come together and spend time together and again. We’re preparing young people for our associations and I think that is phenomenal. I think with the PAAO young ophthalmologist and the leadership developing course. We are achieving more than we ever did attraction the retention of young opthamologists working with us. Very important, the reader leadership, of course is very important. What else we provide that is around our educational tests. Fellowships and foundation is absolutely crucial for us. Remember, the PAAO educational programs should encourage and inspire its members to. Fully participate in the fight for blindness in developing countries and poor regions and this is what we want our leaders in the future to be very aware of. The programs, are, vast and they include research. They’re include clinical training. They include subspecialty training. They include one thing that’s very important. Visiting professor lectures and visiting professors that about American gives to other countries to enrich the communication. Enrich the collaboration. Also, the participation in the congresses that they organized. I’m going to mention something. About research because that’s very close to my heart and the model or the mission statement of my laboratory is we do not do research as an intellectual exercise. Rather, we do research because there is a patient at the end of the day and this is, as John mentioned, in his exceptional talk. This is what we want. This is for our patients. This is human and this is what we want to develop. We have endowment awards and the awards and they are wonderful and from young ophthalmologists to more subspecialty work, and this has transformed the leadership landscape of ophthalmology in America ‘s, and in particular, in the Pan American ophthalmology global members and I think this is extremely important. Last year actually, the year before, right before COVID. Unfortunately we come up with a phenomenal program education for emerging countries, and there’s a committee, Brown Bateman, Rafael Cortez, and Francisco Contreras are the leaders of this. I’m very grateful to them and we would have the opportunity of two first and second recipients of this particular award. One doctor from Honduras. One doctor from Nicaragua and the idea was that they could spend three to six months. One would be at McGill with us. Taken advantage of going to ARVO too and then perhaps visiting NEI and visiting you guys and the doctor from Nicaragua. Cynthia Mendoza would go to the Bascom Palmer did not happen yet, of course, because of COVID, but certainly will happen. We want this. We want diversity. We want young people to join us and we want. Generosity and we want to create those programs. This is the information of the Pan American Association for Ophthalmology. Again, I’d like to thank you all of you for my presence here. Today is an honor and a privilege, and I’d like to leave you with my words in my president’s message when COVID was among us and I said, and I’m going to repeat it in this extraordinary times, we should wear a mask with a smile, even invisible one, to express kindness and solidarity. To everyone around us. Thank you very much.
Dr. Tuminia 02:31:48
Thank you very much doctor Bernier. I certainly enjoyed learning more about the outreach and the educational opportunities that PAAO offers and I’m sure many of our attendees learned some new things from you today. So next, I’d like to welcome Doctor Lisa Neuhold and Doctor Michael Steinmetz from the NEI. They will be discussing current priorities for any NEI and NIH funded research, and grants. Doctor Neuhold is program officer for photoreceptor and RPE Biology, and cell and molecular therapies at the NEI and Doctor Steinmetz is the director for the division of extramural science programs. Lisa.
Dr. Neuhold 02:33:04
Am I un-muted Now I am Ok. Right, you can see my screen.
Dr. Bernier 02:33:12
Dr. Neuhold 02:33:13
Ok, thank you. I am a program director at the National Eye Institute and I’m going to talk about the extramural research opportunities and programs that we have. I outlined my talk here first thing I wanted to talk about was how your program director can help and why you should contact your program director. And then I gave a list of some of the of the program directors at our extramural research program, which I’ll just list for you for your knowledge, so that you have it. And then I want to talk about some of the special programs such as the AGI and the ASI and microbiome, and then what an early stage investigator is and what the benefits are in the definition and then last the national Advisory Eye Council and what its goal and purpose is. So how your program director can help one of the things is that you can talk to them and determine if your proposal or the researcher you’re going to do is a good fit with our institute. It’s a good fit with the mission of the NEI. And so you’re not wasting your time putting together something that can belong that doesn’t actually belong with our institute and then to seek advice on project design and appropriate funding mechanisms. Whether you want to put in for research project Grant, which is an R1 or an R twenty one which is exploratory, or some of the other options that are there. And also to talk about if there’s trends in methodologies and there’s certain types of methodologies that we like people to focus on that we could discuss that and then identify limits and the duration and the and the budget limits of a proposal. And also last we do a lot of discussion of the reviews of your application, so when you get your summary statement, if you have questions about the review, you can call and talk to us. There are several program directors and they cover all areas of vision research and I listed them on the next 5 slides so you’d have copies of who these directors are and for basic research we have them. They cover in cornea, the retina glaucoma optic neuropathies. Retinal diseases. I do photoreceptor and RP biology as well as cell and molecular technologies, and I do stem cell transplants, etcetera. Then there’s the neuroscience and then retinal angiogenesis and immunology. And then we have a lens and cataract program. Another program on Central Vision, visual processing and then. Doctor Wiggs works with myopia and refractive errors and low vision. Then we have a program directors that function to work on training and resources, and so if you have questions about training grants or postdoctoral fellowships or K awards, you could call, you know marriage would be a good person to call and Hockley. He does a lot of focus on small business grants, and James Gao is informatics and computer work. And then we also have 4 program directors that work in clinical research that manage clinical trials. So if you have questions about something along those lines, you could call one of these people. So this is to let you know their emails and who it is. You might feel you could call and talk to. Within our institute there we have 3 current program special programs that are ongoing right now, and typically people apply when they apply to the NIH, they apply for a parent R1 which is handled through the National Institute of Health. Itself, but each institute might have a special programs within the Institute, and so we have these three so you can apply to different things within these programs. So we have the audacious goal initiative which has been around for the past four or five years, and then the Anterior segment initiative, which is more recent and the microbiome. So briefly, to describe what each of these programs is, the audacious goals initiative is mostly to look at connections amongst neurons and how it wires up. They’ve gotten in the dish they’ve been able to cope, stem cells to differentiate into photoreceptors, retinal ganglion cells, but when they’re transplanted, it’s not easy to get them to wire up, but there’s there seems to be a. There’s a problem with that, so the goal of this is to restore vision. The regeneration of neurons and neural connections in the eye and visual system so that the cells of the retina that have been damaged by disease or injury can be replaced by healthy cells and with this program we have developed. There’s three projects AGI projects. One is on imaging, another one is discovery based and the other one is the development of models umm? For the imaging project, we had an announcement out in RFA that was put out in 2014 and we funded 5 applications and the purpose of this project was to develop non invasive imaging techniques to image functional changes in live cells of the retina and optic nerve and one of the things that we funded was the development of this two photon imaging which is then is now been developed and is now being used for. Looking at the response of cells as in conjunction with different therapies, whether it be stem cell therapies or other types of therapies. The other next project that we funded was a discovery based project and the purpose of this was to identify biological factors that affect neural regeneration in the retina and that is to identify the cues that guide axons to the appropriate targets in the brain. What are the compounds that can coax these neurons to go to where they need to go? Allowing functional connections to reestablish between the eye and the visual processing system, and this RFP was put out in 2015 and we funded 6 applications and we had quite a some big success with this program and I put on the next slide just one of many different. Publications that came out. This one was a study that was done by Andy Huberman, where they were looking at Optic nerve regeneration and mouse and what he demonstrated was that visual stimulation was able to help rewire the visual system and partially restore site in a mouse model of optic nerve injury, which is a common model used to study glaucoma and optic neuropathies, and so in order to look at these stem cells when they put the stem cells. In the differentiated stem cells and to look at the axons and how they migrated, they were stained with. I guess it’s magenta. It’s a, it’s the pink stain and green and you can see where the sight of the optic nerve is. Injury is on the left side of the screen and then you can see the migration of the axons that are shooting out from that side. And this was published in 2016 and this was a key advance that came out of this project. Another project, part of the AGI was the development of models for I diseases. There’s models, but there are there weren’t that many good models that recapitulate the human disease that are essential for predicting the new success of the success of new therapies in humans. So the goal is to.
Dr. MIchael 02:41:19
Your slides are not advancing. You may want to unshare and then share again.
Dr. Neuhold 02:41:24
Oh, I’m sorry umm?
Dr. Lansingh 02:41:44
You’ll have to stop sharing Lisa and then reshare.
Dr. Neuhold 02:41:49
Ok, I stopped share.
Dr. Prakash 02:41:51
And share again.
Dr. Neuhold 02:42:04
Ok, can you see the slides, no, oh boy.
Dr. Prakash 02:42:25
Doctor Lansing, would you like to take use her slides that you have in your file? To project.
Dr. Lansingh 02:42:35
Let me go and check them visa.
Dr. Prakash 02:42:43
Should we use this time for any questions at this point to utilize we are running little behind actually, but. After too many if it’s Ok with you, can we take some questions at this point?
Dr. Tuminia 02:42:55
Dr. Prakash 02:42:57
Ok, any questions that you might have. Time this for the NIH speakers anyone?
Dr. Lansingh 02:43:10
I’m now hopefully sharing. Also Lisa slides there anyways.
Dr. Neuhold 02:43:15
They are thank you.
Dr. Prakash 02:43:17
Please advance Ok.
Dr. Prakash 02:43:19
Dr. Neuhold 02:43:21
Don’t know where we left off at.
Dr. Lansingh 02:43:24
I think this was the last slide that you were talking about, but I couldn’t see it, so maybe this is the next one.
Dr. Neuhold 02:43:33
Right, I was talking about models for eye disease.
Dr. Lansingh 02:43:36
Ok, so that’s it, yes.
Dr. Neuhold 02:43:38
Ok, thank you so to develop models of eye disease, so we were put out an RFA. We actually had two announcements, one in 2017 and then we reissued it in 2020 and the purpose of this was to solicit applications that proposed to develop new disease models of eye conditions that mimic important aspects of human Physiology and. Including similar light sensing cells, pathways, and connecting for connecting the eye to the brain and brain regions. And we funded 5 applications from this announcement that covered the development of models and ground squirrel tree shoe non human primates such as marmosets which have the phobia and macaw. On the next slide.
Dr. Lansingh 02:44:35
Dr. Neuhold 02:44:36
You go, yeah I wanted to talk then about the anterior segment initiative. Recently the NEI started a parallel initiative to address challenges in the anterior segment, and we did this because the AGI was such a success. We thought we should have one also on the anterior segment to start looking at different aspects of that. So on the next slide. I wanted to give basically a definition of what the anterior segment is and that is the front of the eye that includes the cornea, iris, ciliary body and ocular lens and what? This is about was that disruptions in the health of the anterior segment can manifest in a variety of ways that mostly get dry eye disease, ocular pain, Shogren syndrome, and uveitis or some of the bigger diseases that you get. And so we’re now focusing on looking at areas that we can build in this and so we put out a request for information to seek advice from the scientific community as well as our Council in order to help identify major gaps in knowledge. And this was put out on you could see the notice Y twenty dash zero zero one if you wanted to look it up and in see details about that. On the next slide, from this, the input of research opportunities on the anterior segment of the eye, we got 52 responses from more than 200 stakeholders on the anterior segment. That means that of the 52 responses, there was multiple people that had signed on, and several of the responses respondents wanted any item to focus more on the effects of inflammation, ocular pain, dry eye, and the microbiome. And start looking at the effects of these in eye health and disease. On the next slide. I just wanted to say that this all came into. We did look at the RFI, which is the scientific community. Then we followed that up with a portfolio analysis to look to see exactly what grants we do have and what’s been accomplished in each of the areas and then in putting together a new strategic plan, we have the Strategic Planning Committee look at some of these areas and give some of their comments. So with that we then are putting together an. Initiatives or workshops or whatever we think is needed in those areas. So the first area I was going to talk about, which is on the next slide, is inflammation. And so where are we? So with the inflammation we’re now in the process of organizing a workshop on immune health and eye health in order to chart a path forward in getting an understanding of the principles of homeostasis to disease state and its resolution in the anterior segment of the eye. So we’re currently working on looking at inflammation, how that plays a role in the disease process. On the next slide, another initiative that we have is 1 on ocular pain and we just put out a notice which was published. Telling people that we were interested in grants in this area and the title of it is ocular surface innervation from cell types to circuit functions, and they want to focus on cornea sensation pain circuits and tearing reflexes. So it’s about ocular pain and the circuits that are involved in that and so the announcement is proposing that they focus on 3 levels of what is the morphological, the molecular and the functional aspects of it. And so this announcement is a it’s a premise for a. Say a funding opportunity announcement that will hopefully follow at some point. The next slide is initiative that we started on dry eye and here again we put out an OC which is a notice of special interest on identification of the development of new biomarkers and effective methods to diagnose dry eye disease. Because early detection is the key in treating a lot of diseases, you don’t have farther, it goes along the harder it is to correct or mitigate symptoms. So in this, they’re looking at the development soliciting applications for people who can develop new biomarkers, and in order to look at early diagnosis and subtypes. And maybe then they can come up with ways of treating different types of dry eye. On the next slide I talk about is the microbiome initiative. And the microbiome initiative is really there’s a need to characterize the microbiome on the ocular surface to understand abnormalities that may contribute to eye disease with the microbiome. There’s two main areas. One is the gut and the other one is the ocular microbiome and the gut microbiome is in a separate. I want to say in a separate category there’s very little that we have on the microbiome and especially the ocular, and it’s not clear even whether there is a microbiome associated. On the on the articular surface and so one of the things that we’re trying to do is to come up with an understanding of what exactly is on the ocular surface and how that plays a role in disease. And one of the things that we’ve discovered in looking at the microbiome of the ocular surface is that it’s a very low biomass tissue. And when you start looking at things that are low biomass, you have huge problems with artifacts and a lot of artifactual data. And so the data from different labs doesn’t reproduce very well, and it doesn’t reproduce very well within a lab. So one of the things that we’re doing now is putting together a workshop on how to standardize. Some of the methodologies. So that when we do put out an announcement on how to look at the. Ocular microbiome we will have developed certain protocols and methodologies best practices for low biomass microbial research in order to study the ocular microbiome. Then on the next slide I wanted to focus on the definitions. A lot of people will ask when they’re put in an application, what an early stage and an early established investigator is. They used to talk about new investigator, but that’s a term that they no longer look at. But an early stage investigator is someone who has completed. His or her terminal research degree or medical residency, which whichever is later within the past ten years and has not yet completed successfully for funding, so you have to be within 10 years of your terminal degree and have never had an R1 or AUO one. An early established investigator is one that’s within 10 years of receiving their first substantial independent R1 So the purpose of that is that once somebody gets their first R1 sometimes it’s hard to keep that program going, so we try to give them an advantage so that they can get their seconds R1 They’re second up out of funding, and so the advantage, though of some of these different. Areas such as the early stage and early established investigator I put on the next slide umm? Right on the next slide, peer review one is to. That you get special considerations regarding publication and preliminary data you’re not supposed to. They don’t not supposed to demand as much preliminary data, or. Big publication record as they do for the seasoned investigator, and it’s supposed to focus a little more on their research track record and the summary statements are supposed to usually get released a little more quickly, and they’re usually in our institute. There were a little more generous on funding. We reach a little farther down in the pay line in order to pick up people who are early stage investigators or early established investigators. On the next slide, I talk about Council and I put the title up here saying that the NIH grant application goes through two level of reviews, and I’ll explain that in a second because there’s really not too second. A second level of review. But anyway, the first review goes through the center of scientific Review, and your applications are assigned as to the scientific review group, and which is often referred to as a study section. For peer review and you can find those study sections that are listed under the CSR website, which I have here. And once they get scored, they’re ranked and then things go to the national Advisory Eye Council for a second level of review. On the next slide. I say contradict it, and I say it’s not a second scientific review. It is a second level of review, but they don’t go through the science in the way that they review it from CSR. They look at the applications. If there’s a problem and it’s brought to their attention that we want to talk about something or evaluate something that was not clear in a summary statement, we can take that to Council and have them weigh in on it. We also go to the Council to advise assisted consult with. Make funding recommendations to the NEI Director on matters related to funding activities, policy decisions and providing a second level of review for research funding, proposals, so they make some of the funding decisions, but on a on a bigger level than just looking at individual reviews. So with that I will open up for questions.
Dr. Prakash 02:55:26
Ok, thank you very much. Doctor Neuhold and I know Doctor Steinmetz is also in the arts. In fact, answering some of the questions looks like, on, the good. The chat room or Q and A, but we are running a quite a bit behind here at this point and I want to actually move on to the next very important topic is that doctor Neuhold has brought up that. You know our scientific review process. I mean, she gave a very nice description of our, you know, programs that we have an incoming and new program that we are laying out and very useful information. So thank you very much for doing that. So the next step is it you know it is it? Is it make very important for NIH, which is the scientific review process and we have great pleasure of having doctor Seetha Bhagwan here. She is the. Here for the International Review program international programs for review. So at the Council of the CSR Program Center for Scientific Review at NIH. So let me introduce Doctor Seetha, Bhagwan and pick up the next side of the story. Doctor, Bhagwan please.
Dr. Bhagwan 02:56:40
Thank you John and thank you everyone, for, giving me this opportunity. Let me see if I can. Reduce the. Screen and share mine. I had everything ready but let there we go. You can see my slides now. Yeah, Ok, so thank you and I really appreciate this opportunity to give you an overview of the scientific review process. Now given that I have 10 minutes, I called down quite a lot of slides and so I’m going to give you a very broad overview. But then hopefully I can share the slides which will have more detailed information and links to not only our websites but other information relevant to. The process of submitting an application to the review of it and post reviews. If people have any interest in it and also I’m happy to answer any questions. And since John had that big picture of the typical picture of NIH, I changed it quickly to the picture of Doctor Collins’s office. So we have something else to look at. Well, most of you know that much of the biomedical research in this country is supported by the federal government and primarily. Why NIH? But what makes it sets it apart is that it’s the only biomedical Funding Agency both domestically and abroad, where the solicitation and funding of proposals. Is separate from the scientific peer review in most other agencies, the same person is wearing both hats off solicited the applications reviewing it, and then eventually funding it so. Of the. Where is that it went? Yeah, there we go. So the 27 NIH institutes and centers 24 of them are involved in that particular process of inviting proposals for a specific program and then following review funding those that are highly meritorious. And they some of these are most of these institutes and centers also have a small review shop to review special initiatives, and they have their own intramural research labs now Center for Scientific Review, which is where I belong is distinct in that in two ways one we only do review. We do not solicit proposals of fund them. Second, all of the NIH, all the applications seeking an I support come to our division of receipt and referral. And it is the gateway for NIH applications where then the applications get assigned two ways one. To a funding institute, which is the primary institute that’s planning to support it, or a combination of institutes who are partnering to Co fund and also another assignment simultaneously to a review branch. Whether it is sent to the scientific review, which is where majority of the research grants get reviewed, or an institute small review shop for a specific program, but those two aspects of an application soon after within a few weeks. Of receiving it is. Occurs at the division of receipt and referral. Now the Fogarty International Center is also very unique in that. Most of its programs are Co funded with its Eyes, Institute power and center partners, and it also doesn’t have a review branch, which is where my second job as the review coordinator of international programs for Fogerty LED initiatives comes in. And so if I beat a bilateral collaborative agreement between United States and another country or several other countries, so recently a few years back, when I had to lead a joint review between NIH and 13 other countries for a global alliance for chronic diseases initiative, we realized what set NIH review part very distinctly 1. Our review process is governed by very restricted, legally binding. Rather stringent confidentiality and conflict of interest rules and review policy and guidelines. So, for example, the South African consulate in UK and Australia, and whether it’s a high income country, middle income country or low income country. Sometimes their panelists can be people who are working with some of the applicants whose applications are being reviewed. They may just step out of the room, but we have more stringent rules on who can be on the panel and even vote on other competing applications. There’s a unique role, as I said of the because scientific review is separate from program, the scientific review officer who manages the review process is distinct from the program official and the Funding Agency representatives in the institutes and centers. And we also have very restricted attendance and access to MRI applications. So for example, in our review meetings, the program official is an observer who’ll answer specific questions only if asked by the Scientific Review officer. And likewise when we scientific review officers attend the Advisory Council instead of each institute, we are observers and only are called upon to answer specific questions. If there are any. We also have a very unique. Scoring system of 1 to 9-1 being the highest level of potential overall impact and nine the lowest, and these are the countries when I told you we worked a joint review had the opposite who ten to one where ten was the highest and one was the lowest. So reconciling that was interesting. And as Lisa mentioned, the two levels of review. And technically says review, but one is the evaluation of scientific review by a peer review panel, and the other is a deliberation of funding of the highly meritorious applications by an Advisory Council. Now both the review panel for the first part of identifying merit and the second for funding these two panels are comprised of the leading experts in the scientific community who provide that input for NIH. So there is broad stakeholder input. Now the three overlapping cycles in our process. So if an application is submitted in the first three months of the year, they get reviewed in the summer, and the award announcements are made in the fall. Likewise of the applications come in the summer, then they are reviewed in the fall, and the award announcements are made in the winter and lastly applications received in the fall are reviewed in the winter and the award decisions are made in the early spring to summer. And more details are in that link. And as I mentioned earlier, the Center for Scientific Review only does review and our job is primarily to make sure that every application has a level playing field and is receives a fair proper review from experts appropriate experts without any bias and in a timely manner so that NIH can fund the most promising research, and as such we have about 247 scientific review officers and counting. We are still hiring a lot so that number will increase. We have over 200 Chartered panels which meet three times a year with those 3 overlapping cycles that I mentioned earlier and also some recurring special emphasis panels which are not chartered but then meet regularly three times a year. We have over fifteen hundred annual review we. Review than. 75 % of the research grant applications anywhere between 62,000 thousand to eighty three thousand and this year, thanks to the pandemic, more applications are coming in and we have. About 18.000 thousand unique reviewers that who serve on our panels and for a very modest token of appreciation and honorarium compared to many of the other agencies. And we have 5 review divisions within CSR and within each of them there are about 5 to 6 integrated review groups, and each of those integrated review groups then house anywhere from A to ten of those chartered scientific review panels, be they chartered or recurring panels. We also do create denovo scientific panels for special initiatives. So just to give you an and an idea, since this is a vision symposium. So there these are just some examples of the vision study sections and CSR. So if you go to the fifth one here, pathophysiology of eye disease, there are two such panels and are they are more clinical in focus. So going back here, it’s the it’s in the neuroscience division. It’s in the brain disorders and clinical neuroscience Review group is where those two are housed. And then there is a by engineering news of neuroscience, vision and low vision technologies. And that goes again. Into the neuroscience division, but into this emerging technologies and training neuroscience panels where most of the small Business Innovation research applications are reviewed and then for fellowships. Also, we have some of these review groups that housed them and also special area grants so that we have enough geographical representation. And, as I mentioned earlier, the scientific review officer is in charge of the peer review process and is usually it. The person is the designated federal official for that meeting and has a scientific research background, be it PhD or MD and some come from academia to industry and then to CSR, and some leave us from Center for scientific review and move on to an NEI and i think NEI has probably the most number of former CSR people. Maybe it’s now program directors or in other capacity so the review officer is the person in charge of putting a panel together of top notch experts in the field with a very strong record of funding as well as publication record and obviously appropriate expertise. But we also want a breadth of knowledge so we do get it’s not always established investigators. We have a healthy mix of very seasoned. Well established, very successful reviewers and we have mid rank reviewers as Lisa pointed. Then we also have a few people who are early stage reviewers. We call them early career reviewers so that they get a chance to observe. See what is considered competitive by the reviewers and be successful in their own measure. We also try to balance the diversity, not just of opinion, but also gender, minority geographical representation of all the institutes at NIH funds, so that it’s a fair process. We select chairs who are considered leaders in the field who have exercised sound judgment and impartiality in moderating the scientific discussions. We assign the applications to minimum, typically 3 reviewers per application, and some of our meetings. Don’t have anywhere from 50 to 100 applications. We managed the meeting. We managed the conflicts so it essentially it’s the scientific review, offices meeting and so we train and guide our reviewers and our chairs to make sure that they adhere to these guidelines and ensure fair and timely reviews. And then following the review meeting we. Release summary statements which contain the critiques and scores from the reviewers as well as a summary of discussion by the panel collectively and. The discussions and the review will pertain to these five main criteria, which is the significance of the project? Is it? Is it a value to the field? Does it have a sound rigor of prior research? Is there a scientific foundation that sets the tone for why the end justifies why this project is worthy of conducting? The investigators, are they capable? Is it a high quality team? Are there any aspects of the proposal that’s innovative? Is the approach sound and rigorously designed taking into consideration the reproducibility and transparency of the methodological process? The environment doesn’t have adequate resources conducive to the execution of that project and based these score five major criteria will get scored anywhere between one and 9. Again, 1 being the best line being the worst and then they reviewers assign an overall impact score. For each application based on how they weight the strengths and weaknesses of these five criteria, now they are not averaged so. If the strengths outweigh the weaknesses and the weaknesses are minor and the project is potentially of high impact, could get a score between one and three. If the there is a mix of strengths and weaknesses, it balanced or impact medium impact, good application scores between four and six and, if the weakness is, override the strengths and the applications aren’t ready for prime time, you get a low impact score between seven eight and nine. That does not mean that the application cannot come back in a revised. Form or in a new form, but it has to be substantially modified and competitive, and that’s where the program officers will guide the applicant. And at the meeting we have anywhere from 12 to 22 on average regular members and additionally 20 more members and they pre COVID days. We’d meet in a hotel basement room without any windows. It’s at all around a what’s called a hollow square. That’s actually a rectangle. Everyone with that monitors. Now we do it by zoom and then we review anywhere from 7 to hundred. Applications now if a member is in conflict, they leave the room and reviewer one will introduce the application present. A critique the reviewers 2 and three will highlight any new issues or any areas of disagreement, and then the panel weighs in. But there is no reason consensus is not required as long as we still justify their scores, then they can vote their conscience. And then as I said earlier, they only discussed the most meritorious. Typically the top half stop scoring half. But if there are applications in the lower half of a panels set of applications would say discrepant scores. Somebody thinks it’s perfect and gives it a one or two, but someone else thinks it’s flawed, gives it a seven or eight to help the applicant out. We do rescue such applications and discuss them. And then after the meeting, the every panelist puts in a score for the discussed applications are not discussed once get an ND not discussed the final votes are averaged and multiplied by 10 to get a priority score. Some institutes would like a percentile and some do not. So we accordingly we have a base. We percentile them and then the post meeting report the summary statement will include the critiques and individual criterion scores for those five. The criteria from each of the assigned reviewers and for the ones that are discussed, the ASRO will summarize. The highlights the strengths and weaknesses, how the panel voted. Did all of them agree with the reviewers and give a high impact score where some of them leaning more towards? Discrepant vote, and anyone can vote out of range as well, so all of that is captured in the resume and provided both to the applicant and to the program. Officials at the Institute so that they can then go ahead and deliberate on funding so the entire time frame is captured here. Applications come in assigned to an institute and review group. Within two weeks, the study sections are put together by the SRO review officer. Recruiting and assigning reviewers within a month. The site they are given about a month to six weeks to review and put in their written critiques and scores. Then the panel meets between one to two three days. The scores are released within three days. Summaries are released within a month or at least a month before council meets. And I forgot to mention, but, tying back to what Lisa said, if there are RO one applications from new investigators and early stage investigators, only the RO ones, we cluster them separately, because as Lisa mentioned, we can’t expect them to have preliminary data to the same extent as established investigators, and these are ones are large independent investigator initiated 5 year projects. So it is not fair to evaluate them on the same basis. And also their publication record wouldn’t be at the same level, so we cluster these RO 1 grant applications separately for seasoned reviewers versus new investigators, including these early stage investigators and any of the other mechanisms are also clustered together and reviewed per their guidelines in the funding announcement section 5. If you are familiar with that part, you would know that there is the criteria mentioned over there. Some of them have unique criteria. Especially the Fogarty ones, and that’s where I come in to also remind the SRO’s that they be reviewed accordingly, and these are the different. I’m not going to go over all of this, but just to tell you the different types of funding announcements, which of course Lisa and others at NEI can tell you more about. These are the ways in which the receipt and referral will make the initial assignments, and you can help guide and expedite the process of assigning your application to the right review panel and these are all the websites that cover letter. The assignment request form where you can look at an NIH reporter to find applications that did well and where you think your application too might be better served, but ultimately it’s the decision of CSR and receipt and referral where a lot of scientific review officers make the collective decision because we are the ones who know where the panel, what expertise is on our panel. To give you a good review. And these are just the rules. Our review formats. We are now doing mostly zoom meetings, but we do a few telephone meetings. We do mostly face to face back in the day. We don’t know how things will change, but we may have a combination of face to face meetings, out of town, meeting once a year to help the West Coast reviewers not be bleary eyed and feel like it’s five in the morning like some of you are feeling and I get reviewers from Africa who are plus six hours and from Hawaii who are minus six hours on my panel. But even had reviewers from Australia and China, so I know how it feels. For those reviewers to be part of our meetings and we are so grateful. And then I told you about these. We have other scorable criteria and these are what reviewers look for in their app in applications that they consider competitive. And these are the problems that they commonly identify as weaknesses. And I’m not going to belabor them. I’m going to leave it there for you to look into more detail. Many former chairs and reviewers have given us some good guidance to applicants. You might want to visit that. Information and I think that’s it with me. So I’ll stop there. I hope I did some justice to what was asked.
Dr. Tuminia 03:17:15
Thank you, seetha. I know that’s very rigorous process that you tried to capture in such a short amount of time, so I’d like to thank you and I’d like to thank all the speakers in the session. As been mentioned, we are running a little bit over time, but we are happy to take up to three questions, so if you would put them in the chat if you run out of time, but think of a question while the other sessions are going on, feel free to put them in the chat and they’ll be captured and we’d be happy to answer them post session. So we are checking the chat. I don’t see any questions at the moment there was one question for Doctor Newhold which was answered by Doctor Steinmetz who discussed a little bit more about the training program. Doctor Hutter asked if virtual reality surgery simulation training is a current priority for funding. And to whom should an? Inquiry be made. And so doctor Steinmetz’s response was that the program is aimed at training individual scientists. So a proposal from a single individual scientist to do research into VR surgery technology would be appropriate. We don’t have a mechanism for training courses for groups of individuals, and that Doctor Neeraj Agrawal is the training officer. So if you have questions about training opportunities, Doctor Argall. Is the person at NEI that you should direct your inquiries to? I don’t see any other questions, so maybe we will wrap up. So I guess if it wasn’t obvious before this year, it’s become especially obvious this year that science, medicine and public health are definitely international enterprises by necessity, and they’re not constrained by national borders. This year, more than any other time in history, I think that’s obvious to all of us, and so I think, as you’ve heard today, NIH can successfully partner with our international counterparts to address health challenges that have global importance. And we can use that doing using mechanisms like the bilateral agreements which are country to country relationships that are established to support and facilitate many areas of vision research and our case and training for the improvement of vision. So I just want to close the session by reemphasizing the importance of these agreements and that I think that from what we’ve heard today, there’s definitely opportunities. That the United States and Mexico can further explore through these agreements to conduct some research. I mean, we’ve heard the areas that are of interest to the NEI. Currently, and you know, I encourage you all to stay tuned. We are producing a new strategic plan under the direction of our new NEI director and we hope to release that sometime by the end of this year and you’ll be learning more about some of the scientific interests that the NEI has and that we’re looking to promote and support. So with that, I’d like to thank everyone for their attention and turn the meeting back over to Maria Julia, or Van. Thank you.
Dr. Lansingh 03:20:45
Yeah, thank you very much Santa and John’s excellent session. I think it has opened a lot of. Possibilities for people to think of what we can jointly do together, now and now. We have a 5 minute recess to jump into the next module that you’ll have the pleasure of, Co chairing with Doctor Francisco Martinez Castro. So see you in 5 minutes.
Dr. Marinissen 03:21:12
Excellent, thank you all.
Dr. Lansingh 03:27:59
Ok, good afternoon everyone. I think we’re back. so. I have the pleasure of getting this session started to by presenting my Co chair for the session which is Doctor Francisco Martinez Castro. Great friend from many years chairman of IEBB Latin America and I won’t say all the other titles because it would be a very long list Francisco. Welcome aboard. I don’t know. He might have his mic off. Francisco, are you there?
Dr. Marinissen 03:28:42
Well, look for francisco.
Dr. Lansingh 03:28:44
I think his microphone is. Go to microphone. He might be connected under his secretary’s name. Ok. Oh well, Ok. Well we’ll get started now while he reconnects because we were chatting, and so evidently he had a problem connecting there or something, I’m not sure. So well, thank you very much everyone for being here. I know it’s been a long session. I hope that you’re able to see my screen is everybody seeing that? Yes great. Terrific Ok, I have more slides obviously than what it’s the time allotted, but since we’re going to be sharing them I’ll just stop on those points that I want to highlight. And if the computer decides to move Ok, so most of this data comes from the vision loss expert group of the global burden of disease Group that is mainly coordinated by the University of Washington and Seattle. I’m sure that most of you have seen a lot of the papers that have been produced and which are just absolutely fantastic. Basically, the way that it’s been done is a systematic review and hierarchical models that have been used to make the estimations of visual impairment, and I’ll just stick to moderate to vision to moderate visual impairment and blindness. And although the notations are in the metric system as is now mostly used. For us in this side of the World Vision lines would be worse than twenty four hundred in the better eye with correction if they’re using it moderate to severe visual impairment will be 2060 and worse. So in this case we used 528 data sources, most of it which were rapid assessment of avoidable blindness, affectionately called RABBs. Which some people criticize mentioning that the problem that they have is they only assign one cause of blindness or. Visual impairment and we know that in real life, many pathologies can coexist with some. For instance, someone with diabetic retinopathy and cataract. So roughly speaking, and here are the confidence intervals, we say that there are approximately 43 million people give or take that are blind and of which 55 % are women. Obviously this is highly dependent in many regions due to cultural reasons that women tend to live longer etcetera, which is not necessarily true in many other places in the world. And when sometimes I want to say well in Latin America or this, well, it depends where what we’re saying. If you see, for instance here what the GBD divided, I’m not necessarily 100 % in agreement, or is the best choices and how it was divided. But when you say end in Latin America, which is essentially Peru and Ecuador, it depends. Obviously if you are, where are you? If you’re in, if you’re a woman, if you’re in Latin America, is you Central America? In which Mexico was catalogued. There is essentially the prevalence drops, one which is very important. And if you go to Southern Latin America, which in general terms includes Chile, Argentina and Brazil, which have a much highly developed economy, then it goes about half. So whenever we say Latin America or any other region where in that region are we mentioning this so moderate to severe visual impairment? As we said 2060 or worse, is we’re talking about almost 300 million people. And once again, it depends if you’re a woman and you start seeing here now. The differences between women and men, even in the and Latin America region, and more so in Central America. So it depends. And that’s why, for instance, two or three days ago I was in a conference and someone was asking, well, the numbers that you were saying don’t match the numbers that I read in this book are Ok. What is the definition that they’re using? Well, I don’t know. So there that’s part of the whenever we are trying to look into the statistics that we’re reading, we really have to see what is the definition that we’re that we’re being used. And similar thing when we’re doing, we’re talking about Southern Latin America. As you can see, the numbers are significantly different than if we were talking about the tropical Latin America region. So I’ll jump this slides because again, this is more for those that who will be reading if they’re interested. Uncorrected visual impairment or refractive errors are a significant cause of blindness. Believe it or not, and of moderate to severe visual impairment on though is not one of the priorities of the region. I did want to call your attention to this, so I’ll quickly skip and jump to the other slides, which I think are more important. Causes cataract. It doesn’t matter where you are. Cataract really, particularly in Latin America, is the granddaddy of blindness. And followed by believe it or not, once again, uncorrected refractive errors and glaucoma. Diabetic retinopathy is extremely important and I believe that the estimations are most probably underestimated due to the fact that obviously as I mentioned, since most of the studies are raped, they only assign that to 1 cause of blindness. So I’ll skip then to what I want to mention which is. Population density and this is something and the number of ophthalmologists you can see, for instance that in Mexico where we have at 42 ophtalmonologist per million population. The number of people are ophthalmology that are actually doing cataract surgery. It’s been estimated to be only about 25 % so therefore all there is that. Actual backlog of cataract surgeries are being estimated to be in the order around point 1.6 million per year. So I want to dwell too much on that, but I think that it’s important that and this thing froze now. Ok. One thing that it’s important and with a group of researchers, we have had the pleasure of developing a simple model to calculate cost of productivity loss due to blindness. And I won’t go into a lot of the details because again, this is more for your own interest. For those that really want to dwell in a lot of this. But how? What does that mean? And here’s the how we calculate it. This data is normally available through a Google search. Not more. Not very important, but now we can do that for a lot of whatever we want to do, either blindness or moderate severe visual impairment. But here’s his last slide and I will finish with this one. As you can see, the cost of blindness in the countries of Latin America that we were able to obtain the data is twelve point one billion dollars per year. And if we calculate that of moderate severe visual impairment, isn’t the order of around 18 million. So if we added these two concepts, Latin America is missing out on thirty billion dollars in loss of productivity. So that’s my last message. I wanted to just quickly give you that projection that we had here and we will finish and we’ll go on to. The next talk, which was going to be given by Doctor Ellery Lopez. Unfortunately, he had to be absent due to some other emergency, so we have. Let’s see, I think it’s. Yeah, it’s it was supposed to be Dr. Ellie Lopez, unfortunately again, as I mentioned, he is unavailable. So on his. But instead of him it’ll be doctor Miguel Vasquez who is sending me a message here. Ok, so let’s see. Ok Miguel Vasquez. Are you already there?
Dr. Vasquez 03:38:55
Hi everybody, there you go. How are you here? Yes, here I am.
Dr. Lansingh 03:39:00
So please go ahead.
Dr. Vasquez 03:39:03
I don’t know if you are. Looking at my presentation yet. Yeah, Ok. Thank you well. 1st of all I would like to thank the organizers of the Mexico, USA Congress on visual health for making this wonderful event possible. The name of the talk will be implemented in implementing telemedicine eye care programs for diabetic retinopathy. So we have no financial disclosures. And thanks to the retina and vitreous department, and also to the Tele Oftalmologia Department of the Mexican Institute of Ophthalmology. Well, the objectives here that we are trying to pursue is to describe concepts related to telehealth in diabetic retinopathy. Describe different characteristics of different types of telemedicine. And also list the characteristics to implement the TELECONSULTATIONS program. All of this applied to diabetic retinopathy detection and treatment. Ok, so we know in henced communication patients pro. Wait a minute. Sorry I have technical. Ok, So it’s all right now. All of us have seen the use of telemedicine. That has grown in recent years due to increasing the recognition of its benefits like enhanced communication of patients with providers, improved access to care for patients in rural areas and also by the early detection, of, disease inoculator vasculopathy us as diabetic retinopathy, but which reasons we have to use telemedicine as a side detection tool? so, nowadays these are the main reasons for ophthalmological teleconsultations in for example in emergencies, to assess the needs to check the patient at a certain moment, or if he can wait for the face to face consultation. Post surgical controls. After the antiangiogenic applications. Disease follow-ups in this case for diabetic retinopathy at first time. Council consultation patient. Medicine prescription also to give the patient A. Patients family sometime emotional support in case of a severe health condition and screening programs such as diabetic retinopathy ROP this is stand for a retinopathy of prematurity and also glaucoma. But let’s take a moment to get used to some important definitions before we continue. So when there we understand as telehealth? As healthcare delivery over distance. Or time using electronic communication technology to enhance healthcare access. Quality and patient satisfaction, and also telehealth adds diagnosis, management, educational administration. Beyond traditional health care delivery, telemedicine is used also to describe provision to traditional clinical service delivery using electronic communication technology, often on a life format. So let’s start with some concepts. So telehealth include includes 4 primary domains. The first one is asynchronous store and forward telemedicine. That is electronic transmission of healthcare data to a provider for the evaluation and service delivery. Also synchronize we have synchronous life audio video. This is real time via directional communication between a patient with a provider using audio visual communications. Also we have M health. This stands for mobile health. This is communication with patients mobile communication platforms, cell phones, tablets and computers. Also in the fourth week group we have the RPM’s This is the remote patient monitoring. This is health data connect connection directly from the patient during their usual activities. Well asynchronous telemedicine. This is store and forward was perhaps the most common use of telemedicine in eyecare before the coronavirus pandemic. In the screening for common eye diseases such as diabetic retinopathy, age-related macular degeneration and glaucoma and ROP. In this kind of telemedicine we have electronic transmission of healthcare data such as images, text, or other digital data, to a provider for evaluation and service delivery. Just seeing methods or other than real time interaction with the patient. As we know, this is a photo from Mexico City. Large cities usually have access to health and technology to treat their eye diseases. But what happened in rural areas that where this is not the case? That patients who are at least likely to receive care are those in lower socioeconomic brackets. Those lacking insurance and those without convenient access to our provider and. A common example of asynchronous telemedicine in eye care is still a retinal examination in which images are acquired at a clinic and whether digitally by optometrist or ophthalmologist at a remote site using mobile units and satellite Internet. In this asynchronous telemedicine can be started with visual health brigades. And towards rural communities and with multidisciplinary team that supports the organization. Now we are using transportation ocular fundus camera software for sending images and data transmission. You will need to train also brigades, both those in the community and those that are in the reading centers, and with the amount of patients we found that is desperately the use of AI. This is stands for artificial intelligence. In deep technology we include here in this artificial intelligence that deep learning technology. That is based on the use of artificial neural networks that constantly receive learning algorithms and continuously add data to increase the efficiency of training processes. An artificial and intelligent programs as we are showing here in this slide. Can train itself by using large data sets to recognize the signs of ocular conditions. Right now we are using AI with diabetic retinopathy and H related macular degeneration, also with well glaucoma and we are collaborating with EYENUK, Evolucare, and TElEDX from Chile. So we have experience with acquisition of wood quality images to be submitted to the AI software with the two cameras on the top. Colleagues who collaborate with us in different international centers also use the two cameras from the bottom acquiring high quality photographs we get from each eye. 2 pictures, one center in the macula, and one center in the optic nerve with the best quality we can get. So we’re receiving images from 22 different centers across the country which send us images to be graded and actually we have graded up to 1000 images. 100,000 thousand images. And the lecture of the images are performed by the Reading center Mailer. Where certified readers and AI softwares analyze the images and send them back with their recommendation according to the ocular stage of the of the disease. Also, mobile units travel to rural zones 2 to three times to a week every year, every year along. But now due to COVID-19 we have had to adapt our medical consultation and to asynchronous life or the ability of telemedicine and to M health using cell phones and tablets. So the most widely used forms of teleconsultations by digitally service providers are the following. So we have telephone consultation. That is made through the standard phone call video consultation. You and your and the patient will can connect using the video call. And the chat you can well the physician can talk with the patient to answer the questions by writing. So we can have also at our disposal three important groups of tools to give teleconsultations and to give diabetic retinopathy follow-ups. Also, web application, mobile apps and also programs or web platforms and here we are, avoiding not safe applications where anyone can take a screenshot and share confidential information. Some of them have paid versions that provide more data protection as we show we can show to you here. These are some of the providers of telemedicine, and also that have locks and information protections to give confidence to the patients and deprivation and the and the providers to the patient and the providers to the patient and the providers. So our conclusions here is that telehealth before COVID-19 pandemic was seen not so close. After this pandemic we must get involved with that telemedicine system and also the progress of telemedicine system. And has to be applied in the clinical and research field and in advance. Very fast from now on. However, there are Internet and technological limitations here in Mexico. In the rural areas. So finally you will realize how much all of us and the patients will love the convenience of telemedicine for your attention. Thank you, thank you very much.
Dr. Lansingh 03:51:17
Thank you very much Miguel Francisco, do you want to introduce our next speaker?
Dr. Martinez-Castro 03:51:27
Yes, of course. Thank you to the organizing committee for this kind invitation. And this is an edit. It’s impossible what show the volition to reply face this new challenge, especially in this post Covid times, Where is my pleasure to present a great friend and President of the Mexican National Center to prevention of blindness and expertise in glaucoma doctor Jesus Jimenez that the right is a nice presentation about the Tele-health in glaucoma. Welcome, Jesus. Are you ready?
Dr. Jimenez-Roman 03:52:30
Tendrá problema con el audio?
Dr. Jimenez-Roman 03:52:34
I’m, sorry once they. Got these two. Share this screen one second. Ok that’s right. Thank you very much for the invitation. Thank you. Thank you for my college shares. Doctor Prakash doctor Martinez Castro. Doctor Charles Van Lansing and Maria Julia Marinissen. It’s a pleasure to talk with the all the colleagues that the President, me and I talk. About the telemedicine and the importance of this technology in this moment particularly. Telemedicine is often referred as the way of the future, but it was not until recently that ophtalmologist filled pressing need to implement the practice into routine care now in, age, of COVID telemedicine is the safest and most secure way for us to connect with high risk patients and to minimize exposure to the pathogen for all parties involved with the recent events multiple real time audio and video programs are available for ophthalmologists use. It’s the impact of COVID in glaucoma on glaucoma care for glaucoma patients and their eye care professionals, the pandemic has led to a right of stressors. It’s very important to consider the progressive nature of the disease that requires close monitoring and treatment. The current health environment is particularly worrisome for elderly patients because they are most risk for vision loss for glaucoma, and also among the high risk groups for COVID mortality. To better understand the concerns and experience of glaucoma patients during the pandemic, the Glaucoma Research Foundation Commission and only online survey in May 2020 the survey drew a national response with a 1051 adult glaucoma. For from 49 states participating in a questionnaire. Notably, the survey found that more than half of respondents 53 % had to delay and or cancel an eye care appointment during the first months of pandemic. This disruption seemed to have significantly impacted patients confidence in their disease management, with approximately one third of glaucoma patients survey saying they were not confident that their disease was well managed. Those who had the lowest confidence levels in their glaucoma management were 30% more likely to have had an eye care appointment delayed or canceled. This feedback highlight the central role of communication in enhancing glaucoma care and the importance of nutrition. The physician patient relationship during the pandemic with physician office open again personal and direct doctor patient communication is paramount to helping patients understand the unique level of risks. And review confidence in their disease management. They COVID office and telemedicine. The survey also reveals that the glaucoma patients place high value on being able to see their physicians in persons 6 in 10. Respondents said they are comfortable, comfortable returning to their eye doctor’s office as long as social distance measures such as face mask and less crowded waiting rooms are implemented. This preference for in a personal physician visits coupled with the technology challenges make patients largely on Interstate in telemedicine. A vast majority, 87 % of glaucoma patients surveyed said they would rather wait six weeks for an in person office visit than have a telemedicine visit in two weeks. What? What are the recommendations for these telemedicine consultants in glaucoma with a low risk patients document? Patient verbal consent to discuss his health information? The length of the virtual visit, the date and time of the virtual visit, the content of virtual visit, and whether the visit was conducted by telemedicine or by phone call in terms to the doctor telemedicine. Etiquette tips work in a quiet space. Be aware of your surroundings. Facial expressions are very important. Prefer smile, be presentable. Speak louder than usual. You use headset. The other hand important in my opinion and my experience is the glaucoma patient. Distancing consulting will be common in the future. But it’s very important to take high risk patients for progression and to communicate the important to maintain, contact and visited personally to the doctor to these patients. In the other point, important point is maintained by patient contact with health orientation online programs. This contact in my opinion could be very important because the patients value this clause. Increased communication and support for the patients usually is easily accessible online. Product platform. Can you see and can mention before? But the other point is they have risk local passions is preferring to communicate to the patient the risk or not coming in to be evaluated. Speak with your staff about our responsibility to be safe because the patients in these conditions need to explore in the office develop together an action plan with a new office protocols. Expand your office team. It’s a very important call. Talk with the office team and consider all the good protocol to say the integrity. How the health integrity of the people working and the our patients. What happened when in the future with the glaucoma management? Considering these points. For me it’s important to say. That in the future we continue with the distant medical advice is possible. That in the future we need to consider a second opinion. Evaluating a studies that the patient. Making before. Taking IOP at home is possible now and the remote Perimetry too. But the problem is the technology standardization. The other the other point is that we have many instruments today. And it’s possible to evaluate Perimetry and IOP. But again, that technology standardization is not concluded and in the coming years could be better instruments and better options to measures different funds in local matches. The other point is the change of the glaucoma management in terms of a medical term, the extended release system surgical devices with time release medications. Exist now, but push in the future because the mobility of the patients with glaucoma in the next months could be very difficult in terms of this pandemic. In actually we need to revaluate to revaluate the massive detection because in it is advisable to reevaluate. These massive diagnosis of glaucoma to incorporate new ECM accessible technology, including the development of our artificial intelligence like say before in modern primary care models in the study of this and other disease. Develop new rules. New preventive eye health policies and multinationals cooperation programs.
Dr. Jimenez-Roman 04:03:36
Probably this imposition will be the start of these behaviors. Doctor Juan Carlos Rueda who is in this picture, is one of the pioneers in Latin American development and implementation of massive programs for that diagnosis of glaucoma and diabetic retinopathy with it with him, we have developed prevail platform which will be launched in coming weeks, which is aimed at product providing advice. Communities or individuals interest in massive preventive aid health programs. Before concluding, I want to make a little reflection. When we speak of entropy, we refer to a cause, but at same time to their organization of a new process. Who can say that pandemic was not cause? It changed our routine and our lifestyle. But new paradigms are being generated in social spiritual technology aspect part, especially the human one. That creation of a new higher order. Finally, take home points that safety and well-being the safety and well-being of the patient is the principal concern of all eye care. Modify standard procedures that enhance patient safety during COVID and makes operate more efficiently and safely by fostering a caring and professional approach to glaucoma care in meets all of uncetainty. We can all navigate the COVID pandemic while continuing to protect the vision of our patients, thank you very much.
Dr. Martinez-Castro 04:05:55
Dr. Lansingh 04:05:59
Well thank you very much Jesus and our next speaker. Is Doctor Bethania Lopez, who is the medical director of the Mexican Institute of Ophthalmology or EMO in Queretaro? And she had a great experience last year being trained for a month as an extra moral activity as well. So with Daniel please go ahead. Betania there you go.
Dr. Lopez 04:06:37
Ok, hello everyone, I am Betania Lopez ophthalmologist at Instituto Mexicano de Oftalmologia from Queretaro, Mexico. First of all, I want to thank you to the organizing committee to this invitation to share my one month experience at NIH. I attended the international Summit in Human in genetics and genomics in 2019 and we were 33 people all over the world from 25 different countries. What is it? What is it summit? The international summit is a program in Human Genetics and genomics, and it is sponsored by the National Human Genome Research Institute and other institutes and centers at NIH and contributions to the foundation for the NIH. As all we know, the number of genetic diseases is on the right bottom and some of them cause disabilities. As a result, there are really impacting not just in individuals but in their families and economics of the countries. In recent years, the advances in Human Genetics research has improved the projects effort, the diagnosis and made possible that some diseases can be treated and prevented and reducing the burden of disease and disability, but unfortunately the. I don’t know I have.
Dr. Lansingh 04:08:18
Yeah, can everyone else please? Close your mics.
Dr. Lopez 04:08:22
Dr. Lansingh 04:08:29
Por favor, cerrar su microfono, salvo la Dra. Betania Lopez.
Dr. Lopez 04:08:38
Thank you one. On the. Other hand, it’s very unfortunately many people in low income countries do not have this opportunity for treatment and prevention of these diseases. So the main goal of this of this program is really amazing and I could get that it’s trying to bring all these huge knowledge about genomics and genetics and treatment to low income countries through training healthcare professional in these aspects and have long collaboration with people overseas. So for me, this kind of program is incredible because at the end have a really impact of the lives of many people in the world. How is it working and the way of working is? It’s a program that is scheduled in four weeks. The first two weeks is about general courses in genetics and genomics, research and medicine. One week of field trips and counseling workshops for all attendees. And one week of personalized meeting observerships and clinics. Those are based on the needs of their countries. Personally I attended the summit because when I heard about this summit I was finishing my master in public health, so my thesis was focused about genetics and refractive errors and for me was really excited to know about this program. So I was really interested about understanding the principles of current genomic technologies, understanding the role of genomics in current and future approaches of diseases. Identify novel ways of using genomic approaches to tackle public health issues, and, I think the most important is connect with international researchers and become part of the international community. The collaborations I understood is the is the main idea of this summit. And of course, for us as a low income countries finding support and training opportunities is amazing and what? I learned. I think the principle was the basic principles of genetics and genomics. I can’t I can able to read and understand genetics and genomics data that is incredible. The current directions and genomic research and future applications. And many tools about how to search and use current available tools that it’s very easy to us to get access like face2gene, OMIM, ClinVar, basics on NCBI. I learn about business models in genetics and genomics and about newborn screening. The last the last week is Advanced Training week for me this week for me was a dream because I had the great opportunity to visit the National Eye Institute because my formation of ophthalmologist. And meet incredible researchers as persons and scientists scientific. That work there. I could establish some networking and collaborations and I and I could observe how works. The translational research and practice. I have the opportunity to talk about my research interests with mentors asdoctor Rob Hufnagel. I be able to talk with Doctor Chu with Doctor Delphine Blain, etcetera etcetera. And I can visit the research lab that was for me was an amazing experience. And of course, the genetic evaluations that is so important to do counseling to these kind of patients with Doctor Delphine Blain. As you see, was a huge knowledge was a food for thought. Really amazing and are really intensive summit with great lesson learned. Of course, my favorite part in the all my colleagues was the field trips. And because we have the opportunity to visit hospitals and institutions and thematics of researching that all attendees and me, we’re very excited about visiting places as NIH Quincy Center, Johns Hopkins University, Children’s National. When I when I finish this summit and what was my plan? When I returned to my country and institute and I was excited but worry about it because what I could do with all this knowledge and all these lessons learned. And I. Think the first thing that I decided to do is create awareness for the field and profession. Because in our in our countries, as there are another kind of diseases that for public health probably are more important. But I think is our duty to create awareness about this topic. So am i have involved about the evaluation surveyor, genetics knowledge and ophthalmologist and pediatric ophthalmologist. And another and another work with a colleagues from another countries and integrating genetics and genomics in the new era. And for me it’s very important the researching so I continue doing researching in astigmatism and genetics and I wanted to starting with inherited retinal disease with retina in my institute. Another topic very important is transmit all this knowledge to the to the future generations. So I I’d like to coordinate teaching program in genetics and genomics in my institute. Currently I have this collaborations on course with some with some researchers from NIH and colleagues that I met in NIH. I hope you have noticed for me the summit was a great day opportunity. I think that the summit changed my way to see the world to see the science and to see the life. But I think the most important and for me was to meet brilliant minds from all cultures and all races. I want to thank you for listening to me and I take this opportunity to thank to my institute, doctor Van, Doctor Raillery doctor Prakash, doctor Tumminia, who made this experience possible. Thank you very much.
Dr. Martinez-Castro 04:16:36
Thank you Bethania. Great presentation. Well, the next speaker is a very nice presentation about the joys and challenges for the night Eye Institute. Found them foreign research, collaboration by the professor for Fabrice Manns, that is a Bascom Palmer Eye Institute, and as you know, this medical school in Miami, Florida. Welcome Doctor and. This is your presentation.
Dr. Manns 04:17:05
Thank you. Thank you for the introduction. Can you see my slides so?
Dr. Martinez-Castro 04:17:12
Dr. Manns 04:17:13
Well first I wanted to thank the organizers of the meeting and Doctor Prakash in particular for the opportunity to present and share our experiences in leading in any I funded foreign research collaboration. I don’t have any disclosures. And also I wanted to first take the opportunity to acknowledge the contribution of the team at Bascom Palmer Eye Institute in Miami. I work at the ophthalmic biophysics center. That’s a lab that’s been established many years ago by Professor Parel, and that has a history of international collaboration, and none of what I’m going to present would have been possible without the contribution of the team and the mentorship of Doctor Parel. So this is really just our own personal experience of what we had to deal with and how we dealt with the issues and challenges that you may face if you decide to start such a collaboration. So again, this is our own specific experience, so each situation obviously is different, but hopefully by sharing some of what we learned and it will be helpful for people who want to start similar projects. I’m not going to go too much in a detail of the science of the project, but just to provide a little bit of context, this was an NEI grant where our goal was to study the role of the crystalline lens of the eye and how it changes with age, on, the development of the visual quality of the eye including the formation of myopia in children and later in life, the effect on the development of presbyopia. And this was a technology driven project. So we developed technology first to do measurements on in vitro lenses, from cadaver to look at to measure the shape of the lens and how it relates to optical properties and how this change with age. And also we developed an in vivo imaging system and ocdt system optical coherence tomography to do measurement of lens shape in vivo as a function of age, and again correlate that with the optics of the eye. So this collaboration was a collaboration between four teams. Our team in Miami, a team in Madrid, a team Hyderabad at the LV Prasad our institute which was mentioned already earlier today and the team in Sydney at the Brian Holden Vision Institute. The NIH component only included the team in India and the team in Australia. The collaboration with Madrid was a separate memorandum of understanding that we had with our institutions. In each location the team consisted of senior established investigators as well as postdocs and students, and this was a great opportunity for the students to learn how to work in a larger international team, but also to have an opportunity to exchange. We hosted several students from Spain. Some of our students went to India and some of our Indian collaborators came to Miami. So the first question is, you know how do we come up with a team? It’s not like one day, suddenly we decided we are going to collaborate with these individuals, even though this could be a way to start such a project. In our case we had the long term collaboration with the team in Australia and in India as part of a program that was funded by the Australian Government. Work on presbyopia. And that led to a first grant that we had on with NIH in collaboration, just with the Australian team on studying accommodation. So this project that I’m describing now on studying the lens, really spun out of these projects and led to this collaboration with both the team in India and the team in Australia. And with Madrid we had previously hosted students, and that’s how we started to collaborate with them so we, by this experience we had worked already 15 years together, so we knew already that we enjoyed working together. And I think this is really important when. People apply for if you apply for one of these grants with an international collaboration, because one of the concerns always from reviewers is how do you ensure that you actually can collaborate? How will you deal with issues so showing a track record of successful collaboration with joint publication is really important for the review stage of the NIH grant. And then also this gave us a lot of experience dealing with long distance collaboration, so we were able to learn how to deal with the time difference and here we had three different time zones for the NIH project across the world. Teleconferences and computer systems to share data and communicate about the project. And also how to ship because we were developing these complex equipment in Miami. How can we get that equipment shipped to Miami? It’s not just a question of putting it into a FedEx box and then it arrives there by magic within a week we had to deal with a lot of logistics issues with that. And this was almost 10 years ago, so this was pre COVID where people were much less familiar with Skype. There was no Skype at the time actually, but even with zoom with working this cross large distances. So I think today maybe some of these issues may be less significant, but at the time it was one of the challenges. We have to face. And again, showing that you can do that successfully, I think is really important when applying 2 when submitting a grant, because that’s one of the factors you know the environment and the team is and how you deal with these issues is one of the important factor for the scientific review. So now we have our team built together and it’s time to work on the proposal. So again, in general, when you submit an NIH proposal with a component that involves a subcontract, even if it’s within the United States, it already, it involves a little bit more paperwork, but the fact that there is a foreign component, there are additional component to a grant. And one of them is a specific section on justifying the foreign component, and I think this is really critical to really explain why the foreign component is needed. Why can’t the work be done just in the United States? And then there are all of these other sections that are always there when you deal with an outside entity, even if it’s within the country, explaining how the people will work together. The different budget modules, different approvals, but I think what we learned is dealing with other countries that have different models and different types of institutions really adds to these challenges. So you know, I think, really, the lesson that we learned is you really need to start much earlier than even usually when we submit an NIH proposal. To make sure that all of the paperwork can be done in time and it’s not just the paperwork of submitting the proposal, it’s really establishing this structure. This administrative structure and dealing with the administration from the different institutions. So now we’ve after a while we get the grant. The grant was reviewed. It actually took us two rounds of review and then we got the great new news. We got the phone call saying that the grant was going to be awarded. And then again we faced a few unexpected issues. One is that we learned that we had to have a separate budget for each country. Initially we had submitted this as one subcontract with our WESTRALIA team. And then for us, the biggest surprise was we got a phone call one day saying Ohh, did you have an agreement with the Indian Government? I think this is different today, but at the time the Indian Government had to approve any foreign project that was going to be started and this created a panic because this approval process could have taken up to six months. Luckily our collaborators in India were able to deal with it. And then from our side we had to abide with all of the financial disclosure and conflict interests, conflict of interest, management requirements that the US government requires. And that may sound a little bit trivial, but it required that the teams from India and from the US. First hand accounts in our IT system and then they went through all of the training that the University of Miami provides rather than create their own structures for that. So I think what we learned from that is it’s really important to check for any rules or requirements specific to the foreign country that you collaborate with. And then setting up the grants took longer than it would have been if it would have just been a US component. So now we have finally set-up We are ready to start, so then we have to deal with the usual issues of working across time zones. We have to. Figure out the issues of shipping the complex equipment and again in the US. This require dealing with export controls, but also because we were dealing in India there were a bunch of import rules that we had to. I don’t necessarily aware of when we started the project. And then we were trying to avoid having to go to India to assemble the project. So we had to really think carefully about the logistics of how we would assemble the system, disassemble it, ship it into pieces, and then have it reassemble it. India, recalibrated and working properly. And another issue that we learned was not that easy to deal with is how we then transfer the data. Each of our data set is 50 gigabytes, so our collaborators in India do the experiments and then they ship us. They send us the data through the Internet so that also created some issues. But eventually its a success when I think back. I’m still amazed that you know the fact that this all happened other than just the administrative and logistical delays. There were really no technical issues in getting the equipment there and getting it worked and recalibrated. And our collaborators have done our experiments on almost 200 lenses, so it’s been very productive experience. And I think you know from the positive sides, you know, these really outweigh all of these administrative issues that we have to deal with. It’s been a terrific experience for our trainees. It allows us to get access to resources in India. The access to tissue that we didn’t have in the US to do the experiment and they had access to our expertise in terms of the technology. And it led to more projects. Since then we have had several new projects with the team in India where we actually did a similar approach. We developed some technology that we were able to use in the clinic for patient care. So just to summarize, some of the main lessons that we learned is with this type of project. It’s really important to start early to really check for any specific rules and issues. To plan extra time in the in the grant management to set-up the agreements and also carefully plan the material equipment and think about how to share data across different institutions. So I’d like to acknowledge the support that we received and thank you for your attention.
Dr. Martinez-Castro 04:28:15
Thank you professor men, and this is a very nice presentation and opportunity for us. Thank you very much for your participation.
Dr. Lansingh 04:28:33
Sorry I was muted. Thank you very much Fabrice. I have everything that is Bascom Palmer very dear to my heart since I still hold my associate professor title though I hardly ever there anymore. But anyways. Please give my best regards to all my friends there, including Doctor Alfonso. So now we’re coming to the last talk. I know that we’re way over time. But I think it’s a very good way of concluding, and I know that many of us are later on moving to another one, so after this talk, what we’ll do? We’re recording all the questions that you have, and we will be asking the presenters to respond offline, so we will send you later in the week. Link to the recording, to the slides that we might end up having, and response to questions if you think of other questions, obviously. After this talk, which I’m sure that they’ll be generating some of those, please don’t hesitate to send to John or to Maria Julia or myself so we can try to respond as best possible with the appropriate speaker. So the next presentation is in charge. By Doctor Clifford Lane and Doctor Guillermo Ruiz Palacios, Clifford is a deputy director of the Clinical Research and special projects at the NIH, and Guillermo is director of LA RED. The network of medicine of infectious diseases at the NIH. So friends, please go ahead.
Dr. Lane 04:30:19
Good thank you very much. Can you hear me?
Dr. Lansingh 04:30:22
Dr. Lane 04:30:24
So actually. I just received a text that unfortunately, Doctor Ruiz Palacios had to leave for another meeting. So i’ll try to fill in for both of us. Which is a challenge to get Guillermo is quite an impressive individual. This collaboration between the National Institute of Allergy and Infectious Diseases of the NIH and the Ministry of Health of Mexico dates back to 2009 and was prompted by the 2009 H1N1 Influenza pandemic. At that time a Guillermo had reached out actually through colleagues in Atlanta Carlos Lopez about was there any way to get some NIH involvement in the setting of the H1N1 outbreak? And you know, could we help support research where there areas of mutual interest so he had arranged for there to be a meeting between my director, Doctor Fauci, and at the time the Secretary of Health of Mexico, and they signed a letter of intent indicating a desire by both parties to work together to create a program of collaborative research in infectious diseases with an initial influence. Focus on influenza. So the initial establishment of the network then was in 2009 It started with four clinical sites in Mexico City. We added several sites in 2012 and up to the present time have been adding sites. The impetus for adding additional sites. Was the Zika outbreak and wanting to have a better idea? Also of what types of infections actually might even be entering Mexico from central or South America. We were very fortunate to have this network positioned in this regard with the outbreak of COVID-19 and LaRed has been very collaborative and played a major role in the current portfolio of clinical research activities that we’re doing in COVID-19 I’m not going to go into any great detail regarding the governance structure we have. Steering committee made-up of representatives of the sites, a governing board above that, including major stakeholders predominantly within in the Government of Mexico. This timeline from 2010 to the present gives you an idea. Some of the studies that we’ve done and some of the work. Again we started out with just an observational study of influenza like illness, then looking at a healthy cohort to get some idea of what sort of carriage there are of the viruses, in particular that we see causing respiratory infections. We extended that and then in 2014 to update that study to get a an idea of more recent causes of infection conducted a randomized placebo-controlled trial showing that Nitazoxanide was of no value and influenza like illness, validated a survey instrument for a characterizing influenza that actually provided some of the help in developing ordinal scales for measuring clinical outcomes in both flu and COVID-19. We partnered with other networks to do a randomized control trial of immune immunoglobulin for influenza. A study of severe respiratory illness, and then most recently a whole series of COVID-19 studies looking at a variety of interventions. Part of the study that led to the licensure of Remdesivir on the study that led to emergency use authorization of baricitinib and have been co-authors On to New England Journal of Medicine Papers reflecting those studies. So it’s been a really positive experience for us to have the collaboration. There’s a coordinating center located in Mexico City that’s a bit independent from any of the sites we try very hard to bring in a junior faculty members when we can to play a major roles in the protocols. Obviously we’ve not had any face to face meetings for over a year because of COVID-19 but we’ve been able to maintain. Pretty good contact through meetings such as through this type of format. I would just add and apologize to Maria Julia for mentioning it without a warning is that one of our major challenges has been getting through the regulatory processes within Mexico at present, and we’re always hopeful that we’ll improve, but it’s certainly in the use of investigational drugs in some of these studies, and particularly now. We’re speed is so critical ways in which we can speed that regulatory set of approvals. From Mexico is something that we’re looking to. Hope to improve overtime. So Guillermo was going to give a few comments right now, this is really the last slide that either of us had about the network. From his perspective I think I think it’s been a positive experience. Umm, I think it has provided opportunities and again it is very heavily directed in terms of its agenda by the needs within Mexico paralleled with the needs of the NIH. So thank you very much for the chance to. Bring this network to your attention.
Dr. Lansingh 04:36:02
Thank you much Chris for that was short and sweet. That’s I appreciate that. Maria Julia. Anything that you would like to add before we open. I think we probably could do one or two questions before we close the sessions, but anything that you would like to have their money.
Dr. Marinissen 04:36:20
Thank you so much and thank you so much. Doctor Lane and it’s a pleasure to meet you and no worries about the unannounced details. I think they are very important because they give our colleagues in the visual health field and idea of you know the beauties of the collaboration. But some of the challenges when we move forward into a more clinical aspect of the collaboration. So thank you so much for taking time to do. To do this. I know you are one of our national heroes working very hard to save us and develop the countermeasures that we need so we really appreciate that you did this for us. Thank you so much.
Dr. Lansingh 04:36:56
Fantastic, well thank you very much. There was one question which I think is quite relevant talking about the short programs, the short training programs one month or there abouts? Is any other speakers capable of answering and what it would require to be able to apply for those?
Dr. Prakash 04:37:18
This is John Prakash. I thought maybe I can address that question. These programs are short term programs and there are actually, you know, a few programs that you know around the. NIH, but the one I believe is being referred is the one that was tenure Lopez had. And this is specifically for genomics and genomic health and eye genetics. And this program is coordinated by is funded by National Institute and coordinated by National Human Genome Research Institute. So this you know, I’d be happy to send more information. Please have the person write to me and I will be happy to provide the details.
Dr. Jimenez-Roman 04:38:12
Terrific, thank you very much John. There was some other question here. Oh well, that was a really responded beforehand. Would just say hi and congratulations. Well, I think that’s about it. I don’t know if Jesus and Francisco, my Co Chair for this session. If you have any other comment or questions, and if not, we give the word last word to the real brains behind this.
Dr. Jimenez-Roman 04:38:47
Thank you only to say that was a wonderful symposium and thank you for the invitation. I feel that this is a good opportunity to start a collaboration programs of different terms that academic, investigation and now the telemedicine will be interested to comment to this course in the future. In a new. Symposium thank you very much for all the people that are participating and the Co chairs and all the personalities that could be here. Thank you very much.
Dr. Martinez-Castro 04:39:33
And yes, and my gratitude. This is an special and very nice symposium to big witness this. Activities, and I hopeful that in the future we are in the same interest to explore in different areas. Education are all they are levels with the patients to promote the self-care with the personal to the contact. In the first, the first time when the patient and it’s also due to. Promote and maybe convince to the training centers that this time to come to modify all the curriculum and the final the alliance that we are witness today and the interest to participate is maybe hope the best future this pandemic area. Thank you very much for participating and invite me to me. Thank you.
Dr. Lansingh 04:40:36
One last question that we have here and I know that perhaps you can respond John, and if not the it’ll be in the chat that we’re gonna be exporting and responding to people. We have a doctor from Guanajuato that says that he has a foundation and that they’re asking if there could be some funding for eye surgeries. I believe this is not the case for NIH, but if you want to briefly respond and then we can expand in a written form.
Dr. Prakash 04:41:06
So, that’s an excellent question. And thank you for that question. I, you know, I very often we are asked that, you know so clearly. NIH has two question in missions. Essentially, the research and the training and search for science to basic science and applied science, and many people who are actually doing in doing services and related to healthcare. They can certainly look into doing research in healthcare process and those are actually, you know, there are several grants that are given in that and there’s several programs, so if they can actually improve the process if they can do healthcare services research, they are also classified and provided in the research programs, so if need be, they can reach out to doctor Lisa Neuhold who gave a talk Michael Steinmetz. But you know, there’s obviously there’s no funding for providing the services. Very clear, but anything that relates to research into you know that certainly is considered. Hope that helps.
Dr. Lansingh 04:42:15
Yep, thank you very much. John and I know that we will expand more when we have the written form of possible. So anyways, I think we’re reaching the end, so I’ll leave the last word to Maria Julia, who has really been the mastermind. The brains and driver putting us all in order to get this Maria Julia.
Dr. Marinissen 04:42:34
Thank you so much, Ivan equally has been a pleasure to work with John with Jesus and you to do this and it’s fascinating what can be done. I think I will close with saying again, it was great to have our Chargé d’affairs or acting ambassador at the beginning of the meeting to show really how interested we are in this bilateral collaboration in many fronts. I think this is an a great time, a great opportunity without getting into politics I think are Chargé mentioned that you know our government now has. He has made clear that global health is a priority and definitely we are two countries share. As we heard today the second, if not the first more fluid busiest border in the world. So there are plenty plenty of things that we need to do together. I just want to say that the chairs have been talking and this will be just the first, hopefully of many future, symposiums. We’re really thinking that by the fall, hopefully, if COVID give us an opportunity, we will try to have a more regional and more global symposium, hopefully somewhere here in the United States here in Mexico or in the United States and really, maybe a series of targeted mini symposium or symposia in the different areas that we discussed today. So with that, I just want to reiterate that here at the embassy and me, as the representative of the Health and Human Services Department in the United States, we are more than happy to continue supporting this collaboration and also we hope that after this we can get a great meeting with the health authorities here in Mexico as well to elevate some of the public health issues of the division health field. So with that thank you so much. Have a great weekend everyone and as my Co chairs have been saying, we will share questions answers. And slides, and perhaps even issue a short statement about this meeting. So thanks everyone and have a great weekend.
Dr. Lansingh 04:44:51
Thank you everyone. Bye bye.
Dr. Prakash 04:44:52
Now thank, you, thank you very much.
Dr. Prakash 04:44:55
Thank you bye bye.
Dr. Marinissen 04:44:56
Thanks to all the participants.
Dr. Prakash 04:44:58
Thank you all.
Dr. Marinissen 04:45:00
And thanks to Doctor Carlos Sanchez. Also in my team that has helped a lot with the meaning yes bye.