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Hello, good evening. Good afternoon. Good day, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David o'regan. I'm a retired cardiac surgeon, the immediate past director, the Faculty of Surgical Trainers of the Royal College of Surgeons of Edinburgh. And I'm currently a professor in the Medical Education Research and Development Unit of the Faculty of Medicine at the University of Milan Life is interesting because you never know who you're gonna meet and where you're gonna meet them. My special guest this evening is Dr Sujay Singh, who is the associate professor of eye surgery at the University of Malaria. She happened to be in murder inquiring about a master's in surgical education program and we started chatting and that's why. And it become very clear. I invited Dr Singh to join us this evening because I felt it was a very appropriate way to sum up what we've been discussing over the past month. Now, Suja commenced as a medical officer and specialist in KKM hospitals and completed her post graduate training in ophthalmology at the University of Malaya. In 2011, she proceeded with a cornea fellowship at the LV Prasad Eye Institute in Hyderabad in India and completed the Malaysian Corneal Fellowship program. She became certified corneal surgeon back in 2015 and joined the University of Milia in 2016. She established a contact lens clinic for complex corneal cases and initiated a renowned corneal fellowship program at the university and has been training a fellow for the past two years. She's coordinated the U MP program for Ophthalmology for the University of Malaya. And she is the head of the research unit and has been awarded a number of grants. She's mentored undergraduates and postgraduate students both clinically and surgically and organized innovative workshops and basic skills workshops for postgraduate students. She's committed to social responsibility activities and has been on radio and television talking about eye health, chatting to you will understand why I've invited this inspirational surgeon to become another sensei of the Black Belt Academy of Surgeons. I could not believe I bumped into somebody not only who shared the same passion for education, but without prompting, described exactly what I've been trying to impart to you over the past four weeks. Welcome, Suja. Thank you very much for joining us this evening and for those of you in other parts of the world, it is actually 1130 in Kuala Lumpur and looking outside. Coming up for later day, we've just had a spectacular fireworks. I hope this evening is as spectacular as I know it's going to be welcome. So tell me about your training to be a corneal surgeon. Uh First of all, thank you, Doctor David for making me a part of this um academy and, and um I, I'll try my best to impart whatever so far I have been training to my students. So II started my training uh for ophthalmology in Malaysia itself. And subsequently, I got a chance I was always interested to do my further fellowship in cornea. And I managed to get a position in the prestigious LV Prasad Eye Institute which is in India. And I was very lucky to be trained there. I did a complete training of about 15 months and then subsequently, I came back to Malaysia and continued the training for another almost two years. So totally in total about three years. So my experience in India of course has been or was wonderful rather. And uh I will say the the training was very structured. I could uh during cornea training, we went into different specialities. And I think one of the passion that I learned over there was this passion of suturing in corneas. And when we were training, we were actually uh I think the previous training used to be will be to see one do one and then teach one. But there I learned that it is not so in the interest of patients. And before we could even actually uh operate on patients, we were asked to do cornea suturing for 20 corneas in the wet lab. And I believe that those practice sessions where each, while each cornea that we sutured was assessed by one of my uh surgeons. And we were given the plus and the minus. And only when we completed that those 20 suturing perfectly were we allowed to even touch the patients? So this gave us a lot of confidence when we approached the patients. Uh And of course, I was blessed with some very good seniors who were very, very kind and who actually took the time and the patience and taught me the various the final surgical points which each of them would have developed during their course. And what I did was pick up what worked best for me. So that's what I always say. It's not everything that your teacher teaches you works best for you but learn from everybody but formulate your own skills based on what works best for you. What was it before we move on? What was it about the teachers that inspired you? OK. I think um the teachers, the dedication, I would say the dedication and the long hours. So even after a very long day, when we wanted to learn something, the teachers, they were available, they will sit down with you. And I remember my first transplant was at nine pm at night after a long day of surgery and my consultant who was there, he sat through me. He talked to, I mean, he talked over the steps with me and we actually, he had the patients to sit with me for the next 1.5 hours while I was still fumbling with my sutures and the techniques and the thing and also rescue us out if needed. So I think it was the dedication and, and there was, I II never found they, they were not approachable. They were there 24 7, you can approach them anytime. So I think it's purely dedication because they, they, they are extremely dedicated. I would say. So take us through then Sujay, what are the important elements of stitching in corneal surgery? What did you learn? And what do you teach as the essentials? OK. So we have to understand that corneal suturing or, or the suturing in ophthalmic, a lot of it is a microsurgical scale. So the first and foremost that, I mean, we we always need to take that first step. So the first step in this would be to get used to the microscope because you have to understand you are operating under a magnification and you should be comfortable handling a microscope. So that is what I learned and that is what I teach as well that even before you do these practice sessions or operate on patients, whenever they have my students have time. I encourage them to sit on the microscope, just take some anything and, and you know, try to focus in focus out magnify uh zoom in zoom out to get that feel. Because apart from being able to know what is your inter the I PD, what is the depth, you must have a binocular vision as well so that you are using both eyes to see the structures. So getting used to the microscope probably will be the first step in corneal suturing. Of course, in the next you need to in understand it that the instruments that are used for corneal surgeries or ophthalmology surgeries are microinstruments. That means they are extremely fine. So the way you need to handle them is also uh is very delicate. The tips are very, very um uh they, they are sharp, but at the same time, they're very tiny and it's very easy to damage them. So the next you should learn is handling of these instruments is because they are extremely expensive as well. So once you have got an idea of the instruments and how these instruments move under the microscopes and all, then you can proceed on with the practice sessions which we did in uh during the fellowship because by then I was already a trained ophthalmic surgeon. So I did have an idea. So the next thing is to know the basics of the suturing, it can be any suturing. But since we are talking about corneal suturing the basics of cornea suturing, how do you handle tissues with how much of force, you need to handle the tissues. If you hold the tissues very um with extreme force, you are going to damage the tissue. And when you suture and when your knot comes, it can either cease wire or it can continue to leak. So, handling of tissues, uh after that, you need to understand the basic steps, which probably I have in one of the slidess that I'll share is to get through the basic steps of suturing. As in when you put a suture, what should be the direction of your needle? What should be the uh the number of throws that you need to give to f uh make a note uh When you, when you are suturing in corneal surgeries, you also must suture under a normal physiological pressure. That is something we I find sometimes that is the one that gives the exact strength to a wound. If for example, if your eyes are very soft and you suture, your sutures will become loose. If the eyes are extremely tight. And when you deflate the eye, the sutures will again become loose. So the suturing should be done under normal pressure even before you go into the final details of suturing as to the suture and the suture depth. And all these are some of the few things that I probably will start off with telling my students who are in still in year one of master's, perhaps you could share with us some some of these elements, you have some slides. Yes. So II yes. And always remember uh when we are operating, using a microscope, it's an occupational hazard and 50% of surgeons complain of, ok, 50% of the surgeons complain of um of backache and neck pain. And so uh there is enough evidence in literature for this. Ok. I think I just now had a trial session. So probably my apologies just a moment. So I think even before we start to learn, the most important thing is you must look after yourself because as I said right now, we probably all of you are prime of your health. But five years, 10 years, 15 years down the line, you may actually end up with having backaches or neck pains. And sometimes, unfortunately, we have had situations where people had to actually abandon practicing surgery. All the more important for ophthalmic surgeons to look into your ergonomics and into your current posturing is because our entire practice is based sitting and looking through a microscope or a slit lamp. So the picture that you see on the left uh on top is a picture when we are using a microscope and we are operating on a patient. And the picture on the right, you see is our, that is our bread and butter outpatient clinics where again, we have to use the slit lamp and in such positions, the height of the slit lamp, the the tilt of the slit lamp matters a lot. So like in this picture that you see the picture on the left, you can see the curvature of the spine. And trust me, this doctor will end up with some kind of lumbar uh spinal problems in later in life. And on the right, the picture that I have put is probably the most correct posture that I have found. It's a picture from the internet of a surgeon sitting and operating. So as you can see the neck is straight, the lumbar, there is a nice lumbar curve which is expected if you see his knees are almost at the 90 degrees placed on the uh foot pedal of the microscope, he is looking straight through the microscope. He is not extending or flexing his neck. He has tilted the microscope to assist into, into that ergonomic position. And uh and and this is probably probably the most important thing for all of you to learn before you even uh you know, uh before you start operating regularly on patients and knowingly correct your posture. If at all, you are wrong, you can even ask your colleagues or friends to observe you, which can help. So once we are in correct position, we know how to handle microscope, we know our instruments well and we have the corneas, I will just quickly run through some basic steps of corneal suturing. So I am not very sure how uh from which uh different departments or which uh place everybody is so quickly. I know I nobody, not many people are interested. So a quick anatomy of the eye. So the front of the eye as you will see is the cornea, the blue area and the white that you see is called the sclera. And the place where they meet is called limbus. I think that is enough for today, the anatomy lessons. So when you have suturing on the cornea, you can have elective cases. Now why I'm emphasizing on this is because if you know the correct steps, if you know the correct technique, you can handle them. Why? Because in elective cases, we decide where we are putting the incision, these are planned, we can take our time, we can suture. But when you are encountered with emergency cases, when trauma cases, these are cases where it is a Zix uh Zix or puzzle, you don't know what you are going to encounter time is always a factor, especially if it is a motor vehicle accident and and patients need to be in and out of surgery fast. So if you have your basics correct, you can't go wrong in trauma cases. So actually, I like to train people on elective cases first, get their basics right and then move on to trauma cases. OK? So these two pictures, the one on left shows a planned cataract surgery where we knew where we are going to put in the incision we can plan out our sutures and it gives us a good outcome on the right. What you see was uh full thickness cornea transplant that we did. Again an elective case. It was a posttrauma case where there was a lot of Iris atrophy. We did a pupil plasty and we did sutures, but everything is planned under control and we can control this. And in fact, why is suturing important is because after the surgery, the visual outcome depends on how you have placed your sutures, especially in elective cases. So if you see these pictures on the top, now you can see both are of cornea transplants, both of them show a corneal button in center with sutures all around. But if you can see there is a small round blue circle on the top left. Now that is a reflection of a keratoscope which is incorporated in the microscope. And when I get a reflection like this, of course, this is a picture of the internet. But when I get a reflection like this, I know my suturing is correct because a reflection is in form of a circle. But as you can see on the picture on the right, you can see the reflection is not, it's in oval shape. And this immediately gives me an idea that OK, my sutures are not of correct strength properly all around. And this also gives me an idea in which ARS or in which um clock hours they are tight or they are loose and I can accordingly adjust them until I get a perfect circle. Now again, as I say, these are elective cases, I have a time, I can spend time and do all of these uh safely. But when we come to corneoscleral repair, everything is a puzzle. You need to quickly fit, fit in the puzzle and get the patient out. Now, these are some of the laceration cases. The one on top you see it's a triangle shaped la laceration. After hammering on the right, you can see these are on the sclera. So remember the center is the cornea and the right is your sclera and these are the lacerations on the sclera on the cornea individually, we also have uh a mixed kind of lacerations. OK. Now why I'm bringing all of this up is because you have to remember when you suture the cornea and when you suture, the sclera, the basic principles are the same, but at the same time, they are different. Why? Because the way you approach a wound on the cornea is different from the way you approach a wound on the sclera. The type of suture that you use for your cornea is different from the type of suture you will use for a sclera. And you must know all of this even before you start suturing such cases, when the laceration only involves the cornea, our approach is different when the laceration involves sclera approach is different when the laceration involves both approach is different. So that is why there are a lot of uh small variations in the basic principles, but the broad basic principles remain the same. OK. So I think this probably this slide kind of summarizes the very basics of corneal suturing. So when you want to suture a cornea, your needle, when it enters the corneal tissue, it should enter perpendicularly. If you enter it an acute angle, you will go shallow. If you go enter at an obtuse angle, you will go deeper than planned. You never take 100% bite. You must take up to 90 to 95% of the depth of the cornea. Why? Because otherwise you find kind of find a conduit for infection and the interior, the internal um anterior chamber is exposed to the uh to the exterior and you can form and cause infections. Now, if you can see these simple pictures that I've put the suture placement is at 90 degree. OK, 90 to 95% depth. Now, the distance of the sutures from the wound on each side should be equal. That is about 1.5 depth as well equal. Now, when we suture cornea, our main aim of suturing cornea is to reduce astigmatism. Because if the astigmatism is high, the patient will have visual difficulties. And sometimes if the astigmatism becomes too high or too irregular, they can't even be corrected with glasses. So it kind of becomes an optical failure where I have done a good transplant, but the patient still can't enjoy a good vision. The cornea graft remains clear. So that is why these small details have to be looked into when you are suturing cornea. So when specifically for cornea, your peripheral wounds should be lo a peripheral wound, you can put longer sutures. But when you come to the center, the length of sutures should become small, then you should bury the knots as um into the trauma. So it does not cause discomfort. So these are very well explained in these pictures. And probably one more thing that I would like to show is this picture. We need to understand that the suture when we have a suture, the, the uh the suture holding power is usually directly under the suture. So the, and as it moves away from the wound, the suture holding power decreases. And that is why it forms a diamond. So in the picture on, on the left, if you will see all these diamonds, they just overlap, they form a zone of compression. And when this zone of compression of uh I mean, when these diamonds overlap, they will not be any suture leak. But when you see the picture on the right, you can see the sutures are placed far apart. When the sutures are placed far apart, the zone of compression does not overlap and these wounds will leak. So that is why it is said that when you have longer sutures, you can place them far apart because you will have a bigger zone of compression. But when you have a smaller suture, like you can see to the extreme, right, you need to put them slightly closer. So these are some of the basic principles of surgery in cornea. Of course, I will not deal with sclera probably that is for another time because um again, the principle changes and one important thing which I would like to highlight your first or any suture should be perpendicular to the wound. So if you will see the picture on the left and see the picture on the right, the first, it looks very anatomically nice. If I put the suture in the picture on the left along the limbus, remember the limbus is the the area where the cornea and the sclera join. And if I put a suture there, it looks quite nice, but it is not correct. Any suture should be at 90 degree to your wound. It is very important. So if you will see this picture, uh actually it's an animation, but because of PDF, I'm not able to place now in this picture, what I wanted to show if you can see the number one, that is the first correct suture to be placed at the lumbars when there is an extensive uh injury. And after you have placed the first suture you can place the next suture at the other edge and then subsequently divide the su uh the entire laceration into half and put the sutures. But mind be mindful of the few things that we have just discussed. The length of the suture on either side should be same. The depth should be 9590 to 95% in the periphery. Means over here, you can put longer sutures, which can be far apart. The central sutures have to be smaller and they can be close apart. Once you have finished suturing, that is the time when you start to tackle any other lacerations, that's that's present. So the key over here in suturing of a mixed laceration, I would call that it involves the, the cornea and the sclera or the white part of the eyeball, complete the scleral suturing, uh sorry, complete the corneal suturing first only then proceed to scal suturing. Of course, scal suturing, the suture is different. And, and for cornea, we use always use Tenn very, very fine sutures, but sclera it's for another day. So I think this kind of sums up most of the the basics corneal sur uh suturing things that I want to say, Doctor David, you're not audible, probably you'll need to. Ok, looking at that diagram, you've got an irregular incision, but as you've clearly marked at each point, your suture is 90 degrees across the incision. Yes. So the vector changes depending on where? Yes, it is. Now you were telling me the other day that you, you were doing a corneal transplant and you handed over to a trainee to put in the last few sutures. What happened there and why? OK. Yeah. So uh so it's uh each one of us have our own skill and our own time strength. Now, no, two people can die in the exact similar manner. So what uh in, in whenever we, when um ok, so in this particular case that I was discussing, there were other complications and the eye was very soft. So every time we tie a suture, the suture tends to get loose. So when I am doing the surgery, I know what is my, the, my strength and how I tie the sutures. But the immediately when I ask somebody else to take over their time strength is different and it could be minutely different. I'm really sorry. I don't know the exact uh I mean, in the terms of the, the exact um den denominator to use, but there will be difference in strength and that is when the previous suture or my sutures will get loose. So the first surgeon's sutures can get loose if the second su uh surgeon comes in and has a different time. Strength. And trust me in that case, which was a case with 16 sutures, we ended up replacing almost 10 sutures after the surgery was complete. So that is how important the time strength is of course, during train, when we are training, we are we kind of expect these things and we are prepared for it. But again, these are elective cases. I probably will not do the same when there is a trauma. Uh perhaps as we continue the discussion, we can go back to full screen and stop sharing. But that is that is interesting that the consequence of not getting the right tension of course, is blurred vision. Yes, I'm not having that perfect cycle. How, what is your observation on the way we are training at the moment? And how do you actually teach corneal surgery? Right, outlined posture, the handling, the instruments and placement very clearly, which is exactly we have what we have described with placing sutures in our banana model, which is likewise circular. And we asked for 12 perfectly rad sutures. How do you teach e skills? And what do you use? OK. So the the good point for us is we do, uh we can kind of replicate the whole thing on animal models. We have something called an artificial anterior chamber where we can mount these corneas, corneas from the animals, we can mount them, we can make zigzag lacerations, we can uh I mean, of course, we, we go through a didactic lecture that I just went through, teach them and then get them to suture. And the good thing is we can remove from the artificial chamber and assess them under our slip lamb or microscope to s to teach them on the, what are the, uh I mean, what are the, their uh strengths and what were the weaknesses in that particular case? So that is one advantage for ophthalmic surgeries. At least we do have uh this, this option of trying these in wet lab and we actually can try on actual corneas rather than bananas or uh uh uh things such as uh tomatoes or apple, uh apple peels or apples. Another thing is a, a lot of times we do get research corneas. So one of the pictures that I showed that was I think two years ago, two yeah, two years ago, we had a cornea workshop where the eye bank actually was kind enough to provide us with 50 human corneas and we caught them, we mounted them on artificial chambers. We went through a didactic lecture and we taught each student how to suture. We assessed the cornea. So that was, I think probably that was more of a starting point for me because before that everything was verbal and then I realized that OK, this is a feasible method, but of course, human corneas, uh they are not so easily available. So we moved on to animal models, which is what I do currently in my, in my practice. And I think as we know, desperate measures, uh desperate times, desperate measures. So maybe I could later show a picture where we, during COVID times when we all were at work and we didn't have patients. We actually bought um silicon half semicircular silicone BS and we made some incisions. Of course, our, our suturing technique had to be changed a bit. The kind of suture we use had to be changed because there's no way a tenon nylon will pass through a silicone B. But OK, maybe my and the students picked up 50% of the principles. So that was a time when we actually tried a lot of things during COVID and we realized, I mean, if in dire situations, these silicone balls can work. But I think so far, I'm quite consistent with um animal eyes, uh either bulls eye or most of the time. It's bull's eye. What about fish eyes? I'm just thinking I can go to the supermarket. That's why I get all my low fidelity model from I feel a little bit too tiny for us. A bit too tiny, a bit too tiny. Even even with 10 0 sutures. Yeah. Yeah. Yeah. So the bull's eye or both sides fit us perfectly. OK. Yeah. So when I started, did my first coronary artery bypass, the only instruction I had was just be quick. What's your comment on that? Ok. Yeah. So, um that is a very, very uh common statement I feel and I also am guilty of doing that. But in the end, what matters is perfection rather than time for me. Uh Of course, I will not deny. There are times when you need to be fast. And I think in those situations, instead of um how will I say instead of stressing the that my, my uh my colleague or my junior? Uh I'd rather take the case in my own hands and finish it off. That is, I think probably as we age, we get more insight into all of these for me, time is not a factor. As long as the work is, of course, there is, of course, I do draw a line. You can be sitting and doing uh things when you are not capable. But if you are capable and I see the student can do, I don't look at the time, especially in ophthalmology if anybody uh I mean, any, any of the audience they have, we are very fond of doing cataract surgery in five minutes. And that is a matter of pride and we, you know, we, oh, I finished cataract in five minutes. But even if I do it in 20 minutes and I get the same vision and I'm careful. I don't rush. So I don't believe in rushing um anybody and neither myself. And that is why I have, I think the fellows I have, I tell them cornea suturing is a work of patients. You don't have patients, please don't take cornea fellowship. Because as I said, even the last week when we had to replace 10 of the sutures. Uh There will be people who will not be very patient to do it that and, and they can just leave it. So for me, no, I don't see the time. Of course, I do have my own uh I do draw a line at a certain limit but there's no point rushing anybody. So II think that's my personal take and knowing what, you know now and having been to the program of training, what do you think are the important elements of training apart from patients? Um You mean training the the students? Yes. All right. So I think uh I, when I started training, I think we were still in that era of uh C one do one teach one kind of thing probably in my earlier phases. Then over the period of time, I have seen that now there are a lot of simulated models. There are these teaching programs which were not there when I had started off. So I think these changes that have occurred and going more into virtual trainings. And another thing that I think recently that we were talking about is some in ophthalmology. They have come up with something called as Oscar score. I never get, remember the full names. I've written it down. It's called an ophthalmology surgical competency assessment rubric Oscar. Now, in this, what happens is each surgery they have deconstructed the way you were, we were speaking the other day. So, this, what we follow in our university is we follow this for MC or cataract surgery and the entire cataract surgery has been deconstructed into steps and the students are graded, um, as beginner as, uh, no, sorry, as, no way, as beginner, as advanced beginner and competent and unless they are competent, they don't move on to the next stage. So I think these are few of the changes that I have noticed. But if for me, I think I trained in one of the best places where I had the best um pre surgical training and I had the best hands on. I think that also counts. Um volume does count. I believe you can refine your skills with as the numbers increase. And that is why they say the older you get, the better you get at least in medicine. Yeah. So how do you advise your students to practice? OK. So practice. Yes. So I think I still follow the animal models, as I said, Doctor David and we have regular workshops. We tried. I mean, so in our university, every six months, there will be a batch that will be giving the final exams and then they'll move into what we call as registrar or pres specialist training for one year. So what we do, of course, these didactic lectures always are happening. We have regular cornea classes and, and I would like to invite you this Wednesday on another cornea teaching that we have on suturing um is going to wet lab. So please find a place with wet lab and you can actually go through because reading is different. When you practice on a uh in wet lab is different. And when you do it on patient, it's much different. So of course, get your basics right. Understand them well, but wet lab is the way to go. So you need to find some method of practicing. And if you have nothing bananas uh um uh in cataract, there is a step where we have to remove the capsule of the lens and they say you practice it on tomatoes. Um So whatever comes in your hand, invest, I will say I've always advised my students to invest little bit on sutures, uh sorry, surgical instruments for themselves. Some basic ones, you don't have to go for very expensive ones. Just take some basic because you can be dependent on others. You have a small pouch of, you don't need much. You just need few used sutures from your ot you have your own uh needle holder, you have your own forceps, you have your own time forceps. That's it. You can practice very well even at your home. Get, get a mentor who can guide you. I had an excellent senior. I cannot thank her enough. Her name is Doctor Sh uh apart from all my consultants, she was very critical of every case that I did and I am really thankful to her for being so find a mentor, get some instruments, whatever is comfortable if you can, uh if you have access to wet lab, that will be the best. And you said she's, she was very critical. Yes. But you still thought she was good. Yes, because I want to learn the correct method. We all want to learn the correct method in the end. So she was critical in a positive way I'll say and, and yeah, II mean, it's been almost 10 years, but I still remember her very fondly fabulous. There are two other things that struck me. You, you were using a tomato for capsular work. Yeah, explain how the tomato is used for capsular work. OK? If I tell you the truth, I have never used it, but I have advised people to use it. So you basically you. So in when you do a cataract surgery before you can access the lens or the nucleus as we call of the lens with your ultrasound probe, you need to make an opening and this opening should be in a continuous curvilinear manner. Again, a very nice round because if there are edges, the force with which the fluid goes in the eye, it can tear off and it can cause various complications. So, so the way you do that is very intricate and you can, so what you do is you just need to remove the tomato skin without any pulp coming out and it has to be an absolute circle with no tags. So, tomato a bit. Right. Tomato probably. Yeah, you can try. But, um, frankly I have been lucky, I won't deny. I have always had, um, I will say about the volume and to practice on patients and excellent seniors and, and teachers that has really helped me to where, I mean, at least the passion I have for corneal suturing and we always learn everything every day. So, and you're continuing to learn yourself. Yes. I think that is the reason I'm sticking to and I, um, sticking to teaching and with my daughter aiming to go into medicine, I feel I kind of owe it to her to the next next generation. Probably. So I'll try to do that as long as I can. One of the pictures you had up before we started, we don't have to call it up again. You apologized it for being out. But that was a picture of your daughter who's how old she is? 1616. And she is putting sutures in a banana skin. Yes. Yes. Fabulous. Fabulous. Does she want to do surgery, um, following your footsteps? No, she, she says she doesn't want to get scolded by me. So probably some other field but surgical field. Yeah, she doesn't want to be scolded by you. Yeah, because she knows mom is mom is too, too much behind perfections. So I know. Wonderful. Absolutely wonderful. I think we've had a perfect description of the principles of attending to basics and without asking. So has described all the important elements that we have elucidated over the past month, posture and look after you the way you stand, the way you sit, handle your instruments with respect. Remember that the instruments themselves are potentially lethal and can cause damage if used with excess force, particularly forceps get your basics right. It is useful to have a model that gives you feedback a bit like a microscope showing you where the tensions are, use your needle properly 90 degrees across what you want to stitch 90 degrees into what you want to stitch the lovely nuance or the tension you put on the suture when tying the knot, one of our uh audience previously asked me how much tension you need to put on. And the simple answer is for skin just being able to dimple the skin is enough. If you start pressing, that's too much in microsurgery, that means that all your sutures need retention. Because otherwise you get blurred vision, know your tissues. You have one suture for the cornea, one suture for the sclero. It is same with all the other tissues in the body. Be meticulous in the placing of your sutures to get the zone of apposition. So it's not under tension. You might wonder why we do this. It's not a master but also emblematic of the need to get perfect apposition. Use every opportunity to practice. We've heard about goat size bananas, tomatoes, find a sense who will help you refine your techniques. Remember that mastery is not an endpoint but a journey and you're learning every day, the more you polish, the more you shine. I think you will agree with me that. So has summarized everything we have been talking about with basic surgical skills training and although you might dismiss it as cornea surgery and not wanting to know any more about corneas cos, I'm never going to do it. The principles of stitching and the principles of surgery as described are the same across the board. And I believe a good surgeon could operate in any part of the body if they stick to the basic skills and they know the anatomy and respect the tissue and understand the feel of the tissue because the instruments on extension of your fingers. Thank you very much for joining us this evening. I'm delighted that we're going to be working together not only a sense in the face to face, teaching in the ophthalmic postgraduate students as well as basic skills students. And I'm delighted you're doing a master's in education in mou in our unit. I'm very excited at the prospect and I think ladies and gentlemen, you now can see why and more clearly, we attend to the basics and get them right. Thank you very much. Indeed. Thank you. Thank you. I'm going to see you next week and we will continue the series on basic skills and focus on scissor skills. Thank you very much for your insight and wonderful description of how to do it properly. I wish you all well, I look forward to seeing you next week. Yes, thank you. I think there was just one question that I saw in the chat box if I, we have just two minutes. So, um R and Gupta Us. Ok. Uh Was the fellowship in India sponsored by the hospital in Malaysia. If not, was it costly? Um ok. Um So my fellowship was not sponsored. Actually, I'm an Indian citizen, settled in Malaysia. So I went to India to do my fellowship. It wasn't sponsored. How much was it? You can always um because mine was 10 years ago. So I probably it would uh the, the co this um I mean, the price may have changed and I don't want to give any wrong information. But if you ask me, was it very expensive? No, and we cannot put, if you can afford, we can't put money to um uh to our training. So please invest if you can and they are very, very accessible, you can just drop them an email. Um Thank you. Wonderful. Uh John R Yes. Um Thank you for the talk and uh yes, thank you. I think the rest