Welcome and thank you for being here. I'm so glad that you're joining us for another episode of the nonprofit show. Today is our dedicated Ask and Answer episode. Thank you to Fundraising Academy for being our underwriters of each and every Friday. We are so grateful to have their continued partnership and sponsorship as the exclusive sponsor, in fact, for today's day. Julia Patrick is here. She's the CEO of the American Nonprofit Academy. I'm Jarrett Ransom, honored to play alongside Julia each and every day for the nonprofit show. I'm your nonprofit nerd CEO of the Raven Group, and we are coming up on our 600 episode. Thank you so very much to our presenting sponsors. Those of you watching, you can see their logos on the screen and we encourage you to check them out. Those of you that might be tuning in and listening, I will go ahead and let you know who our sponsors are because they are big deals. So thank you so much to Bloomerang, to your part-time controller, Fundraising Academy, Nonprofit Nerd, American Nonprofit Academy, Staffing Boutique, Nonprofit Thought Leader, and the Nonprofit Atlas. So thank you so very much. These companies keep us going and growing. You can find all of our episodes on Roku, YouTube, Bimeo and Amazon Fire TV. For those of you that are podcasters, you can also stream us on your favorite podcast channels. I think we just got a notification from Buzzsprout that we've had over 100 downloads currently for our nonprofit podcast. So thank you to all of you that are downloading and listening to us wherever you might be tuning in. So we're so grateful to have you. Yeah, it's really fun. It's it's been really an interesting thing. And I want to make sure that we give a great shout out to our producer, Kevin Pace. He's on with us every day. And when those days when I'm off or Jared's off or we're doing other things, Kevin is still here. So those 600 episodes that we have, you know, produced and put through, he's he's behind that. And he's the one that's taken our files and put them into that podcast format. And it's really been an interesting thing to see because, you know, we really started and and pridefully so as a broadcast as a streaming. And so we really felt like, OK, the visual part was where we needed to be. Or at least maybe I should say I felt that I felt very strongly about that, Jared. And it's so it's been great because I know you really like to consume media through podcast formats. And correct me if I'm wrong, but don't you pretty much listen to a podcast every morning as you're working out or getting started? Every morning, in fact, it's like the first thing I turn on as I walk out the door to walk and as I am, you know, getting ready for the day. So I have a couple that I go back and forth with. And then I also just took a really long road trip and I listened to an audible book and it was the Brene Brown Atlas of the Heart. So I'm a bit I'm a really big, you know, audio consumer. Yeah, I think that's great. And, you know, we've talked a lot about the notion of self care and self motivation and encouragement and all that. And I think that's one of these things about this podcast consumption. And I really appreciate that you just shared that, because I think for you, it seems like it really serves you well as a motivational launching pad daily. Is that right? Oh, yeah, it definitely helps to set my mind for the day or the week or whatever is kind of going on. And, yeah, it's it's it's become a ritual, you know, kind of like taking that first sip of the coffee cup. It's like, oh, it just feels so good. Yeah, I know it's really it's it's an interesting thing. And I think, you know, we can have good habits and we can have bad habits. And and I think this is a really cool thing that you've been able to do. Hey, I want to chat with you briefly, because before we get into our questions and we have some great questions and we have a lot of them. But talk to me a little bit about what you did with Bloomerang yesterday, because you really did something super interesting. And I'd love to know more about it. Absolutely. Bloomerang, as you all know, is one of our exclusive our presenting sponsors, rather they've really been with us from the very beginning, March of 2020. So we owe a lot to Bloomerang for believing in us when we weren't even quite sure what we were creating. And they offer webinars, they have offered webinars and they asked me to come on and present. I gave them a couple of my key topics that I am typically asked to present on. And so the one that they hooked into and I presented yesterday to 600 people and again, it's a virtual webinar was was is finding and living in your zone of genius. And it was a an hour long webinar. And for those that were, I guess, registered will also receive the recording. I think you might actually be able to find it online, too. I'm not quite sure, but I can check that out. So, you know, really glad to give back and be of service to our partners and truly our community at large.  And so really just being of service to share our expertise and our personal experiences with the world. Yeah, I think that's great. You know, Bloomerang was so generous with us to have us broadcast from their booth at the conference, the global conference. And and it looks like we'll be doing some other things with them in the future. And so it's really cool that you were able to do that and really share your knowledge, because, you know, getting an hour in that type of a format is much different than just doing our daily 30 minutes. You can go a lot deeper. And so it was really cool that you were able to do that, Jared. Good job. It was very engaging. We had similar to here where, you know, the audience participation was through Q&A and then a chat box. And so there was no video component for the attendees, only for those of us that were panelists. And so it was it was really good. It was a very engaging, very engaging conversation. Awesome. Well, good deal. I'm really I think that's super cool. And I always love to see what Bloomerang is going to be talking about. And it's it's really fabulous because they're not just talking about their product and their services. It seems to me like their content is really, you know, for the betterment of the sector. And so that's it's a really wonderful thing that we get to see that. I guarantee you, finding and living in your zone of genius had nothing to do with a donor database. Right, right. And exactly. And so good for them. Good for them, you know, is really good. You're investing in the nonprofit leaders. Yeah. And we don't see that enough.  And they want to, you know, promote or hawk their wares, which is great. And I respect that. But, you know, we we do want to find people to talk about, you know, bigger picture issues for our sector, for the betterment. So that's really cool. Well, hey, I mean, we've got a lot of questions, but I did want to start with that today. And and I'm really, again, thrilled and proud of you for doing that. And you know how I love the name withheld, city withheld. And we're going to kick off the day with that. All right. So I've been asked to interview for a direct development director position of a nonprofit that I'm familiar with. The issue is that I don't or that I know the current DD. The CEO is going to fire them and has expressed an interest in hiring me as a replacement. Any strategies on how to manage this? No wonder this is name withheld, city withheld. You know, this happens more than we probably admit are more that we talk about. And what I am seeing here is that they know the current development director, but they don't state how they know them or if they're friends, professional colleagues, right? I was just talking to a company yesterday, actually in Florida. They used to be with another company. We're talking about the AFP icon and conference in Vegas. And I use the word incestuous by saying our sector is very incestuous. And, you know, we've also talked, Julie, about how once you hit this point in your career and this point of your reputation, you no longer apply for jobs anymore.  So I see that very much in this question that we've received. And so what I would encourage you to do, and I believe firmly in transparency and honest communication, but I would really have a self-reflective time of who is the current director of development? How might your relationship change with this person, knowing that this is a consideration? And, you know, I say consider that because what we don't see in this question is are they close?  Like how are they perceived in each other's relationship? You know, we've all been in very kind of awkward situations before. The most recent one I can think of, Julia, I was actually given a contract over someone else that introduced me by way of this contract. It was very difficult. And for me, with my integrity, I knew that I had to tell the person that made this introduction. And I said, look, this is very uncomfortable for me. I have chosen to take the contract and I wanted to be the first to tell you before things got hairy. And then also, you know, just really give you that, that honest, this is how it came about. Now, the short of the long is it was a horrible contract. It ended early and I should have seen the writing on the wall. Oh my God, that's hilarious. Yeah. And of course, I called the friend back and I said, you know, hindsight's 2020. And now I know why neither of us should be working with them. Right. You know, I'm really mortified that and I don't, I'm mortified that a CEO would go forward to another professional and say, I'm interested in possibly hiring you after I fire the current person. I just think that's reprehensible. And I agree with you the tap on the shoulder. I mean, we've talked about this and we're continuing to talk about this and that the marketplace, the labor pool is shifting and there's more opportunity for the professionals in our sector undoubtedly. But it just seems to me that that is a real suspect way to do business. And my sense of this, and it really is interesting, Jared, because it dovetails exactly what you just said is you're like that contract was not a good relationship, right, for whatever reason. And I just wonder, and I don't know what you think about this, but it just seems to me that if that's the way the CEO is behaving or thinking that it's not a healthy way to approach these decisions and that's going to maybe be reflective in other ways that the organizations run. So what could happen to you if this is happening currently and you're being tapped on the shoulder, it could also happen to you down the road. So there's a lot to consider here. Yeah, I just feel really uncomfortable with that. And at the end of the day, your integrity is the only thing that you leave this planet with, I think, you know, not to be too preachy, but I think that's kind of the thing. Okay, so now we're into the next question. And again, name withheld. Okay, this is a tricky question. We love those. We run a human services nonprofit and our CEO does not want to speak out against the social conditions or causes that drive people to receive our services. This is a huge deal. Our CEO wants to remain neutral and discuss only our programming. I'm frustrated by this. I think this is a poor decision. Very interesting. I am fascinated with this because I served as a board member for the nation's largest domestic violence shelter more than a decade ago. And I was of the belief that every time there was a national issue that involved domestic violence that our organization needed to speak up and not, you know, shame or get involved in the individuals, but to eliminate what was going on. We have tons. We know lots of information. We have tons of education. We have statistics. And I always thought it was a great platform or a time to become a source expert to talk about, you know, the actual ecosystem of or ecosystem of domestic violence. And it was very controversial and the majority of our board members, they didn't think we should do that. Interesting. Yeah. I feel the same way that when something is national, local, you know, regional, that this is a great opportunity to share the mission of your organization and the solution that's provided to the community residents and those, you know, that could seek services and support. I've worked with a lot of human service organizations. In fact, that is typically, I would say 75% probably of my portfolio, maybe 60%, but the majority regardless have really been in this human service space. And I think the best way, honestly, to talk about your mission is to talk about what I just said is that solution to the community problem. And so whether it's homelessness, whether it's poverty, whether it's, you know, access to health care, I think there's a lot to position your organization. As you said, Julia, and I love this, that you're like, we are the go to, like we are the resource for this ecosystem. And so I'm curious, you know, at the core name withheld, if you can find out from your CEO why they are so hesitant in sharing this because there needs to be more. You know, I really think there needs to be a better understanding. The other thing I highly recommend, and I don't know your budget or your size of your organization, but you might want to address this with a public relations agency. How might they address this and how might they, you know, create vernacular and language to support a win-win opportunity? I think that's a great idea because it seems to me, and again, we don't know what, where they're serving, but even if they just had a fact sheet of 15 different points that every time something publicly comes up, they could send out to the media to reflect upon what the actual situation is. Because a lot of times we don't know. I mean, we're undereducated about these root causes or what's available, you know, who's impacted. I mean, I think that could be just a basic thing. Any, every organization should have that, by the way. That's right. Our quarterly, I think you said. Well, yeah, depending on what's going on, absolutely. I mean, that should be, to your point, Jared, you know, that's information that you would put in your grant applications when you're talking with donors or donor investors, funders. I mean, these are stats that we should all know and we should be using. So anyway, but very interesting. I think this is a topic that really needs to be amplified because this is a common thing. There are a lot of nonprofits that don't want to stand up and wave their hand and say, we work in this space. That's right. Kind of controversial. Very interesting. Well, name with help. I feel your pain. Okay. Oh, so this actually came to you. Oh, okay. Okay, wow. Let me get this up because this is like a really good one. Several weeks ago, Jared Ransom, the nonprofit nerd, gave a stat that was and the national average win rate of a grant proposal. I can't remember what that number was. It was uncomfortably low and I need to share this with our CEO. These questions come in for you. I know. As soon as you said that, Julia, the first thing I wanted to respond with without even seeing the question was 30%. Like I have this feeling that I know where we're going. Call it intuition. Call it mind reading skills. I'm not quite sure. 30%. So Andre, that was the national award rate and I forget when I found that data. So it might be worth looking again to see if there's updated information. Giving USA is one of my go-to research information and resources. So giving USA and it pulls from accumulative data points across the United States. And so 30% was and possibly still is that national award rate and it is uncomfortably low. And the silver lining is you can absolutely increase it. It takes some strategic planning, some strategic thought process and initiatives and tactics. But I have been able to get my workload when I was only doing grants, Julia, to 60%. 60% award rate. So that doubles the national standard from 30 to 60. And again, that's a much higher percentage. So that's an average, is that 30%? But there are ways to increase it. Yeah, I'm Andre. I'm not, it was uncomfortably low and I need to share this with our CEO. That is fabulous because I think that and I hear you say this number and I'm always like, oh, that can't be right because it just, you know, we hear about grants, grants, grants, everybody, you know, seems like they're getting them and it just seems like there's so much more out there than there really is. And so... Much more. Well, and what I also like to say because a lot of people have this misconception, Julia, that grants are the end-all be-all. Like they are that magic pill and they're not. The truth of the matter is it's very competitive out there. We talk often about the 1.8 million nonprofits in register in the United States alone, not to mention our friends around the globe. And so, you know, really looking at that, you also, the other 30% Andre that I'm going to toss in there is you never want your operating budget of your organization to be made up of grants. So more than 30%. So you want 75% of your operating budget essentially to come from individual giving. No more than 30% to come from grants. And the reason for that truly is you become solely dependent on that grant funding and it is competitive. It's becoming more and more competitive. And so you want to diversify your funds. I can tell that forever. And I'm glad that you put that in because I think when you just give that other 30% stat, it puts it in context.  It's like, no, it's not only what are you going to apply for, but what should you have as that pie? How are you dividing that pie up? And I'm going to be really forward here. I think the misconception of grants truly comes from the lack of education in the startup space. And so a lot of people have been told, oh, once you become a nonprofit, then you can get grant money. And guess what? Grant money does not have to be paid back. Well, that is not a sustainable, scalable business model.  So you're already a skew.  That is very dangerous. Yeah, it's so scary. Okay, that's cool. I think it's a characteristic trait, lack of education, and information for the smaller, more startup organization. That's where I see it and hear it the most. That's cool. Well, that's a really good... I mean, yeah, that's good information. And I appreciate you sharing that because it kind of curls my hair when I think about that. I really do. Okay, let's talk to Mitch from Ames, Iowa. He writes, We are considering a short day on Fridays where the office closes at noon. This would only be for the summer months and would end on September 1st. We have never done this and we are wondering if it will make us look like we are goofing off. Funny, Mitch. I know a lot of organizations that do this and they do not change their four-day a week schedule. So they keep it the same as it's always been. This is typically done like Memorial Day to, I don't know, maybe that's the day, September 1. And so it is that Friday off and not even just closing at noon, but Friday off. So essentially just taking that Friday as a rest recovery day. To me, I definitely do not see this as goofing off and I think it really matters as how you position this in your language, right? Like how you put this on your website.  There is nothing more highlighted right now than mental health in the world. And so I do not see this as goofing off. And I, you know, to me that really makes me sad that that even came about in my way of conversation because I really do think that we owe it to our workforce and to ourselves because we're part of that to have the ability to recharge. Burnout is serious and our suicide rates are extremely high. So do you think that it is a good idea and for the organizations that you've seen to like totally close off the entire office or do you like a 50-50 where say one Friday half the staff is off and, you know, you have it the scale to prove? Yeah, I think it depends for the agency and the community. The organizations I know they take it completely off. They're smaller. So I think it really depends on your service lines and what you offer to your community, right? You exist to provide a need in the community. And then what I have seen also is, you know, just the request of not working but please check your email. So if something does come in at least it's not a three-day weekend it can be addressed promptly. So really kind of having that check-in. But again, that is not required. It's a request. Yeah, it's interesting. You know, when I look at this, Mitch, my sense of it is and maybe this is the wrong approach but you need to look at this in terms of your employee retention. You know, because the marketplace is so tight and it's so such a challenge. And if this is one thing that you can do that helps protect your team to your point what you said about, you know, work related stress and pressure and all that. But just the actual HR issue, I think you need to really dig into this because... You know what would be interesting, Julia and to Mitch, our viewer that asked this question, you might want to take a look and assess your organization and the cadence of your organization. Where are their peak seasons? When are their lower seasons? When might you be able to consider this? An organization that I know that's doing this for the summer, they are highly engaged with the school system. And so they're taking this time off because the schools are closed during the summer. So that cadence worked in harmony. It might be Mitch that based off of, you know, your organization and your community need, the summer might not be the best time to do it. There could be another opportunity to provide this. Right. Yeah. I think that's very wise. Very, very wise. Well, you know, Jared, his time once again has flown by. I say this pretty much every day. Okay. I mean, it's always like, what happened? Thirty minutes. Cool. But anyway, again, I'm Julia Patrick, CEO of the American nonprofit. I've been Academy. I've been joined today to the great pleasure of my week by the nonprofit nerd herself, Jared Ransom. Hey, Jared, thank you so much for, for really giving us some great information this week, not only on the nonprofit show, but off the nonprofit show with Bloomerang. Of course. Happy to be of service. Well, it's been a lot of fun and thank you again so much for doing that. And we want to make sure that we thank our sponsors again without them. We would not be here having these discussions. Bloomerang, your part-time controller, the American nonprofit Academy, nonprofit nerd, fundraising Academy, staffing boutique, and nonprofit thought leader.  And so we are very appreciative. Thank you. Absolutely. And hey, as we like to end every episode, and especially I think this is important on Fridays, you know, stay well so you can do well. We need to rest up and really be prepared for what hits us on Monday. And so, Jared, thank you so much. I'm speaking to you, sister. Thank you. I hope everyone has a great week including yourself, Julia. I'll see you on Monday.


Hello and let's talk about Naomi Osaka and women's tennis. The 22-year-old tennis player of Haitian-Japanese descent won her third Grand Slam at the US Open on Saturday, beating Victoria Azarenka of Belarus. Osaka's victory was a culmination of a fascinating campaign, both in terms of tennis and politics. In each of her seven matches, she wore a face mask with the name of a black American who had fallen victim to racism. George Floyd, of course, but also Breonna Taylor and Trayvon Martin and Tamey Rice. Long men and women whose lives were snuffed out by a brutal racist system. Naomi Osaka was taking a stand just as other sports persons, such as basketball players in the US, had done earlier. And it is a vital stand to make at this point, as killings have continued in the US even after the massive protests following the murder of George Floyd. But Osaka's political statements are also part of a traditional women's tennis of highlighting radical causes and struggling for it. A key part of this has also been the struggle for equal pay and prize money. We talked in news clicks, Leslie Xavier on these issues. Thank you, Leslie, for joining us. So we see Naomi Osaka's statements that were made during the force of the US Open. And this is, of course, part of also a global tradition, so to speak, a global practice that has been going on around the world. We've seen similar protests by basketball players in the United States, both the men, men and women's players, and also a number of sports persons other celebrities raising issues around Black Lives Matter, racial justice. But today, to go to another aspect specifically about Naomi Osaka and also women's tennis as a whole, we do know that there is a long tradition of women tennis players raising the key issues of the time standing in solidarity with protesters and definitely also using the support and the platform it provides to make some of these political points. So we'll talk a bit about this and especially about that in the context of women's tennis. So largely, if you look at it in tennis history, it has been the women and not the men. I mean, and that continues even now in this generation. So if you look at Black Lives Matter movement, it's not the... I mean, yeah, some of the men's players, two players have come out and spoken about it at large, but no one has explicitly took a stance like the one that was taken by Naomi Osaka.  So, I mean, someone like Roger Federer or Rafa Alnader, for instance. So that way, if you look back, if you go back into tennis history, the pro-touristry to start with every generation has had a Naomi Osaka of sorts. So let's get back to the 70s, late 60s, 70s where Billie Jean King was ruling the courts.  And it was in a very early stage for women's tennis as women's professional tennis. And she was very vocal about equal-play status for both men and women. And she pushed for it right through both us in the capacity as a player, while as a player. And at the same time, later when she became an administrator and played a prominent role in the women's tennis association WTA, she pushed for it, she keeps continuing pushing for rights. And also at the same time, she was one of the first professional women athlete to come out as openly gay. And subsequently, she also was an activist for LGBTQ rights. And so here is a character who has transcended sport. Though we keep talking about her with tennis as an artistic saying that she fought for equal pain in the tennis realm. But she has been part of organizations which has worked outside as well. And also at the same time, tennis is but a reflection of what was happening in the feminist movement in the 70s. If you look at it, the period was defined by such struggles in all walks of life. And Billie Jean King and her contemporaries, the women players of her time just carried it forward into their realm, into tennis. But of course, the establishment, there was, I mean, she faced odds. There was also a narrative being played about the selfish nature of demanding equal pay, which is always a narrative that's pushed across any labor movement for that matter, even now. And then trying to limit the fight that she represented into just the scope of tennis, which was again, when we look at it now with hindsight, it was not. And then the next generation, Martina Navratilova came, and she again was a abit activist for LGBTQ rights. She was also openly gay, and she also faced a lot of criticism in the tennis fraternity itself, people targeting her being caustic about her. And this was pre-social media era, so she probably was saved from a lot of, I mean, a storm that at least stays now. But even if you negate that aspect that it was a pre-internet and pre-social media era, there was a lot of attacks on Navratilova while she was a player, from rival fans to generally to patriarchal segment of tennis followers and people in the tennis establishment. And Serena came subsequently again, taking forward that fight for equal pay, which has yielded results now. And Serena also stood off late recently after she became a mother. She also stood for that, that rights of a woman tennis player, because earlier the two rules were such that women would dread taking a maternity break because they would lose their ranking points, and when they return, they would have to start from scratch. But then a couple of years back, the WTA changed that rule, and they introduced this aspect that women tennis player returning from a maternity break would retain a ranking points and also would get a wild card kind of entry into tournaments and into Grand Slams, where she can potentially be seeded if her ranking was high enough when she left in the first place. So that was a very progressive move by WTA. And of course Serena and a host of players were the reason for that, because they were very vocal about it. And understandably, I mean, it was very heartwarming to see that in this year's open conducted under lockdown, there were nine mothers who were part of the main draw, and three of them reached the quarter final stage, which was unprecedented for a Grand Slams. And then, of course, Serena Williams and Victoria Sarenka fought each other in the semi-finals and Sarenka reached the finals and got beaten by Osaka. So yeah, so this look at tennis as a whole across generation, there has always been women who have stood up and fought the system, fought for rights, fought for things larger than larger than what their sport is and the scope of the sport is. So this, I mean, this precedent was set possibly because their journey in sport itself is a huge struggle, starting from childhood possibly, and then it continued through their careers where they face different obstacles when they reach a certain stage. And it's also very clear that even when you reach the age stage, also, the struggle or the challenges are different, not necessarily what they face when they were a teenager training and coming up the ranks. So these struggles mold them to stand up for a larger course in life in general and using their professional standing and the platform that they receive being at any player for that course. And that's what happened with Osaka as well. And so in this context, of course, we, the struggle for equal pay and has actually been very central to the whole discussion. It's been going on for many years and tennis that way does seem notoriously conservative sport that way too. But what is happening with that right now if you could talk a bit about it because it has been a continuous demand for women players throughout many years and still, it seems quite far away. Or does it? No, it's not because in the last few years, things have gotten better. Things are moving in the right direction and some of the slams have, including Wimbledon, have brought the price money of the women almost on par with the men. And so parity is, I mean, now the understanding is there and it's a huge change for the sport in itself because of the, I mean, it's pretty clear that you use the politically correct word there that tennis is conservative. So across, I mean, it's not just when we talk about men and women, it's also there across race as well because if you look at tennis and the demography of tennis players, the top 200, top 300 players, you can just count on your fingers how many black players would be there, how many brown players would be there.  And so it's that way tennis has not cracked the race barrier, but they seem to have cracked the gender barrier that way because now more and more women are benefiting from the momentum that this fight for equal pay gathered over generations. And it was a fight that lasted generations, but then it's reached a stage where things are better. So when Naomi Osaka stands up with the mask on her face, presenting a case for a larger case that she believes in, she's taken note of and she's been taken seriously and because of the stature that she has gained, being a woman's tennis player with all the rights that being a woman's tennis player gives her account. And in this context, finally, a quick question about India itself, has any of this, what do you call, is any of this being even reflected in the Indian tennis circuit because actually now there's very little talk about, or you hear very little about Indian tennis these days and what is a very quick look at the scenario there? So Sumit Nagal was there in the main draw of the US Open this year. I mean, if you look at Indians who featured in the US Open, Nagal played and second round he lost to Dominic Piem, the eventual champion. And Rohan Bopanna played the doubles draw and second round he lost as well. And so that's more or less sums up where Indian tennis stands in the global scheme of things. He has best doubles player, not progressing beyond the second round, the third round and India's best singles player not progressing beyond the second round. Having said that, that has been the story for the last 15 years or so where at the slams we have been exposed, except for the occasions when a doubles player has clicked for Neanderthals or for Sanya Mirza. Of course, the partners also matter in that case. As far as the larger global movement, whether it touches the Indian circuit, in the sense as a professional setup in tennis over here in India, it's not reached a stage where it would matter because in any case our players at the national level, our players are at best semi pro. You can't even call them that because they're dependent on a lot of the federation or the organizers or all the small sponsors that they get. If being professional is, the idea of being professional is earning enough to sustain yourself on tour and train and get better and compete at the various tournaments, then we have not reached there yet. So the support from the federation and the government for taking these players to competitions, it's there. But as far as making a career out of the sport, we have to break into that upper strata of tennis which we haven't yet. And there are many factors to it. One quick factor that I would like to mention now that we have spoken about India is that we lose our talent to Ivy League. So it's a very tricky scene there because in the US, if you look at it, none of the US tennis players go to college because college what happens is that you can't turn pro if you're in college. That's the rule of NCAA. So if for any of the US players, upcoming US players, 15 years, 16 years old gets into college, then you or she stands to lose five, six years of valuable time where she can grow in the pro circuit. So tennis is such a sport. While we opt to go to college because for us that's a window to a parallel, I mean a tangential career path. So we have lost a lot of talent on that. And even tennis players who have stuck to the game post that someone like Somdev Devverman was India number one 10 years back. He made it to the main row of a few Grand Slams as well. And Somdev was NCAA champion. So but then he came out of college and he was nowhere in the world too. So you can understand where that where that loss happens to Indian tennis. It's just an observation and a side note to this. But the main point about this discussion was surrounding women players and how they have always stood up. And so adding to that discussion, I would like to mention Victoria Asaranka, the runner up at the US Open and the struggle that she, the personal struggle that she went through and her she reaching the final in itself is a huge victory. She was in the middle of a custody battle. She had to leave the professional tour because of that. Because she the court ordered that she couldn't leave California with the son, young son, two year old son. So she decided not to travel around for competitions and stick on till court decides otherwise. And then now a favorable ruling has come. So she has gotten back into competing. So it just sort of sheds light on how the state of women, I mean, I mean, we are not talking about a commoner here. We are talking about a very, I mean, a Grand Slam champion and an elite athlete, one of the top players in at one point, one of the top players in the world. And she's still acid proven by the way she reached the final this time. And no one is immune to the patriarchal setup that's the hallmark of our society. So breaking that in itself is a big fight. And my reckoning is that these pioneering women players, and I would call Osaka also a pioneer for what she did. They are forced to do these things because they are fighting the system right from the workbook. Thank you so much. Our next segment is on the Delhi riots groups. In a major development, activist Umar Khalid has been arrested in connection with the riots and more arrests are likely in the next few days. Over the weekend, we got to know that CPIM General Secretary Sitaram Yachuri noted academic Jyothi Ghosh and activists Yoga and Riyadh were among those named in disclosure statements that were part of supplementary charge sheet as part of the probe. This riots probe by the Delhi police is very symbolic of India today. What should have been an investigation into the deaths of over 50 people has become an investigation into those who protested the CAA, NPR and NRC and some kind of grand conspiracy they were all part of. We are no closer to knowing who was responsible for the deaths. We don't see signs of BJP leaders who made hate speeches being punished. What we do see is students and activists being hunted down and painted out to be archfiends. We talked to Sitaram Yachuri on some of these issues. Here is what you had to say. What is your response to this and what do you think is the logic of the Delhi police in making these kind of allegations and these kinds of statements? Well, honestly, you can't see any logic. There is no logic in this at all. Now we will have to wait and see how they are going to establish this link between peaceful protests against the CAA and NRC and NPR with what they call Delhi riots but it was actually Delhi communal violence. Now in that communal violence, 56 of 53 people officially died. Now who is responsible for that? Any charge sheets? If you are investigating that, that ought to have been your first priority, nothing of that sort. Then before this violence took place, there were these hate speeches, incendiary hate speeches by union cabinet minister, by Delhi BJP leader and according to that timetable announced by them, this violence began. Any charge sheet on that hate speeches? None. So what is the police investigating? And that is where the entire political conspiracy aspect comes in. The police is acting directly under directions from the union home ministry and there is a political motivation to this. It is not really the question of delivering justice, establishing the truth but to actually act their political right. So this is what it appears from this very clearly. And also when they say that no, no, he has not been charge sheeted and the defense that they are giving. Now the question is how did this thing come into the public domain? How did this thing appear? And this is the methodology and they apply everywhere. Names appear in somebody else's statement so claimed, of aggregated, whatever it is. And on that basis, the procure orders for, you know, framing charges and then they frame and then people are arrested under UAPA etc. This is the way that Bhima Kori's own thing proceeded. This is the way the other things are happening. So I mean, this is a clear cut. It's a political issue. It is a state sponsored political maneuver, manipulation, a conspiracy if it so be. So that is what it is. So I mean, that is not going to stop us from exercising our right to peacefully protest on what we think are violations for the constitution. And it's not only my right, it's my duty to protect the Indian constitution. And that is something we'll do. And that's why I keep reminding them they should learn that I belong to that generation that fought the emergency. We re-established democracy in the country because of which they are also in government. And therefore, you understand before that we'll fight this also. So in this context, you mentioned, of course, the Elgar Parishad case, but specifically with reference to the daily riots, it's clear over the past few months that like you said, it's entirely been about the anti-CA and NRC protests and nothing to do about the violence.  Of course, this is the way I'm trying to intimidate. That's what they're doing. Any dissent against this government is tantamount to their description of being anti-national. And therefore, the most draconian of measures like the UAPA, the NSA, the Sedition Act, they're all invoked. That is curbing of dissent. This is an outright large-scale authoritarian assault. And this assault is being mounted against Indian democracy and against the Indian constitution itself. And that is something that is just not acceptable. That's all. We have time for today. We'll be back tomorrow with more news on the country and the world. Until then, keep watching NewsClick.


All right, I guess we'll get started. So topic is surgical treatment of ocular surface discolors. So we're talking about the ocular surface. It's not just the cornea. We're also including the lids and tarsal congenitiva as well as the bulbar congenitiva. And these are kind of the surgical procedures I'm going to go over, basically, anything to do with the ocular surface I'll try and mention. So congenitiva biopsy. Obviously, for a biopsy, anything, any sort of congenitival tumor, anything that's suspected to be CIN or pigmented lesions, congenitival biopsies are also helpful in diagnosing ocular secretarial pemphagoid. So you see linear staining of IgG against the base of membrane in OCP. So basically, my techniques for a biopsy are marking the borders, if it's not obvious. Typically, if it's not a pigmented lesion, I'll mark the borders because I'm going to inject lidocaine underneath the congenitiva. And that'll kind of obscure the margins of the lesion. With anything that's suspected to be congenitival melanoma, it's recommended that a very wide margin is used. The shields recommend a 4-millimeter margin, which is quite large. Sometimes if it's not possible, then you can go a little smaller than that. And they kind of advocate what's called a no-touch technique, basically not touching the actual lesion, if you're suspecting melanoma. And then I recommend cryotherapy of the cut congenitival edge if there's any sort of suspicious lesion, whether it be cancer or even like a CIN. And I use employed the double freeze thaw technique. So I'll show a little video. So basically, take the cryoprobe and go just on the conge edge. I'm not cryoing the sclera. This is the one. There's one cryoprobe that freezes in between when you're not pushing the pet petal down, so watch for that. And I basically just very lightly, barely get it to freeze.  And I have basically overlapping spots across the conge edge. So basically, until you see that ice ball and then I kind of take the foot off the petal. And so you get the idea. So I kind of march across. And then once I hit all the spots, I'll go back and do it again. So double freeze thaw just to make sure you don't to miss any spots along the congenitival. And this is to prevent any sort of recurrence if there's any sort of neoplastic cells along that cut congenitival edge. Next, talking about tarsorphy. So for really any sort of non-healing cornea epithelial defects that are recalcitrant to other treatments. So one may be surprised even if someone's been on vantage contact lenses for a while, not healing. Once they get a tarsorphy, they can heal really quickly. So it's something about just the patient's own tissue against their epithelial defect that can get them to heal. So consider it with ligophthalmos. You can make the tarsorphy temporary or permanent. You can make it medial. You can make it central. You can make it temporal, depending on whether or not you want any sort of opening for the patient. Typically, I'll put the tarsorphy in a temporal position just so they can still see a little bit and they can get their eye drops in. And there's different ways to do a tarsorphy. The most common is gonna be with a suture. This can be temporary or permanent. And with a permanent tarsorphy, you kind of debride off or cut off just the thin strip of the epithelium off the eyelid margin. So you can get the eyelid margins to fuse permanently. Other sorts of tarsorphy, there's glue tarsorphy, or basically take accrylate glue and glue their eyelashes together. It's not great, but I suppose if you've got someone who can't undergo a suture tarsorphy for whatever reason, it's a nice temporary fix. Botox tarsorphy is injected into the actual levator muscle to cause ptosis. And it's nice because then their eyelids aren't actually fused or sutured together so you can actually manually open up the eyelid really easily for examination, but obviously with Botox, it lasts about three months. So it's gonna be for people who need a little more long-term effect, but maybe not permanent. Next, teridium excision. So this is kind of a subset of congenitiva biopsies. So my indications for excising a teridium is, most obvious is gonna be any sort of teridium that's heading towards the visual axis or in the visual axis. Sometimes you can have a teridium that looks fairly small, but it's causing distorted vision because it can induce significant astigmatism. Or other times there may be a teridium that doesn't meet the above two criteria, but there is persistent discomfort or redness or inflammation that's not relieved by topical drops. So here's an example of a teridium. You can see here and it's inducing flattening in the area that the teridium is in on topography. So this may be visually significant. With excision, it's important to remove the underlying tenons layer to prevent recurrence. And when you remove the underlying tenons layer, the actual defect on the congenitiva after you remove the teridium, it actually kind of gets bigger because it relaxes. You wanna send the specimen to path to rule out any sort of dysplasia or neoplastic lesions. Sometimes you get surprised. As far as what to do after the teridium is off, they used to do, people used to do bare sclera. I mean, they just took the teridium off and that was it. There was a very high recurrence rate. It was about 50% recurrence with this technique. One could consider primary closure of the congenitiva with suture. I might only consider this with a really small teridium, really small congenitiva defect, but I typically will not be doing this for a teridium. These are the two most common techniques that are done to prevent recurrence. Congenitival autographed, which you could maybe term congenitival transplantation of the patient's own congenitiva or suturing or gluing down amniotic membrane. So congenitival autographed has the lowest rate of recurrence. It's been reported about 2% to 5% recurrence of terigia after congenitival autographed. And you basically take a free congenitival graph from the superior bulb or congenitiva. You then leave that superior congenitival defect open. And then you take that graphed and apply fibrin, gruel and or suture to the area where the teridium was excised. And it's important to seal the graph to the cut congenitival edge, again to prevent recurrence. Amniotic membrane is useful if the superior congenitiva is not available for a graft, such as scarring, if there's a TREB, or maybe a patient with significant glaucoma who might be getting a TREB, you probably might consider doing amniotic membrane. Sometimes you get a double-headed teridium, a nasal and a temporal one, so then I'll use a congenitival autographed on one of the teridium and amniotic membrane, not for the other. And again, you can apply it with fibrin glue or sutures. Mitomycin C I will use interoperatively if it's a recurrent teridium that's being removed. And this is to prevent further recurrence. So what I do is I soak sponges with mitomycin C and then tuck it underneath the congenitival edge, wait two minutes, take out the sponges, and then do a really copious rinse. There is a concern for complications, months to maybe even years later with scleral melts and infectious scleritis. So this is why I don't use mitomycin in all the cases of teridium excisions. When you use the, what's your indication for using the fibrin glue versus the suturing? So I do both, so I used to do suturing when fibrin glue didn't exist and it takes forever. So then fibrin glue is really, really easy. But then for billing purposes, I think you need to show that you sutured something. So I'll usually put two sutures, like two vicaral sutures at the limbus and then use to seal for the rest of fibrin glue. Next I'm gonna talk a little bit more extensively on limbal stem cell deficiencies and limbal stem cell transplants. So limbal stem cell deficiencies may be partial or they can be complete. And you'll see congenitivalization of the cornea, a thickened, vascularized irregular surface. There may be chronic inflammation, persistent epithelial defects, stroma ulceration, corneal scarring, and in some cases there could actually be corneal perforation with non-healing epithelial defects. So here's a good example of limbal stem cell deficiency of pretty much almost all of the limbus. There might be a little quadrant of relatively healthy limbus here, but this is all vascularized. You can see the blood vessels growing in and there's corneal scarring. Here's an even more extreme example with very prominent new vascularization and congenitivalization. You might see a little thinning of the cornea centrally. This is an example of stroma ulceration. So you've got 360 degrees of limbal stem cell deficiency, but then this is a non-healing epithelial defect. So with limbal stem cells, so these cells are defined by the capacity for unlimited or prolonged cell renewal to produce at least one type of highly differentiated progeny. And it's defined by their niche, which is kind of like their environment or their place. And it depends on the contact with the surrounding cells, extracellular matrix interactions and local growth factors. This is a major target of gene therapies and limbal stem cells are different than embryonic stem cells. Basically you've got the limbus separating the congenitival in the cornea and somewhere in the limbus you've got these corneal or limbal stem cells that cause kind of corneal differentiation and protects, it basically is a barrier for preventing the congenitiva from growing onto the cornea. This slide and basically just showing that this is a path slide, basically highlighting goblet cells taken from a biopsy of congenitiva that's kind of grown onto the cornea. So it does show that there is indeed congenitivalization of the cornea. There are basically six types of limbal stem cell deficiencies. It can be congenital, traumatic, iatrogenic, autoimmune, neoplastic or idiopathic. Congenital, the most common category is gonna be anoradia. So anoradia, I mean with the name, you think no iris, but in actuality they usually have some sort of iris, but also with that is pretty severe limbal stem cell deficiency. Other congenital conditions are ectodermal dysplasia, kid syndrome, keratitis ichthyosis deafness syndrome, and keratitis associated with multiple endocrine deficiencies. So these are gonna be more rare. Traumatic is also very common. Chemical and thermal injuries, contact lenses can actually induce limbal stem cell deficiency. If there's any sort of inflammation or infection that extends to the limbus, that could destroy limbal stem cells. It's also associated with neotrophic keratopathy and chronic bolus keratopathy. The prognosis of a chemical injury depends on the extent of the ocular surface involved and the amount of limbal ischemia that is seen acutely. And there is a classification scheme for this called the Roper-Hall classification, which basically grades limbal ischemia and kind of comes up with a prognosis. So you can see if there's a lot of limbal ischemia, there's a poor prognosis, and usually the cornea is very opaque and it's hard to see virus underneath. So here's an example of acid burn. There might be just a little bit of limbal ischemia, but it's not too bad because you actually can see some pinkness and some vessels. So if you see pink or if you see red, that's actually a good thing. That's a good prognosis. So this, if you kinda look back at this classification, I'd probably categorize it as a little grade two lesson that there are limbal ischemia. So still a good prognosis. And there is some haziness as seen in this picture here. Here is an example of chronic non-healing cornea ulcer post-alkali burn. Really not seeing limbal ischemia here. So this is also a good prognosis overall. Here's an example of an alkali burn with ischemia seen acutely. So this is a pretty large area. So this is very, very white. This is NACA. This is classic limbal ischemia. And then subacutely, this space just never really fills in with blood vessels. So everything else is fine out here. You see blood vessels kinda growing in here, but there's really nothing here. So this will pretend a poorer prognosis. This is an example of kinda more extensive limbal ischemia where you see limbal ischemia going all the way around and you can see that the cornea is very cloudy. And again, poor prognosis. You can get limbal stem cell deficiency from iatrogenic causes such as multiple limbal surgeries or cryotherapies to the limbis. Long-term topical medications, preservative can actually cause limbal stem cell deficiency. If there's any sort of anti-metabolite use such as 5FU or mitomycin either interoperatively or in topical form. And also radiation can induce limbal stem cell deficiency. Autoimmune causes include SJS and TEN syndrome, oculosecaterosalpinephagoid, any sort of chronic limbitis from atopic disease, vernal disease, or fluctenial disease, and also peripheral ulcerative keratitis including morins ulcer. Neoplastic, I put teridium on here. Technically could be considered neoplastic even though it's benign. And also CIN and something like screnous cell carcinoma and lastly idiopathic. So transplant, there's actually certain transplantation classifications that are done. So if you have a limbal stem cell deficiency and you wanna do a limbal stem cell transplant, it can be an autographed meaning from a patient's own tissue. So this could be harvested from the same or fellow eye. Usually it'd be from the fellow eye that is not affected or it can be an allograft which is harvested from a cadaveric tissue or from living related tissue. And usually kind of more HLA matched. And these are some of the abbreviations. There's lots of abbreviations used here in relations to the limbal stem cell transplant. So conjuntival limbal autographed. So this is from the patient's fellow eye. There's living related allograft from a living relative. Most common one that we'll see is a K-Lal keratolimbal allograft. This is from cadaveric tissue. These last two are not really used in the United States because these involve expanding limbal tissue outside of the eye and then putting it back in the eye. But I won't mention that later. So this is basically what we're doing. So the recipient has their limbus and kind of fibrovascular tissue removed. There is donor kind of peripheral corneal limbus that's harvested and that is sutured onto the recipient. So conjunctal limbal autographed. So again from patient's own tissue. So this is indicated in unilateral limbal stem cell deficiency and could be from chemical or thermal injuries, teridium, the source again, same eye or unaffected fellow eye. Up to six clock hours of the donor tissue can be safely harvested without risk to the healthy fellow eye. And the nice thing about this type of procedure is because it's the same if it's the patient's own tissue, there's not gonna be any risk of graft rejection and the patient doesn't need any systemic immunosuppression. Living related allografts indicate in bilateral limbal stem cell deficiency, the source is a living related donor with an optimal HLA match. And obviously the donor can't really have any other sort of risk factors for a limbal stem cell deficiency because it's not the patient's own tissue, systemic immunosuppression is still required. But because it's a living related donor, it kind of improves the prognosis for any future transplant, coronal transplant that's done down the line. So this is what's done. So this is the donor being harvested, patient also kind of has the peripheral cornea and a bit of scleral taken off as well as the fibrovascular tissue over the cornea and then the donor tissue is kind of sutured at 12 and six o'clock. So here's an example of donor tissue being harvested here. Curator limbal allografto-calow. So this is from Caterveric limbal stem cells. The peripheral cornea is the carrier for the limbal stem cells. Systemic immunosuppression is required and this may eliminate or delay the need for PK. If there's a lot of corneal neovascularization and there's a concern for extensive limbal stem cell deficiency, doing a limbal stem cell transplant prior to a corneal transplant can improve the prognosis of that corneal transplant by about 80%. So limbal stem cell transplants allow for healing of persistent epithelial defects, oculosurfstability and regression of neovascularization and then the chronic inflammation that is seen does subside. So here's the technique. So first the recipient, congenitiva, is marked off with coterie and this is gonna be the border for what is removed. So it's a couple millimeters back from the limbas. And then the fibrovascular panacea is removed along with that peripheral skirt of congenitiva right here. And then once everything is exposed, looks like this. And then the donor cornea is punched in the middle, usually about seven or seven and a half millimeters in the middle, so you got a donut. And then this tissue is split. And then the anterior part of that split is sutured. So here's another diagram, so seven and a half millimeter in the center and then about at least a millimeter of scleral tissue. And you actually need three halves just because when you manipulate things there's not quite enough tissue if you just have two halves so you need a little bit more from another eye. So you actually need two globes. And then when this split thickness is done we take kind of usually split it two thirds, one third and then this anterior one third is what gets sutured. You don't want to suture this whole bit of thickness because then it's way too bulky. So that's the reason for deep bulking and then the limbo stem cells are gonna be in this anterior one third anyway. And so then you can see kind of these three halves just to fit in the three pieces all around the patient's cornea and then this is sutured down with tenonylon. And this is showing a piece of tissue. I think this is not acutely post-op. This is acutely post-op, so it's pretty red. And I think in this case amniotic membrane was put over the whole thing as well. So all these pieces are sutured down and then amniotic membrane on top. So that's the K-LAL technique. I'm just gonna put a brief slide on this new technique for limbo stem cell transplant that's been talked about called slet simple limbo epithelial transplantation. I think what this was talked about in the Grand Rounds last year. But basically instead of doing that whole K-LAL procedure patients kind of cornea epithelium and fibrovascular tissue is removed and then you basically take small pieces of limbo tissue either from the patient's fellow eye or donor tissue, kind of cut them up into very small pieces, put them on the cornea. Before that you sandwich it between two layers of amniotic membrane. So you lay down amniotic membrane on the patient, then use fibring glue to glue down these little pieces of limbo tissue, kind of in the periphery, and then glue down or suture another piece of amniotic membrane on top. So this, I think long-term it hasn't really been studied too much. I have a feeling this may work for maybe partial limbo stem cell deficiency, maybe not for complete. But that remains to be seen. Okay, this is another, so the last kind of category of limbo stem cell transplants I'm gonna talk about is ones involving ex vivo stem cell expansion. So either taking the patient's own healthy limbis from a fellow eye and growing that in a lab on a sheet of amniotic membrane and then transplanting it back in or taking limbo stem cells from a category donor and growing that on a sheet of amniotic membrane. So we don't do this in the United States, but I think it's being done in Japan and maybe some other places in Asia. And if the patient's own tissue being used and those systemic immunosuppression is required, so then donor tissue is taken, it's grown onto a sheet of amniotic membrane and then sutured onto the recipient. And then this is showing after they expand the limbo epithelium on the amniotic membrane for three weeks, this number one is showing the limbo stem cells kind of on top of denuded, this is denuded amniotic membrane epithelium and then this is the actual amniotic membrane like the stroma. So it's showing that the human limbo stem cells are actually growing on top of amniotic membrane. So that's kind of cool. Postoperative management just overall for a limbo stem cell transplants, topical medications with steroids and cyclosporin, maximize lubrication, total occlusion. You might consider a torso for you to help with healing. This can be permanent or temporary. There may be a subsequent PK needed and then systemic immunosuppression is usually needed for about 12 to 18 months, maybe longer for younger patients. And these are some of the agents that are being used. Systemic steroids, cyclosporin or tachylimus and azathioprene or mycophenolate. Next is curator prosthesis which is also used for a limbo stem cell deficiency. It's kind of a surgery of last resort. Usually it's in a patient who's had multiple PK graft rejections and maybe they've even had a limbo stem cell transplant already. Problem with curator prosthesis is that there's resulting glaucoma which can be very hard to control. They often need a tube and they're at very high risk for infection as well. And this is basically what it is. It's got a front optic that patients look through and that gets threaded through a corneal graft that's been punched out in the middle. And then there's a back plate. This is the older version of the K-PRO which had a PMMA back plate with a locking ring. But there's a newer version that has their back plate made of titanium and there's not a locking ring. So here's some pictures. So this is of the older type of Boston curator prosthesis. So it's got PMMA in the back so that you can't really see the back plate as well. You can see those little holes here that are put there just to make sure there's enough nutrition that can transport in between. And then this is the newer titanium version which is a lot more apparent because it is made of titanium. But it's got the same type of holes in there. Switching gears to contactival flaps. So this is surgery that's done for things like a chronic sterile ulcer. A painful belay with poor visual potential might consider it for an unstable corneal wound such as progressive thinning. I don't really recommend it for active infection although some people have done it with success or if there's a cornea perforation. Can be a partial contactival flap meaning covering part of the cornea or a complete flap which is turned to Gundersen flap. You do need to remove the patient's corneal epithelium so that the contactiva can stick on top. So this is diagram of the Gundersen flap. So a superior contactival incision is made pretty far superiorly. You kind of dissect down. You got to do a 360 degree pyritomy and then you take the superior kind of large flap and bring it down over to cover the whole cornea. And the cornea needs to be denuded of epithelium and then kind of sew that down and then that stays permanently. So as you can tell it's gonna impact vision. So I typically will reserve this for patients with very low visual potential who need a contract. Mucous membrane grafting. This is for reconstruction of contactiva mucosa in inactive secretarial contactival disease from inactive SJS or OCP that's maybe not so late stage. And you can achieve better ocular surface lubrication by improving the tear film distribution and eyelid movement. Bucomucosa is usually used. So this is something that has to be combined with oculoplastics. This does not replace limbal stem cells however. Next, just wanna briefly touch on amniotic membrane transplant for severe Stevens-Johnson syndrome. And this is kind of the email I'd sent out last week regarding the protocol. So basically anyone with severe or extremely severe acute SJS will need an urgent amniotic membrane transplant. So the definition of severe is basically staining over at least a third of the lid margin on at least one lid. Any corneal epithelial defect that's more than punctate staining. If there's bulb or pebral contactival staining greater than one centimeter than urgent amniotic membrane is advised. And that's kind of the paper it was taken from. And it's usually better to do this sooner rather than later. So if it could be done within a week of the patient's eye symptoms, better prognosis there is. And the purpose for doing total amniotic membrane transplantation is to prevent kind of chronic scarring and inflammation that can occur with chronic SJS. There's various methods for putting on the amniotic membrane. This is the method we've been doing kind of more recently. So you take a large, the largest size you can get of amniotic membrane, which is five by five centimeters. And this is cryopreserved amniotic membrane. Take that square piece, split it in half. Then trim the patient's, all the lashes and suture an edge of the amniotic membrane just anterior to the lash line with a running 80 nylon. Then you tuck the amniotic membrane kind of over the lashes and tuck it into the fournesses and then take 6.0 proline and go through the eyelids and suture to bolsters. These are kind of some foam bolsters that I've used. I think here we've been using like IV tubing and using that those as bolsters. And then after that's done to all four lids, then a prokera is placed. And this is a prokera is amniotic membrane that's attached to a kind of a plastic ring and that gets put in. And then the amniotic membrane takes about a week or two to fully dissolve. And after it's dissolved, the proline can be removed, the 80 nylon can be removed, the prokera residual ring can be removed. And then the patients reassessed to see whether or not they need a repeat transplant. So if there's still epithelial defects, if there's still a lot of inflammation, then a repeat transplant might be indicated. But usually people do well with just one. Next, talking about superficial keratectomies. So this is a procedure where there's removal of the corneal epithelium, it may or may not include bowman's. There's no replacement tissue that is placed. So the indications are gonna be removal of any sort of superficial tissue. Technically peeling off a teridium off the cornea would be considered a superficial keratectomy or peeling off a Salisman nodule which usually sits on top of bowman's membrane. Epithelial basement membrane just refuse so basically if you're taking off the corneal epithelium, you might consider it for a very superficial scarring but this would only be involving kind of epithelium. Sometimes you get suspected corneal CIN which is like kind of a gray white sheet growing over the cornea. So if you suspect CIN, that epithelium needs to be sent to path. Taking out a retained superficial foreign body could be considered a superficial keratectomy. And there's a couple types. There's manual which is the most common type. So either scraping the epithelium off with the blade or peeling something off with forceps whether it be a teridium or Salisman nodule and also diamond burr polishing of underlying bowman's layer is considered part of superficial keratectomy. PTK is also maybe considered a subtype of superficial keratectomy. So this is using the eczema laser, same laser we use with BRK and Lasik to ablate tissue as a form of keratectomy. The Visix laser which is made by AMO has an actual PTK setting where you can set like a big broad beam and you kind of program how many pulses you want that big broad beam to go. Here at Moran we don't have the Visix but we've got the Alcon WaveLight EX500 laser so it can't give a full broad beams but what we do is we basically program it for PRK. So we're basically doing PRK but doing it for the purpose of removing anterior stromal irregularities. So what kinds of problems can you treat? You can treat granular dystrophy by just kind of smoothing out some of the anterior, those anterior crumbs. It's been done with in post-lasic striae and we're talking like striae that have been there for a while. Acutely, if there's striae, you wanna relift a flap and kind of take off that pithelium, get it to smooth out but let's say you've got striae that are chronic, could consider PTK to remove it. You can use it in certain scars. It's not good for anything deeper than a hundred microns in depth. It may not work as well in post-tropetic scars or traumatic scars. I think that's my last slide.


For example, if the stop if we end up doing this I don't know if the stop and Hertz is 30 cents and you take a thousand shares you'd be risking $300 So you're the what the question you're asking me is with BP with buying power and margin Which is something separate, but you need to know what your dollar and Sense risk is which has to do with the share quantity you're taking and I think maybe that's something that you're that you're not Doing correctly if for example, if it's 20 cents and You take a thousand shares it'd be $200 So if you don't want to risk $200 and the stops 20 cents and you have to take less than a thousand You could take 500 risk a hundred bucks. I don't know what the stops going to be in this. I'm just using this as an example I'm not really been anything today. We're gonna look at two things. They're okay. They're not amazing They're okay Yeah, well, we'll talk I figured you weren't doing it that way Brad and Mimi was asking about the stop last week, too Which made me nervous that made me Mimi Are you actively trading now or you're just watching because you asked me about a stop like five minutes into a trade? We will go over that for Brad and maybe Mimi needs to help too when we're done here today. I Just Don't know if we should watch two things or one We should probably watch two any questions before we get started Hain and Hertz Are the two calling my home because no one knows my number Sales sales sales Okay, that's fine Mimi. We're still gonna go over the Margin and risk and stops and all that we'll do that for Brad then interesting day interesting day So market gapping down this morning see what happens here Should be some political news out this afternoon. We'll see what happens here not surprised markets gapping down at all So watching this very carefully here Watching it very carefully didn't call an option this morning almost did Trying to be a little conservative here, but not surprised at all. We're down this morning not surprised whatsoever So let's watch two I wish we could just see one thing and say this is amazing. Maybe we'll get a day like that Maybe we'll get a day like that this week. It's only Tuesday Good luck everyone. If I see something here, maybe we should watch Hertz first So now I switched I've got Hertz in the main Hain on the side here Just remind me of that question Brad. Okay stops gonna be 30 It's gonna be I guess it's gonna be it's gonna be Hertz and I do not have the entry 85 by 30 85 by 30 Hertz and it just get in it now. It's gonna break get the stop at 30 20 30 20 30 Hertz It didn't it didn't break, but it looks like it's gonna I don't know why it's sitting there and Hain's probably gonna work, too This is probably gonna work, too. So that for some reason just has a really crazy bar there What's going on with this? 87 by 30 is valid. This didn't break yet. I like it. I know what's going on with us here And this is gonna work, too. What is going on with this? There there there there shoe That was really weird. Okay, great. Here we go Hertz and The Hain look like it was working, too first target on this though 1960-1950 Well, I took it early that could have worked against me Let's just see here. If you if you if you didn't get filled hit it with another ECN It was acting strange there Hit it with another ECN.  It's not that far away or wait So let's look at the other one, too I just don't like the way this is trading here after that first bar, but HTZ You got to start checking that Brad. Well, we'll go over all that later. You have to start checking that Here HTZ is anyone in it? Galahad didn't get filled. I don't know if you pressed it again Galahad here Hertz Turtles in it. Galahad's in it now And this just doesn't look right here even though it's dropping 1940-1950-1925 Let's just let's just see here. This is acting strange, but this guy I think 1950 is realistic here if you ever don't get filled press it again with a different ECN Broken here yet. Why is this taking so long? 1975 let's find that number See here if you had your water sitting and you didn't get filled you would have gotten filled just now see But you don't know if that's you never know if that's gonna happen or not But if you had an order sitting you and when this little jiggy went up you would have gotten filled And this is dropping. It's just acting really weird. It's almost acting like you can't trade it so Just gonna leave it.  I don't know Is this bar real here because I read it differently Let's move off of this and see. I don't know I I had a different number there and now it does look like that printed did that print or not What does everybody have for the high in the first bar? Gallia likes perfection, but that's preventing you from doing well.  I really want to leave it where it's at. I gotta be honest with you I don't even think that this should go back up here So I you know do what you want if you want to move it up move it up. I think I'm gonna leave it In fact, I am so Brad did get the HTZ. Okay Here we go. Let's try to hold this down in the 50s So I was having an issue with 75 and I really can't see any reason that makes any sense why That Here's the market Here's the market crap here be in this and I'm gonna look at something here to maybe call an option in this Just stay with the trade stay with the trading and to try to do more than one thing at a time Just stay with this trade. You have to stop in you have it in I decided not to move it But it's struggling with 1975 it's gotta go that with them especially with the market here I don't know why that is having a hard time with that number. We got it I mean You know, if you wanted to piece me a lot of that, but it really wasn't much I'm trying to stay with this I mean, I think it looks great, but It did not break 75 yet. I'm talking about HTZ And I'm trying to get some options out here for people in the letter and watches at the same time But I really just don't think it made any sense to get out of anything there and Hain is setting up again. Hain you could short if you want stop 70 It's it's about 50 cents Hain you could short put the stop at 2670. I'm really gonna stick with HTZ I don't know why it's doing this, but I'm not putting this stop. I'm not moving it So, I mean do whatever you want to do with that. I don't think it should be backing up over this over 20 I'm gonna find out right now. We're still in it. I'm not moving to stop That's how I size myself anyways Highest point in hit was 25 still hanging on let's just see and Hain went back down to the low and now is bouncing to so Don't just I think everybody should have the stop where we originally put it not over 45, but it's totally up to you You know, you'd lose more than one hour and we are gonna go over that today This is holding I don't like the way that it was struggling with 75 And I can't see any problem with the number and based on the market. They should just go so I don't really want to move the Stop I don't want to give it any more excuses here Okay, I sent out two options letters for anybody that's on the letter where we're just in this here now waiting This holds this is really gonna go and I'll call it again Hain I told you you could do and I gave you that I gave you that I gave you the stop So if you wanted to do that, I'm not doing two things here at the same time Hey, never really gave you if you wanted it wasn't a small stop looks like it went down to the low I don't know if it broke any further. I'm not doing anything else right now. I'm focusing on this Gally had I'm not gonna get an argument with you about the market If you did Hain and Hertz great Trying to focus on this Make sure you have it at 35 Make sure you have it at 35 Hey, hey, so he's a 26 for those of you that did that that worked.  I really don't want to do anything else after this I think this has been very choppy. I think being focus is the best thing We ended up having a half decent day yesterday for a Monday. I really just don't want to do anything else I'm sticking my guns with this if you did both great You're still in this if you did it and Hain went You got a watch 26 though. It's at the target. This was a good gap. So I believe it goes But this did reach the first target. So if you did that and you did it late, I would scalp it Gally had you are arguing with me if you're trying to tell me you think you know better than me about the market. I think you're Smoking something over there in London. All right. Who's an HTZ? Who killed it? Who got out if this goes back down to that number 70 1975 it will break But it hasn't yet. It struggled with it It's very jerky I'm not giving it over the high and I really don't want to do anything else Happen to that we need to be a little more relaxed here. It is summer after all. What was the one the other one? Z what happened to that? Oh, I didn't even rate this You got lucky not doing that sucker. What was the other one? There was another one, too I'm sure a singer that's up to you as far as how much you want to have on as far as your wrist shower singer saying would you do this one? We have the other one on it's Up to you how much you really want to have on at one time that you feel that you can stomach It's pretty much the best answer. I can give you there This set up. This was late If you've got more than one trade on say two three four five for the overnight If you're if you have a problem mentally with that then don't then don't do that many You know, I don't I don't know what to tell you with that some weeks I don't call any some weeks. It seems like a calm word is earning season You got to be aware of that. There'll be more an earning season than non earning season. Here we go. Hello Here we go HTC have no idea why I had a problem with that number But here we're getting back down around it and as soon as we hit through it We should have an ice drop and then we're out nine forty six If you don't want to have too many trades on then don't don't do the new ones I like the new ones. I'll explain why whenever we get out of this, but I have to also answer Brad's question Gollyhead wants to challenge me and say the markets higher Here we go. Yeah, I hope that see if you would have gotten filled here You would have you would have you would have gotten filled. I was in an unusual situation, but she would have gotten filled Here here, you would have gotten filled for sure here if you hadn't gotten filled So here we go four pennies under the low HTC Apple's done with that move Let's look at everybody else here This today may 8th. All right. Here we go. Let's just watch this drop 1960 1950 Okay, so I just made two options calls and Gollyhead disagrees with me, so he's probably not gonna do them Here hey, if you want to do it again, you could do Hain if you didn't do it scalp it stop 2660 Everything's fine. If this breaks 26, you can have another big drop the stock can move again If you're an HTC, I'd stick with it. This is having no problem. What's Brad's question here? So Brad based on Wherever you got filled. Let's just let's just make it easy here today Let's say you did 90 by 35 and I'm just trying to make it easy here. Let's say you did 90 by 35 What's the risk in that Brad? And I'm just gonna try to make it really easy for Brad here trend trader Then I'll send them to you right now. We'll have to figure out that problem. Are you getting the big emails? 35 is what 35 is what I'm talking to Brad or anybody else wants to answer, but I really want Brad to answer No 90 by 35 Here here we go. Hold on Hello, there it is some movement. Okay Here we go. Here we go Don't you dear bounce Here we go. Yay breaks 50 if not, we're out Wow and a nice column. We stuck with it too and I had the stuff of the right place Yeah, here out out great. This looks like it could get to 19 there today with the market I don't know what time Nice trade And we held it till the point that we needed to okay, let's get back to what I was saying. All right, let's go here No, it's not a dollar 50 You take the amount here. It's gonna try to break 50. You take the amount take the amount and the amount is 45 cents is how you will determine your risk so 45 cents That's not gonna have anything to do with your buying power here This is gonna try to break if anybody's still in it. Watch it. Watch it. Watch it. I think it's gonna break 50 now though 45 cents. So again, if you take a hundred shares That'll be what 45 dollars 200 shares and be what 90 dollars and so on and so forth That's how you have to figure out your monetary risk I think you're a little bit all over the place with that Brad So if you would normally risk a hundred dollars per train How many shares could you hear it just broke great great call great credit for stealing it here? Oh, wow, look try to hold it if you can get it under 30 here. Is anybody still in it? This was a good call and I did was so bouncy bouncy. I said 1950 I stuck with what I said here It got to 25.  What a nice move if this hadn't acted so bizarre We could have taken more in there, but I just wasn't gonna do that today So anyways 200 shares would be 90 bucks. Go ahead. Didn't you make money today? You wish what? Did you make money today? Yes or no?  What are you wishing for? You just made money today? 1990 times 200 shares equals what? That's what's gonna come out of your buying power Brad I had if you don't stop change your attitude You are never gonna turn your situation around you are never never never gonna turn it around your attitude is so negative We've discussed this before here HTC is getting down to 19 if anybody's in it watch it look at that bar Here it's at 19. This was a great call I'm fine with what I did on this though personally Brad you would take 19 dollars and 90 cents times 200 shares and that's what it's gonna take out of your buying power Go ahead.  So you're clearly not doing it If you made money today, you should be happy and you shouldn't be complaining Do you hear me complaining that I got out of this and it's still going? No 3980 Brad is saying that's right So that's what it's gonna take out of your margin or something. I didn't figure out exactly on a calculator, but Estimated it's close to four grand. So that's what it's gonna take out of your buying power Now do you understand it Brad? Mimi you've been getting them I'll send them to you Mimi, but you've been getting the options calls So they're probably in your span is the first I heard that you have had an issue I will send them to you as well Mimi That was a really nice call They're probably in your spans Mimi, but I just sent them to you and any single solitary person that's still in this You should have your hand in the button to get out of this any second if you held this down to 19 It doesn't break 19 get out if it does stay with it and see where it goes. It's ended up being huge trade Oh my god, it just broke it just broke. This is crazy. Look Wow, this went more than a dollar from where I called it. This is insane And you know why people were trying to buy that that was a great call Is anyone still in it and I'm not saying you should be but I'm just wondering is anyone still in this to get that through 19 unbelievable quality I said, yes, dude are put a stop over 19 Brad made 70 dollars and hey and he's happy if you've sized yourself, right? That's what that's what that's what counts That's what counts because what you don't want to do and I think maybe this is why you've only been allowed Sometimes to take one trade bread. I think you're over sizing yourself But now you know now you know how to do it. So I don't think you're going to make that mistake again I think everyone should be out of this. I was out of this a while ago But it was a good move was profit. It was money and I wasn't crazy about any of the gaps today This did work. This had the biggest move. I think This had a couple little plays in it, but it was really weird here. I just didn't like the way this traded out So you could have scouted this here here. They both worked. This was the best one. So I picked the best one It just took a little bit longer to go I wasn't curious about anything really today. I gotta be honest with you. So I'm glad we stuck with this I wouldn't take the max shares of your buying power unless you have to unless you have to to to meet the requirements of whatever Your risk is per dollar and cents to get the position for the cost of the stock If you have to if you have to to do that then fine if you do not have to do that then don't It's not you shouldn't be maxing out your buying power every day. No just for so Because then your risk is not consistent either All right, so I think brad's got that down Mimi you've been getting the letters. I just forward them to you, but probably just check your spams Is everybody out of this? That was a great call. I'll send it to you right now jackie You're on it too It's not too late. So don't no one have a cow Does anyone want to go over anything? It was a great call So turned out to be an easy day, which I couldn't see before the open But I did see this here the red in the market Gala had if you just did the trade that I called Which was a spy put and you told me 15 minutes ago that you think the market's along Then that is another problem that you had that I didn't even know you had So if you believe the market's along, why are you shorting it? I have no idea what you're doing gala head Why would you do something that you don't have conviction in why? No, you're not following me. You're not following me You are not that's why you're having problems. You are not following me But you will you will a hundred percent screw up this trade. I guarantee it to happen You will screw it up even if it works Because you don't believe it's going to work and you did it anyways I honest to god If you don't see the trades I call you shouldn't be doing them. You think that this is a long and I called the market lower today From the option letter you should have all gotten it But if you do not think the markets along short if you think the markets along, why did you do the trade?  I don't I don't know You really need to pay for a retake of the class and you need to stop looking at other things And and you shouldn't have done that trade because you're going to screw it up because you don't even think it's going to work Today was a good day Could have had a little bit longer. I don't care You got to be happy for what the market gives you any questions from anyone about anything at all James the acid today was a great day. You are correct today was a great day Every day you make money in the market is a great day And it's not to say the days you lose aren't great. You might have learned something from a day that you lose I think it's unfortunate sometimes when There's two or three days in a row where things don't seem to be shaping up immediately a quicker fast And that was the case last week It was almost the case yesterday turned it around today was good I think these are challenging times here in the market where you got to get the read right You got to get the read right We stayed with this trade. We almost stopped out It worked. It was it. It was a good read and it was a good call And you just got to keep doing what I've taught you if you veer off course You're 100 responsible for the decisions you make Pred says you learn quicker when you lose. Well, that's a good way to put it Well, you learned about sizing today. So that was important Okay, have a wonderful day everyone good luck Wherever you're doing on your travels or wherever you're going today I will see you back in the room tomorrow morning I would not do anything else tricky here political news coming out this afternoon. Trump talking at two