Editorial

As the Covid pandemic death toll was staggering, crematorium workers bore the burden of the crisis, more than anyone else and had to work round the clock. When relatives and friends were unable and unwilling to participate, these brave souls carried on their work with courage and determination. Aravind’s postgraduate residents in association with the Rotary Club of Madurai Midtown organised a programme to felicitate them for their noble service.

Vision centres located in rural and suburban areas play a significant role in creating eye care awareness in the community. They regularly organise free eye screening programmes for different age-groups and most of these programmes receive great response.

Aravind centres observed Retinoblastoma Awareness Week in a splendid way. It was truly gratifying to see the little survivors enjoying the event with their family members.

Accolades

ASCRS Film Festival Awards 2022

Aravind team with the ASCRS Awards 2020, 2021, 2022

Runner-up

  • Dr. R. Venkatesh, Chief Medical Officer, Aravind-Pondicherry
    Category: Glaucoma Surgery
    “The lost sponge – Safe application of MMC sponges in trabeculectomy”
  • Dr. Fredrick Mouttapa, Senior Consultant – Paediatric Ophthalmology Services, Aravind-Pondicherry
    Category: Quality in Teaching
    “Dyes in Ophthalmology”
    Special thanks: Dr. Apurva Nagtode and Dr. Vinitha Susan John
  • Dr. Sathya Ravilla, Medical Officer, Paediatric Ophthalmology Services Aravind-Tirupati
    Category: Special Interest
    “Are you aware of your posture when you operate?”
    Special thanks:
    Dr. Navaneetha Reddy, Dr. Sahithya Gogineni and Dr. Munisankar (Orthopedician), Mr. Naveen (Aravind Communications) and Sr. Iswarya (Instruments Maintenance Dept ) and OT staff

Legendary Institution Award for Aravind Eye Hospital

May 21

Rotary International District 3190 honoured Aravind Eye Hospital, Madurai with the Legendary Institution Award Rotary in recognition of its contributions to community ophthalmology. The award was presented at the inaugural session of the Rotary National Conference on Community Ophthalmology.

Best Nurse Award

Aravind-Sankarankoil, May 12

Ms. S Sangeetha, Community Eye Clinic,Sankarankoil was felicitated by the Red Cross Society with “Best Nurse Award” on the occasion of International Nurses Day.

Aravind Events

World Health Day Observance

Aravind-Coimbatore, April 1

Aravind Eye Hospital along with Shanti Ashram, Indian Academy of Paediatrics (IAP) and Young Indians (Yi) Coimbatore organised a programme to observe World Health Day on 2nd April 2022. Dr.G.S.Sameeran, I.A.S, District Collector- Coimbatore was the chief guest. Dr.Kalpana Narendran welcomed the gathering and insisted on the importance of early eye screening for children to prevent needless blindness. Dr.Kezevino Aram, President, Shanti Ashram, in her special address highlighted the health status of children in India. Dr.S.R.Subramanian, Head, Sustainable Development Programme, Shanti Ashram & Ms.Monica Christina, Community Development Organizer, Shanti Ashram gave a presentation on Governance Impact on Nutritional Security of Rural Children by the District Administration & COVID 19 Research & Response Desk. Coimbatore district collector, Dr.G.S.Sameeran launched two joint initiatives with ICPH for children’s health and wellbeing: 1. Eliminating childhood blindness in Coimbatore: Training, screening, evaluation & management led by Aravind Eye Hospital and 2. Masoom: Keep children safe led by Young Indians (Yi) Coimbatore.

Regional Centre for Research

Aravind-Coimbatore, April 4

In an effort to inculcate a culture of research and to encourage doctors and scientists to do it meaningfully, Aravind decided to open a regional research centre in each of its tertiary hospitals. As a first step, Dr. P. Namperumalsamy, Chairman-Emeritus, Aravind Eye Care System opened a research centre at Aravind-Coimbatore. The hospital has initiated four projects and plans to extend its research activities to become a self-sustained research wing.

C.A.A.R.E - Cornea Aravind Alumni Refresher E- Meet

Aravind-Coimbatore, April 10

Aravind-Coimbatore organised a virtual meet of the alumni of Cornea departments across Aravind Eye Hospitals. 88 alumni took part.

Taking Eye Care to the Rural Masses

 Aravind – Madurai, April 20 -28, 2022

To create awareness on eye diseases amongst the rural community, Vadipatti vision centre organised two free eye examination programmes at Poochampatti village. The first one was organised in collaboration with of HelpAge, mobile medical services on April 20. A total of 58 people underwent eye screening. Among those, 22 people had eye problems and were referred to Vadipatti Vision centre.
The second programme was organised on April 24 in association with Kasthurba Gandhi Hospital. A total of 55 people underwent eye screening. Among those, 12 people had eye problems and were referred to Vadipatti Vision centre for counselling. Four underwent cataract surgery.
Vadipatti vision conducted school children eye screening programme at Charles Matriculation School, Vadipatti on April 28. A total of 300 students underwent eye screening. Among those 52 were identified with refractive errors and referred to Vadipatti vision centre.

Guest Lecture at Alumni Meet

April 25, 2022

Mr. Seran, Manager-Patient care, Aravind-Salem delivered a talk on Lateral thinking at the  Alumni 2022 Lecture organised by Dr. N.G.P Arts and Science College, Coimbatore.

Smartphone Applications in ophthalmology

April 27, Aravind-Salem

Aravind Eye Hospital, Salem, conducted this interprofessional webinar which was attended by ophthalmologists, engineers and allied healthcare workers. A total of 104 persons took part.  The webinar had interactive sessions covering topics, scope of smartphone applications in ophthalmology, designing of applications, Aravind’s experience in using apps and artificial intelligence in apps. From Aravind- Salem, Dr. Manohar Babu, Chief Medical Officer, Dr.Lokeshwari. A, Consultant, Cornea and Refractive Services and Dr.Saranya, Comprehensive Ophthalmology Fellow handled the sessions. Dr.Shanthi S, Assistant Professor, Department of Computer Science and Prof. Kavitha N.S, Department Electronic and Communication from Kongu Engineering College, Erode shared their inputs.

Motivational Talk

Aravind – Salem, April 22

Prof. Kannan, Aliyar Arivuthirukovil was invited to give a motivational talk to all staff members. It was a highly interesting and thought-provoking session.

Team from Novartis Visits Aravind

Aravind-Madurai, May 13 

Aravind Eye Care System and Novartis have been working together for mutual development and to share inspiration and practices in leadership, culture transformation and talent management. The teams work together on six work-streams focusing on different areas of growth. As part of this, a team from Novartis – Sunil Modali, Denise LeClair, Muthusamy VS, Anil kumar Sistla visited Aravind to participate in a workshop related to the data generation work stream.

Honouring Crematorium Workers

Aravind – Madurai, May 3, 2022

Postgraduate residents of Aravind Eye Hospital, Madurai and Rotary club of Madurai Midtown organised a special event to honour and appreciate the selfless service of the staff of Madurai Anjali gasifier crematorium, Keerathurai during the Covid days. Dr. N. Venkatesh Prajna, Secretary, GOVEL trust and Mr. Mathan, Chairman, Anjali Foundation appreciated the staff.  Mr. S. Venkatesan, Member of Parliament – Madurai; Dr.J. Sangumani, Dean, Virudhunagar Medical College; senior members of Aravind – Dr. P. Namperumalsamy; Dr. G. Natchiar; Dr. R.Kim were present at the meeting. LIC policies and gold coins were gifted to the family members of the crematorium staff.

Observing International Nurses Day

May 12

On the occasion of International Nurses Day, Aravind Eye Hospitals organised programmes to recognize the efforts of allied ophthalmic personnel and to keep their spirits high. Doctors and other staff joined the celebration. Sweets were distributed to share the joy of the occasion.

World Retinoblastoma Awareness Week

May 21

On the occasion of Retinoblastoma Awareness Week 2022 observed from May 8-14, Aravind Eye Hospital, Coimbatore and Madurai organised special programmes on May 14 and 21 respectively. Retinoblastoma patients with their families were invited to the special celebration. A total of 122 retinoblastoma survivors (with 284 attenders) registered and all were examined thoroughly by Dr. Parag Shah, Dr. Abhishek, Dr. Prema and Dr. Puja in the department of Paediatric Retina and Dr. Divya from the Department of Orbit. Dr. Vanniarajan explained about the importance of genetic tests; Dr. Kavitha, from Orbit Department explained in detail about customized prosthetic fitting.

Dr. Pranesh and Dr. Prithivi entertained the audience  through games and a magic show. Refraction was performed  and glasses were given. Motivational cards designed by Aravind nurses with the help of Ms. Rajakumari were  given to all survivors to keep up their spirits and celebrate their conquest.

An interactive session was also arranged for parents which provided an opportunity for them to share their experiences of their child going through the disease.

At Aravind – Madurai, the survivors’ meet was arranged at Nithyatha. 88 children and their families took part. Senior leaders of Aravind took part in the celebration

Aravind - Coimbatore
Aravind - Coimbatore
Aravind - Coimbatore
Aravind - Coimbatore
Aravind - Madurai
Aravind - Madurai
Aravind - Madurai
Aravind - Madurai

Summer Camp

Aravind – Madurai, May 16 – 21

Aravind Eye Hospital, Madurai organised summer camp for the children of staff members of the hospital, AMRF and Aurolab. A total of 50 children from the age group 8-14 took part. The camp was arranged in Nithyatha and so, most of the activities and sessions were held outdoors. Tree walk, farm visit, swimming, smart cooking, storytelling, drawing/craft sessions and edusports were the highlights. Other sessions included introduction to archaeology, and conservation of nature.

Workshop on Refractive errors and Refraction Assessment

Aravind –Coimbatore, May 20

First year trainees arranged the workshop under the guidance of senior MLOPs of Refraction Department. The following topics were covered in the workshop – hand washing, dilatation, visual acuity and interpupillary distance measurement, autorefractometer and muscle balance. Models of equipment and instruments used in refraction, and cubical arrangement were displayed. Ophthalmologists – Dr. Jayanthy and Dr. Balasaraswathy evaluated the trainees’ performance and selected the best three. The entire exercise has helped the first year trainees to gain knowledge of refraction and the various steps involved therein.

Poster Presentation at ARVO-2022

Denver, Colorado, May 1-4

Neuro-Ophthalmology & Retina Departments of Aravind – Coimbatore, in collaboration with Vanderbilt University Medical Center (Nashville, Tennessee) presented a poster titled, Assessing vessel density variability in OCT A scans as a means of differentiating papilledema from pseudopapilledema.

Webinars

IOL Formulas and Biometry in Difficult Situations

Aravind-Coimbatore, April 17

The CME discussed types of biometry, how to perform biometry and the challenging situations. A total of 256 persons attended the webinar.

Refresh your Basics in Neuro – Ophthalmology

Aravind-Madurai, May 18

The CME covered topics such as corneal nerve palsies, disc edema, optic nerve sheath fenestration fenestration and supra nuclear palsy. 153 persons attended the webinar.

Fight against the Mighty White – Multiple Facets of Retinoblastoma

Aravind-Madurai, May 11

On the occasion of Retinoblastoma Awareness Week, Aravind-Madurai organised the webinar in which unique case scenarios were discussed. Discussion also evolved on multidisciplinary approach to tackle this life and sight-threatening eye condition in children. 117 persons took part.

AMRF

Guest Lecture

AMRF, May 12

Dr.Beth Mills, UKRI Future Leaders Fellow, Translational Healthcare Technologies Group, Centre for Inflammation Research, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, UK visited AMRF and gave a lecture on  Diagnosis of Infection: Utilising Optical Molecular Smart Probes from the Lung to the Cornea.

PhD Defense

AMRF, May 16

Ms. A.Divya, Department of Proteomics defended her PhD thesis titled Interaction of Pathogenic Fungi with Human Corneal Epithelial cells. She carried out her studies under the guidance of Prof.K.Dharmalingam, Director-Research.

Aurolab

Webinar - Cluster Endophthalmitis: How to Handle it

April 9
Aurolab in collaboration with All India Ophthalmic Society organised the webinar which had prominent surgeons such as Dr. R.D. Ravindran, Dr. Namrata Sharma, Dr. Haripriya Aravind, and Dr. Rajesh Sinha as the panelists. Dr. R. Revathi and
Dr. D. Chandrasekhar moderated the session. Dr. Nirmal Fredrick,
Dr. Lalitha Prajna, Dr. V.R. Saravanan, and Dr. Shivakumar spoke on various facets of the topic. Mr. R. Krishna Kumar from Aurolab presented from the industry perspective.

LAICO

Management Training and Systems Development for Hospital Administrators/Managers

April 1-30

 LAICO ran the one month course to develop the skills of eye hospital administrators or managers. A total of 17 participants from nine countries, Cameroon, DR Congo, Uganda, Ghana, Kenya, Nepal, Sierra Leone, Somalia and India took part.

Publications

  1. Gurnani B, Kaur K, Venugopal A, Srinivasan B, Bagga B, Iyer G, Christy J, Prajna L, Vanathi M, Garg P, Narayana S, Agarwal S, Sahu S. Pythium insidiosum keratitis ‑ A review. Indian J Ophthalmol. 2022 Apr;70(4):1107-20. View More
  2. Rathinam SR. Commentary: EyeSmart EMR based analytics of big data: LEAD‑Uveitis Report 1: Demographics and clinical features of uveitis in a multi‑tier hospital based network in Southern India. Indian J Ophthalmol. 2022 Apr;70(4):1268-9. View More
  3. Das MR, Krishnadas R. Commentary: Glaucoma following penetrating keratoplasty: A double whammy. Indian J Ophthalmol. 2022 Apr;70(4):1246-1247. View More
  4. Sindal MD. Commentary: Predicting need for treatment in retinopathy of prematurity – The elusive Holy Grail. Indian J Ophthalmol. 2022 Apr;70(4):1277-8. View More
  5. Adithya VK, Baskaran P, Aruna S, Mohankumar A, Hubschman JP, Shukla AG, Venkatesh R. Development and validation of an offline deep learning algorithm to detect vitreoretinal abnormalities on ocular ultrasound. Indian J Ophthalmol. 2022 Apr;70(4):1145-9. View More
  6. Jayaprakash AA, Aswin PR, Rathinam SR. Joint pain liniments and gum lotion in the eye ‑ A consecutive case series of mistaken identity. Indian J Ophthalmol. 2022 Apr;70(4):1159-1162. View More
  7. Radhakrishnan N, Pathak N, Raja Subramanian K, Das DR, Ningombam R, Khaitan I, Gandhi N, Rahul R, Prajna NV. Comparative study on costs incurred for treatment of patients with bacterial and fungal keratitis ‑ A retrospective analysis. Indian J Ophthalmol. 2022 Apr;70(4):1191-1195. View More
  8. Chandrashekharan S, Chakrabarty S, Tanwar M, Madhuvarasu B, Uduman MS, Ramakrishnan R. Outcomes and favourable prognostic factors in patients of phacomorphic and phacolytic glaucoma managed by manual small‑incision cataract surgery: A retrospective study. Indian J Ophthalmol. 2022 Apr;70(4):1216-1221. View More
  9. Senthilkumar VA, Pradhan C, Rajendrababu S, Krishnadas R, Mani I. Comparison of uveal parameters between acute primary angle-closure eyes and fellow eyes in South Indian population. Indian J Ophthalmol. 2022 Apr;70(4):1232-1238. View More
  10. Babu N, Baliga G, Puthuran GV, Ramasamy K. Retinal detachment in eyes treated with Aurolab aqueous drainage implant for refractory glaucoma ‑ Incidence and outcomes. Indian J Ophthalmol. 2022 Apr;70(4):1287-1293. View More
  11. Bhaskaran S, Flora J, Perumalsamy V, Durairaj DC. Visual impairment in children with multiple disabilities in schools for children with special needs in South India. Indian J Ophthalmol. 2022 Apr;70(4):1307-1311. View More
  12. Sivakumar P, Tagare S, Kumar M. Diagnostic accuracy and clinical utility of bed side tests versus laboratory tests in the diagnosis of ocular myasthenia. Indian J Ophthalmol. 2022 Apr;70(4):1331-1337. View More
  13. Mishra C, Kim U, Dheera MS, Krishnakumar K. Combined treatment modality including topical 20% fluorescein dye in the management of phthiriasis palpebrarum – A case series. Indian J Ophthalmol. 2022 Apr;70(4):1327-1330. View More
  14. Chandrakanth P, Gosalia H, Verghese S, Chandrakanth KS, Narendran K, Narendran V. Slit-lamp based intraocular lens microscope ‑ A novel technique of rapid office‑based microscopy. Indian J Ophthalmol. 2022 Apr;70(4):1381-1383. View More
  15. Brayan J, Chandrakanth P, Narendran S, Narendran K, Narendran V. PHACOSIT: A sitting phacoemulsification technique for patients unable to lie down flat during cataract surgery. Indian J Ophthalmol. 2022 Apr;70(4):1396-1401. View More
  16. Gurnani B, Kaur K, Nath M. Publication addiction during COVID‑19 pandemic ‑ A rising boon or a bane. Indian J Ophthalmol. 2022 Apr;70(4):1402-1403. View More
  17. Anitha V, Ravindran M, Venkatesh R. Outpatient temporary tarsorrhaphy: An alternative, cost‑effective, non‑surgical model for ocular surface disorders. Indian J Ophthalmol. 2022 Apr;70(4):1434-1436. View More
  18. Prithvi C, Sneha C, Shishir V, Hirika G, Raman GV, Chandrakanth KS, Narendran V. Smartphone Gonioscopy with a Magnifying Intraocular Lens – A Cost-Effective Angle Imaging Device. J Glaucoma. 2022 Feb. [Epub] View More
  19. Kohli P, Parida H, Rajan RP, Kannan NB. Bilateral Central Retinal Vein Occlusion in a Neonate. Ocul Immunol Inflamm. 2022 Apr 11:1-5. [Epub] View More
  20. Gnanavelu S, Boopalan S, Ponnat AK, Puthuran GV, Krishnadas SR, Mishra C. Angle-closure glaucoma secondary to Malignant hypertension- A difficult conundrum. Ophthalmol Glaucoma. 2022 Apr 7. [Epub] View More
  21. Huang P, Narendran S, Pereira F, Fukuda S, Nagasaka Y, Apicella I, Yerramothu P, Marion KM, Cai X, Sadda SR, Gelfand BD, Ambati J. Subretinal injection in mice to study retinal physiology and disease. Nat Protoc. 2022 Apr 13. [Epub] View More
  22. Ghorpade A, Anitha V, Ravindran M. Colletotrichum asianum: A Novel Phytopathogen Causing Human Infection-A Case Report. 2022 Apr 14. [Epub] View More
  23. Rajendrababu S, Puthuran GV, Alia LA, Uduman MS, Wijesinghe HK. Intermediate‑term outcomes of combined phacoemulsification and Aurolab aqueous drainage implant in eyes with refractory glaucoma and coexistent cataract. Int Ophthalmol. 2022 Apr. [Epub] View More
  24. Kohli P, Mishra C, Baliga G, Rajan RP. Multimodal imaging of congenital retinal macrovessel with secondary foveal hypoplasia. BMJ Case Rep. 2022 Apr 20;15(4):e249563. View More
  25. Gosalia H, Chandrakanth P, Verghese S, Rammohan R, Narendran K, Narendran V. Rapid Office-Based Diagnosis of Demodex Using an Innovative Smartphone-Aided Intraocular Lens Tool. Eye Contact Lens. 2022 Mar 24. [Epub] View More
  26. Thulasiraj R. Primary eye care – Key to universal eye health. Indian J Ophthalmol. 2022 May;70(5):1448-1449. View More
  27. Krishnadas R, Ravindran RD, Namperumalsamy P. Govindappa Venkataswamy: Reimagining eye care in the third world–From provincial to planetary. Indian J Ophthalmol. 2022 May;70(5):1450-1452. View More
  28. Gurnani B, Kaur K. Analysis of COVID-19 publications in the Indian Journal of Ophthalmology during two years of the pandemic and their impact on ophthalmic literature. Indian J Ophthalmol. 2022 May;70(5):1522-1532. View More
  29. Babu N, Kohli P. Commentary: Inverted internal limiting membrane flap for large macular holes: Evaluation of new surgical techniques need new macular hole closure classification systems. Indian J Ophthalmol. 2022 May;70(5):70:1694-1695. View More
  30. Mishra D, Kaur K, Gurnani B. Commentary: Can we depend on the point‑of‑care rapid antigen testing for SARS‑CoV‑2 for routine ophthalmic procedures and high volume ophthalmic settings?. Indian J Ophthalmol. 2022 May;70(5):1765-1766. View More
  31. Gurnani B, Kaur K, Nag T. Commentary: Paradigm shift in scientometric indices and publication policies of various ophthalmology journals. Indian J Ophthalmol 2022 May;70(5):1807-1808. View More
  32. Rao S, Maheshwari D, Pawar N, Kadar MA, Ramakrishnan R, Uduman MS. Clinical profile and long term outcomes of eyes with choroidal detachment following trabeculectomy. Indian J Ophthalmol. 2022 May;70(5):1635-1641. View More
  33. Garg G, Venkatesh P, Chawla R, Takkar B, Temkar S, Damodaran S. Normative data of retinal arteriolar and venular calibre measurements determined using confocal scanning laser ophthalmoscopy system – Importance and implications for study of cardiometabolic disorders. Indian J Ophthalmol. 2022 May;70(5):1657-1663. View More
  34. Mishra C, Muraleedharan S, Kohli P, Kannan NB. Anterior-segment optical coherence tomography findings of endothelial precipitates secondary to silicone oil emulsification. BMJ Case Rep. 2022 Apr 27;15(4):e249568. View More

Training

Enrolments for April 2022

Course title
Training Centre
No. of enrolments
Long Term Fellowship Programmes – For Ophthalmologists
Fellowship in Anterior Segment & IOL Surgery Madurai 1
Pondicherry 1
Fellowship in Cornea Coimbatore 2
Fellowship in Paediatric ophthalmology Madurai 1
Fellowship in Glaucoma Madurai 1
Coimbatore 1
Fellowship in Orbit and Oculoplasty Madurai 2
Coimbatore 1
Fellowship in Retina Pondicherry 1
Fellowship in Medical Retina Chennai 1
Fellowship in General Ophthalmology Madurai 1
Short Term Training Programmes – For Ophthalmologists
Neuro Ophthalmology Madurai 1
Coimbatore 1
Management of Retinopathy of Prematurity and Paediatric Retinal Disorders Coimbatore 1
Clinical Observership Program In Diagnosis and Management Of Glaucoma Madurai 1
Coimbatore 1
Phacoemulsification Pondicherry 1
Madurai 1
Coimbatore 2
Small Incision Cataract Surgery Coimbatore 2
Madurai 2
Management Courses
Management Training and Systems Development for Hospital Administrators / Managers LAICO 17

Statistics

Patient Statistics – April 2022

Hospitals
Total
Madurai
Tirunelveli
Theni
Coimbatore
Pondicherry
Tirupur
Dindigul
Salem
Tuticorin
Udumalpet
CbeCC
Chennai
Tirupati
Kovilpatti
Hospital Out-Patient Visits
Paying (New & Review) 236,492 54,444 27,289 8,279 31,010 27,494 4,821 7,567 12,369 5,550 4,428 4,069 33,394 12,923 2,855
Free:Direct walk-in (New & Review) 93,994 25,113 7,993 2,823 10,779 12,523 1,854 4,630 1,398 2,567 10,883 12,736 695
Outreach Out Patient
Comprehensive Eye Camps 33,663 8,371 4,076 975 5,798 7,695 559 1,569 105 73 3,564 878
Diabetic Retinopathy Camps 1,280 554 57 98 504 67
Refraction Camp 2,805 130 530 382 530 952 201 80
Mobile Refraction Unit 1,796 736 1,060
School Screening 2,321 441 608 519 753
RoP Screening 1,687 168 351 209 747 87 101 24
Vision Centres 62,701 22,487 13,550 5,513 1,900 12,838 1,212 2,229 1,702 1,270
Community / City Centres  15,412  8,489 2,438 2,081 2,404
Total OP Examinations 452,151 119,756 56,284 20,360 52,445 64,601 8,446 7,567 22,125 7,053 8,770 4,069 49,811 27,314 3,550
Total number of camps 152  31  25  8  27  26  2 7 7 1 10 8
Surgeries
Cataract 44,893 11,673 3,733 1,087 5,795 9,809 597 720 2,205 579 1,067 298 4,320 2,769 241
*Other Surgeries 21,232 6,355 2,375 452 3,630 3,310 89 110 538 50 80 100 2,870 1,200 73
Total Surgeries 66,125 18,028 6,108 1,539 9,425 13,119 686 830 2,743 629 1,147 398 7,190 3,969 314
*Other surgeries include major surgeries, minor surgeries, intra-vitreal & other injections and laser procedures.