Cataract surgery is one of the most common procedures performed worldwide. Light adjustable lens (LAL) is the only artificial intraocular lens that allows physicians to design, trial and customize a patient’s vision after cataract surgery. Watch to understand the key information every eye professional should know about this new technology and analyze real world outcomes from the first year of LAL use at Mayo Clinic in Rochester, Minnesota.
Good afternoon and welcome. Thank you for joining us today for the light adjustable lens. What ophthalmologist should know webinar. I'm Doctor Rudy Seller, an ophthalmologist and cataract and refractive surgeon at Mayo Clinic. And I will be your moderator for today's discussion. We're so very glad to have you with us today with that. I'm pleased to introduce our speaker for today's webinar. Doctor Michael Maher is an ophthalmologist and cataract surgeon at Mayo Clinic in Rochester, Minnesota. Doctor Maher has over 20 years experience in cataract surgery. He's a graduate of the Washington University School of Medicine and completed his registered training here at Mayo Clinic in Rochester. Doctor Maher conducts clinical research focused on cataract surgery outcomes using big data from EMR data analytics. Please join me in welcoming Doctor Maher, Doctor Sala. Thanks a ton. It's really a pleasure to be here and frankly, what an exciting topic. So I look forward to spending the next hour together. These are our formal objectives. But, but really, I think the better way to summarize the objectives is informally and informally, the, the real goals here depend on who you are and what you're looking for. But if you're personally considering implanting this lens or doing post op adjustments. I think there's gonna be something here for you. If you're thinking about referring patients for the light adjustable lens implant, I hope there'll be useful information here for you as well. If you're not directly involved in using the light adjustable lens and plan of referring patients, it's still very relevant to know about the light adjustable lens and plan adjustment con uh in the in the adjustments we perform in the context of performing ophthalmology related care to these patients, especially during the adjustment process. And then finally, you or a family member may be considering getting this lens implant yourself and just interested in more information. So we kind of thought the best way to go over this would be start with a typical patient presentation. We'll talk for about 10 minutes or so about this and then we'll get into all the interesting discussion and questions. So the patient is really a very typical kind of scenario for a lie digestible lens implant. This is an 80 year old female with a history of mono vision left eye near bilateral cataracts. She comes to his myopic with astigmatism with two plus NS mild epiretinal membranes and importantly, her pupils dilate to eight millimeters in both eyes. When we look at it traces corneal topography, she is significant with the rule, slightly oblique corneal astigmatism in both eyes with a magnitude of about 1.9 doctors. So our plan with her to summarize was that we elected to proceed with bilateral cataract surgery with the light adjustable lens implant. With her strong history of mono vision, she was committed to mono vision or blended vision, committing her left eye and ear in the post op period. So her specific refractive goals were the one fully correct her manifest as stigmatism to target the right eye plano and then three titrate the amount of near vision or myopia for the left eye to the functional level that she would like. We selected initial IOL powers targeting the right eye slightly on the hyper optic side of the plane and we'll talk about that and then we actually target the left eye a bit nearer to maximize the potential for future adjustments in each direction. So step back, what is this lens implant? It's this unique new technology that's been FDA approved for a little over a year and a half or so. We've offered it the male practice for a little over a year. It's a three piece silicone lens implant. What's unique about it? Is it photo reactive marima in the lens implant? The front surface of the lens implant has an active shield UV filter. The back surface of the lens implant has a UV blocker. The only way to place this lens implant is by using the company's injector. You cannot place this with holders and folders. So how does it work? So, conceptually there are these photo reactive mamers or perimeters in in the lens itself. And what happens is when you shine very specific wavelength UV light on the mamers, they cross link and then through an osmotic gradient, the uncrossed link mari diffuse to this area and cause a very predictable amount of lens swelling refractive change such that you can put pretty much any mathematically possible two dimensional pattern on this lens implant and cause appropriate lens shape changes. So on the right, you see kind of typical profiles for a hyperoptic or a myopic adjustment, but you can also do more complex profiles. All right. So in pra practice, how does this really work? So it's FDA approved for a total of up to two doctors, a sphere and an additional two doctors, a cylinder correction. And you can adjust in quarter doctor increments. If you don't do a spherical adjustment, then you can capture more of this potential and potentially correct up to 3 to 3.5 diopters of cylinder in one plane. So a typical clinical course would be 1 to 3 adjustments followed by two what we call lock in treatments that begin at least 17 days. After second eye surgery, you have to wait at least three days between each light treatment during this treatment course. For bilateral patients. It's really ideal to simultaneously adjust both eyes as 80% of our patients. And this is consistent with trial data. Ultimately choose mono or blended vision, you can actually undo a previous adjustment. So long as they are remaining, mari patients wear UV protecting glasses until a day after their second lock in treatment, there is no upper time limit in terms of how long you can wait before completing the adjustments or lock in process. So we're the exclusion criteria. Importantly, who can't get this lens implant the by far major one where we end up excluding patients or patients who can't dilate to at least six or 6.5 millimeters because you have to be able to see the entire optic to do an adjustment. A relative contraindication also has a history of ocular HSV, an unstable bag, taking photo sensitizing medications. We'll talk about those in a bit for a patient who just can't sit still or is unwilling to sit still or logistically return for the adjustment process. And again, remembering this is a silicone lens implant. So if you expect future in interactive silicone oil, this would also be contraindicated. So potentially UV sensitizing medications, there are actually a lot of them. But in our experience, this really isn't a major exclusion criteria because most people are on these medications, they're typically stoppable and you can do a wash out before you do adjustments. So what's the trial data show? So when you compare it to, uh, monofocal lens implant controls, the light adjustable lens implant here in the bars is the purple, the controls are in the gray and about 70% of patients that have 2020 vision uncorrected or better. Twice that rate compared to monofocal controls. If you look at 2025 or better, you get to 92% and 99% 2030 or better. Again, uncorrected vision. What about astigmatism in the trial data? The average patient had 1.2 doctors of pre op cylinder and then the average patient ended up with a quarter doctor of cylinder and the after all the adjustments were completed, that actually a more interesting way to basically look at uncorrected visual outcomes for astigmatism is is to look at what percent of patients had uncorrected vision worse than 2030 after their their selected lens implant. What you find here is for monofocal controls, that's one in five acres soft torque data. It's one in six techni torque, it's one in 10. And then for light adjustable lens implant, it's about one in 100. All right. So what about blended vision? So a couple of LAL series show that for blended vision, a couple of interesting points. Number one, when you think of mono vision, blended vision with contacts and other things you think of patients having, let's say a two diopter difference between their two eyes or being about a minus two. And what you find is the mean amount of myopia that patients select with the light adjustable lens implant is typically significantly less than that about 1.3 to 1.5 diopters when this is offered to a broad section of patients, about 80% of patients against select a blended type vision. So when you look at pan optics data, you have about 40% or so of patients who are 2020 both distance a year and then the light adjustable series that number bumps up to 75 to 80%. All right. So, back to our patient. So the actual cataract surgery itself, it's really the same as traditional cataract surgery with one exception. And that's the implantation lens implant itself. So for the lens implant, you have to load the lens in the injector, so it doesn't come preloaded and the loading process is a little bit tricky when you inject the lens implant, I'm gonna play the video of one of the lens implant injections for our patient here. It, it, it's something where with traditional lens implant injection, we think of the, the lens coming out very slowly. You almost have to work to unfold it. This is much different. This lens implant really springs out of the injection and, and it can come out fairly rapidly. So you have to inject it exquisitely slow, especially in the context of having more rigid haptics and then the trailing hap that can be placed either with the injector, oftentimes with the second instrument. All right. So post op instructions are really identical. With the exception of the fact that patients starting with their first eye surgery have to wear UV, protecting glasses supplied by the company from the time of their first surgery until a day after their final lock in treatment. All right. So our patient, they had uneventful cataract surgery. We did the two eyes separated by a week. And that's typically how we do this. The right eye you can see here the pre adjustment manifest refraction was plano plus one and a quarter with the rule. And you can see the topography associated with this or target adjustment for the right eye was distance plano. The left eye pre and post op again has significant with the real corneal stigmatism, a magnitude of of two doctors access in 95. And the target refraction for the left eye was gonna be the near eye or target of minus one. So we proceeded with doing the first adjustment for each eye. So how does this work? You have this device called the light delivery device and you basically type in the patients free adjustment manifest refraction. And then your adjustment goal, you use a contact lens and it's very similar to the way you think about a yag contact lens to couple you type in the date. And basically, the surgeon's responsibility is to just keep this adjustment radiculo centered on the lens. And you can see this live feed of what you see on the monitor. The treatment algorithms typically run for two minutes or less per adjustment, per eye. And the actual adjustment takes place in the central five millimeters of the optic, just central to the insertion of the haptic in the optic itself. But otherwise, every part of this adjustment is actually automated by the machine with the treatment algorithm. So our patient had an uneventful adjustment but the actual lens shape change that typically takes place over 24 hours. Now, when a patient's gonna notice their change, they're very much dependent on what dilating regimen one uses. And for some patients, we have to use a pretty aggressive dilating regimen at the time of the adjustment just to be able to facilitate visualization of the entire optic. All right. So how did our patient do? So after the first adjustment, our patient interestingly had almost like a little magical experience and we got unsolicited patient portal messages the next day where the patient experiences very significant change both in their astigmatism correction and e correction in their eye where they functionally developed this vision literally overnight. So what did the numbers show? We saw him back? 12 days later, the right eye uncorrected was 2015. The left eye, the near eye was 2040 distance 2020 near using the two eyes together, they were 2015 distance 2025 intermediate 2020 near the I trace has a function on that lets you check the alignment of a toric AOL. And as you know, basically, when we do a toric adjustment or spirit or cylinder adjustment on the light adjustable lens implant, it becomes a toric. And using this torque check function, we can check the alignment of the axis adjustments we did to see how accurate or valid it was. And what the data shows for this patient was that the axis is really right on the money and any rotation in the adjustment wouldn't have benefited this patient. They were actually very happy with their functional vision as is after one adjustment, elected to proceed with lock in where their final uncorrected vision after after final lock in was distance 2015, intermediate 2016 and near 2020. So this is kind of a springboard in terms of a typical patient and I may turn this back over to doctor sell so we can get into all the interesting questions and discussions around this unique lens. Yeah. Thank you, Doctor Mar. That was uh an excellent presentation of the case. And uh absolutely, it does, it does bring some uh interesting questions. Can you please discuss what will happen? For example, if a patient does not wear their UV uh glasses, that's a great question. So this is a point of anxiety and concern for patients and others. So theoretically, if you don't UV protect that lens anytime before it's locked in, you could if you get exposed to that very specific 365 nanometer wavelength of light Crosslin the lens and have an unintended shape change. Now, practically speaking, this is actually pretty unlikely. So the company has actually embedded an active shield on the front part of the lens to help protect the lens from ambient UV light exposures. And there's actually unpublished data from a Mexico practice where for several patients, they actually had the patients not wear the UV protecting glasses. And you can think about Mexico sunlight and those patients actually did fine. So what does that mean for us here at Mayo? We for sure, instruct all our patients to follow the FDA guidelines that we the UV protection indoors and outdoors. We find a significant number of patients have the anxiety that they forget to wear their glasses for one little blip in time that they'll mess the whole thing up. And we can really tell them with confidence that that they don't have to worry about whi which really provides significant comfort to the patients. And what happens if the patient requires another diagnostic procedure, for example, or treatment, even sleet lamp exam or an oct? Great question. So you know, this process from first surgery to last adjustment typically takes two months or so and it can take significantly longer. And other things happen again, remember the only thing that can affect the shape of this lens implant is 365 nanometer UV light. So it's been studied when you look at slit lamp picca I trace fa oct yag and Argon lasers, it shows that these actually don't have any impact on the unadjusted lens implants. So what's this mean for all this? Practically, you can provide normal, typical emergent eye care both in terms of diagnostic and laser procedures during the pre lock in process. Without fear of harming this lens. The only caveat would be is if you do an fa if you're the one doing adjustments, you wanna wait at least three days after an fa for the dye itself to wash out. Ok. And let's assume that a light adjustable Lation needs a Yup salot toy. Done. How would you address that? Yeah, that's important. And that's relevant. So maybe I'll answer this one backwards if you're gonna do a Yang capsulotomy post lock in post lock in. This is just a silicone lens implant that happens to have a shape that's customized for that patient's eye and you do a Yang just like you normally do a Yang. Now pre lock in, it's a different story. Pre lock in. If we speak candidly, we know that lens pits and inadvertent laser strikes happen with Yang capsulo is and what you for sure don't want is a lens pit in that central uh potentially adjustable part of the lens implant that can interfere with the adjustment. So what do you do if you have to do a yag pre adjustment? What you do is you make a horseshoe type yag and you actually make that horseshoe shape outside the central five millimeters of the optic. So you don't take any risk of pitting or impacting the unadjusted part of the central lens implant optic. OK. And another technical question, many monofocal I oils, if inadvertently placed upside down in the or then, uh, can be left in that position with minimal optical consequences. Is that also true with a light adjustable lens? Yeah, that's a good interesting question. Yeah. So uh we, we know kinda that happens sometimes with the light adjustable lens implant. It's an unequivocal. No, you can't leave it that way because if you go back to the previous slides, the lens implant has a UV filter on the front part. It has a UV blocker on the backside. If you put it in upside down, that UV blocker now is on the front and is impossible to adjust that lens implant. So that's a, that's a strong no. And how about sulcus placement of the light adjustable? Um Can it be placed in the sulcus? Yeah. So great question. So yeah, so some people would say that it's a three piece lens implant, that's a disadvantage versus an advantage. But it is an advantage that you could potentially place it in the sulcus. Can you light adjust it in the sulcus? Absolutely if you can get exposure to the whole lens implant, but you have to think about what kind of pattern you're gonna put on that in the context of lens stability. If you have a lens that's stable or you can do anything to make it more stable using optic capture, then that's something that's potentially reasonable to do. And is there a way to treat higher amounts of corneal cylinder, uh higher than two diopters, for example, using the light adjustable? Yeah. So that's an interesting question. So what are the potential ways you could do this? So, so, so, so they're really two. One is it's been reported and we've done it before. You can use a limbal relaxing incision at the time of surgery to decrease the magnitude of corneal stigmatism and then use the light adjustable lens implant to kind of clean up or or very precisely adjust the final two or less diap as stigmatism. So that's one option. Option number two is remember, you can adjust two doctors a sphere and two doctors a cylinder, but these are an additive. So if you have a patient where you don't have to do a spherical treatment, you can borrow from that two doctors of sphere to do a cylinder adjustment that that's potentially greater than two. OK. And can you please tell us what range of lens powers are currently available? Yeah, sure. So, so the a concept for this lens implant is somewhat traditional. It's 1 18.4 in the middle of kind of the range. So 16 to 24 adapters, it's available in half di steps at the shoulder. So between 10 and 15 and 25 and 30 it's in one DIAP steps. But again, remember you can adjust this, you can special order lens implants for your high my patients between five and nine diapers. So practically what does this mean? The light adjustable lens implant really may not be an option for your high mile or your high hyper open. And we've had a high mile to who we had to reject because we didn't have the lens implant power available on that shoulder of the range. But that's a fairly unusual situation. Ok. And can you please elaborate a little on the theoretical basis for the potentially increased depth of field associated with the light adjustable lens? So this is a terribly interesting topic that we're all still novice as it at trying to understand what we know. The light adjustable lens implant has negative spherical aberrations. But those negative spherical aberrations potentially can be augmented by the light adjustments we do and the type of adjustment we do actually matters. So, if you have a patient, for example, who's Plano and you adjust them to be myopic with a target of minus a half or more than minus a half, you will actually create negative spherical aberrations with increased depth of field for that near portion of the eye. On the other hand, if you had the same patient, you started out at minus 1.5 and then adjusted them back to mias one, you would actually not create those negative spherical aberrations. So although we can't dial in and use or select these kind of negative spherical aberrations to increase depth of field. The way we select our initial lens implant powers where we basically start close to plano and creep towards myopia actually gives us the ability to control or increase the depth of field through these negative spherical aberrations. And it's thought that this is the reason why patients, when given the functional option, they choose and settle in oftentimes at this minus a quarter to minus a half instead of a higher level of myopia. Ok. And I know many wonder how about the long term reflective stability of the light deductible lenses? Do we have any data on this? Yeah. So thankfully, you know, despite the fact that this is new technology, there is data. So there's a 2020 study out in Germany in the journal of cataract refractive surgery by um Burkhardt Dick and pier that basically for 400 something patients that showed the lens implant was very refractive stable out to seven years. And intuitively, it makes sense because once you lock it in, it's a silicone lens implant, that's what it is. All right. And can you please tell us what are our male refractive outcomes with the light adjustable ones? So we're humbly learning, but this is kind of a an an exciting thing. So for our patients, if you look at the outcomes and this, this, this might be kind of busy but, but I'll break them down for distance eyes. We ended up with about three quarters of our patients at 2015 18% at 2025% at 2025. For the bilateral uncorrected vision for patients pursuing mono or blended vision. We had all our patients end up at distance 2020 or better with two thirds being 2015. For intermediate vision, 100% of the patients were 2025 or better. And for near vision, we had two thirds of the patients at 2020 then 92% of the patients at 2030 or better knowing that this number isn't always just driven by what we do. It's driven by the choices that the patients make in terms of how much trade off they want between distance vision and and nearer myopic correction. And I may II I can show some graphs to kind of get into this in a little more detail. So when you look at our distance intended adjustment, so if you look at distance eyes, we started out with spherical equivalents of, you know, 1 to 1 and a quarter diopters and almost uh well, actually every patient ended up within a quarter diopter of attended intended after the first adjustment. So the distance spherical adjustments are quite precise. What about a stigmatism adjustment? So we adjusted anywhere from two and a quarter doctors to, to to nothing. The majority of our patients were within a quarter doctor cylinder after one adjustment and everybody was, was at target for cylinder after two adjustments. So what about near eye? So this graph, this is interesting, this isn't the outcome, this is what patients wanted. So for the near eyes, after first adjustment, we started out with patients with typically a mild level myopia to test drive near a mono vision anywhere between minus a half and minus one, a couple of patients tried it and they didn't like it and they want us to unadjust them and take us back to Plano, which we were able to successfully do the rest of the patients. Most of them then settled in on anywhere between minus one and minus 1.5 at their final target for what they wanted. Then did we achieve it? So these are the actual results and what you can see is for all our patients except for one, we ended up at their myopic target. There's one patient who is about a minus 1.5 or then they wanted to be more minus when it was all said and done and there weren't enough maro left. So we couldn't give them the more minus, they were still functionally very happy. OK. And I'm interested to know how those um how do those reflective outcomes compare with the male monofocal and Tori Iols? This is a big point of interest for us. So I'm gonna show you busy graphs here. So this is just unobstructed data that's directly taken out of epic 7000 cases, multiple surgeons red or monofocal lens implants, green or torque lens implants. And what you see is how many letters did we gain with the final post op refraction on the right is the exact same data. It's just it's a cumulative kind of density plot. So what this shows is to simplify it is for both the torque and the monofocal half the patients ended up having only one line of improvement with their post op refraction. 75% of patients in both groups about ended up with two lines of vision gained with the final post op refraction to put in perspective. If we left everybody a fake, a this curve would be way off to the lower right hand corner. If we had kind of perfect refractive outcomes, it would be a dot in the upper left and then the green zone, these are our actual wide adjustable outcomes. So it turns out and the yellow is what was thought to be theoretically possible with the lal trial data. So it turns out our refractive outcomes are really meeting or exceeding expectations. That's beautiful results. And what future technical improvements are theoretically possible with a light adjustable lens platform as you see it. So this is very interesting and I and I kind of give give two answers here. One, this is FDA approved for spear and cylinder adjustments. But theoretically, you can do any mathematically describable pattern on this lens implant. So you could potentially do more adjustments. You could have user selection of spherical aberrations and so forth. So even though it's not approved for that, those things are possible. Number two, there's been an interesting idea floated that this platform could be changed from what it currently is, which is a one hit model. So you, you, you cross link those perimeters with one hit of 365 nanometer UV light. If you change it to where it requires two hits of UV light, especially in a wavelength that doesn't really occur in nature, then you could eliminate the need to lock in the lens implant and actually leave these lens implants. So they're indefinitely adjustable over time. So long as macro or retain. So these are things that we, we believe people are working on right now. All right. Now, what would be um the national volume trends regarding availability and the use of light adjustable lens? All right. Well, I'll speak to the to the US. This is where we have data. So in the US, we have about 10,000 active cataract surgeons. At the beginning of 2022 there were 246 light delivery devices. So think of this as facilities where you could get the light adjustable lens implant. 2023 that number probably went up about 80% or so. So about 450 in terms of actual number of lenses implanted in 2022 is about 25,000 in 2023 42,000 with the annualized rate based on the January numbers. But this still represents a very small fraction. So most recently, about 1.4% of the US cataract surgery volume. So I'm just gonna summarize basically And then we can even get into some more questions. So the uh this technology has been worked on for a couple of decades. It's pretty amazing and it's here, the FDA approved adjust up to two doctors of sphere and cylinder. You have negative spherical aberrations that likely increase the depth of field. But the glare and halo profile of this is similar to monofocal much reduced relative to multifocal lens implant. If you look at all comers, 80% of patients who get the lal end up selecting a blended vision, but those who don't want that have the ability to try it and undo it during the beginning of the adjustment process. Um The main contraindication to be aware of with this lens implant is poor dilation. If you can't dilate to 6.5 millimeters or so, then unfortunately, it's not an option for a patient. So I may turn it back over to doctor sell and we'll see, I don't know if we have other questions that so wonderful Thank you, Doctor M. Let's dive into some questions that we did get from the audience here. So we got um to the participants asking how does this lens do with hyper, with moderate astigmatism? Yeah. So, so we found that outcome wise, it, it, it really doesn't matter if you start out with a myo or a hyper, you can still accomplish basically the same thing. So I haven't seen any variability in outcomes in terms of pre-existing refractive error. Now related to that is the idea of previous refractive surgery. So what we find in our practice is patients who've had previous refractive surgery are disproportionately attracted to this lens implant. So that the, the the pool of patients who've had previous refractive surgery as a pool of all our cataract surgery is a pretty small number, but it represents 30% of the patients who pick the LAL. And there's published data on this that suggests on one hand, the patients who've had previous roof practice surgery because of increased risk of roof fract surprise or potentially a better candidate to get this. And then on the other hand, to the extent that they have higher order corneal aberrations, this lens implant won't fix those and they're at risk for worse outcomes are related to those aberrations that again is not controllable by the LAL. Ok. There is another interesting question here. Uh, are you concerned about delayed minor shift in our position, disrupting refractive outcomes and the participant, participant also asked, how far have you looked out to assess this great question? You know, the refractive stability, what you know, and, and that, that goes into the realm of capsule rus lens stability lens shifts. And as far as we know, there are no major issues here unique to this lens relative to any other lens implant that having been said, everyone's not just ours for the most part, the US experience is limited in this realm, but it would be hard to expect that the refractive stability issues would be inferior to another lens implant based on what we know right now. And we have two interesting technical questions. Very important ones. One would be can support stuff do the post operative adjustment such as a trained optometrist, for example. So good question, my understanding is there are models where that where that happens if you think about the adjustment process. So the most critical part about the adjustment process likely isn't the actual technical process where you apply the light treatment. It's that refraction that final refraction drives everything and to the extent that that's a great refraction that's valid and consistent. Then then then you end up with good outcomes. The biggest barrier I think to good outcomes in the adjustment process has to do with dry eye cornea instability where you don't necessarily have a consistent refraction and then you're not necessarily adjusting to kind of what the long term target's gonna be. And the second one was, how long are you? Are, are your post op appointments when you're adjusting? They're long not because of the adjustment, but because it's so critical because you don't get unlimited adjustments, you get three to get them. Right. And so the, the time you, you need a very competent person to do that refraction, you have to make sure that refraction is consistent with your topography and with your expectations and we get surprises where we see the patients and the numbers don't line up and then the bias has to be towards not adjusting and deferring and seeing them back because you, you, you don't get unlimited tries here. And if one is patient with the process, both from a provider and a patient point of view, then you can work through these things. I I think the enemy of the whole thing would, would be impatience but, but it is very resource intensive, I would say from a time point of view, both for patients and and, and for the practices, high effort, high yield. Yeah, there is another question here about the consequences on the cornea during the light um process. There's, there's actually published data on this that, that, that, that the published data suggests that the UV light exposure um does not have any, any deleterious effects or impacts that, that we're aware of. All right. And how would you summarize your main challenges, challenges so far with the lens. Uh II, I think the two realms of challenges are putting the lens implant in the eye at the time of surgery. It is not the same as using a traditional lens implant. And one has to have a lot of respect for the loading and placement process for this to go. Well. So that's number one and then number two, I think one has to be humble and patient like we talked about during the adjustment process and have a bias towards not adjusting unless you have a high level of confidence in the numbers that you're adjusting to. I think if you do those two things, then then there's a very, very high likelihood that you can have really good outcomes using this. All right. So these were the questions here on the form and these are all great questions. Um So thank you again, Doctor Moore and thank you to everyone participating today uh with over 250,000 outpatient visits for eye care each year across all our sites in Minnesota, Arizona and Florida Mayo Clinic, welcomes patient referrals for rare serious or complex eye conditions to discuss a patient or learn more about referring a patient to mayo clinic, contact our referring physician services at 1 805 331564 or by visiting mayo clinic dot org slash medical dash professionals. Thank you again for joining us today. We hope to see you again at one of our other webinars coming up in the next few months, you can uh find our next webinar, which will be on November 15th. Uh And you can go ahead and enroll using the resources tab. Thank you so much for joining us. Thank you everyone.