[Music] good evening and welcome to doctors on call I'm Dr Ray Christensen a faculty member from the Department of Family Medicine and biobehavioral health at the University of Minnesota medical school duth campus I'm also a family physician at the Gateway Family Health Clinic and Moose Lake I'm your host for our program tonight on eye problems cataracts GL coma macular degeneration the success of this program is very dependent upon you the viewer so please call in your questions tonight or send them by email to our address at pbsn north.org the telephone numbers can be found at the bottom of your screen our panelists this evening include Dr Charlie arens an opthalmologist with St Luke's ey care Miller Creek Medical Clinic Hermantown Dr Todd Brittain opthalmologist with Ralph iare specialist in Hermantown and Dr Joe morous and opthalmologist with the Essentia Health our medical students answering the phones tonight are Henry Larsson of Spring Valley Minnesota or whoops Spring Valley Wisconsin as an old Wisconsin night I'm already in trouble uh Conor molich of Redwing Minnesota and Joe Miller of St Michael Minnesota and now on to tonight's program on eye problems cataracts glaucoma macular degeneration please call in your questions gentlemen it's great to be here this evening nice to be together again uh this is always a a good program um I think I'd kind of like to hear a little bit about uh your your practices so Joe can you tell us a little bit about your work thank you I I uh work for essential health uh we have a uh group of uh five MDS and six optometrists we have specialists in vit retinal surgery um pediatric Opthalmology and cornea as well as general Opthalmology uh and then we have six optometrists who are uh wonderful Physicians and uh uh so yeah we have a we have a fairly broad-based uh practice and uh I personally do General Opthalmology a lot of cataract work a fair amount of glaucoma work uh and I treat some uh some floaters as well Todd yeah so I'm Todd briten I'm a comprehensive opthalmologist at RI care in Hermantown Minnesota and uh we specialize in cataract surgery eyelid surgery uh family um Eye Care uh we have four doctors currently working with us two opthalmologists and two optometrists and I've been in practice here in Hermantown for approximately 5 years now and Dr erens Charlie hi a little bit about your practice uh I work at St Luke's at the at the Miller Creek Medical Clinic um within the St Luke system we have three opthalmologists and one optometrist um all of us are General opthalmologists and we run the gamut of basically all s almost all surgical uh and medical disorders of the eye um I myself am a general opthalmologist like the other two here um doing a lot of refractive cataract surgery retina we do a lot of um medical retina including injections um we have Outreach LS uh throughout the area as well so I'm primarily at Miller Creek and then I have an Outreach up in himming so we can service the northern area of the state too with all of their needs thank you all it's just great to have that coverage Todd you brought the the eye with you do you want to talk about the normal eye for us a little bit absolutely yeah I can go over some and you guys can fill fill it in where he Goofs it up here and anyone can jump it at any time so but um we will start with the model um um so like to start at the front of the eye so we have the cornea clear part of the eye like the Dome over the eye if I remove this cornea you'll be able to see the iris that is the Color part of the eye of course the pupil in the middle of the iris which is the the opening uh in the iris through that pupil we can see the lens uh of the eye and in this space uh lies a substance that we call Vitus it's like the jelly within the eye and you'll be able to see in the back of the eye the optic nerve blood vessels rad radiating out to the back of the eye and then of course the retina um again going back to the to the front of the eye white part is the Scara and attached to the Scara you can see the extraocular muscles very good anything else you gentlemen want add no nice job good primer Joe cataracts I think that's pretty common uh as we get older and we're all getting older so very uh yes cataracts can occur at any time of life but of course they get uh almost Universal once you've once you've hit probably 55 to 60 years old your lenses are no longer Crystal Clear like they were when you were uh 12 years old and and uh and uh the the the cloudy of the lens uh begins to affect the vision uh we worry about cataracts when they start to affect your your lifestyle and and affect your ability to to to uh visually do the things that that you want to be able to do or need to be able to do all right Charlie let just talk a little bit about macular degeneration so macular degeneration is extremely common particularly in northern Minnesota and it's a basic I like to describe it as a slow thin out or dying out of the central part of the retina the macula which is where we see the most clear and and where we when we're looking centrally that's that's where it is affected um there's two main types dry macular degeneration wet macular degeneration there's varying subtypes within those but that's kind of what what I like to talk to patients about the dry macular degeneration Tech um tends to be about 90% of the patients who get it um with maybe 10% of the visual problems wet macular degeneration tends to be about 10% of patients with about 90% of the problems so wet macular degeneration can cause some serious visual issues for patients um and so it's it's one of those that we monitor pretty closely gets worse as as patients age um it's more in our elderly population above the age of 60 to 70 years old um so we see quite a bit of it um there are some exciting treatments out there now for both forms of dry and and wet that um we can we can talk about later but that's kind of the gist of macular degeneration think just another backgrounder then we should probably Focus but Todd maybe a little bit about glaucoma I was thinking about it as you were running through the iris there anyway and I if you just chat a little bit about it oh sure yeah and we can jump back to the model I think it's helpful and explaining glaucoma but um the biggest thing to take home about glaucoma is this damage to the nerve in the back of the eye um often related to higher pressures within the eye but not not always um the most common form of glaucoma in our country is open angle glaucoma and I think to explain this it's helpful to look at the the eye again at the model so um one thing I didn't mention in the um my original discussion of the anatomy of the eye is where fluid is made within the eye the eye constantly makes fluid it's how it keeps itself pressurized that fluid is made um back here in the back of the eye um but it's not where where the fluid drains uh the fluid actually has to travel travel around the lens and then out through the pupil and then it has to drain in this little angle right here so I just remove the cornea so the cornea was right there um the fluid's going to drain between the cornea and the iris um in open angle glaucoma that drain doesn't work quite as well as it should and so the pressure can build up within the eye and then that elevated pressure can damage the nerve in the back of the eye so that's one form of glaucoma another form of glaucoma is where that drainage angle is slightly narrow or at sometime you know in some instances it's closed off completely um and that again causes an increase in pressure which damages the nerve in the eye um all of our treatments for glaucoma revolve around lowering the pressure and that can be with uh drops or laser or um if the glaucoma is very severe with uh surgery um in the operating room glaucoma can be sneaky um it can impact your vision uh long before you ever notice it um which is why it's important to have uh regular visits with your eye doctor where we can do uh specialized tests you know to detect glaucoma early and treat it Joe we were talking earlier a little bit about sometimes when you're doing cataract surgery you can you can treat the glaucoma uh at that time also there is a uh yeah there are there is a set of surgical procedures called microincisional glaucoma surgery that um at least initially have been kind of done with uh in conjunction with cataract surgery uh one is called an ice tent which is uh two little tiny uh uh tubes if you will that are implanted in the ey it's actually the the smallest implantable device uh that's that's currently on the market uh and um those tubes basically bypass the tracular measure work which is the drainage angle of the eye and and serve to to uh modestly lower the incate pressure so and there are other types of uh implants and various techniques for this kind of which kind of shows you that that there's not one that's above and beyond the rest it's a it's a very much evolving uh uh area in in Opthalmology Charlie what causes glaring in Vision especially at night and I think if we I I I suspect we're going to say cataracts or other things I was going to say there's a lot of things yeah you can do that and then we'll I think we need to look at cataracts a little bit too so yeah so I I think um obviously that that is kind of a loaded question when when we go in and see patients um and we see patients having glaring at night and they're 75 years old yeah we're going to think about cataracts first so that's that is primarily one of the things that as we slowly as the lens slowly gets more and more dense more and more cloudy it's going to cause glare it's going to cause streaking star bursting off lights particularly at night especially when the pupil dilates a little bit it catches all the light traveling through all parts of that lens and it's going to start scattering and that's what causes the glare um it can be a little tricky though especially in younger patients when we have glare and Halos um because it could be caused by dry eyes it could be caused by abnormalities in the cornea uncorrected astigmatism or uncorrected refractive air so there's a lot of times where we'll get consults for cataracts and we've got these other things that that might be playing part of the role um in our evaluation and it's kind of on us to help identify those and and talk with those about the patient Joe I'm going to swing back to you because we kind of talked about this a little bit earlier uh a friend had cataract surgery she was able to change her vision after her surgery with a type of treatment is this a new technology uh there's a that might be talking about the light adjustable lens um uh that would be that would be one example of a of a technology lens that uh that is um out there that that you can kind of lock or you can adjust the refractive eror so a lot one of the things with cataract surgery is in a sense it's like refractive surgery in other words when we change out the lens of your eye we can put any power of lens in there that we want to and usually uh in many cases anyway people would like to get rid of their glasses um but that's not an exact science and so there's a if you end up you you put this lens in there and it ends up being not exactly perfect what you wanted uh this this technology that that uh that's known as a light adjustable lens can be adjusted with a a laser and then once you get the um once you get the or I shouldn't say laser it's it's a light UV yeah UV light it's it's a yeah actually Todd knows more about this than I do because he puts them in but uh but um uh and then once you're happy with the refractive error then then there's another light that you shine in there that locks in the uh the refraction and and then theoretically it's good for forever so another kind of amazing technology that's out there very good Todd this is a question for you and I'm I what is what is the background in cataract surgery and military background is there something between cataract surgery in military I'm not aware of anything I'm not either okay so so much for that seeing a lot of questions on dry eyes and watering eyes you're up great um this is uh something that well is there a specific question or just talk okay let's I we'll bring one here my eyes won't stop cry watering is there something wrong with either my tear duct or is there something else I can do to stop it I don't have an age I don't have anything more than that maybe uh yeah so um we get this we get have this conversation all the time at least in my clinic I'm assuming you guys do too but um tearing es especially if you have irritation dry eyes is extremely common up here um we see it all the time we've got cold dry Aid Winters that really um play a role here and there's other things that can cause tearing too so dry eyes is predominantly you know what what I see in my clinic is as the driving factor for tearing and watering you can have other things you can have um if if the eyelid is not approximated to the eye appropriately it can't the tears can't access the drainage system and so that might be playing a role in the teers if the drainage system is clogged that might be playing a role in tearing so when patients come into our office and we see that there's a multitude of different things that it could be and it's kind of on us again to to kind of break down and find out what the problem is um dry eyes is extremely common and a lot of times since it's less challenging to treat it in the sense of it's not invasive we'll probably start treating that first and see where things go other comments yeah I think it's either a reflex problem like dry eye as um you know as Charlie mentioned or sometimes the tears aren't leaving the eye like they should so a drainage problem so Todd because you're the expert on the eye um this is a really good question I think we need to put it out there how do I protect my eyes while watching the solar eclipse oh yeah so uh solar eclipse coming in April um so you do not want to look directly at the solar eclipse um the safest way to watch it is indirectly um the method that I've seen is to make a pinhole in a piece of paper and Shine the eclipse through the paper with the sun behind you um there are special glasses that you can wear um your sunglasses will not work do not wear your sunglasses and look at any eclipse um there are there is a list I saw on on our Academy website the American Academy of Opthalmology of approved you know eyewear that you can uh wear to watch the eclipse great that's it's really very important because um there's been there's a diabetic question that's been just sitting here I think we're going to end up doing is jumping around a little bit because there's a lot of questions coming in thank you um I'm a diabetic should I be concerned about my eyes and vision and Joe jump well the short answer is yes uh diabetes is a disease uh that has many uh complications uh as it goes along um and one of the organs that that can be profoundly affected by diabetes is is the retina which is of course the visual organ of the eye in the back of the eye as Dr Brittain uh pointed out and and um diabetes is a disease of the blood vessels and that's another one of those sneaky diseases as well that in the early phases uh doesn't have symptoms and yet may require treatment in order to uh prevent uh severe vision loss in the early phases so usually people who have diabetes they're recommended uh in type two diabetics they're usually recommended to start seeing their eye doctor annually for a dilated fundus exam uh usually people with type one uh especially if they have younger onset it would be within the first five years of of being diagnosed so um it's very very important to get that screen most diabetics that I see do not have uh diabetic retinopathy and and and those that do it's mild and they don't need treatment but there are plenty of people that we see who could have done a lot better if they had come in earlier uh and the other of course the other piece of that is the best thing you can do uh I'll I'll give you two best things you can do one is to keep as tight of control of your blood sugar as you can and two if you're a smoker you got to quit smoking uh smoking and diabetes is like matches and dynamite not a good combination smoking is not good for anything in the body are there any non-surgical treatments for cataracts I don't know any not that I'm aware of so there there's a lot of promises out there but realistically the cataracts are going to slowly develop uh everybody gets cataracts um if you live long enough and you start to have visual symptoms you'll need to have the cataracts removed and so that's kind of the conversation I have with my patients is how do you determine when to take them out um I look at three things the big um I look at what their vision is so you know usually on average patients who are best corrected to 2030 2040 um we're starting to think about it I look at the lens make sure that the lens matches what I'm seeing with the patient's Vision the third and most important thing is what are their symptoms and are those symptoms bad enough for the patient to want to undergo the risk of surgery um so there are patients out there who even though they're 2020 and we can correct them down if they're having sign significant enough symptoms and like Joe had mentioned earlier if it's affecting their daily life or they're not doing the things that they want to like driving at night or they're having to wear sunglasses all the time because the the brightness um those are reasons to to consider surgery Todd a person with macular degeneration and glaucoma had a complete loss of vision when looking in the direction of the sun should they be concerned yes yeah I think that's the answer um you want to talk about we kind of talked about macular degeneration a little bit anything more you want to add on that while you're there with it no I think I think the importance with macular degeneration is just um uh routine Eye Care senior eye doctor you know as scheduled and then I I think there's a lot to be said for monitoring at home you know as well I think a lot of us uh tend to be dominant with one eye and it's not until we cover that dominant eye that we may notice change changes in the other eye so I often um instruct my patients you know uh we used to we used to give out tests you know for macular degeneration uh for patients to look at every day um a lot of patients would would lose the test and it's it's hard to keep track of these things so um but just testing your vision while looking at something up close is a good way to test for changes um what we're testing there is often um the the progression you know specifically from the dry formac togen generation to the wet form the reason this is important is they they are treated differently you know the the wet form you know is treated with injections and medications and the dry form um is primarily prevention with diet vitamins not smoking can can I go back so that patient the person who called sorry um it sounded like they had a specific question on whether or not they should be worried about like looking into the Sun and so obviously what um Todd said is that yeah if if you're having vision changes come and see one of us or or your primary care provider but one of the things that um with these chronic diseases and what I tell talk to patients is you now have an optic nerve that's not functioning like it was when you're 20 you have a retina that's not functioning like you were when in 20 so if you all of a sudden are looking at a really bright light you're flooding all those retina cells with bright light and they're trying to recycle and and and send that signal back as fast as they can but they don't work as quick and so it's that that is slowed down and so that's why they're getting that dull image so it might just be as simple as well I'm I'm now flooding the system there and I gota let it catch up a little bit but if it's a new change like Todd said we should see so I I wouldn't be panicking that that that vision is that permanent vision loss is imminent um and it might just be part of the disease process but you should have one of us check it out Jo we talked a little bit bit earlier about floaters so always there's always a floater question uh what is the current current treatment recommended for dry eyes and floaters it's kind of a double up all right well I mean those are those are two separate issues that that they're they're common enough that they often occur together that but they're not necessarily related uh or caused by one one's not caused by the other dry eyes you know the foundation of treatments is is lubrication um and the other the other piece of uh of treating dry eyes that's important is to we have oil glands in our eyelids called Moman glands and and uh uh making sure that that oil is is healthy so I mean warm compresses is kind of the very very basic treatment of that uh so that's kind of the the the initial uh treatments of dry eyes and there are many many others the the dry eye industry is a multi-billion dollar industry in this country so it's it's extremely common and it's a it's a it's a thing that causes a great deal of suffering and then Vitus floaters are uh suspended opacities in the in the jelly in the back of the eye that that's between the lens and the and the retina uh and those opacities tend to accumulate with age the um there is a an aging process by which the um Vitus becomes separated from the from the retina uh and that's typically when when floaters classically show up although there's there's different various uh types of floaters if a lot of times people will get floaters and uh within a month or two they they seem to drift into a place where they don't notice them as much so typically in the acute phase we don't treat floaters although if someone gets gets brand new floaters uh they should come in and get looked at because there's a tiny chance that you could have a retinal tear uh that would only be detectable by uh an eye doctor on a careful dilated exam so you know if someone acutely gets floaters they they need to be seen within I'd say 48 hours or so uh and then if people have chronic flers that last longer than six months and they're bothered by them uh there are a couple of treatments out there one is called laser Vitalis uh which is a kind of a tissue disrupting or it's actually really vaporizing uh those those opacities uh and that's that can be a long slow process is good for for uh relatively focal floaters and then there's a small subset of people with floaters chronically that that have you know almost like a giant Galaxy of them rather than rather than a tiny little constellation and uh those people can go onto a more major surgery called vitrectomy surgery where the where the the jelly of the eye is just removed along with all the floaters and then that's replaced with the saline salt water we'll continue on this just a little bit um the question is uh Terry this person has tearing of the retina in the past does this come back and should this person be concerned so Todd uh thoughts on that one uh so I guess without knowing further history it would be dependent on whether it's been treated I'm assuming this patient has had it treated with either um laser or um you know sometimes will freeze those areas um certainly there's a a risk that they could develop a retinal tear again um you know I would advise a patient like this if they should ever experience any new floaters any new flashing lights that they should be seen right away by their eye care doctor then I I agree iritis want talk about iritis a little bit sure so iritis um anything in the medical uh language that has itis at the end of it means inflammation so when we talk about iritis it's specifically inflammation of the iris um it's kind of synonymous with anterior uvi so uvia is is the iris the the cular body the choid of the eye which is a little bit that we're talking about the the like very small anatomy in those cases but basically you have inflammation inside the eye and there can be a large number of things that that can cause that um it can cause redness pain light sensitivity um and if not treated appropriately can lead to other things like secondary glaucomas um and and vision loss and so these can run the gamut from it's very very mild easily treated to um patients having kind of a more long drawn out treatment with potential for vision loss or even systemic um issues so a lot of patients who present with iritis can be presenting as either an initial sign or symptom of a systemic inflammatory disorder or as a as a secondary symptom of their of their of a systemic inflammatory Disorder so a lot of those patients we end up um testing and and um looking for other disease processes we're learning a lot more about inflammation in the body and disease yes just really is coming along ocular migraine any one of you U Joe I Todd go ahead yeah I can cover it I I have ocular migraines myself and at first they are very scary um so our our textbook ocular migraine is um typically a shining shimmering uh geometric shape uh that you see in your vision often lasts for approximately 20 minutes um sometimes you will get a light headache you know after you notice the visual symptoms um but once it is gone it is gone and you do not have any other symptoms um there they can be brought on by stress uh lack of sleep dehydration um but the important thing to realize about ocular migraines is that they are um harmless you know provided uh they when they go away they go away way and you don't have any other symptoms anything more to add um Joe this gentleman's brother had cataract surgery and developed an infection in his eye and lost his vision how common are complications from cataract surgery generally speaking complications of cataract surgery are not common the the infection rate is somewhere in the neighborhood of one and between 1 and a th000 one and 2,000 uh of bacterial infection inside the eye but that can be a devastating complication um so and and uh uh other big complications similar to that are retinol Detachment is also about a one in a thousand chance uh after cataract surgery um it's it's rare in this day and age with small incision cataract surgery but you can get bleeding underneath the retina which can be also a devastating comp uh complication of cataract surgery um and uh yes there are a very small number of people that actually go blind from cataract surgery which you know Dr Erin alluded to earlier excuse me is is a very strong part of the reason why we don't do cataract surgery just when cataracts show up we we want the the benefits of doing the surgery in terms of increased rision to outweigh the risks small though they may be Charlie the prognosis for someone with myopic eyes so those big deep eyes as well as cataracts can the cataracts be removed to improve the vision and what can be done uh some people are very myopic and have a lot of difficulties so I I guess I and you can all jump in on this so I guess the I I suspect that the question means you know a younger patient who's myopic without without visually significant cataracts is kind of how I'm going to address that I that's all we can do yeah so I can kind of address that so there are patients with high myopia um who want what's what my let's go back what is myopia oh yeah so sorry myopia is basically nearsightedness so I'm nearsighted um without my glasses on I can see from me to you just fine if I try to look at the tree off in the distance it's blurry I got to put my glasses on so that's near sightedness and that's what the majority and even I would say I would argue that more and more percentage of our population is gearing towards as we're more on our devices more into books and um those types of Ventures but so if patients have high myop um the shape of the eye is a little bit longer uh you can have problems with with your vision and so if you're looking for a refractive change um there are you can do PRK lasic there are surgical Corrections there's contacts glasses um the wide gamut there are a certain population of patients who have high myopia who who don't qualify for lasic or refractive surgery and so those patients might might be good candidates for what what we would consider refractive or clear lens exchange where we basically go and we do the cataract surgery um as the refractive surgical choice not because it's visually significant in the sense that they're having problems but because they're doing it for the refractive outcome of not needing glasses Todd switching switching horses again eyelid surgery talk about eyelid surgery and why we do it yeah so we do eyelid surgery for a number of reasons um upper eyelid surgeries primarily done if the upper eyelid is um drooping coming down or if there's excess skin overhanging the eyelid and it's impacting vision and um you know not just impacting Vision but interfering with the patient's daily activities um eyelid surgery in this case you know involves uh removing that skin or raising the upper eyelid or both um with regards to the lower eyelids often times it involves tightening the lower ey eyelid um over time as we age sometimes the eyelids start to uh come down sometimes even turn out um which can be quite uncomfortable and bothersome leads to a lot of trouble with dry eyes um in these instances will tighten the lower eyelid put it back into a normal position uh to uh treat the symptoms I've seen a lot of Elders too or the lids turn in mhm and so some more uh that's very helpful in that area too so let's go let's put a preventive hat on a little bit one of the questions is prevention of glaucoma cataracts macular de Generations tips for protecting eyes any one of you I I guess I can go so basically I I tell patients the biggest thing you can do is eat a good healthy diet um eat your green leafy vegetables your or basically the fruits and vegetables if you if you smoke quit if you don't smoke don't start um obviously doing doing the routine eye exams will help so that we can identify like we've talked about earlier if we can identify um if we can identify you know glaucoma macular degeneration early enough in the disease we have a pretty good darn darn good chance of presenting significant vision loss later on um a lot of times vitamins are always asked and um what I talk to patients if you're eating a good healthy diet and you don't have any eye issues at all keep eating a good healthy diet that's the best thing you can do if um if you don't a good multi just a regular multivitamin would be a good idea there's a lot of discussion about the specific I vitamins for macular degeneration I tend not to put patients on it unless if they me meet the certain criteria based on the studies I agree and I I like to say that uh for for macular degeneration in particular it's it's kind of handy because the the risk factors that are modifiable parallel those very closely of those for heart disease so smoking uh hypertension high cholesterol and body mass index are all independent risk factors for macular degeneration you can't do very much about your age or your family history which are the other risk factors for macular degeneration glaucoma not very much preventive you can do although there's there's some thought that kind of you know staying fit and healthy and and kind of maintaining cardiovascular health might be somewhat protective against glaucoma that's more theoretical never been proven in uh yeah same with cataracts I don't know of any real strong uh recommendations in terms of preventing cataracts other than don't live long enough which we don't recommend can you have can you have cataract can you can you be put to sleep for cataract surgery now usually you kind of put us out having been there uh but so you you can um it would take a special case because the risk of having general anesthesia is much higher than than IV sedation so the large majority of what we do is IV sedation um and some people need a little more some people need a little bit less um in the right patient in the right situation general anesthesia may be required or can be done where does a fluid come from or travel to when a person cries or has Lac lacrimation uh tears where does that come from I don't think we covered that we talked about it but Todd sure so now primary areas are lacrimal gland um which is located underneath the uh upper eyelid um this often uh comes into play with reflex turine which we talked about with the dry eye symptoms um that's why counterintuitively we get tearing when our eyes dry out it's kind of our eyes last Stitch effort to try to moisturize itself when it's dry what causes floaters after um cataract surgery uh and I know you do some laser work sometimes times afterwards so whoever wants a Jo up I'll talk about that I one Theory I have is about floats becoming more prominent after cataract surges now all of a sudden patient can see them a lot better uh I know in many cases those floaters you know I can document that or I can look back through my notes and I can say okay I saw this person's floaters before I took their cataract out I took them out and all of a sudden they really notice them so that's that's at least some of it um but I think there probably is a subset of people in whom that natural aging process that I talked about where whereby the vitus and the retina become separated from each other I think there's a a certain percentage of people in whom that process happens at or around the time of cataract surgery quick answer is there difference between eye drops with and without preservatives yes one has preservatives and one doesn't but you know if people are some people not to be uh uh uh TR but uh some people are uh sensitive to preservatives for most people that are not taking eye drops more than about four times a day uh they'll do just fine with preserved eye drops very good thank you all great job I want to thank our panelists Dr Charlie arens Dr Todd Brittain Dr Joe morouse and our medical student volunteers Henry Larsson Conor molich and Joe Miller this is our final program for the season our thanks to all the Physicians Mental Health Specialists phone volunteers and others who have been with us throughout this season of doctors on call we' hope that you've enjoyed these programs also want to thank Linda liskowitz for all of the work that she's put in to make sure this happens thank you and good [Music] night [Music]