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Glaucoma Research Foundation presented this webinar recorded on April 2, 2020 featuring a discussion with ophthalmologist and glaucoma specialist Terri Pickering, MD with President and CEO of the Glaucoma Research Foundation, Thomas Brunner.
Tom Brunner: Good afternoon. My name is Tom Brunner and I am the president and CEO of the Glaucoma Research Foundation. Welcome to our webinar on tips for glaucoma patients during COVID-19. Today we'll be addressing some of the concerns expressed by glaucoma patients during these extraordinary times. We hope our answers will go some way toward answering your questions and helping reduce the stress and discomfort we all feel.
Now, it's really my pleasure to welcome Dr. Terri Pickering, who has kindly joined us today to answer your questions. Terri is a graduate from Harvard. She is a glaucoma specialist at Glaucoma Center in San Francisco. She went on to do her ophthalmology residency at the University of California in San Francisco. And after finishing her fellowship at the USC-Doheny Eye Institute in Los Angeles, moved back to San Francisco. And we're just delighted to have her with us here today.
Dr. Terri Pickering: Oh, thank you, Tom, it's my honor to join you here for this webinar.
Tom Brunner: Well, I know it's going to be helpful to a lot of people. So let's start right in. And the first question we have is one that's been on a lot of people's minds: how do we deal with the anxiety and stress that we all have right now?
What I'm doing is just taking a deep breath and trying to relax a little bit. And, importantly, stay informed, but not too informed. Don't let yourself get inundated with too much news. Set a certain amount of time aside to catch up. But there's a lot of news that can be kind of unsettling. And I think minimizing that can help. And maintain your regular routine. All of us are doing a new thing here, working from home or sheltering at home.
So, try to keep to your regular routine, get up the regular time, have regular activities, and that can also help to keep you calm. And meditation is something that you may be already doing or you might try; and there are websites that you can find with some techniques that might be helpful. And what my wife and I do is, we go out every day for a nice walk anywhere from a half an hour to an hour and it's great to enjoy nature and get some exercise. So I encourage that as well.
Now, we do have another question for you here. And this question is: has your doctor's appointment recently been canceled? And that is a question that we hear a lot, and we will discuss that in just a moment. But we thought we'd find out what the trend is from our participants.
Dr. Terri Pickering: Another great point, Tom, about managing stress and anxiety is, even though we have to physically distance ourselves from each other, we do need to maintain social connections. So reaching out to our friends, even colleagues, phone calls, social media, texting. It helps us to stay connected and remember that we're not all alone that we're not isolated.
Tom Brunner: Yeah, very important point. That's interesting… almost half of the participants have had an appointment cancel. So that leads us right to the first question, Terri, that I'd like to ask you, which is, what should a patient do in terms of either canceling or postponement of a regular doctor’s appointment?
Dr. Terri Pickering: The key word in this question is “regular” doctor's visit, and so the answer is yes… if it is a regular routine appointment, in a stable patient, you should expect that your appointment will be canceled or postponed. These are guidelines being issued by the CDC and the Surgeon General to reduce crowding and reduce exposure to COVID-19. However, if you are unstable, or you have new, unusual symptoms that have developed recently, such as changes in your vision, you feel the vision floaters, flashes, any eye pain, headache, red eye and anything unusual or new. Or if you have concerns that your glaucoma is unstable, you definitely want to call your doctor's office to make sure that a delay or postponement of your visit is appropriate for you. The bottom line is if you have concerns or questions, absolutely reach out to your physician's office. Although many of us are on reduced or limited hours, we will have someone check messages and we'll be able to return your call.
Tom Brunner: If I do have to go in, how can I ensure that my visit will not expose me or others to the virus? What can I do to be sure if it's required that I go in?
Dr. Terri Pickering: That's a great question. I think it's important to call your doctor's office to see what safety precautions that they may be taking. For example, some practices maybe reconfiguring their examination schedules and their waiting rooms to reinforce physical distancing. They may also want you to wait in your car until it's time for you to come in for your appointment. So make sure that you have a mobile phone with you, in case your doctor needs to contact you to tell me when it's appropriate to approach the office. You may be asked screening questions as well. And some physicians are taking extra precautions. We do what we routinely do for hygiene, we are washing our hands more frequently. We're also wearing masks. The issue of masks… some patients may come in with their own masks. If you want to wear a mask, that's fine. But the other key factor here is that you also want to call your primary physician, your primary care practitioner to see if there's any particular steps that you need to take given your own pre-existing conditions before you go anywhere for a visit to any doctor's office.
Tom Brunner: I think that's an important point, Terri, because certainly one of the things you see is that the people that have the greatest impact of the virus are those who have other medical conditions. So I think that is a very important point to check with your primary care doctor to make sure that it's okay for you to go in.
Dr. Terri Pickering: Absolutely.
Tom Brunner: What about urgent care?
Dr. Terri Pickering: Urgent care… if you're concerned that you may need urgent care, depending on the nature of the concern, your doctor will decide if you should come in during the shelter-in-place or if it should be immediately after the shelter-in-place is lifted. Or, most practices are covered by an on-call physician who can also give you further guidance.
Tom Brunner: Now, what about elective surgery?
Dr. Terri Pickering: Elective surgery is that which is not considered urgent or an emergency surgery. If it is elective, yes, it should be postponed. Again, this is in accordance with the Surgeon General, the American College of Physicians and the CDC. And the reason is that we want to avoid unnecessary exposure of patients, of course, to the coronavirus. We also want to avoid unnecessary exposure of any surgery center to the coronavirus that may be brought in by a patient (unwittingly of course), or a family member, or even some of the vendors, and so on, that we need to come into the center to do routine maintenance and bring in supplies. So, again, it's this concept of physical distancing. The other key is that if the center or operating room is exposed to coronavirus, it may be put on hold for deep cleaning. And that would delay access, if there's an emergency, to our ventilators. So this is a crucial, vital resource at this time. And we need to keep our ventilators pristine in case they're called into emergency use to save lives. We also need to preserve any spare supplies and the personal protective equipment and hospital beds. And again, the ventilators for people, now that we know that there's a surge in cases coming.
Tom Brunner: So, Terri, the next question that has also come up is: what about pink eye or conjunctivitis? Is that caused by the virus or can it be a problem? And also, what about antibiotic drops for that?
Dr. Terri Pickering: This is a great question because it is true [that] coronavirus can cause pink eye or conjunctivitis. The reports on incidents, however, are conflicting. Basically, some data states that the rate is between 1% and 3% of patients will have pink eye or conjunctivitis. However, a recent anecdotal report from a nurse said that the vast majority of the patients that she saw had pink eye. Now some describe it as a routine regular pink eye, others describe it as the eye itself being white, the eyeball being white, but the eyelids the area around the eye -- the lids were pink and not the eye itself. Regardless, it is possible that you can develop pink eye with coronavirus as you can, frankly, with any viral infection.
The second question, should you ask your doctor to call in antibiotic eyedrops? If you have coronavirus or you suspect coronavirus, your first avenue of contact should be your primary care doctor. You want to call them and they'll be able to guide your management from there. But in general, we do not prescribe antibiotic eyedrops for viral conjunctivitis because the antibiotics treat bacterial conjunctivitis. Now, there are antiviral eyedrops, but they are not for coronavirus. Unfortunately, we don't have any specific eye treatments for the pink eye caused by coronavirus at this time.
Tom Brunner: And I think there's also a question about the discharge that might be from an infected eye.
Dr. Terri Pickering: That's right. So, again, like any virus that can spread by touching, discharge, or tears from an infected person's eye, the eye, the mouth, the nose, any mucous membrane, respiratory droplets can spread, unfortunately, the coronavirus. So you want to, if you do have pink eye, this is time to really practice physical distancing. You want to wash your bed clothes frequently, wash your hands before and after instilling any eyedrops, if you are using glaucoma drops, and maintain strict hygiene precautions if you have other people in your home.
Tom Brunner: And I guess this just reinforces one of the rules about not touching your eyes or face. And washing your hands, and isolation and social distancing. There's really not touching your face or rubbing your eyes, and that's hard.
Dr. Terri Pickering: One of the questions [from a webinar participant] is: do children present with the same red eye symptoms? I don't know because I only treat adults.
Tom Brunner: Another question for you, and this has been in the press a lot, is the whole issue of using some these malaria medications. Hydroxychloroquine. Are these safe for glaucoma patients, what's the update on that?
Dr. Terri Pickering: Hydroxychloroquine is Plaquenil. It's been around for many, many years. It's typically used for patients with what we would consider autoimmune disease such as lupus, or some types of arthritis. So it has been around for years it has been used concurrently with patients who already have glaucoma. And in routine doses for those sorts of treatments, there has been no association or contrary indication for patients with glaucoma. The problem is that we don't have sufficient data right now to know what the impact is of the dosing that would be used to treat COVID-19. Because this would be a different dosing regimen. It would be a high dose, but for a short-term period. and we have no data in terms of knowing how that might impact glaucoma patients or eye pressure. But at low dose for longer term, kind of the opposite case, there has been no impact on glaucoma specifically. It does have the potential to cause what is called a retinal toxicity and damage to the retina, which is why we do monitor patients on Plaquenil. But again, we do not know if this is also true for a high dose short term period of treatment.
Tom Brunner: So again, [this is] perhaps a good question for both your primary care doctor or your glaucoma specialist if you're thinking at all of that.
Dr. Terri Pickering: My understanding is that this treatment should only be used for patients who are quite ill. So at this point, I think it's a matter of weighing the risks and benefits.
Tom Brunner: So, the next question is about: what can I do to protect my eyes?
Dr. Terri Pickering: This is a great question and there's actually a lot that we can do, that all of us can do to protect our eyes. One of the simplest things to do is to try to switch from contact lenses to glasses at this time. Many of us are at home or even working from home, so it might be easier to just wear glasses instead of contacts. Now of course, some patients because of their particular prescription, may not be able to do so, but if you can, this is a good idea. You want to disinfect your eyeglasses, you can wash eyeglasses with soap and water. You also want to avoid rubbing your eyes. This comes back to just our basic routine. Try not to touch your face, your mouth, your nose and your eyes. And you always, always want to wash your hands with soap and water for at least 20 seconds before and after touching your eyes or instilling any eyedrops. Especially if you need to use routine moisturizing eyedrops for patients who have dry eyes.
Dr. Terri Pickering: If you're working on a computer all day, whether at home or at work… Now, most of us at home, many people are still working on their computers from home. Remember the 20-20-20 rule. Basically every 20 minutes of computer work, you want to look away for 20 seconds and try to look away for at least a 20-foot distance, or out a window. And that helps reduce eye strain.
Tom Brunner: That's another one that's hard to follow, right?
Dr. Terri Pickering: One of the questions [from a webinar participant] is, should I wear safety goggles? I'm not certain. I would imagine that safety goggles would be useful for people who are healthcare providers who may be exposed to more airborne droplets. Or if you're caring for someone who is under suspicion for or diagnosed with COVID-19. But again, in that instance, you would want to contact your primary care provider to see what they recommend for protection and prevention of transmission.
Tom Brunner: Okay, I think we have another [polling] question for our participants. Do you have your doctor's contact information on you at all times? In your wallet or in your pocketbook or on your iPhone? [It will be] interesting to see how many of us do that. And then Terri, you could explain the importance of it when we see the results here.
Dr. Terri Pickering: Absolutely. I think it is important to keep a list of all your doctors.
Tom Brunner: Not just your ophthalmologist, but all the physicians?
Dr. Terri Pickering: All the physicians. Yes.
Tom Brunner: And I think you said also… all the medications that you take. Again, if you end up, even if it's not COVID-19, if you're in a car accident for example, and you end up at the hospital…
Dr. Terri Pickering: If you have to go to the emergency room, yeah. It's good to have it in your phone… But for security, many of us may password protect our phones. So you rightly pointed out, Tom made a good point… In case of emergency, you may want to just write the information down on an index card and tuck it in your wallet someplace so they can have a physical view of it. You may not be able to verbally relay the information.
Tom Brunner: Good point. And what about extra medications? This question comes up quite a bit. Especially with this new emergency situation. And I guess some people have difficulty with the way the medications are used and how the insurance policies are. Could you comment about the need for extra medications and what people can do?
Dr. Terri Pickering: Absolutely. I think it's always good to keep an extra supply of medications in the event of an emergency. In fact at the beginning of the COVID-19 shelter in place, one of the recommendations was to get extra prescription medications. Make sure prescriptions are up to date to avoid having to make trips back and forth to the pharmacy. But also, in case medications run out, it's always a good idea to have a little extra supply. For example, if you're fortunate to get a sample of your eyedrops from your doctor, I always tell patients put this aside or save it. But always keep up and maintain your regular refill schedule so that you do have extra. And then also, should you be hospitalized at any point, you should call or have a friend or family member call your ophthalmologist as soon as possible so [your eye doctor’s office] can order your medication.
The primary care doctors may not be familiar with eyedrops for glaucoma, frankly. And so it's always good for [your eye doctor] to be able to communicate with your doctor while you're in the hospital or with the charge nurse. And as we mentioned, keep a list of all your medications and your list of all your doctors and their phone numbers with you. Once you leave the hospital try to start a fresh bottle of eyedrops once you get home to reduce any potential contamination. One of the tricky things about being in the hospital, even before the COVID-19 emergency, is you may take your medications with you. I think it's a good idea. But you may need to get special permission to use any medication that you bring from home. So just be prepared for that. And the hospitals may outright decline it, so again, just contact [your eye doctor] right away so [they] can sort it out for you, and if necessary, call in what you need to the hospital formulary.
Tom Brunner: Yeah, that's certainly another important point. Staying in touch with your doctor, I think is a really important message here so that [your doctor] knows what's happening.
Another question for you, Terri, is: how can people get their meds if their insurance doesn't allow a refill? Any comments on that?
Dr. Terri Pickering: This is a very good question, and it's real life, it's tricky as well. Unfortunately, it is difficult to get refills before the appropriate date. However, double check with your pharmacy or call your ophthalmologist -- call your eye doctor -- and [your eye doctor] can try to intervene on your behalf. There are certain things that [your eye doctor] can try to do. Again, [your eye doctor] may be able to provide you with a sample, or, be able to provide you with an alternative [medication] in the same class. That's not always the case. Some medications are the only one available in their class. But there may be an option that you can use almost as, I guess I could call it, a stopgap measure, until it is time for you to refill your prescription. The insurance companies are really tightening down and being very strict about the refill dates, unfortunately. The other thing that you can do might be worthwhile… this is just an aside… is to check goodrx.com to make sure that you're getting the lowest price for your medications in your area.
Tom Brunner: Yeah, I did that recently. And I was surprised to see the variation in pricing.
Dr. Terri Pickering: [One of our webinar participants has commented]… “I can't leave my house right now.” For patients who can't leave their homes because they're at very high risk, whether due to age or other preexisting medical conditions, many pharmacies now deliver. And I believe many of them deliver for free. I think CVS and Walgreens deliver for free. I think Safeway might, so call around [to find out]. I think a lot of the pharmacies are kind of stepping up to try to help people. Costco, I just heard on the news a night or two ago, is now having certain days, certain hours, for seniors and those with preexisting health conditions to come in and that... During those hours, the pharmacies open as well at Costco. So again, the key is to plan ahead so that you have a plan in place for when you do need to get a refill.
Tom Brunner: That's something to think of not just here in the current crisis but generally, because you never know when you might have some inability to get medications and having an extra bottle can be very useful.
Now, one of the other questions that has come up during this pandemic is, what about the research that is going on that Glaucoma Research Foundation funds, and how are these people doing during this period? And also, just in general, what about the research? I just want to assure those of you who are following our work that is ongoing, just as our team are all working from home and continuing to work on our activities, also the scientists are working as best they can and using technology, Zoom and [other] communication by computer, working from home. But also where it's essential, spending time in the lab to continue this critical research.
One of the programs on vision restoration, which people have asked about, they are making some good progress and they're actually investigating [how] to restore vision, how to put new cells back into the eye that can then integrate back into the retina and even grow a new connection back to the brain to actually restore vision. So it's some very exciting work and some amazing, very new technology that is making some of these ideas possible, and something that we're very optimistic that we will see not only technology that can actually restore vision, but better ways to preserve vision, to protect the retinal nerve cells that we all already have. So that work is continuing and we are very focused on that and look forward to being able to pursue it full time after this period here, that we're just in a slowdown right now with the isolation rules and the social distancing, which makes it a little challenging. But nonetheless, as I said, the work is continuing.
Dr. Terri Pickering: Thank you, Tom. So there are a couple of questions that have come through [from webinar participants]. One is: if I don't have enough medications, and can’t get my prescription filled, can I skip some times when I put my drops in. And the answer, unfortunately, is no. The dosing schedule for your eyedrops is timed based on the time that the medication wears off. So if you skip a dose, your eye pressure will start to rise again. So this is an important fact to realize, and you need to contact your physician's office again; if they're on limited hours, leave a message. And they'll either call you back if you need medication, or you can contact their on-call coverage.
Another question is, how long can I use my eye medication without contamination? As long as you're the only one using the bottle, and as long as you're following proper hygiene, washing your hands before and after, you use your eye medication as you normally would, which is basically until it runs out.
Another question I saw previously was, why would you stop using contacts and switch to glasses. That's just to reduce the amount of the time that you have to spend touching your eyes… to reduce the risk of you contaminating your eyes by putting in the contact lenses and touching your eyes frequently.
Another question was, if patients have recent fluctuation and need to get their eye pressure checked frequently, perhaps twice a week, would it be a good idea to purchase a tonometer, such as a... well, they're basically over-the-counter tonometers. The problem with the over-the-counter tonometers that are available to the public is that, at this time, the accuracy is not... they're just not that reliable. They can read falsely high or falsely low, which can give you a false sense of security or a false sense of alarm. So, again, reach out to your physician and see if they can come up with a plan or some alternate suggestion for you.
Another question is: how often should I disinfect my eyeglasses? And what should I disinfect with? For the eye glasses themselves I would just say soap and water and then dry them with a clean cloth. A soft T-shirt or one of the lens cloths that comes with your glasses when they're given to you by the optometrist would be ideal. I would not disinfect with any commercial grade disinfectants or anything that has solvents because that will strip the coating and can strip out of the metal or plastic of the frame. Soap and water, with rubbing. Just normal rubbing as [you] would wash your hands.
Tom Brunner: Another question is about telemedicine. And clearly that is playing a major role now, Terri, as you and other ophthalmologists… if a patient feels they need to come in, the first approach is a telephone conference, right? To see you have certain questions for them about possible exposure and what are the symptoms and that sort of thing. I think we're already starting to use more telemedicine to determine who has the need to actually come into the office versus who could be postponed. And I certainly think we're going to see more of that, and there's more instrumentation. There are more accurate home tonometers coming along. There are actually home perimeters even. There are even programs that you can run on an iPad. So there's no doubt that we'll be, I think we're going to see, one of the good results that will come out of all of these changes that are going on right now will be increased utilization of telemedicine, not just in ophthalmology, but in all forms of medical practice, which will be much more convenient for patients and for the medical community and I think will be an important advance.
Dr. Terri Pickering: I agree, Tom, I think it will become more common, both now and also in the future even after the public health emergency is over.
Tom Brunner: There was a comment that about the iCare home tonometer for measuring eye pressure, and that is FDA cleared with certain specific indications on how it's used.
Dr. Terri Pickering: Right. It is. We don't really endorse any products at our practice. Because even with that device there's a learning curve and there can be... how shall I put it… it can be somewhat unreliable in the measurements. There's also, with any and all of these devices, a bit of a financial and access barrier as well. So in the future, I'm hoping that there is a simpler, easier device and also one that is more reasonable [cost] for patients. I think that's a great idea frankly. We're just not there as of yet. But I think that we will be there soon.
Tom Brunner: I think it's going to be a lot more incentive for companies to develop less expensive and more user-friendly devices.
Dr. Terri Pickering: Right. Another question was: should our eyedropper bottles be sanitized? Again, if you are following good hygiene using your bottle just for you keeping it in a cool dry clean place, there's no need to do extra sanitization above-and-beyond, unless you think someone in your household has been exposed to COVID-19 and has somehow contaminated it. In which case, you would wash it with soap and water. It is plastic on the outside so you could I suppose use a sanitizing wipe or other solution, but you do not want to put anything involving a commercial solvent on the bottle tip itself. You do not want to introduce that into your eyes. So if you think the tip of the bottle is contaminated, again by some unforeseen, unusual reason, then you would probably want to discard that bottle. I can't think of any way that would be safe to sanitize the bottle tip itself if it had been contaminated by someone either diagnosed with or suspected of having COVID-19.
Another question is: I have a lot of dry eyes, what should I do? How often should I place drops in my eyes? It depends on the individual patient's case. I would refer you to your routine physician because they're more familiar with your care. Dry eyes can be treated with a variety of different treatments. So again, depending on where you are in the course of your condition and what treatment you've tried in the past, there may be some alternatives. And so, this is very specific. If you want to know how often you should put drops into your eyes that you would have to speak to your own personal physician about it, or your own personal ophthalmologist.
Tom Brunner: I guess, Terri, paying attention to dry eye is probably important because again, we're trying to avoid touching and rubbing our eyes. Your glaucoma meds are clearly the most important but dealing with dry eye can be important too. And, again, just to make sure that we avoid touching our eyes.
Dr. Terri Pickering: And there are many other techniques for caring for dry eyes. And one that we often overlook is controlling the environment. So like you Tom, I have also been working at home and doing a lot of work on my computer and so on. And also preparing for this webinar. And I discovered that my eyes were getting very dry and I thought, well, this is odd. I don't really have dry eyes. And then I realized that in my home, I was sitting directly in front of the heating vent. Without doing it on purpose... that just happened to be where I sat down. And the minute I realized that, I was able to move. I was able to be more conscious of following the 20-20-20 rule. You can look outside the window for 20 seconds, but you can also blink or simply close your eyes to stimulate tears, redistribute tears. And remembering to blink frequently when we're on the computer is important as well.
Simple twists like that can make a big difference. So again, for each individual, you have to know where you are in the course of the disease the severity of the disease, what has worked for you in the past what you've tried in the past. So you do want to reach out to your ophthalmologist.
Another question, is are patients at more risk if they have eye implants? And the answer is no. They are not at more risk if they have eye implants of either getting COVID-19 or getting the conjunctivitis. So the risk for patients with implants is if they should get a bacterial conjunctivitis, not a viral conjunctivitis. Just the mere fact of having an implant does not put you at higher risk for getting either type of conjunctivitis. So the simple answer is no.
Another question is, should I avoid punctal occlusion? You don't have to if you wash your hands before and after, like I said, for at least 20 seconds. You can also if you like, use a clean, fresh tissue over your fingertips, if you're concerned, while you do your punctal occlusion. The key is you just want to follow very strict hygiene precautions. And have a consult over the phone with your primary care provider if there's someone in the home who is ill with COVID-19 or suspected of COVID-19. That raises the bar of how you want to take care of yourself.
Tom Brunner: Terri, I just want to say thank you very much for making time be with us today. I think we've answered almost all the questions that have come through. I hope this has been helpful to our participants. And not only you, we want to thank you, but we certainly want to thank the healthcare workers, like you and many others who are on the front lines really working to keep each and every one of us safe. We can't be thankful and grateful enough for their selfless efforts to care for those who actually have COVID-19 and at the same time, taking care of those who have urgent needs. I want to say that at Glaucoma Research Foundation, we really remain committed to our glaucoma patients, even as we deal with this national emergency. And we really are working hard to continue our work, continuing our research. And to continue our mission to restore vision and cure glaucoma, and provide information and education about glaucoma.
Our goal of a world that is free of glaucoma is really uppermost in our minds, even as we all deal with the necessary precautions to preserve our vision in the near term. So, do take your health and vision seriously. And, working together will overcome the current pandemic, and will advance research to cure glaucoma and restore vision.
Dr. Terri Pickering: Thank you very much, Tom. I really appreciate all the hard work that you and the Glaucoma Research Foundation do to help support our patients and education and fundraising and your search for a cure. And I'd like to say that in our practice, it's an honor to partner with Glaucoma Research Foundation and it is an honor and pleasure, of course, to care for our patients. Thank you very much for this opportunity.
Tom Brunner: Well, thank you, Terri. And I also want to remind our participants to please visit our website at www.glaucoma.org. We'll have updates on both the COVID-19 as well as our research and other information of importance to glaucoma patients. At the top of the screen, you'll see a search box [on our website]. I really encourage you to use that because there is a huge amount of information on almost every topic, almost any question you might have. By using the search box you'll find a lot of useful information. And there are also other resources available about the coronavirus and its impact. I encourage you to visit the American Academy of Ophthalmology website and also the Centers for Disease Control and Prevention, which have regular updates to their websites. So with that, I'd like to just add my personal thanks, again to Terri and to all of you who have taken your time to join us and certainly for your ongoing interest and support of the Glaucoma Research Foundation. So please, stay home, stay safe, and stay healthy, and we look forward to seeing you again in the future.
Dr. Terri Pickering: Thank you very much, Tom.
Last reviewed on May 28, 2020