During this live surgery event, we present a small lecture on the risks, benefits, and indications for vitrectomy surgery in patients with proliferative diabetic retinopathy. This is followed by a live surgery in a case of proliferative diabetic retinopathy, with audio explanation from the surgeon of step by step maneuvers to achieve the best outcomes and minimize complications. We also field questions online from those observing both during and at conclusion of the surgery.
Surgeon/lecturer: Dr. David Miller, vitreoretinal surgeon at Retina Associates of Cleveland, USA.
>> Yep, we can hear you fine.
DR MILLER: Okay. We’re good? And Dan, as those chat questions come up, you can just… If there’s a pause in my conversation, you can just say: Here’s a question for you. And we’ll try and answer a few here and there. All right. So… Look at that. All right. Can you lower the table a little bit for me? You stay where you’re at. You don’t have to move at all. Keep going. Keep going. Keep going. So part of getting ready for any surgery is getting yourself in a comfortable position. The head down too. The eyes are a little bit… There you go. So part of it is getting in a comfortable position. I like to do every case at about the same height. Which is probably low for me, but… Or low compared to others. I like the bottle height, and so on, at a certain location. To make sure the infusion pressure into the eye is being constant, case to case. So we blocked the eye. We gave her a retrobulbar. She still has some eye movement here. Go ahead and look to the right for me, Mary. Okay. Look to the left. There you go. Look down. There you go. A little bit of movement. Look straight ahead. That’s fine. We can probably work through that. So the first thing is the sclerotomy placements. We’re doing a 25-gauge vitrectomy today. And on the back of the trocar there’s a scale. 3 millimeters here to here, and 3.5 is right there. She’s pseudophakic. I prefer 3. We’ll measure this off the limbus. Is this painful at all, Mary? Check for anesthesia. A little pinch? We’ll see. Sometimes we’ll supplement the block during the case. Make a little indentation here. The measure. We’ll displace the conjunctiva. And we’ll go in fairly flat. Maybe 30 degrees. And I don’t tend to elevate up. I just go straight in. The cannula ends up pointing a little bit back towards me. So trying to make a longer wound. Longer wound tract for easier closure. Again, I’m gonna use 3 millimeters. Now, I like to put these at 3 millimeters posterior to the limbus, at about the 3 and 9 o’clock position. Why is that? It gives us greater range of motion inside the eye. And again, a nice long beveled wound tract is the best. Here’s… I guess it was actually a 4, not 3.5. So it’s 3 on one side and 4 on the other. I’m using the first mark again. So it may be just above the horizontal. But more or less 3 and 9 o’clock. And again, I’ll make my wound nice and flat. And you’ll see how these cannulas are kind of pointed towards me, not straight up at the ceiling. We’re gonna pull off the veil there for the infusion cannula. Again, you can see how this is going pretty smoothly, mainly because of Jenny here on my right. If your case isn’t quite as smooth, or a little more stop and start than this, don’t be discouraged by that. We’ve been doing lots and lots of cases. I think today we’re doing nine or ten. And so experience really makes up the difference there, and again, having an assistant who can anticipate all the moves, and has done thousands of cases with you, is a huge advantage. So we’ve got the cannulas in. They’re veiled. We’ve got the Goniosol on the cornea. It’s lubricated. Or you can use a viscoelastic. Pseudophakic patient. Light pipe in my right hand. I’m sitting at 12:00. Vitrector in my left. And we often check for the infusion cannula in the eye, and it’s there. I don’t think you can see that at the scope. I tend to look… Maybe I can get that in the view. There it is. A little bit of metal glint there. We’re in the eye. Infusion is turned on. And we’re gonna zoom in for you guys. Okay. I’m gonna come down. But you focus first. We’re gonna focus our eyeballs. There we go. I’ll try and zoom in more to make the screen image better for you. The first thing I like to tell people, doing a vitrectomy, any vitrectomy, is just to hold the instruments still. So when you get in the eye, try and see your cutter port before you hit go. And kind of hold it behind the lens. In this case, it’s an artificial lens. Or the real lens. But try to get yourself in the midvitreous or anterior vitreous, and kind of just hold still. You don’t want to chase the vitreous around. You want to let it come to you. So little movements go a long way. Very subtle. Very patient. And you can see the vitreous hemorrhage is clearing very nicely. Old hemorrhage here down below. And we tend to take the port and keep it pointed away from the retina. It’s always safer. So instead of putting the cutter port this way, driving the towards the retinal surface, we kind of keep it this way. It’s always a little safer. Got a little air bubble there. We’ll get that out. Okay. I continue to take out this hemorrhage. Now, where do we start in a diabetic case, if we’re looking at a case of tractional retinal detachment and posterior vitreous separation needs to be created? We’ll tend to start in the periphery, kind of severing all the anterior and the posterior traction first. So we’re gonna work in the periphery, and work our way towards the center, actually. In this case, there already is a posterior vitreous separation, so it’s gonna be a little easier. Now, that’s something that can be evaluated and checked on the ultrasound. Prior to surgery. You doing okay there, Mary? We all right? Okay. Just be quiet. I’m kind of just talking to the audience here a little bit. If you’re having any discomfort, just let us know. Okay? And so we kind of start in the periphery, working out this vitreous hemorrhage. And the posterior — and the anterior vitreous, I guess. Posterior hyaloid. We want to make sure it’s not attached in the back. So I would always recommend severing all the anterior and the posterior traction first. And then working on the… Let’s see if we can get that focused a little bit better. There we go. There we go. So here’s the optic nerve, of course. Here’s the macula, looking a little beat up, with some RPE changes. She had some subretinal hemorrhage here, is what happened. Looks like she has a ruptured aneurysm. Or something right along the superior temporal arcade. It’s white. Sclerotic here. Rupture site is right there. Subretinal hemorrhage going out from here all the way out. It’s old. Down to here, and over. And it looks like the aneurysm was right there, and it’s probably involuted. So that is something you will see in diabetics. And really, it looks like it was probably a big component of the cause of her vitreous hemorrhage. And in fact, this eye looks like it has less retinopathy than the fellow eye. So we’re just looking around. We’re gonna move on to the endo laser here in a moment. Sometimes what we’ll do is, because we know the blood’s been here so chronically, and a lot of it was white, it may cause some post-op pressure problems. You’ve got a scleral depressor? We’re gonna take out that inferior vitreous base. Sometimes what we do is take a little bit of blood out of the vitreous base, where it settles inferior. This is not a necessity. It’s just something we find to be a little useful, a little bit more advanced move, frankly. Jenny is scleral depressing the inferior retina and vitreous base expertly for me, and we’re gonna take some of the blood out of this area, with the idea being that she’ll have to clear less on her own, postoperatively. I would not recommend this as a starter move, for anyone who’s new to the procedure. But for those who are advancing their skills, it can be pretty helpful to kind of trim some of this up. The threat being, of course, that you could damage the retina or cause a retinal tear down here, which would be much more difficult to fix. You don’t have to get all of it, again. You’ve just got to get — the more you get, probably the less problems you’re gonna have, in terms of eye pressure. You can see how thick it is. Now we’re doing this under low aspiration here. We’re not doing this aggressively. We’re just trying to get… Come up a little bit more anterior. Yeah. There you go. The view may be a little obscured here on the screen. I apologize for that. Sometimes these things way out in the periphery get a little odd. That’s fine. You can come out. So now we’re gonna move on to the endo laser. And the goal of the endo laser is to treat underlying pathology, ischemia, just like panretinal photocoagulation in the office or anti-VEGF injections, to lower the VEGF load. This is a directional laser probe. So by sliding the shaft of the fiber optic out, it will bend. It’s already got a precurve in it. So that’s kind of nice. I find that to be a very nice instrument. We’re gonna use that. Let me find the foot pedal. All good. Here’s my laser spot. It’s nice and round. We’ll put a few spots in, to try to get the take power right. We’ll try and turn it up. Another 100 would be fine. Thank you, Christine. And you can see the white burns showing up. They don’t have to all be exact. They don’t have to all be perfectly spaced or centered. The goal is truly just panretinal photocoagulation, which is just a destructive procedure. I don’t think we have to put it in too hard or too complete in her eye. Sometimes you’ll see the entire retina obliterated from panretinal photocoagulation cases. But at the same time, not to put it in really opens you up to more difficult proliferative diabetic retinopathy. If you do a case and don’t put laser in, quite often the neovascularization will not have the vitreous structure to go up into, so you won’t see it, and then it shows up on the iris or up on the ciliary body. And at that point, it’s very difficult to treat. You know, neovascular glaucoma. So I think you’re always better off putting in PRP at the time of surgery if at all possible. Even if the proliferative diabetic retinopathy is mild. And again, this patient’s had multiple anti-VEGF injections before she came to me. Including mine. So that’s part of the reason why we’re not seeing a lot of active neovascularization in this case. We may take out a little more of that peripheral hemorrhage. The ruptured aneurysm down here can be treated with laser. But I think it’s pretty well involuted. We’re probably just gonna leave it alone and not create a problem. And that blood all looks pretty old. Right? There’s your aneurysm. We’ll switch hands here so I can reach the other side more easily. It does help in any vitrectomy techniques to be able to use the left hand and switch back and forth. I would encourage everyone to work with that. Certainly the easiest instrument to drive around is the vitrector itself. More so than the laser probe. But it can be very handy for all kinds of cases. Especially when you get into retinal detachments and more severe tractional detachments. Now, sometimes, if the block is a little inadequate — she just mentioned a little discomfort there — we can supplement the block. That may not be a bad thing to show. Let’s show that. You’ve got some lidocaine on a cannula? And some scissors? So she’s having a little discomfort with the PRP here. And we saw her eye movement. So we know the block was not ideal. And so what we’re gonna do is make a little cut down here in the conjunctiva, and supplement the block. So I got a pair of forceps here. We’re gonna pinch the conjunctiva in the inferior temporal quadrant, Westcott scissors, make a little dissection plane. Ideally onto bare sclera. There we go. Cut through Tenon’s capsule. A little dissection there. Jenny has the block already ready. Jenny from the Block has the block. Before. And we just infuse that right there. Sometimes we’ll cut both sides down, but I think in this case, probably not. Because we only have to laser the temporal quadrant. We’ll be fine. And this we just let go. You see the Tenon’s kind of ballooned up there, and this incision in that quadrant? We don’t have to sew that shut. That’ll close on its own. So you know it’s a one-minute procedure, perhaps. Maybe two. And the patient’s more comfortable. The surgeon’s more comfortable. The nurses are more comfortable. The anesthesiologist is more pleased, if no one’s having discomfort. How is the zoom there? How are we doing on the image? All right. So Dan, any questions that are popping up yet? That’s fine. I remember a couple of the questions from prior… I was looking at this last night. People were asking about diabetic retinopathy, tractional retinal detachment, dissection planes. I always start at the optic nerve. I always start with severing the peripheral vitreous first, like you saw in this case. But then I come down with instruments, including the vitrector, retinal forceps, and picks. And try and get the neovascularization off the nerve first, then work my way out along the arcades. That’s how I establish the plane. And diabetic retinopathy cases like this are a bit… You know. The old jack in a box, I guess, or a box of chocolates. You don’t really know what you’re gonna get until you get the hemorrhage cleared up. Got a nice look from Jenny on that. So you don’t really know what you’re gonna get until you get in there. And I want to take out a little more of that hemorrhage. Go back to the vitrector. All right. And again, we’ll be cautious here, under the aspiration. Not to aspirate too hard until we see what we got. So we’re gonna take out more of this blood. Which lowers our risk of post-op high pressure problems. Blood that’s this old — you get a ghost cell glaucoma. Right? The old — blood cells turn white. They’re no longer very malleable, and they get stuck in the trabecular meshwork very easily. So it’s always kind of nice to remove old blood if you can, as much as you can. And again, the safer way to do this is typically to point the port away from the retina. In my case, I’m kind of pointing it up towards the lens. I’m also just using low aspiration. I don’t have the foot pedal depressed all the way. Let’s switch hands again. Back to my left hand. I tend to always start temporally with the vitrector. Left or right-handed. Doesn’t matter. I think you get more freedom of movement from the temporal port. And so as you develop your opposite hand, it just becomes a habit. And eventually you always start temporally. That’s what the eye wants to give you. And you can see the port right there. That’s coming right through the port, the light pipe, to give you an idea of the anatomy. We’ll take that out. Again, this is… Just gonna lower the amount of blood that’s free floating in the eye. Post-op day one, week one, week two. We can eventually get through that with eye drops, keeping the pressure under control if it’s out of hand, et cetera. But always a little nicer to have to use less eye drops or less complications. Okay. We’re gonna go back to the laser probe, I think. I want to do a little more temporal and superior laser. Where that hemorrhage was blocking me. You can see now with the hemorrhage out of the way that we have several more rows of laser that we can put peripherally. We also know that with the block, the patient is more comfortable and tolerant of this peripheral laser. No more noises there. Very good. Very good. We do avoid the nerve here. Right there. The long ciliary nerve. You put enough PRP in, heavy enough, in the periphery, you will get pupillary dysfunction. Quite often it will come back, but not always very well. So we try not to injure the nerves controlling pupillary function. And we’re almost done here. And of course, what we always do is take a look around with the scleral depressor. Jenny already has it in her hand, again, anticipating my moves. It’s very helpful. Makes things very smooth. And I cannot emphasize enough that if you’re doing vitrectomy surgery and you want to limit your problems, this is probably one of the best places to start, is right here. Scleral depression. So you can see my scleral depressor. Let’s focus that. I’m gonna refocus the device, and you can see very clearly the vitreous base. Ora serrata is right there. Laser marks are probably one disc diameter away from the ora serrata. A little blood in the vitreous base there, faint. We go around the eye, and we check for those tears. The patient may be a little uncomfortable here nasally, but not too bad. We can get through it. Jenny lowered the irrigation, which lowers the pressure in the eye, which makes my depression — lowering the pressure makes my scleral depressor easier to have its effect. Can’t see the peripheral retina in every spot, especially in inferior and under scleral depression, because of the blood. That’s to be expected. And we’ll go to the temporal side again. Switching hands is a complete necessity, if you’re doing a thorough postvitrectomy evaluation. You have to be able to switch hands and scleral depress with the opposite side, and hold the light pipe with the opposite hand too. So that’s about it. So you can see that that’s the conclusion of the case. There’s still some blood zipping around in the eye here. The little cells — you can see them in front of the light pipe. But that’s gonna have to work its way out on its own. Ruptured macular aneurysm that’s on the mend. Subretinal hemorrhage that’s clearing. Typically in a macro aneurysm, we don’t get permanent visual loss from submacular hemorrhage. They can be… At least not severe. Now we’re gonna pull out these cannulas. And I’m gonna kind of pull them out in the way that I came. I don’t pull them out this direction. I pull them out the way I put them in the wound. Because it’ll offset from the conjunctiva. And I’ll tend to press down on the wound a little bit. On the roof — I call it the roof of the wound — to kind of collapse the tunnel that we made. So I’ll hold pressure there for just a few seconds. And then move to the other side and do the same thing. Kind of check with my finger there a little bit. Very good. Those feel good. And then the last one. And again, press down on the roof of that last wound, so it kind of collapses the hole shut. Give it a second. If I don’t like the pressure… A lot of times, I think one of the best tricks is just to wait a minute, maybe even two, sometimes. It seems like an hour, but you want to make sure you’ve got — you see? We’ve got a little bit of a wound leaking. You see? The eye is a little soft because I’m pressing in, right? So we’re gonna take some balanced salt solution and firm up the eye. But we’re also gonna let these wounds collapse a little bit. So time is on your side. Before you run and get stitches and sutures — we very rarely actually sew wounds closed. I don’t think there’s anything wrong with that. It’s just sometimes patients, by the time you get the suture out and cut down and start closing wounds, if you would have waited just another minute or two and refirmed the eye, you would have been fine. Again, we have the BSS all ready. We’re just gonna go through the pars plana, about 3 millimeters back. Always nice to keep the eye not hypotonous, especially in a diabetic, because they tend to bleed easily. Low pressure is gonna make that more likely. So we firm the eye up. Wait a minute. There we go. We’re holding nicely. And so we’ll pull out the lid speculum. And we’re gonna get these drapes off. And get you patched up. Mary, we’re all done. You did great, okay? You’re welcome. You’re welcome. So we will come over and wrap things up, and go through the questions again. Or any other thoughts. So thank you very much for your patience there. We’re about… We’re kind of ahead of schedule. That’s fine. So we’re gonna break back to the questions. We’ll just start there, I think. I guess it’s share, right? Like that? Yeah, right. Oh, there we go. And then the big screen, yep. That’s all right. It doesn’t matter. Because the questions are the same. So… This question was the first one. And I don’t know if Lawrence has people’s responses available to us or not. But what is the possible risk to vitrectomy surgery? The audience did very well with this. The vast majority selected — there it is — all of the above, at 82%. Certainly all those things can happen in vitrectomy surgery, and I’ve seen them all happen. It’s always discouraging to have a complication. My only words of encouragement to you are not to overreact. Keep going. Try to make minor adjustments, not major adjustments, to your technique. If you get a complication that’s recurring multiple times, over the course of weeks or months, yeah, there’s probably something wrong in what you’re doing. So probably best to reassess or asking some colleagues. Next question. Move on to that. What are the best locations — excuse me — just wheeling Mary out of the OR here. Bye, Mary. I’ll see you out there. So what are the best locations? Really 3 and 9 o’clock, about 3 millimeters posterior to the limbus. So the advantage is it gives you more movement of the eye. These instruments are rather flexible. They’re thin and flexible. And if you’re stuck in the superior quadrant or you’re only gonna be in the superior quadrant up high or down at the horizontals — if you’re at the horizontals, you can reach inferior to the lens, the natural lens, as well as superior to the natural lens, just as easily. If you’re a little bit superior, even at 10 and 2, it’s hard to work in the inferior quadrant in a phakic patient. You know, you have to reach across the back of the lens to the peripheral retina. So much more access to more of the retinal space. Peripheral retina at 3 and 9, plus less flexing of the instruments. Less rotation of the eye, on these weak instruments. The other choices were: Too posterior to the limbus, at 5 millimeters, may put you into the retina. So you don’t want to make an iatrogenic break, tear the retina, by going too far from the limbus. So 3 to 4 millimeters is your safe zone. I recommend you stay in there. Next question. What is the best way to prevent post-op retinal detachment? Certainly using a wide field viewing device, as we were using, is very helpful. I was using something called the EIBOS. A more common one is probably called the BIOM. I think they can both work well. They both have advantages and disadvantages. The advantage in mine, that I like, is that there’s no inverting lenses needed within the microscope. So all the inversion devices are done with prisms, and that device is hanging under the microscope, so you don’t have can extra mechanical parts that fail and break down. Ophthalmoscopy with scleral depression is still the most important thing to do, in terms of detecting retinal tears, retinal detachments, at the end of the case. I recommend everyone check with a scleral depressor, with the endoilluminator, at the same time, like I did. If you’re not comfortable with that, you can use indirect ophthalmoscope on your head, and use scleral depression. Low aspiration and vacuum can be nice. You saw me use that technique in the vitreous base, to limit the possibility of peripheral retinal tears. And avoid the vitreous base with the cutter. I was a little bit in the base myself, but generally, that’s a more high risk location to be working. On to the next question. Indications — you saw this covered in the lecture. The audience was very good here, with all of the above at 92%. No trouble. Thank you. And maybe one more question. Oh, that was it. So again, thank you, everyone, for your attention this morning. Again, I appreciate all the help of the people at Cybersight. I did get the cap, Lawrence. Found it here this morning. Thank you. And the staff here too, with the help of these cases. It does truly take a team. If you can work with the same people on these cases all the time, it’s certainly well worth your while to try and invest the effort to do that. Yeah. One of the questions was: Do you inject anti-VEGF? Yeah, absolutely. We kind of covered this a little earlier. Anywhere from one day to two weeks would be very useful. The next question: What is the cutter speed needed to be used in posterior vitrectomy? The cutter speeds have changed a lot over the years. It used to be as slow as 600 cuts a minute, and now we’re running as high as 10,000 cuts a minute, 15,000 cuts a minute, with a dual cutter, a dual blade action on the cutter. And we general do run at the 15,000 cuts on this machine. It doesn’t have to be that high. It can be 3,000, 4,000, 5,000. It’s all a matter of how you’re tailoring that with your aspiration and how close you are. Anything that’s mobile, like a retinal detachment in the eye — if the retinal surface is not mobile, you can run more aggressively, with higher aspirations. The cut speed being here creates less chatter on mobile retina, and it can be more subjective. So another question here… What is the endpoint for vitrectomy and endo laser photocoagulation? The real endpoint in vitrectomy surgery… Again, if you’re trying to do this safely and efficiently, you want to just clear the visual axis. So you saw me dancing around in the periphery, because we had the time. I’m trying to kind of make a little better post-op result, maybe a little lower eye pressure problems. But the real goal is just to clear the visual axis. Even if you see a tunnel down to the fovea. That will get you there, for the most part. Probably take out the hemorrhage superior to that. Because it tends to hang down, if someone’s upright. And then as far as the endo laser photocoagulation, I think the pattern you place there is about the same as what you do in the office. Burns every two and three spots apart. I don’t do them one spot apart anymore. Mine are much less aggressive. I need more space between the burns. Depends a little bit on the severity of the disease. Which system am I working? I’m actually using the Dutch Ophthalmic System, vitrectomy system. It’s called the EVA. E-V-A. It’s maybe a few years out of its design and first production, and we were one of the first locations in the country to get onto this platform. We do find it to be very nice and to function to our liking very much, my partners and I. For the endo laser, we’re using an adjustable probe, on an iris. I’m not sure who the laser maker was. But it’s a diode laser box with an adjustable probe. As far as the endo laser and spot size, the spot size created in the burns is completely dependent on how close and far away you hold the endo laser probe from the retina. So if you back up, it casts a bigger spot. If you get closer, it makes a smaller, more intense spot. So I kind of go to the location from about the midvitreous, ideally. But I’ll get closer to make the more intense burns. So instead of always adjusting the power on the box, sometimes I’ll just get closer to the retinal surface to make a burn, or a little farther away, if the burn is too intense. Preoperative preparations for this particular surgery was… The exam in the clinic, the B-scan, the fundus photo and angiogram on the fellow eye, and an Avastin injection last week. And PDR with a tractional retinal detachment… Where do you go with anti-VEGF or vitrectomy, is the question. And the answer is: You almost have to always use vitrectomy in tractional retinal detachment, especially if they’re threatening or involving the macula. If you’re at a spot where the tractional detachment is outside the arcade, not threatening the macula, it’s quite possible that you can watch that indefinitely. And treat that with panretinal photocoagulation, and/or anti-VEGF injections. Certainly if you’re giving an anti-VEGF injection, even for a peripheral tractional detachment, you probably want to reevaluate that within a couple of weeks, to see if it’s contracting and pulling the macula. So I would say… Certainly you want to use anti-VEGF before vitrectomy surgery in TRDs, and sometimes you won’t need to even do the vitrectomy, depending on the location of the tractional detachment. Yeah. Well, thank you, everyone, for… Let’s see. Yeah. So in terms of… If there’s no posterior vitreous detachment present, at the start of the case, and where do I want to initiate it? The answer is always at the optic nerve. I will cut the anterior-posterior traction first out in the periphery, but I won’t try and peel the vitreous out there. The retina is great. And in the periphery, you can pull really hard against the optic nerve, very rarely creating a problem. You can avulse a retinal vessel. Yes, I’ve done that. You can’t cut a retinal vessel. I’ve done that, unfortunately, too. But it’s been a while. And for the most part, you can be more aggressive and get away with more maneuvers, over the optic nerve, than anywhere else inside the eye. So I would always suggest all your moves starting at the optic nerve, whether you’re dissecting fibrotic tissue or creating a posterior vitreous separation. Or getting your dissection plane, in cases of severe fibrovascular tissue over the arcades. Yeah. So… As far as suturing for the sclerotomy, we use 7-0 vicryl when that need arises. It’s very rare. I think we probably suture a wound maybe once every three or four months here, and that’s doing 10 a week or something. So it’s probably under 1% that we actually suture the wounds, but I’ve been doing this a long time, and I’ve got great staff and equipment, so depending on what system you’re on, if the wound’s leaking, and you can’t get it to stop after working with them for five minutes, let’s say, at the microscope, pressing on the wound and massaging it, and reinflating the eye, then I think you’re always safer to put the stuff in. I think it does lower your rate of infection and postoperative hypotony problems in the office. So I wouldn’t be afraid to throw that stitch, especially if you’re not doing as many cases. And wound construction — it looked kind of simple. I just slid these things in. But that’s probably one of the most difficult things for people to get right, that can make the biggest difference in the world. It’s very subtle. You know, do you go straight in, do you go in and pop up and go down? All these things is can distort the wound subtly, and make a big difference. So I would say be cautious on the wounds, and the fallback spot to throw a suture is a small price to pay for a more secure outcome. All right. I think that wraps up the open questions. Thank you, everyone, for attending, again. And enjoy the rest of your day. This will be posted on the Cybersight web location with all the other lectures done, live lectures and surgeries, that are there. It’s a great resource for all of you to look at. I encourage you to take a look, and I’m sure you’ll find many other interesting things there. Thank you.
July 15, 2019