A Vision of Hope: Glaucoma Patient Turned Advocate Shares Her Story

Maria Sampalis, OD:

Hi everyone. I’m Dr. Maria Sampalis. Thank you for watching the podcast today on Ophthalmology 360. Hillary Golden was diagnosed with severe glaucoma. Despite having no prior knowledge of the disease, Hillary was set out to learn a lot more than what she can and raise awareness about normal tension glaucoma, a type of glaucoma impacting approximately 30% of glaucoma patients in the US.

Here today is Hillary and her Glaucoma Specialists, Dr. Zachary Vest from Mile High Eye Institute, to discuss patient and physician perspectives on diagnosing and treating normal tension glaucoma. Hillary, thank you so much for taking the time and coming on the podcast and listening to share your story.

Hillary Golden:

Yes, thanks. I’m happy to be here and help raise awareness.

Maria Sampalis, OD:

Yeah. What is the first sign and symptom you experienced to get pushed to get checked, and what tests and procedures did you undergo at the doctor’s office?

Hillary Golden:

So my first symptom was not a glaucoma symptom, but it was a stye on my eye. So I went in. I was diagnosed in July of 2020, so it was during COVID shutdown. I went in to get checked, and I saw an OD, and the OD said, “Would you like to do a full eye exam?” And I said, “Well, it’s been over a year, so I’ll do a full eye exam.” They did a full eye exam on me. When they dilated my eyes… I worked with the tech at first, and when the doctor came in, she dilated my eyes and looked inside and said, “I don’t like the look of your nerve.”

And I said, “Well, I don’t know if you know why I’m here, but I’m here for a stye, so I’m more worried about the stye.” And she said, “Well, I’m more worried about your nerve.” So that was kind of like, I’m like, “Well, I don’t even know what that means.” And she said, “Well, it could… it’s a sign of glaucoma.” And I was like, “Well, I don’t think I have that, so let’s just do this stye thing.” And she said, “Well, you could have glaucoma. Your pressures are normal, so I want to do some more testing to find out what’s going on with you.” The first test they did was a fundus picture. So they took a picture of the nerve, and she looked at that, and then she did of a hand test. She had me cover one eye, and then she said, “How many fingers do you see?”

And I said, “I can’t see your hand.” So that’s when we knew something was wrong. And she said, well, I’m going to have you come back and do some more testing. Less than a week later, she had me come back, and I did a visual field test and an OCT, and at that point, I had lost almost 40% of my vision. So that was at diagnosis, and she said, “I need you to go see… I don’t want to give you drops or anything. I need you to go see a glaucoma specialist ASAP.” So the next couple of days, I went to a glaucoma specialist and kind of went from there.

Maria Sampalis, OD:

Yeah. No, that’s great. A lot of optometrists are primary care in eye care, and we diagnose a lot of diseases and treat and work with ophthalmology to take care of our patients. Dr. Vest is Hillary’s experience going to the doctor like one thing being diagnosed something else typical patients with glaucoma? And how important is the role in comprehensive eye care in detecting glaucoma?

Zachary Vest, MD:

Sadly, Hillary’s experience is not atypical. I mean, most folks that are diagnosed with glaucoma are not diagnosed because of symptoms that are bringing them. In reality, as we know, they’re going to be later in their disease process. As Hillary already mentioned, she had quite a bit of injury without any symptoms from her glaucoma.

So folks getting those regular screening exams, their annual exams are extremely important because that’s when we want to find glaucomas before it’s developing symptoms. And so that role of primary eye care, comprehensive docs optometrists is just vital in terms of trying to diagnose these individuals and trying to prevent them from going into someone who has symptoms or is at risk for vision loss.

Maria Sampalis, OD:

Hillary, what do you know about glaucoma and normal tension glaucoma when you were diagnosed, and what have been some misconceptions about glaucoma that you had?

Hillary Golden:

I knew nothing about glaucoma when I got diagnosed. I knew that when I’d been to the eye doctor in previous years, they did the eye puff test or the pressure test or however they did it. And I knew that was for glaucoma, but I didn’t think that that was in any way going to affect me. I just thought, you don’t get glaucoma until you’re retired, right, so till you’re much older. And I just thought there’s no way that I could have glaucoma. So it was definitely… that was first misconception, right.

So I was wrong about that, and I was wrong that you have symptoms or you know if something was wrong and the brain interpolates data. So when you have two eyes, and you don’t have too much central vision loss yet, your brain is filling in all that data, so you’re still seeing what you need to see. So you don’t know that you can’t see. Now that I, if I cover one eye, can definitely see areas where I have vision loss. But unless you do that, and even if I’d have done it at that point, I don’t know that I would’ve noticed.

So it’s not something you notice, number one. And number two, you can get diagnosed with glaucoma at any age. So that’s why, again, going back to the importance of the primary care docs and optometrists, if that’s your first line of defense and it’s super important for patients to go every year and get their eyes checked because you just don’t know what’s lurking underneath.

Maria Sampalis, OD:

Yeah. I think that’s very important. I have a practice in Rhode Island, and it’s more of a geriatric practice and I do have a lot of glaucoma patients, but last week, I had a rare case. It was a young female came in, 25 years old, ended up having high pressures, and diagnosed with [inaudible 00:06:05] Syndrome.

So that has been something, I think, that we should be all aware of, that it can happen any age, any demographic. It could be any patient that comes through the door, so it could be any type of glaucoma. So that’s why routine eye exams are important. Dr. Vest, from a clinical perspective, can you explain normal tension glaucoma and what clinical distinction it has compared to other glaucomas?

Zachary Vest, MD:

Glaucoma obviously is a spectrum of disease, and historically, we used to associate glaucoma with high pressure. That’s why Hillary mentioned that air puff test. Lots of times, people say, “Oh, I’m screened for glaucoma, and they check my pressure.” But we know a good number of patients don’t have what we would consider high eye pressure. In reality, glaucoma is not a disease that’s dependent on pressure. Eye pressure is a risk factor for glaucoma, but glaucoma itself is just a progressive injury to the optic nerve, and that can happen at any eye pressure.

And so part of our issue is patients really just knowing that it isn’t strictly about, “Oh, my pressure’s in the 20s, or I have a pressure in the teens, and I’m okay” because we certainly get new patients that get diagnosed and they’ve never had a high eye pressure and they think… they’ve had doctors tell them, “Oh, you don’t have glaucoma because your pressure’s normal.” And we really have to stress to patients, “Normal is about what’s normal for your eye.” And the things that are a little different in normal pressure or low-pressure glaucoma is that we typically find there are more systemic risk factors with patients because the pressure isn’t strictly driven by their high eye pressure.

What I kind of discuss with patients is that, ultimately, that optic nerve is kind of right where the eye pressure, the pressure that’s around your brain, the CSF fluid, and your blood pressure, they all kind of meet at that one point. And there’s structures and anatomy there that can be different from person to person. And so we have a bunch of different forces on the optic nerve that are independent of eye pressure. And so we certainly see lots of more systemic issues, whether it’s vascular issues, people with more commonly have migraines, or Raynaud’s phenomenon. Lots of times, people have other blood pressure issues.

Sometimes, there are other health issues like sleep apnea. So lots of times, it’s not just the eye issue itself, it really is a constellation of what’s going on in the body, which is more common in low tension glaucoma patients and not just a situation where the eye is not regulating the pressure appropriately, which is more commonly the case in high-pressure glaucomas where there really is some problem with the eye pressure itself. The normal tensive patient, it’s usually a reflection of more going on systemically than just what’s going on at the optic nerve head.

Maria Sampalis, OD:

Hillary, can you tell us about your experience with normal-tension glaucoma and how you feel it differs from other types of glaucoma?

Hillary Golden:

I have… You kind of mentioned earlier about what did I know about glaucoma when I was diagnosed, and I said nothing. Now I know a lot about glaucoma because I’ve researched it, and what I’ve realized is there’s a lot of glaucoma patients that do a lot of research. So there’s a bunch of us. There’s different websites and support groups, and the information that people… that we have access to in the studies that we’ve looked at. So I’ve done a ton of research in the interim between diagnosis and now. So just like Dr. Vest said, normal tension glaucoma is kind of a, we don’t know everything we need to know about it at this point.

So there’s other things going on. I have orthostatic hypotension, so when I stand up, I get kind of that head rush. And so a lot of patients have that. I have a history of migraine, so a lot of the things that Dr. Vest mentioned or things that I have that are risk factor. So even though maybe I’m not at the risk factor age or things like that, I still have those risk factors. It’s also more prevalent in women. So women are more at risk for normal tension glaucoma. And it’s one of those things that the sad thing about normal tension is it’s not diagnosed until you’ve lost a significant amount of vision usually. So by the time that it is showing up because maybe you’ve got a visual field or maybe there’s been some other… the OCT showed something, someone did an OCT on you, then those are the ways that you find out, but it’s really difficult.

So that’s why, as a patient, I am advocating for people to go to their eye exams because there’s a lot… I went to four different ophthalmologists in five years previous to my diagnosis, and two of them were specialists, and no one found the glaucoma. So it wasn’t until the OD looked in my eye, and did a full eye exam, and took more time with me that it was found. And maybe it wasn’t there yet, right. So we don’t know. I’ll never know, but it wasn’t found. So that’s the scary thing about normal tension is that it’s usually not found until there’s a lot of damage. And so that’s why, again, it’s so important to keep up with your annual exams.

Maria Sampalis, OD:

I agree with you, Hillary. Dr. Vest, you talked about risk factors for normal tension glaucoma, but how many people in the US have normal tension glaucoma? Do you have that data?

Zachary Vest, MD:

So that’s a little bit of a difficult question, right, and part of that’s just getting good data in general, and that’s partially because we know about half of people with glaucoma in the US don’t even know they have glaucoma. So it’s really this silent entity. In terms of, as you mentioned before, there are lots of estimations trying to figure out how much normal tension glaucoma there is. And that’s also all those data sets also have some little bit of asterisk behind them because if you’re taking it from your clinic data or your referrals, those patients have already kind of been screened and sorted out.

And those numbers are anywhere from 15 to 30% of the glaucoma patients may have normal tension glaucoma. But when they did some kind of population studies out in Baltimore, it was about almost 50% of the patients did not have pressures above 22 when they were diagnosed with glaucoma. And so, I think it really is likely a higher percentage of patients than we expect. But as Hillary mentioned, there’s a lot of risk factors.

There’s a lot of different demographics that this hits, and it’s likely going to be based on probably regional population differences about how often a clinician may see normal tension glaucoma in their clinic really based on what’s the demographics of the patients they see. And there are going to be certain areas where it’s going to be much more prevalent than others, but it’s certainly, I think, something that we don’t necessarily think about enough, and it is probably much more common than we think it is.

Maria Sampalis, OD:

Hillary, what treatments did you start, and were they successful? And currently, how is your eyesight? I know you said you lost about 40% before your vision, unfortunately.

Hillary Golden:

The treatments that I started on, at first, I started on one drop, an alpha blocker, and I used that, and then I was… we did SLT. So SLT is kind of known to not necessarily work for normal tension, but there’s very few, if any, side effects or problems from it. So it’s worth a shot, right. So we tried SLT. That didn’t really work for… Maybe two weeks my pressure was lowered, and then after that, it went up to normal. So when I was diagnosed, my pressures were 13 and 14, so I have super low pressures. I’ve stayed kind of… With one drop, I stayed pretty much in the… where we wanted me to be.

Over time we’ve added… I’ve gone through different drops and some of them worked and some of them didn’t, and some of them caused really bad side effects. So I had a sclera bleed before and didn’t want to use that drop anymore. And every drop has a side effect, so you’re not going to find one that doesn’t. So I’m on one drop at night and one drop in the morning currently, and then the drop I’m on in the morning, I can actually use three times a day if I wanted to. So if my pressure does go up, I have that kind of in my back pocket to add another drop. So that’s what I’m on currently.

And we did try SLT a second time on me just to see if maybe that would work. Again, it lowered my pressure for a little bit, and then it came back up. So, for me, I’m sticking with drops for now because for most normal tension patients, to get your pressure to be low enough, you really have to go with a more invasive surgery, like a trab, and different ages you’re going to do that more quickly. So if I was 20 years older, maybe we would do a trab on me, but for now, we’re just going to try to buy time with the drops, and new therapies are coming out all the time, and we’ll keep an eye on those as well. But for now, I’m on two different jobs.

Maria Sampalis, OD:

Hillary, you mentioned that your pressures can go up during the day. Do you monitor your pressures at home? Do you have a device that does that, or…

Hillary Golden:

Yeah. So for me, I have a home tonometer, the iCare HOME2-

Maria Sampalis, OD:

Yes.

Hillary Golden:

… and it’s an amazing device. Dr. Vest was mentioning, some patients go to the office, and that normal tension glaucoma might be more prevalent than we know. Also, if you go to the… if you’re going to your glaucoma specialist, I go about every six weeks because my eyes are more severe. Some patients go every three months or every six months. So if you’re going every three or six months and you’re getting your eye pressure checked once every three to six months, and that’s your pressure when you go. So depending on what’s happening, what time of day.

So I know for me, personally, if I’m more stressed if there’s a lot going on, my pressure’s going to go up, right. If I’m in traffic, right, at the end of the day and I get home from work and I take my pressure, it’s higher, and then before I go to bed at night, my pressures can be as low as eight. On average, I’m at nine or 10 at night before I use a drop. So the tonometer has really helped me. It’s given me peace of mind. For some patients, it might not do that for them, right, because you can definitely go overboard with measuring.

So when I first got it, I was measuring at different intervals of the day, and I was just so worried at every point and, “Oh my gosh, it went up a point. Why did it go up?” And now that I kind of know what my diurnal curve is and I’m comfortable with it, and I know that like, “Oh wow, this morning my pressure was…” Usually, my pressure in the morning is about 14 or 15, and if I see it at 17, I might get nervous. But there’s lots of different factors that go into it, and it’s given me peace of mind.

So I highly recommend it for patients if they feel comfortable with it and if it’s going to work for them. You can also rent the home tonometer, which is a nice alternative too. So if someone wants to just rent it for two weeks to kind of get their baseline and find out what their diurnal curve is, then they can rent it and just get an idea and then turn it in, and they might not want to have it all the time.

Maria Sampalis, OD:

All right, thank you so much. Dr. Vest, patients that you’ve put on glaucoma treatments, have some been more successful treatments than others? What has been your experience in the field?

Zachary Vest, MD:

So I think Hillary mentioned kind of our views of SLT, and I kind of mirror that it’s a low risk, but it may not yield the results that we’d like. I think one of the other things that Hillary mentioned that’s really changing how we view normal tension glaucoma is kind of this ability to monitor folks outside of office hours. There are lots of medicines we have that work very well. And as Hillary mentioned, if we see patients at eight in the morning and they took their jobs an hour ago, we know we’re catching them at essentially probably the max efficacy of those morning medications.

The other things that we’ve started to think about, besides just what pressures are outside of office hours, is also what type of medications we’re providing folks and are they really providing coverage all day. And that has been also one of the different changes. Hillary mentioned she was put on a medication early on that we historically as a community have thought about as having some sort of neuroprotection or using in low tension glaucoma patients for various reasons. But more and more folks are starting to do 24 hours studies looking at what medications really work for 24 hours and maybe cut down on some of these fluctuations that Hillary was mentioning.

And we certainly know prostaglandin analogs do a good job of working overnight and cutting down on fluctuations. Carbonic anhydrase inhibitors typically also do a good job overnight, and SLT does a good job overnight. So some of those elements, I think, we kind of gravitate to a little bit more because of they maybe have a little bit more protection throughout the day. Some of the other medicines, like beta blockers, typically are really just going to work during the day.

So they may be supplemental therapies, but they’re not going to be first-line or monotherapy options for lots of patients because they’re not going to get the pressure that much lower, and they’re not really working after daytime hours for most patients in terms of reducing their pressure. So we do put a little bit more thought into what medication classes we’re putting normal tension glaucoma patients on because it isn’t just about their pressure in front of you in clinic. It’s also more about what’s going on throughout the rest of the day. And so we do have to consider some of those elements.

Maria Sampalis, OD:

Yeah. Hillary, do you worry about your vision in the future, what it might look like?

Hillary Golden:

Definitely. I mean, it’s one of those things whenever I first started going to Dr. Vest, and he can attest to this, just about every visit I would go to I would cry just because it’s like I said, I didn’t know a lot about glaucoma, and I was learning. And the more you learn, the scarier it can be, but to me, knowledge is power. So if I learn a lot about something, then I feel like even though I have no control over this disease whatsoever, I feel like I have some control just knowing what’s going to be helpful. I can also be compliant, right.

So I can use my drops when I need to. I can track my pressures and see where I am, and that helps me be in somewhat of control of this as I can. So it’s very scary. I mean, glaucoma is very scary. And then to know that when I was working for a company and I was selling a glaucoma medication and I went to the training, and we had several doctors come to the training and teach us about glaucoma and show us different visual fields and say, “Okay, what would you guys do if you saw a visual field like this? What would you guys do for this visual field?”

And I saw these visual fields, and I’m thinking, “This is weird because my eyes are worse than all of these visual fields, and this isn’t good.” And I think that’s when it really sunk in, and it hit me that my glaucoma was severe and that most patients don’t have… their visual field doesn’t look like mine. And whenever I sit in the waiting room to see Dr. Vest, and I look around at all the patients, and most of the time, the patients are older, and I look at them and I think, “Gosh, my eyes are probably worse than all these people in the waiting room, and they’re a lot older than me.”

So that’s definitely a scary thing to deal with. And some days it’s… some days, I cry, and I can’t handle it, and it’s too much. And some days, I’m totally fine. I do what I can, and the more I’ve accepted where my eyes are and the more I just take care of myself, and I do everything I can to control this disease, then that’s all I can do. And that’s why I’m okay.

Maria Sampalis, OD:

Yeah. But you’re an advocate now, right. You’re coming out. Everyone knows your story, other people that are in your situation. I’ve done some interviews in the past with people that had retinal disease and lost their vision and their advocates to help others, and they share their story, and they’re inspirational.

I mean, you’re doing that today by coming on the podcast and discussing your story, and it must be tough to say these things and that you’re losing some vision, that you’ve lost some vision. Dr. Vest, what can ophthalmologists and optometrists do to help patients preserve their vision?

Zachary Vest, MD:

I think one of the first things is really for us to just kind of get the idea of glaucoma doesn’t happen below a pressure of 21. I mean, that just needs to be scrubbed from our community memory banks. And so I think really looking at each patient and really evaluating the nerve. I think as we start to get more imaging tools, patients are being dilated less. And there are lots of times where patients are going for years without actually… with only having photos or other technologies to avoid dilation. But we really still need folks to get their nerves looked at and examined, as Hillary was mentioning. That’s just really vital because that’s really where the diagnosis starts is screening those optic nerves and how they look.

I think one of the other elements that’s difficult for providers and doctors is trying to balance the making sure patients [inaudible 00:24:09] the seriousness of their condition because it is, there’s still a percentage of patients that are going to lose vision from glaucoma, which makes it a very daunting task. So we don’t want to kind of sugarcoat a diagnosis. We want patients to understand the severity of their condition. But at the same time, we also don’t want to be so heavy-handed and fatalistic that patients give up being invested in their care and understanding that there are lots of good therapies. We have good diagnostics, that this is really a partnership that we kind of have to go through this system together and try to take care of patients.

And we really want to make sure that if they are feeling really empowered to have a active voice in their role, that means if they’re having side effects with drops, if they’re having issues being compliant with drops, if they’re noticing increasing symptoms. Those are all things that we want to know about so that we can help navigate and troubleshoot that issue. The biggest issue is that patients that kind of want to just go along with what the doctor says and they will not maybe bring up some of these issues that are keeping them from using their medications or barriers that are preventing them from being successful with therapies is a big issue.

And so doctors need to make sure that they have an open communication with their patients so that they can make sure that they really understand how well patients are doing with their therapies and how things are going. Frequently, we ask patients, “How is everything going? Are we using our drops?” And the patients say yes. And 95% of your patients will say yes. But we know just from studies and really good studies that that is definitely not the case. Patients have a lot of issues with drops, whether it’s running out of drops early, difficulty putting drops inside their eye, side effects of drops that Hillary mentioned. And they’re going to put their drops in just like we scrub our teeth really well before we go to see the dentist.

Patients are going to make sure those drops get in their eye before they come and see you. And so we are not going to get a real good picture of really what’s going on in those other six weeks, three months, six months that’s going on for that patient. And so I think that’s a big element. And then ultimately, I think, as Hillary mentioned, that we have to be honest in terms of what we know and what we don’t know. And there’s a lot about glaucoma that we don’t know, and there’s a lot about new technologies, new advancements, new developments. It’s going to hopefully change the therapies that we do, not just in… for Hillary, but when I’m practicing that what I do for glaucoma now is going to be different in 10 years and 15 years, and that’s going to be great advancements for patients.

And then I would advocate the final is that there are lots of patients that do have symptomatic loss of vision from glaucoma, from other eye conditions. And there are lots of resources, whether it’s low vision specialists, occupational therapists, that do provide a lot of benefit to patients to help them navigate when they do reach a stage of their vision being compromised. And lots of times, that may even be a diagnosis. And I think that’s an underutilized resource for our patients to help them continue to understand even if they have visual impairment, they can still have a very fruitful and rewarding life in terms of their interaction and their use of their vision in [inaudible 00:27:29] that is a key component I think we can provide for patients is looping in other providers to help really coordinate care to care for them.

Maria Sampalis, OD:

Hillary, what steps have you taken to advocate for yourself and other individuals for normal tension glaucoma?

Hillary Golden:

So I’m in several different support groups for glaucoma, and I’m also in a group called FitEyes, and there’s a great group of people there that do a lot of research. In the support groups, I’m always trying to help people. People are scared of different procedures and drops and ask, “What side effects are these drops going to have on me?” And try to… without giving patients medical direction, just try to support people. I also tell people to be an advocate for yourself. So when we go into doctors, I mean, they’re used to seeing bad eyes all day long, right.

So Dr. Vest, he gets a lot of really hard cases, and so he’s used to seeing these crazy things with people’s eyes. So when I go in there, I have to… like Dr. Vest said, you have to have a partnership with your glaucoma specialist because I have to be able to communicate to him what’s going on with me because maybe before me, he saw somebody that he’s going to have to do a major surgery on their eye, and then he sees me and I’m okay for now, right, but I’ve already lost a lot of vision. But if I’m emotionally not doing well that day, I need to make sure that I communicate that to him and that, “This is hard or these eye drops, I can’t use these drops anymore.”

And I’m one of the people that I’m not one of the 95% that says they’re using their drops and don’t complain. I’m one of the 5% that complains, right. And I say, “I don’t want to use this drop. This drop…” When I had the sclera bleed, I said, “I’m not using this anymore. My eye is full of blood. It’s scary.” And it’s totally, the thing about the bleed was it’s benign. It’s going to go away in a week, but it’s scary to the patient, right. And so the doctor sees these things all the time. You just need to remind the doctors that you’re your own person, you’re an individual, and to you, this is very scary. To them, it may not be so scary.

So it’s important to advocate for yourself if you’re having side effects. If you have a side effect with every drop, you’ve got to tolerate some kind of side effects. So you can’t just say, “Can’t use any drops.” I mean, you can, and they’re surgical options for sure, but if you need to be on a drop and maybe you’ve had surgery, but your pressure’s not where it needs to be, and you still need to be on a drop, you need to be able to stand up for yourself and say, “This is what drop I find that I can tolerate the best.”

So that’s what’s important. That’s what I try to tell patients. That’s what I do for myself, and just communicating to patients that it’s okay to tell this to your doctor. It’s okay to question them. If you just take whatever they say and you go home, and you’re confused. That’s what I see all the time with patients. So they need to really stand up for themselves and say what their concerns are, and that’s what really makes a difference.

Maria Sampalis, OD:

Yeah. I mean, doctors need to communicate a lot better sometimes and tell patients what we do for tests, why we’re prescribing this drop, how it is an open communication, if they don’t like a certain drop or for what reason. And I had a patient that was open-angle glaucoma high pressure, and they couldn’t afford a certain prostaglandin had to go generic. And that happens often, but I’d much rather know that instead of them stopping taking the drop. And I’ve had that conversation a few times. So now it’s part of my discussion when I prescribe the drop. “This, I think, is the best drop for you.

If this does not work with your budget, please let me know and call me, and we will work with you because we’d much rather have you on the drop.” So open communication, the patient-doctor relationship is important. I want to thank you both for coming on the podcast today. Hillary, for sharing your story and Dr. Vest for sharing your experience and being brave enough, Hillary, to come on this podcast. And I think you’re going to inspire a lot of people and maybe are going through the same thing. And thank you, Dr. Vest, for doing what you do and for other optometrists and ophthalmologists that make a difference in patients’ lives.

Hillary Golden:

Thank you. Thanks for having us.

Zachary Vest, MD:

Yeah, thanks for having us. Appreciate it.