Transcript

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00:00 Dr. Rani Banik
Of all the five senses, most people would agree that VISION is the most precious. But imagine waking up one morning and noticing that you can't see out of one eye. It's gone completely black. Well, that's what people experience when they've suffered a type of eye stroke known as central retinal artery occlusion, also known as CRAO. It can be devastating. And worse yet, in most cases, that vision loss is irreversible.

The good news is there is a new treatment that is cutting-edge that can help some people with CRAO regain their vision. So tune in to this week's episode of The Eye-Q Podcast™ with me, your host, Dr. Rani Banik and my special guest. And we're going to be talking about the latest treatment options for CRAO. Stay tuned…

00:52 Narrator
Welcome to The Eye-Q Podcast™ hosted by Dr. Banik, America's integrative Neuro-Ophthalmologist. Get ready to explore the intricate connections between the brain and the eye through neuro-ophthalmology. Journey with Dr. Rani into the world of integrative ophthalmology, where cutting edge science meets holistic wellness.

Discover how to protect and preserve vision through powerful preventative strategies based on eye-smart nutrition and lifestyle modifications. Whether you're an eye care provider, or just curious about how to maintain healthy vision so you can see the world more clearly, join Dr. Rani for exciting and eye -opening discussions, which will no doubt raise your ‘Eye-Q!’

01:32 Dr. Rani Banik
Hello, everyone, and welcome to another episode of The Eye-Q Podcast™, where you can gain insights about vision health and brain health and elevate your 'Eye-Q'. I'm your host, Dr. Rani Banik, America's Integrative Neuro-Ophthalmologist, and today I'm so excited to welcome a very special guest.

This guest is someone with whom I've worked very closely for the past 14 years or so in an academic setting. And he is a wealth of knowledge. And I'm so excited to bring him on and to have him share some of his insights.

Dr. Richard Rosen is the Belinda and Gerald Pierce Distinguished Chair of Ophthalmology and Professor of Ophthalmology at the Icahn School of Medicine at Mount Sinai. He is Chief of Retina of the Mount Sinai Health System and Retina Fellowship Director, as well as Vice Chairman, Director of Ophthalmology Research and Surgeon Director at the New York Eye Ear Infirmary.

Dr. Rosen is also an honorary professor in Applied Optics at the University of Kent in Canterbury, United Kingdom, where he was awarded an honorary doctorate in medical physics. Dr. Rosen received his bachelor's degree in psychology and anthropology at the University of Michigan and his MD from the University of Miami School of Medicine. Dr. Rosen's research and interests include new treatments for macular degeneration and diabetic retinopathy, innovations in diagnostic retinal imaging, and vitro retinal surgical instrumentation.

He helped pioneer the introduction of multimodal en face OCT SLO and Adaptive Optics SLO imaging for clinical applications and pioneered quantitative capillary density mapping for OCT angiography. And he is currently developing cellular imaging using clinical OCT along with robotic tools for vitreoretinal surgery. It's my greatest pleasure to welcome Dr. Richard Rosen as a guest on The Eye-Q Podcast.™ We are so fortunate to have him with us today.

So I'd like to welcome Dr. Richard Rosen, MD. who wears many hats. But first and foremost, he is an ophthalmologist who specializes in retina. So welcome, Dr. Rosen!

03:55 Dr. Richard Rosen
Thanks, Rani. It's a pleasure to be here. Yes, I've been looking forward to this conversation for some time.

04:02 Dr. Rani Banik
When we first discussed having you on the podcast and what we may chat about. we're decided to talk about some really interesting topics having to do with eye stroke. But before we get into that, I would have you share with the audience - How did you end up doing what you do, what you love? Like, how did you get into retina as a subspecialty in ophthalmology?

04:24 Dr. Richard Rosen
I sort of got into retina through the backdoor. I was a photographer from the time I was in high school. And I had the opportunity when I was in graduate school to start doing eye photography for retinal specialists. And I was fascinated by the beauty of looking at the retina. And he was very kind and introduced me to retinal surgery. I got to watch him do some surgery, understand a little bit about laser treatment at the time. It was just at the beginning of fluorescein angiography. And my career has sort of expanded from there as retinal imaging has increased. And then I went on to medical school and decided to go into ophthalmology and then specialize in retina.

05:23 Dr. Rani Banik
Yes, that's fascinating. So you actually became a specialist or skilled with a different skill set and then you ended up going into medicine. How was that transition,going from being a photographer into the role of a provider? How was that experience?

05:45 Dr. Richard Rosen
I had an interesting education. I did work at the medical school at the University of Miami from the time I was in high school. So I was involved with a lot of research. I was actually in

cardiology and I worked in a very innovative lab. So I had some exposure to working in hospitals. But it was very different because of course how a photographer interacts with patients is very different than the physician.

06:16 Dr. Rani Banik
So it was with very different kinds of responsibilities, right?

06:24 Dr. Richard Rosen
Yeah, to say the least. Yeah, absolutely!

06:27 Dr. Rani Banik
So as a retina specialist, just so our listeners can hear, what are the top three things you manage on a daily basis? What do you see most often in your practice?

06:36 Dr. Richard Rosen
So I see a lot of macular degeneration and diabetic retinopathy primarily. I see retinal detachments. I do a lot of trauma involvement. I'm involved in training clinical fellows, both surgical and medical. And I have research fellows as well in my imaging lab.

07:03 Dr. Rani Banik
Yes, and if anyone's ever been to New York, you should definitely stop by and visit the imaging lab in New York Eye and Ear Infirmary. It's phenomenal. Basically, Dr. Rosen has so many interesting tools and technologies available and really cutting-edge technology. So it's definitely worth a visit.

So I know amongst one of the things you treat, you also do manage eye stroke, in particular, various different types of retinal stroke. So could you just share what are the major categories of retinal strokes and how are they different?

07:38 Dr. Richard Rosen
So probably the most common has to do with the occlusion of the veins, either a branch vein occlusion or central vein occlusion. We see microscopic occlusions actually in things like diabetes and sickle cell disease.

And of course, arterial occlusions are less common, but are much more damaging and have a worse prognosis very often. So branch artery occlusions, central artery occlusions, ciliary artery occlusions, and of course, the ones that have to do with the optic nerve I refer to you or one of them.

08:26 Dr. Rani Banik
To put this in perspective, there are different types of eye stroke. Because I think when people hear eye stroke, they think of only one type, perhaps a type that they've had or maybe a family member has had. But there are various different types of eye stroke and it's important to distinguish amongst them. So there's retinal strokes and then there's optic nerve strokes and they're managed quite differently.

So let's actually begin with central retinal vein occlusion or even branch retinal vein occlusion. What are some treatment strategies that you employ that are considered standard of care in today's world?

08:59 Dr. Richard Rosen
So today we're fortunate that we have a lot of new therapies, specifically these anti -VEGF injections, which have been tremendous. Previous to that, we found that using steroids injected into the eye was very effective in many cases. And there was a large study, the SCORE trial that we did, sponsored by the National Eye Institute, which showed that the injection of certain steroids would really benefit and reduce swelling and improve visual acuity in patients with vein occlusions. But steroids have some greater number of complications.

So the anti -VEGF drugs, when they became available, they've really sort of taken over for a large part. And it's very effective in terms of improving vision and restoring vision. The thing with vein occlusions is that you have a little more time, but you don't really know at the time when you lose vision, whether it's an artery or vein. So time is a critical element in any sort of eye stroke.

10:15 Dr. Rani Banik
We know that the imaging does that help to distinguish between the two, like when you're saying you're not sure if it's an artery or vein that's the issue. I’m assuming the imaging plays a key role here.

10:25 Dr. Richard Rosen
Yeah, so in a vein occlusion basically you have a backup of a lot of fluid. So the retina becomes very swollen, which is why it responds to these injections. In an artery occlusion, the occlusion occurs before the blood actually reaches the eye, eithin the optic nerve. so basically it doesn't respond to the anti -VEGF.

So you need some different kind of strategy. So what we'll talk about today is how we're really trying to move that forward. So we're fortunate in this era of interventional radiology that we have treatment for like heart attacks, which have been just tremendously save lives that you know i've watched this evolve over my career and of course now we're getting into that in terms of treating stroke within the eye that occurs due to an arterial occlusion.

11:28 Dr. Rani Banik
Now let's talk a little bit about more about central retinal artery occlusion or branch retinal artery occlusion. What exactly is going on? What's the pathophysiology here and how is it different than a vein occlusion?

11:42 Dr. Richard Rosen
So in about 95% of cases, it's due to some sort of either an embolus, a small piece of a clot which breaks off from someplace either in the heart or in one of the large arteries in the neck and then lodges within the small vessels going into the eye, typically within the optic nerve itself.
If it's a smaller piece, it may break off and lodge somewhere further down the line, so you get a branch artery occlusion.

In about 5 % of cases, it's inflammatory. So it may be due to temporal arteritis, which is an inflammatory condition that we see generally in patients that are around in their 70s. And that's treated.

12:34 Dr. Rani Banik
In that situation. It wouldn't be a clot necessarily, but inflammation of the vessel that closes off its lumen basically. So different in its pathophysiology, but the same outcome, Very severe vision loss.

So if a clot is coming from elsewhere, before we talk about the treatment that you mentioned earlier, what should we do? As clinicians, as eye care providers who are seeing a patient with a sudden onset vision loss and you see perhaps a cherry red spot in the retina, what's the very first thing people should do?

13:12 Dr. Richard Rosen
Well, depending on what the availability of treatment is, the standard of treatment has been to try to lower the pressure, dislodge the clot, and use some form of dilation of blood vessels. So people have used breathing into a paper bag, which raises the level of carbon dioxide in the blood and causes the blood vessels to dilate.

If you're in a hospital or you have a situation where you have the availability of a gas mixture of 95% oxygen and 5 % carbon dioxide, that will do the same thing. That's called carbogen and that's typically not available in offices. So breathing into a paper bag actually is the cheap and dirty way to do it.

Trying to use pressure- lowering medications such as glaucoma medications or some systemic carbonic anhydrase inhibitor like Diamox, which is given orally, which can lower the pressure. People have also used some sort of sublingual nitrates that are used typically for angina will dilate the blood vessels very quickly.

So in an emergency situation, the other thing is you can actually do a small paracentesis in the front of the eye and lower the pressure very, very quickly, either with a needle or with a small eye knife that will very rapidly drop the pressure. And sometimes the shock of that will dislodge a clot.

14:59 Dr. Rani Banik
I know there probably aren't many large clinical studies looking at this, but approximately like what level of pressure lowering are you looking to achieve? You know, let's say someone has normal pressure and their pressure is 15 or 16.How low do you need to go, what should your target be if you're using any of these agents?

15:16 Dr. Richard Rosen
You want to get it down to zero. With a paracentesis, you'll bring it down very rapidly to zero You know, obviously when you do that you want to avoid damage to either the delicate structures if you if you let a little fluid out of the eye you don't want to injure the lens but you can if you do it carefully you can bring the pressure down pretty rapidly.

15:41 Dr. Rani Banik
And there's no risk of a choroidal hemorrhage or anything like that if you do that that quick?

15:45 Dr. Richard Rosen
No. I really haven't seen that.

15:50 Dr. Rani Banik
Have there been any large studies? I know it's very hard to do this type of a study but or even a retrospective study looking at some of these interventions, these interventions that have been used for decades basically and written about in textbooks.

16:06 Dr. Richard Rosen
Well, there was one large study that was done in Europe, which was a randomized control study between using interventional clot busting drugs versus what they call the standard of care, conventional care, which was conservative. And that really, for many reasons, didn't show an advantage of doing this interventional radiology approach with TPA. So that was one big trial.

Probably 10% will get better on their own to some extent, but most of them won't get back the kind of vision that the patient enjoyed before this happens. They may get back something like
20/100 vision, but most patients will wind up counting fingers.

16:58 Dr. Rani Banik
It becomes a useless eye. Yes, it's very unfortunate. Now let's let's delve into some of the latest cutting edge technologies that can be used for central retinal artery occlusion. I invite you to share with us what your experiences have been with some of these newer technologies.

17:17 Dr. Richard Rosen
So our interventional radiology colleagues have really perfected the ability to enter and float a small catheter all the way up from the groin to the ophthalmic artery which enters the eye and actually squirt a tiny bit of this medication into the ophthalmic artery and watch the clot dissolve. And this is done using a combination of imaging that is done. They look for actually restoration of flow by what's called a choroidal blush. And that signals that you restored the vision.

So the ophthalmic artery, which is the first branch off of the carotid artery, the internal carotid artery, which feeds the eye and feeds a large part of the brain, is very accessible. And so they, by bringing this catheter up, they can actually open this and patient will notice an improvement very rapidly.

18:32 Dr. Rani Banik
It's really remarkable how some patients can benefit from this, but there are some limitations to this, right? So it's not for everyone. It's not indicated for everyone with central retinal artery occlusion and not everyone improves, right?

18:47 Dr. Richard Rosen
So, timing is really critical. So we know that we get the best results within about six hours. Unfortunately, people don't always realize what's happening. Either they wake up and they don't see, or it may be in their non-dominant eye and their other eye is seeing well and they don't recognize that this has happened. And so by the time they see a provider, it's beyond a period of time.

So the problem with these clot -busting drugs is that besides only working successfully for a short period of time, they're given later on, they have some potential side effects of bleeding in other places. If you give them intravenously, which is what they're typically done for other types of clots in the heart and such, after a period of several hours, probably like five to six hours, they may cause a bleed in the brain.

So we prefer to do the more interventional approach where they actually feed a catheter up. It's only a tiny little bit of medicine, so it doesn't really affect the brain.

Now, the eye is unique. It's different. It's a part of the brain. but it doesn't behave the way the rest of the brain does in the sense that if you give the clot -busting drug late, it doesn't cause any bleeding within the eye. So it's safe. So actually, we will do it up to 12 hours. Ideally, six hours, but even up to 12 hours after the initial vision loss.

20:39 Dr. Rani Banik
How have your results been? What have you seen with your patients?

20:44 Dr. Richard Rosen
So better than half the patients improved significantly. When we say significant, at least three lines of vision. But we have many cases where patients have gone from bare finger counting to good vision, talking about 20/40 vision, 20/30 vision. So it's really phenomenal in terms of the restoration. This is something that we never saw.

For years, we tried the conservative approach. We tried to be very hands-on when patients would come in to the Infirmary all the years that I've been there, and it was disastrous. Very few would actually respond. And here, it's become a more typical outcome that most patients will get some significant benefit from it.

21:36 Dr. Rani Banik
So I wanted to ask you about the logistics. How do you get this treatment to patients so quickly? How does it work in a hospital setting? What are the teams that need to be involved here?

21:48 Dr. Richard Rosen
So we have an amazing multi-specialty group. Basically, we have the interventional radiologists. We have the stroke neurologists. We have the emergency medicine doctors. We have, of course, residents and fellows that are doing a lot of the footwork. And then we have a teleconsult service of retina specialists.

Now, previous to a few years ago, the interventional radiologists, because they were most concerned about safety for the patient, they would say, well, we want a fluorescein angiogram to prove that there's a central retinal artery occlusion.

Because even though you can look in and you say, there's a cherry red spot, and that oftentimes takes a while to develop, they really wanted to be sure because, you know, unfortunately, you lose an eye is one thing, but you don't want to put somebody's life in danger. So they would say, well, we want a fluorescein angiogram. So this is where it started when I first got involved with this approach.

And more recently, we noted that one of the earliest features that we see is with OCT. And OCT shows a change in the reflectivity. So we have a loss of definition of the layers of the retina very, very early, which is an indication of ischemia. So what we did, initially I had, I put one of these automated OCTs in our urgent care at the infirmary and we found that we could see very early these changes and then we've expanded that out.

So now we have them in a number of the emergency rooms throughout the Mount Sinai system. So a patient comes in, sudden vision loss, even before they're dilated, we can take a picture and know if this is potentially an artery occlusion. So we can get the team going very, very quickly, get them on the table for intervention within less than two hours.

24:07 Dr. Rani Banik
That's phenomenal. So who is operating these OCTs? Are they eye care providers or can emergency department personnel operate these OCTs?

24:16 Dr. Richard Rosen
So the emergency department personnel can do it. It's like it's a one touch sort of OCT. Simple, OK. Very simple. talks to the patient in a number of different languages and actually directs the patient

And typically, if you can get a good image, if the patient is fixating, you get a good image, then we know that we can see the effect very quickly. So if you don't get a good image, then often it's because the vision loss is due to either bleeding in the eye, which could be from a patient either who had a vitreous detachment or diabetic retinopathy, or something else that would have prevented us getting a good picture. So then that we need a more comprehensive evaluation of the eye, but we know that it's not an artery occlusion.

23: 46 Dr. Rani Banik
So basically, a patient comes in, they wake up with sudden vision loss, they go to the emergency department within the Mount Sinai system. Before the ophthalmologist gets called and even before the patient gets examined, they get this OCT done. Is that kind of the protocol that you have in place right now?

25:33 Dr. Richard Rosen
They'll call a stroke code, an eye stroke code. And basically then somebody will see the patient, they'll get a history, they will take this image and they will let, we have this sort of protected chat where the entire team knows that a patient has come in or a patient is going to come in, so everybody's prepared to move everything forward by the time the patient gets there.

26:07 Dr. Rani Banik
Excellent! This has been so fascinating. I also help to help manage some of these patients and just to learn the intricacies of the protocols you have in place. It's really, really good to know what's going on behind the scenes. So we're going to take a very, very short break and we will be right back for more discussion with Dr. Richard Rosen.

27:27 Dr. Rani Banik
Well, welcome back everyone to The Eye-Q Podcast™. Today we're speaking with our special guest, Dr. Richard Rosen. And we just had a really interesting discussion about various types of retinal strokes, not optic nerve strokes, retinal strokes. And we're talking about CRAO or central retinal artery occlusion.

So I wanted to ask you, Dr. Rosen, after the patient has been initially diagnosed and treated, whether they're in the window for this clot busting treatment or not. How do you manage them afterwards? What happens in, let's say, the weeks or months after the actual, the initial ischemic event?

28:08 Dr. Richard Rosen
So it's very critical that the patient, even if they're outside of the window, gets a comprehensive stroke workup. Because we know that there is a high risk within the first few days of this kind of event happening. The patient may need to look very carefully at the patient's heart with echocardiography, we need to look at the brain to make sure, see if there's any evidence of occlusions other places in the brain. We need to look at the carotid arteries to see if there's any potential, you know, other kind of occlusion that can happen because the artery plaque has built up and maybe the plaque is not stable and may produce strokes in other parts of the brain.

And then the follow -up will be determined by what they find. So maybe the patient will need to be on some form of blood thinner over a long period of time. One of the things we found initially when we started doing the interventional approach was that because of the concern about the brain. They weren't starting patients on blood thinners following the intervention. And we found that some of those patients reversed. So they improved and then they got worse. Typically, if you have this sort of angioplasty or some sort of intervention in the heart, they'll put you on some sort of aspirin and Plavix or some other type of blood thinner over the long period of time to protect because it's a delicate interval after one of these events has occurred.

30:07 Dr. Rani Banik
Yes, absolutely. And I really just want to reiterate this - that this type of eye stroke is not just limited to vision. It really is reflective of systemic disease. And so if you see a patient with an arterial occlusion, you have to treat it as a systemic disease.

And that means referring the patient to a cardiologist for echo, carotid ultrasound, as Dr. Rosen was explaining, or perhaps even a Holter monitor to look for arrhythmias like atrial fibrillation or paroxysmal atrial fibrillation. And also to refer them to a stroke specialist, make sure they get an MRI of the brain, perhaps MRA of the brain and neck.

And in my experience, a lot of patients who have been evaluated by stroke specialists end up also not only being on anticoagulation, but also being on statins afterwards. So we usually leave all those decisions to the neurologist who's helping to manage the patient, but it is a team effort here. It's not just that we as eye care providers are managing this patient throughout their entire journey. It requires a team effort.

31:05 Dr. Richard Rosen
Right. Just to that point, even seeing the presence of a small fleck of cholesterol somewhere in a small blood vessel. If you look in the fundus, it's an indication that the patient really needs a comprehensive workup. They may not have a stroke at that point, but it may be they're at risk for that happening. Because when you see that, it tells you that there's some sort of unstable plaque somewhere in their vascular system.

And we know that over a period of years, those patients very often, sometimes they get worked up and they don't find anything, but over a five-year period, there's a significant risk, almost 50%, that the patient will have something like that.

31:57 Dr. Rani Banik
Yes, so the plaque that Dr. Rosen's is mentioning about, it's what we typically refer to as a Hollenhorst plaque, correct? I don't know if the names changed since then, but that's typically how it's written about in textbooks. So it's a harbinger of more serious disease.

Get your patient the work up. And it may be negative, but that's OK, because you may have saved the vision's vision, or you may even save the patient's life if you get them to the right providers in a timely manner.

So what about from an eye perspective? What are some things you watch out for, for either CRVO or CRAO long-term?

32:33 Dr. Richard Rosen
So the thing that we most are concerned about is the potential for new blood vessels that form after an occlusion because you have a situation of ischemia and in vein occlusion we have what's called 90-day or 100-day glaucoma where basically new blood vessels form in the front of the eye and the pressure goes up sky high and requires a lot of intervention. This happens to a lesser extent with artery occlusions maybe three or four percent but it's still something that needs to be watched. The patient needs to have gonioscopy to see if there are any of these blood vessels that are forming.

And the recommendation from the central vein occlusion study, which was done a number of years ago, was basically monthly follow -up for the first six months to make sure that none of these blood vessels are formed. Interestingly enough, in the artery occlusions, they happen much quicker, somewhere in the range of about a month or two.

31:42 Dr. Rani Banik
In both cases, the patient needs careful, close follow -up for at least that first six months. Now, those are great recommendations. Again, if you're an eye care provider, make sure you follow these patients closely and do the gonioscopy. Absolutely check the gonioscopy.

I wanted to just pick your brain a little bit about this, Dr. Rosen. So in terms of stroke, we know that over the past decade plus, there's been a lot of increased awareness about stroke. There have been a lot of public service campaigns- advertisements, billboards, et cetera, kind of warning patients about stroke symptoms and letting them know they should seek care immediately if they have any of these issues.

They've used the acronym FAST, so F-A -S -T. F stands for facial asymmetry, A stands for arm weakness, or could also be leg weakness, S stands for speech, so if someone has slurred speech, and T is for time to call 911. So that's been kind of the acronym that's been used. Now it's been expanded to be BE-FAST, so B-E in front of FAST, B is for balance, and E is for eye symptoms, vision issues.

This is kind of what we're we're, you know, trying to raise awareness for amongst the public. But unfortunately, people still when it comes to vision, they still don't quite get it and they wait. So any thoughts, Dr. Rosen, and how we can maybe elevate this awareness of vision issues and get try to get people to seek care as soon as possible if they have a vision issue, whether it's loss of vision or painless loss of vision, or double vision or something else that may be a symptom of premonitory symptom of stroke?

35:36 Dr. Richard Rosen
Well, you really hit the nail on the head. This is the biggest problem that we have is getting patients in rapidly. I think that people tend to think, well, my eye is not working well today. Maybe it's going to be better tomorrow. Or they don't because we have two eyes, one good eye covers up for the other eye. And so I always recommend, know, look, put one hand up.

36:05 Dr. Rani Banik
Yes, do a cover test.

36:07 Dr. Richard Rosen
Yes, do a cover test if you think anything's unusual. So if you have any sort of disturbance, because even if the one eye goes out, it's going to disturb your balance to some extent, so you can lose visual fields.

And so I think part of it is- the eye care community at large needs to recognize that we've moved beyond the old conservative approach, which basically was sort of apathetic because they said, well, there was nothing we could do. And realizing that there is something we can do, but we have to do it very, very rapidly. And so, you know, a lot of our efforts now are trying to increase awareness that we have this available and to where, how patients can get this.

I mean, we've sort of dispersed this within the health care system, our health care system, and we've gone out and lectured to community physicians and different groups to try to let them know that this is a new era. We have the possibility, but we have to act fast.

37:00 Dr. Rani Banik
Absolutely, yes, and I think it's one thing to make eye providers aware, both eye care providers and health care practitioners, but patients need to know. I think the public needs to know. There's no way yet to really disseminate all this information unless there's a major public health campaign. So hopefully, in the future, there will be something like that. Perhaps someone will make a donation. And then that will be supportive of this type of an eye stroke campaign.

Well, I wanted to wrap up for today. I wanted to thank you so much, Dr. Rosen, for your valuable time. I know you're so busy seeing patients and doing research and traveling. And I heard you're getting an award coming up very soon. So congratulations on your award. But are there any last thoughts you'd like to leave the audience with?

38:11 Dr. Richard Rosen
Think of your vision as very precious. We have to, if anything is different in your appreciation of your world at any point, you know, you have to stop and check yourself and you can't rely on the fact that this will probably get better later. And it's better to have a false alarm and you know, then to, and the problem is, you call your provider, you may not be able to get an appointment, but we definitely have the service within the health care system. The patients can walk in with this and they should go immediately and not put it off because basically you have one shot.

39:17 Dr. Rani Banik
Yes, time is of the essence. So for everyone listening, don't wait. Get it checked out. It's not just a smudge on your glasses. It's not just you being tired. Have a low threshold of suspicion and get it properly checked out. So we'll thank you again, Dr. Rosen.

If anyone would like to reach out to you, maybe ask a question or refer a patient or perhaps go to see you as a patient themselves, how can they get in contact with you?

39:23 Dr. Richard Rosen
Well, they can get in contact with me through my office, which I have a service. The number is 212 -979 -4288. They can also reach me if they call the infirmary or the main healthcare line at Mount Sinai Healthcare System.

39:54 Dr. Rani Banik
Okay, wonderful. Well, thank you so much. We really appreciate your time, Dr. Rosen. Thank you.

39:56 Dr. Richard Rosen
Thanks, Rani. This was great. Thank you.

40:00 Narrator
Thank you for tuning into The Eye-Q Podcast™. We hope you enjoyed today's episode and learned something new to help elevate your Eye-Q.

If you loved what you heard, don't forget to subscribe. Leave a review and share the podcast with your friends. Stay connected with Dr. Rani Banik for more eye -opening insights on eye health, nutrition, and lifestyle. Until next time, keep your vision clear and your 'Eye-Q' sharp!