CATARACT SURGERY: Everything you need to know @MichaelRChuaMD

have you been diagnosed with cataracts or considering cataract surgery I'm Dr Michael Chua I'm a board certified ophthalmologist with Puente Hills Eye Care and in this video I'll discuss everything you need to know about cataract surgery I'll talk about how we plan for it how it's done risks of the procedure post-operative instructions and what to expect during the whole process by the end of this video I want you to know almost as much about cataract surgery as the eye surgeon doing it for you let's first discuss what cataracts are and what causes them so what are cataracts here's a cross-section of the eye and you can see that inside the eye is a clear lens whose job is to focus light on the retina the image is sent through the optic nerve to the visual cortex in the brain allowing us to see as we all get older the proteins within the lens can begin to Clump together and form deposits these deposits cause the lens to become cloudy and scatters the light passing through the lens this is a cataract and it's the scattering of Light which causes the symptoms usually associated with cataracts the visual symptoms that cataracts cause include cloudy or blurry vision decreased night vision seeing glares and Halos sensitivity to light and fading or yellowing of colors when should I get cataract surgery patients ask me every day when is the right time they should get cataract surgery well the primary factor that we eye doctors look out for is whether your cataracts are making it difficult for you to carry out the activities in your daily life like we mentioned before since cataracts can cause blurry vision and glare these visual symptoms can have a large effect on quality of life and when these symptoms are starting to affect a patient's daily life that's when we start having the conversation about planning for cataract surgery so for patients who are considering cataract surgery these are the types of questions I ask to gauge whether these cataracts are what we eye doctors call visually significant is your vision preventing you from being able to safely do your job and are you able to drive safely particularly at night is your vision causing any difficulty with chores at home like cooking doing yard work taking medications or walking up and down stairs are you having problems reading or watching TV if you've answered yes to any or several of these questions and a new pair of glasses still hasn't provided Improvement in Your Vision then talking with your ophthalmologist about cataract surgery would be a good Next Step okay so you have a cataract and it's visually significant now let's talk about the cataract surgery evaluation your eye doctor will perform a thorough cataract evaluation during your visit with them during this appointment we'll perform a series of tests including an auto refraction in which a computer scan gives us an estimate of your refractive error such as if you're nearsighted farsighted or if you have astigmatism we'll also perform biometry by using specialized equipment such as the iol master to measure the size and shape of the eye this will allow us to pick the correct power lens to implant for you during surgery we'll also perform Optical coherence tomography or OCT which is basically a scan through the retina which allows us to check for retinal diseases like macular degeneration or Epi retinal membranes which can affect your vision and even after cataract surgery we'll also check your visual Acuity your eye pressure and perform a full dilated fungus exam of your eyes to screen out any other conditions that can affect your surgery or your vision during your exam we'll also grade the severity of your cataract with grade 1 being mild grade 2 being medium grade 3 severe and grade 4 very severe after your examination we'll talk to you more about what cataract surgery entails as well as the benefits and the risks of surgery so we've been talking about cataract surgery quite a bit now but how exactly is it done well we perform cataract surgery at an ambulatory or outpatient surgery center meaning you go home the same day of surgery no need for an overnight stay we give you topical anesthetic eye drops to numb the eye and an anesthesiologist gives you light sedation to relax you during the procedure we then position a microscope over the eye and make small one to two millimeter incisions into the cornea we use special instruments and probes to break up the Cloudy lens into small pieces which are then suctioned out of the eye once the Cloudy lens has been removed an artificial lens called an intraocular lens or iol is inserted to the eye to replace the natural lens the iol is made of a clear plastic material and is designed to focus light onto the retina allowing the eye to see clearly again like with any medical procedure we should discuss the risks and benefits of cataract surgery the primary benefit of cataract surgery is improved Vision this improved Vision translates to improved quality of life because that improved Vision will allow you to complete your daily activities more easily that clearer vision will also allow you to appreciate the fine visual details all around you like your HDTV the faces of your family and friends or just your local environment the other benefit of improved vision is safety with better Vision you'll have improved death perception allowing you to navigate stairs and Corners throughout your home more safely many patients also mention that they feel much more safe driving after cataract surgery with the improved Vision you'll also be able to more easily do whatever work or chores you need to do and you'll be able to enjoy your hobbies a little bit more okay now that we discussed the benefits of cataract surgery it's also critically important that you understand the risks of the procedure I'm about to go through a comprehensive list of risks of cataract surgery but it's important to remember that cataract surgery remains one of the most well tolerated and safest surgeries that exist in the world today one of the most common side effects of cataract surgery is dry eye disease a meta-analysis published in 2022 looked at all the previous studies on dry eye disease after cataract surgery and found that 37.4 percent of patients who receive cataract surgery develop dry eye within the first few months after surgery now the majority of these patients responded well to treatment with artificial tears and the researchers found that dry eye symptoms and severity returned back to pre-surgery levels on average one to three months after surgery the researchers also identified risk factors for developing dry eye after cataract surgery they found that female patients as well as patients with a history of autoimmune disease diabetes thyroid dysfunction as well as patients who took systemic antihistamines all had increased risk of developing post-operative dry eye I think post-operative dry eye is particularly important because even though it's the most common adverse effect of cataract surgery it's often not discussed many patients will say they feel gritty Sandy foreign body sensation in the eye after surgery which is probably a combination of the corneal incision healing as well as some post-operative dryness but again most patients return back to their Baseline status a few weeks to months after surgery the next thing we look out for after cataract surgery is infection or endophthalmitis the reported rates in the medical literature are post-operative eye infections are in the order of about one in one thousand which is quite rare injecting antibiotics into the eye at the time of cataract surgery has been shown to decrease the rate of infection so that's exactly what all of our surgeons do at the end of each cataract surgery in our practice it's very important after surgery not to rub your eyes and to wash your hands before using your eye drops if you were to have an eye infection or end optimitus after cataract surgery we would have you see one of our retina colleagues who would inject antibiotics into the eye to fight the infection okay the next complications to discuss are retinal tears and retinal detachment the medical literature such as this 2022 population-based study from Sweden report a 0.5 percent incidence of retinal detachment after cataract surgery about a one in 200 risk many other previous studies report similar rates and the most common risk factors for retinal detachment after cataract surgery are male sex younger age as in less than 60 and longer eyes the theory is that patients who are older than 60 they more likely have already had what's called a posterior vitreous detachment in which the vitreous or the jelly inside the eye has already naturally detached from the retina but in younger patients this process might not have occurred yet and if it hasn't occurred yet it commonly does after cataract surgery and as that vitreous detaches from the retina there's always a risk of causing a retinal tear and subsequent Detachment and this risk of retinal detachment is increased in patients who are more nearsighted such as a prescription bigger than -4 minus five because they have longer eyes and because they have longer eyes their retina tissue is stretched out over a larger surface area and that thinner retinal tissue has a higher risk of tearing and detaching rental detachments are serious complications and would require additional surgery but thankfully they are quite rare after cataract surgery and while we're on the topic of victory's detachments and retinal tears one common symptom patients see after cataract surgery are floaters now it's possible that the floaters were there prior to surgery but after surgery since the vision is clear patients might notice them a little bit more the other possibility is that after surgery the patient might have experienced a posterior vitreous detachment or again the jelly coming off of the back of the eye causing the development of new floaters in most cases these floaters go away over the course of a few months in some cases though it's possible that the floaters stick around for longer the next complication to be aware of is posterior capsular tears once we're in the eye sometimes we find that the capsule or the structure that holds the lens is weak or for whatever reason it breaks during surgery sometimes when this happens we may need to change the lens we put in the eye or put it in a different location for example in front of the capsule instead of inside of it there's also a chance if the capsule is not fully intact that it may be safer to stop the surgery before the entire cataract is out have the eye heal up a little bit then have a retina colleague come in at a later time to fully take out the Cataract when this happens the recovery time can be a little bit longer but usually the vision still ends up very clear after surgery the rates of posterior capsule of Tears according to the medical literature is around one percent but it's also dependent on variables such as the density of the Cataract history of eye trauma or previous eye surgery in the operative eye the next possible thing that can happen after cataract surgery is retinal swelling or cystoid macular edema this retinal swelling usually occurs within a few months after surgery and is more common in patients who have risk factors such as diabetes history of retinal disease or history of inflammation in the eye it usually responds well to treatment with steroid or anti-inflammatory eye drops posterior capsular or pacification or PCO is another condition which can occur after cataract surgery in PCO the back or posterior part of the capsule becomes cloudy this cloudiness can cause blurry vision if you've had cataract surgery and you notice over months or even years after surgery that the vision is slowly starting to get more blurry go see your ophthalmologist and they can check for posterior capsular or pacification treatment for posterior capsular pacification involves a laser procedure called a yag laser capsulotomy in this procedure we use a laser to create a small opening in the posterior capsule to allow light to pass through more easily this procedure is typically quick and relatively painless and it can improve Vision significantly one last possibility after cataract surgery I'll discuss is that the lens may not be providing the desired Vision some patients May notice that the vision after surgery is not quite as crisp as they wanted the surgeon may consider switching out the lens to a different one that may provide better vision for you patients with a history of Lasik PRK or radial keratotomy have a higher risk of this occurring our formula is to choose which intraocular lens to implant into the eye are a little bit less accurate for patients who previously have had vision correction surgery because the cornea of patients who have received these surgeries has been reshaped since LASIK or PRK involves removing thin layers of tissue from the cornea to reshape it it's a bit more difficult to accurately measure the eye and determine in the appropriate lens power for cataract surgery we have special formulas to help us choose the correct intraocular lens for post-lasic corneas but still there's an increased risk of a refractive surprise meaning some leftover nearsightedness or farsightedness after cataract surgery I know we discussed a lot of potential complications but remember cataract surgery Still Remains as one of the safest and most well tolerated surgeries that exist several studies in the medical literature state that about 95 percent of patients are satisfied with the procedure and were recommended to others but like anything else in medicine and especially in surgery a perfect outcome after cataract surgery is not 100 guaranteed okay now that we've covered the risks and benefits of the procedure let's talk about the different available lens options I've discussed lens options for cataract surgery in depth in a previous video that you can watch here but let's review them briefly now there's three important Concepts to discuss first before discussing the different lens options the first topic is accommodation and presbyopia when we're all younger such as in our teens and 20s our eyes have the ability to autofocus so for example if we're looking at something far away then we want to focus on something up close look what happens to the lens inside our eye the lens it's flexible it's able to change its shape so that we can keep the close objects in Focus throughout the day the lens is constantly changing its shape so that we can keep everything in Focus this process is called accommodation as we all age though we lose the stability of autofocus or accommodation this is called presbyopia most people begin to develop presbyopia around age 40 and that's why as we all get to our 50s and older we start needing reading glasses to see things up close the second concept to understand is visual zones it's useful to think about our visual World in three visual zones the near Zone consists of the visual field about one foot away things that we usually do in the near Zone include using our cell phone or tablet looking at the food on our plate reading a book menus or prescription bottles Hobbies such as arts and crafts sewing or knitting the intermediate Zone consists of things that are about two to three feet away everyday activities using intermediate Vision include computer or laptop use putting on makeup or looking at the mirror looking at the speedometer or GPS while driving a car looking at items in the grocery aisle and cooking the distance zone comprises of objects further away about five feet and further things that we use our distance vision for include looking at street signs particularly when we're driving watching TV or movies reading the chalkboard or the whiteboard in front of the class and outdoor activities like hiking or playing sports when we're younger we're able to maintain everything in Focus because we still have our ability of accommodation so if you wanted to watch TV then look at your phone there's no problem however when we're older we lose this ability this photo simulates what that's like notice we have the distance Zone in Focus but now our intermediate and near zones are blurry this is why an eye doctor May prescribe bifocal or progressive glasses which have special stronger lens Powers towards the bottom of the lens allowing you to see things up close the last concept we'll discuss is astigmatism astigmatism is when the surface of the eye or the cornea is irregularly shaped usually the cornea is supposed to be round like a ball but in some people the cornea is shaped more like an egg which causes blurriness and Distortion of vision there are special lenses that can account for your astigmatism allowing you to see more clearly and I'll discuss them in the next section okay now that we understand these Concepts let's review the different lens options for cataract surgery the first lens is the monofocal lens this basic single Focus lens optimizes vision for one zone most people choose to have their lens set for distance Vision but since they can only provide one zone of vision you'll need one or two pairs of glasses to see near and intermediate objects some patients particularly those with a history of myopia or nearsightedness are those that do a lot of near work like reading books and knitting may prefer to have their focus set to near Vision than wear glasses for intermediate and distance Vision the pros of these monofocal lenses are that they provide crisp Clear Vision for one visual Zone and they're covered by Medicare and private insurance the cons are though that you'll require one or two extra pairs of glasses for the other visual zones for example if you set your vision to distance you'll need glasses for near and intermediate Vision the next option for lenses is monovision monovision is when one eye is set for distance and one eye is set for near decreasing your dependence on reading glasses with some time the brain adapts and is able to blend the vision from both eyes together giving you a larger range of vision monovision is usually done using monofocal lenses although some eye surgeons also aim for a little bit of monovision with multi-focal or extended depth of focus lenses which we'll discuss next the pros with the monovision approach is that you'll have a larger range of vision and a decreased dependence of needing reading glasses the cons though is because the focus points of the eyes are different you may have difficulty with 3D Vision and death perception some patients may also not be able to adapt to the Blended Vision so we may recommend to do a trial of the Blended Vision with contact lenses first to see if it's a good option for you the next type of lenses consists of multifocal or extended depth of focus lenses these special lenses are able to provide a range of vision allowing you to see in two or in some cases all three zones of vision some examples of lenses in this category include the symphony and vividi lenses which usually provide distance and intermediate Vision or the Synergy and the panoptix lens which can provide distance intermediate and near Vision the pros of these lenses is that since they deliver a larger range of vision there's a decrease dependence on reading glasses that sounds great right we now have these lenses that help you decrease your dependence on reading glasses so you don't necessarily always have to carry one or two pairs of glasses on you well there are some trade-offs with these lenses that you need to be aware of one is the lenses can produce rings around lights and these might be more noticeable at night while you're driving there can also be decreased contrast sensitivity or sharpness particularly in low lighting conditions despite these trade-offs these lenses have a high satisfaction rate with 95 to 97 of patients who receive multi-focal or extended depth of focus lenses they choose to have the same lens implanted again but the thing to remember with these lenses are that there may still be some instances where you might need to wear reading glasses particularly for very small print up close or in dark lighting conditions for the majority of the time though during regular everyday activities you'll be fine without glasses the next set of lenses toric lenses are for patients who have astigmatism the purpose of the toric lens is to account for the stigmatism in the cornea allowing light to be more effectively focused on the retina providing clearer vision during cataract surgery we're mostly working on the lens inside the eye so we aren't significantly changing the shape of your cornea therefore if you have a stigmatism before cataract surgery and if we don't put in a torque lens or do a cornea procedure to account for your astigmatism you'll still have blurry vision at all distances and will need glasses to correct your astigmatism all of the above lenses mentioned previously have torque options the pros with these lenses is that they provide crisp vision and patience with astigmatism and a decreased Reliance on glasses the Cons with these lenses is that the surgical process is a little bit longer to line up the lens but an experienced cataract surgeon can do that for you the last type of lenses I'll cover are the light adjustable lenses these are a newer class of lenses in which the power of the lens can be adjusted in the office after it's been implanted basically how it works is we perform a typical cataract surgery and during surgery will implant a light adjustable lens after the surgery you come into the doctor's office for several visits and receive light treatments in the office to adjust the power of the lens so that you can set the focus where you want it these light treatments can also dial in astigmatism correction into the lens to account for any astigmatism depending on your preferences this might require two or three different adjustments until you get that Focus to a point you're satisfied with after you settle on a lens power that you like you then come in for an additional visit for another light treatment to lock in the power of the lens so with the light adjustable lens you're looking at around three to five visits post-operatively to dial in the power of the lens and since you're receiving a special light adjustable lens and receiving several additional light treatments that require quite a bit of time and expensive equipment to deliver the light treatment the light adjustable lenses are usually the most expensive lens options that surgeons offer for cataract surgery okay now that we discussed lens options for cataract surgery let's discuss phenthosecond laser during femtosecond laser assisted cataract surgery your eye surgeon uses a laser to create precise computer-controlled Cuts in the eye doing regular manual cataract surgery we usually perform a capsolotomy meaning we open the front capsule of the lens using a needle and sharp forceps this opening in the front of the lens allows us to insert our instruments into the lens to suck out the Cataract the laser as opposed to a handheld needle is able to make a perfectly centered perfectly sized round capsulotomy in the front of the lens this precise opening in the capsule helps to make sure we have a perfectly centered lens in the eye at the end of the surgery this is particularly important for toric and multifocal or extended depth of focus lenses because they need to be precisely centrally placed to work correctly the laser is also able to subdivide and soften the Cataract making cataract removal easier for the surgeon lastly the laser is also able to correct a small amount of astigmatism by making small incisions in the cornea for routine cases of cataract surgery pentosecond laser is not necessary many Studies have shown that safety outcomes for both regular manual cataract surgery and laser-assisted cataract surgery are similar there are certain cases though where femto second laser surgery is especially useful for example for multifocal or toric lenses where lens centration and precise positioning is critical to crisp Vision laser is also helpful for higher risk cataracts such as those more difficult or severe grade three to four cataracts that's because these tougher cataracts of require more manipulation and energy to break down the Cataract and to remove it from the eye the laser makes this process Easier by subdividing and softening the Cataract okay now that we've discussed the different lens and Laser options for cataract surgery let's talk about what to expect on the day of surgery you'll want to coordinate transportation to and from the surgery center before your surgery date because you won't be able to drive yourself home after the procedure as you'll still be under the influence of anesthesia in preparation for the anesthesia you'll receive for surgery on the morning of surgery you'll want to be NPO NPO is an abbreviation for the Latin phrase nil per us which means nothing by mouth this means no food or drink the morning of surgery generally you can take your regular medications though with a small sip of water are since there's a low risk of bleeding with cataract surgery patients usually don't need to stop taking blood thinners prior to cataract surgery however doctors May instruct patients to stop blood thinners if the cataract surgery is combined with another procedure such as a glaucoma surgery it's best to discuss with your doctor if you have specific questions regarding your medications and cataract surgery you also don't want to wear any makeup lotions creams perfume or aftershave the day of your surgery on the morning of surgery you'll come to the Ambulatory Surgery Center about an hour before your scheduled surgery time this allows enough time for you to complete your registration at the front desk and also to get situated and ready for surgery after registration at the front desk you'll be brought to the pre-operative area where a nurse will ask you about your medical history medications allergies as well as measure your Vital Signs such as your blood pressure and your heart rate they'll confirm which eye is receiving surgery and you'll complete a consent form for the surgery the nurse will also give you dilating eye drops numbing eye drops as well as antibiotic eye drops lastly they'll insert an IV which the anesthesiologist will later use to give you medications and of course don't forget the hair net at our Surgery Center you won't need to change into account so wear comfortable clothing when you're ready for surgery you lie on a wheeled Gurney or a stretcher if you'll be receiving a torque lens your eye surgeon will use a marker or other tool to make a few small marks on your cornea which they'll use later to align your toric lens during surgery If you're receiving laser assisted cataract surgery you'll first be brought to the laser machine we'll make sure you're properly positioned during the laser and during cataract surgery it's very important to keep your eyes and head nice and still you'll be instructed to look straight ahead at a few blinking lights while we position the laser dock onto the eye once everything is in place we perform the laser procedure which usually takes around 30 seconds after the laser procedure you'll be transported to the operating room if you're not receiving the laser procedure you would skip that previous step and be brought straight into the operating room instead once you're in the operating room you'll basically have a pit crew of technicians nurses your anesthesiologist and your surgeon to get you and your eye ready for surgery we'll use tape to help remind you to keep your head still during surgery we'll connect you to heart monitors and oxygen sensors so that we can keep track of your vital signs during surgery your anesthesiologist will give you light sedation to get you nice and relaxed for surgery it's not full general anesthesia you won't be totally knocked out and there's no breathing tube but sometimes we'll give you some oxygen via nasal cannula a nurse will then thoroughly clean the eye using Betadine solution we'll then cover your body and your face with sterile drapes after we've scrubbed our hands and we're properly gloved and gone we position a microscope with an obnoxiously bright light over your eye then we perform the surgery after the surgery we put some ointment on the eye then cover it with an eye patch and a plastic Shield you go home to rest and then we see you in the office the next day there are some important post-operative instructions you should be aware of we send you home with a pair of sunglasses on the day of surgery they're going to come in handy because a lot of patients notice that their vision is a lot brighter after cataract surgery that's because they've adapted to slightly dark Envision through a hazy Cataract and suddenly after that cataract is at and replaced with a clear lens everything is much brighter and for some it might actually be a little bit uncomfortable so I recommend using those sunglasses whenever you go outside at least for the first two weeks to help you while you adjust to The Brighter Vision those sunglasses also protect your eyes from any debris pollen or wind in the environment when you go outside as an eye doctor I generally recommend everyone wear UV blocking sunglasses whenever they go outside anyway post-op or not so I think it's a good habit to have we also give you a clear plastic Shield after surgery I recommend you place the shield over your eye at night before sleeping for one week we also give you tape so you can keep the shield there while you're sleeping this Shield helps prevent you from accidentally rubbing your eye on your pillow while you're sleeping you don't need to do any special head positioning it's okay to sleep on your side on your back however you normally sleep after surgery I also recommend some activity restrictions after surgery I recommend no heavy lifting as in nothing over 15 pounds no bending at the waist and no strenuous exercise that involves a lot of bouncing for two weeks I also recommend no eye rubbing and no splashing water directly into the eye no swimming or hot tubs for two weeks you can shower you can wash your face and you can wash your hair starting the day after surgery but you either want to turn your head away from the water in the shower or just gently close the eye that receives surgery when washing this is all just to prevent soap and water and bacteria from getting in contact with your healing eye I also recommend no eye makeup for two weeks after the surgery a lot of patients also ask me about cooking after surgery I recommend that patients take a break and let others cook for them at least for the first two to three days after surgery after that you can ease back into cooking but the same rules apply no heavy lifting for example a large pot of water and avoid bending at the waist for the first two weeks also you want to make sure to avoid any steam or debris getting into your eyes while you're cooking in terms of going back to work sometimes it depends on exactly what you do for work and how you're healing but generally most patients can return to work within a week after surgery patients also ask me about driving after cataract surgery in California at least the DMV screening standard is vision of 20 40 or better in at least one eye this is one of those case-by-case situations and I'd recommend discussing with your eye doctor before going back to driving after your surgery if the surgery went smoothly and patients are feeling and seeing great that you can usually return to driving as soon as one or two days after surgery other tips I recommend are to make sure to wash your hands with soap and water whenever you use your eye drops or if you put your hands anywhere near your eyes there are some symptoms you can expect after surgery you'll have a little bit of eye discomfort grittiness dryness itching and irritation as that corneal incision is healing your eye may also be a little bit red and your vision may be a little bit blurry for the first few weeks after surgery you may also have some mild swelling around the eyelid and also you might notice some new floaters you may also have some grogginess or nausea from the anesthesia these symptoms are generally normal and usually improve after a few days or maybe in the case of floaters over a few months there are some symptoms though that are concerning and you should let your eye doctor know immediately if you're feeling any of the following severe pain headache or extreme pressure around the eye a sudden decrease in Vision worsening redness in the eye continued sensitivity to light after a few days or a sudden increase in lots of floaters are seeing flashing lights or if you see a shadow or shade appearing in your field of vision these particular symptoms may be a sign of early complications such as high intraocular pressure infection or retinal tears and Detachment and should be treated as soon as possible so make sure to contact your eye doctor if you have any of these concerning symptoms the last subject we'll talk about is the recovery of your vision after cataract surgery most people see better one to three days after surgery but it could take four to eight weeks for the cornea and eye to stabilize and fully heal after surgery everyone heals at different rates for example patients with a history of diabetes generally take a little bit longer to heal and patients are out by history of radial keratonomy sometimes require three to four months before the cornea and refraction stabilizes we usually recommend patients wait at least four to six weeks before getting checked for a new pair of glasses after surgery this is because the prescription of your eyes may be changing slightly for the first few weeks after surgery as the eye is healing okay so that was a thorough overview of everything to expect before during and after cataract surgery I hope this video covered a lot of the most common questions you may have regarding cataract surgery if you find this information helpful please give us a like And subscribe to the channel for future updates and if you live in the Los Angeles Orange County or Inland Empire area and are interested in the Cataract evaluation feel free to visit our website or give our phone number a call to make an appointment today and if you made it to the end of this video that probably means that you're really interested in Eye Health and have the motivation to improve and preserve your vision you can watch my video here to learn more about the best ways to slow down the progression of cataracts I'm Dr Michael Chua with Puente Hills eye care see you next time

Channel: Michael Chua, MD

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Length: 31min 3sec (1863 seconds)

Published: Thu May 04 2023