to-the-point
To The Point
Episode 6

A Crash Course on Scleral Lens Fitting for Dry Eye

Unsure of when to use scleral lenses for dry eye? Not sure where to start? Hosts Leslie and Jackie talk with guest Melissa Barnett, OD, FAAO, FSLS, FBCLA, about the benefits and challenges of fitting these lenses in patients with various ocular surface conditions.

Leslie O'Dell: 00:06 Ocular surface disease, it's complex, chronic, and progressive, but rife with opportunity for the enterprising optometrist.

Jackie Garlich: 00:14 The mission of this podcast is to make this condition more understandable and accessible to those interested in specializing in it, so let's get To the Point.

Jackie Garlich: 00:25 Hello and welcome to another episode of To the Point podcast. I'm Jackie Garlich, and I'm joined by my cohost, Leslie O'Dell, and a third super exciting person, Dr. Melissa Barnett. If you are listening to this podcast, you have an interest in dry eye, so you likely know who Dr. Barnett is, but I'm going to be her hype girl for a second and tell you how incredible she is.

Jackie Garlich: 00:50 So, Dr. Barnett is the principal optometrist at UC Davis Eye Center. She has published multiple papers on the use of scleral lenses and keratoconus. She is the past president of the Scleral Lens Society, and a Fellow of the British Contact Lens Organization. She is also an award winner, and I wanna highlight a couple of them. She received the Theta Award for Excellence for Mentoring by Women in Optometry, and she was awarded the Young Optometrist of the Year by the California Optometric Association.

Jackie Garlich: 01:22 So, we are so very happy to have Dr. Barnett on the podcast today to talk about the use of scleral lenses in the setting of dry eye. Welcome Doctor Barnett, thank you for being here with us.

Dr. Melissa Bar...: 01:35 Thank you so much for the kind introduction.

Jackie Garlich: 01:37 First of all, Leslie, do you fit scleral lenses?

Leslie O'Dell: 01:40 So, when I was at the Dry Eye Center of Pennsylvania, there were some of the doctors in the practice that had a big interest in, RGP and scleral lenses, so it was kind of like I referred to them, and it's something that I need to build, so I'm actually really excited to have the conversation with you as well today, Dr. Barnett. So, we're sort of both novices when it comes to scleral lenses, so you can really share your knowledge here with us.

Jackie Garlich: 02:06 I did, it will be great to kind of talk to you about this too because I did fit scleral lenses, at my other office, when I was in an ophthalmology group, I fit a lot of scleral lenses, but I really hated it in school, and so I grew to love it because of how amazing scleral lenses can be for a patient, and how like life change they can be. But I do feel like I taught myself a little bit on how to do scleral lenses, 'cause I disliked it in school, and I sort of liked it after I graduated, which was like an unfortunate timing situation, but so maybe we could like... I was hoping today we could just talk about when to use a scleral lens for dry eye, and for those that are new to scleral lenses, like how to start with that. So maybe we could talk about like the when, like when you would offer that to a patient. That seems like a good-

Dr. Melissa Bar...: 03:00 Sure.

Jackie Garlich: 03:00 ... starting point.

Dr. Melissa Bar...: 03:01 So I'm very interested why you hated scleral lenses in school?

Jackie Garlich: 03:05 You know what, this was like... I hated it because I felt it was hard. (laughs) That sounds really bad, but you know when you don't feel like you're good or confident as something, you're just like... like math for example, you know, if you're like, "I'm just not good at math. I really don't like math." It's really just like you're maybe just need to be better at it, but I felt like insertion, removal with a patient was like so challenging, and it really all became because I wasn't good at it myself, you know, and so then I just wasn't as confident in it. But, I don't know what changed my mind really. I mean, I started at that ophthalmology group and so I was like I had to fit scleral lenses there. (laughs) So that started it-

Dr. Melissa Bar...: 03:45 [crosstalk 00:03:45] your chair, and you had to fit scleral lenses.

Jackie Garlich: 03:46 Right, exactly. And then I had this like wonderful experience with this like, one of my very first patients I fit, she was like horrible vision, she was in this car accident, and, you know, I ended up fitting her with a scleral lens, and her vision was so much better, it like literally... I mean, she had vision- terrible vision in both eyes, and so when I fit her in a scleral, it was like I was crying, her mom was cry- like it was such a great experience that I was like, "Oh, I'm all in on scleral lenses. This is amazing."

Dr. Melissa Bar...: 04:12 Scleral lens fitting is really intuitive. So, you're lucky that you had scleral lenses in school, so I graduated about 20 years ago, and I was at the point where, yes, scleral lenses were around because in the 1980s with gas-permeable materials, and sorta the resurgence of scleral lenses, they existed, but we didn't have them in school at that time. And so, actually how I got into scleral lenses was in practice when I joined UC Davis working with three corneal specialists in a large referral practice, I saw the need for this technology. And you're exactly right, you know, we have these patients on a daily basis where you are helping not only the patient, you're helping their families, and their children, and just so- improving their quality of life so much, it's absolutely amazing. And so, yes, I've been there crying- (laughing)

Jackie Garlich: 05:10 Mm-hmm (affirmative).

Leslie O'Dell: 05:10 (laughs)

Dr. Melissa Bar...: 05:11 ... along with my patient. I- you know, I have a fit at 8 o'clock and 10 o'clock, and it's always the worst when it's the eight o'clock patient, and I'm crying, they're crying, everyone's crying.

Leslie O'Dell: 05:23 (laughing)

Dr. Melissa Bar...: 05:23 Then I tell my staff, "Oh it's- it's so amazing and life changing,” and try to keep it together the rest of the day.

Jackie Garlich: 05:27 Yeah.

Jackie Garlich: 05:29 (laughing)

Dr. Melissa Bar...: 05:30 It is, you know, it's life changing, and seeing some of my patient even recently, and seeing them back, and you know, they're telling me how much the technology is helping them. So then getting to your question, you know, when do you use a scleral lens for dry eye, it is at a point where you have tried some other things. So according to DEWS II, scleral lens therapy is tertiary therapy. So here I'm talking about someone with, say, moderate dry eye. So they've tried some preservative-free artificial tears, ointment, prescription eyedrops. Scleral lenses come before any surgical therapy, so surgical punctal occlusion, tarsorrhaphy, and they're in that sort of third step when you're treating someone for ocular surface disease and dry eye.

Dr. Melissa Bar...: 06:24 Now, a lot of the patients I see have severe dry eye, they have Sjogren syndrome, graft versus host disease, Steven-Johnson, they've tried everything already, (laughs) and now it's time for scleral lenses. And these patients are so incredibly appreciative, and one of my goals in life, thank you for having me on this podcast so we can share it, is really to share with all rheumatologists that scleral lenses exist, you know, that it's an option for our patients. These are patients where you put the lens on, and the patient instantly has that sigh of relief. Like, "Ugh. It- this is wonderful. This is amazing." And I have so many patients with Sjogren syndrome where scleral lenses are beneficial. A lot of those patients are in multifocal scleral lenses as well just to help, you know, their presbyopic, to help their near vision.

Dr. Melissa Bar...: 07:20 Of course, I do have patient who have Sjogren's who are not in scleral lenses, but they're really this life-changing technology. You know, we know that these patients can be suicidal because their dry eye is so severe, and just having this little piece of plastic that can help them function, and do whatever they wanna do, and enjoy their time with their family, and their friends, and their work. It is incredibly rewarding.

Jackie Garlich: 07:45 It- yeah, I mean, I do love sclerals for that. It really can change someone's life, honestly. I mean (laughs) like you said, there's patients- I mean, even those post-LASIK patients that there's been several news stories about people just with intense pain or dry eye, and I mean, these people have options, you know? So that's wonderful. So, if you're wanting to start and like get into scleral lenses, what do you recommend starting with?

Dr. Melissa Bar...: 08:16 Sure, so there're a lot of great resources, so live workshops are the best, so if you can have a patient, and even, you know, these can be done in your practice, many companies will come in and do them free of charge in your practice. If you have the patient in your practice, and you're fitting them with lenses, you can see first-hand how great this technology is. Now, there are workshops that we do at all sorts of meetings around the world to teach practitioners and staff too, because that- the staff component is really important, how to handle scleral lenses. And the Scleral Lens Education Society of course is a wonderful resource, the Gas Permeable Lens Institute. There're many webinars and videos on how to fit scleral lenses at this time, and of course there are books and guides, such as Contemporary Scleral Lenses: Theory and Application. There's a clinical guide called the Clinical Guide for Scleral Lens Success, which can be downloaded in multiple languages.

Dr. Melissa Bar...: 09:24 And I would recommend starting with one or two fitting sets, and getting really comfortable with those to start. It can get confusing, there are many great companies out there, but the terminology's not exactly the same for each set at this time. We are working on that. So starting with one or two, evaluating your patient base, is it mostly dry eye? Is it mostly irregular cornea or is it normal cornea? And working with a company, using their lenses, and utilizing the fitting consultants who are really helpful, and they know the designs inside and out. And then, going from there, so I always say if you're on a desert island, and you have a scleral lens and an eye, and hopefully a slit lamp on your desert island-

Jackie Garlich: 10:10 (laughing)

Dr. Melissa Bar...: 10:10 ... you know, just put the lens on the eye, look at it, evaluate it, see how it fits, and then you can go from there. But the reason I asked why you didn't like scleral lenses in school-

Jackie Garlich: 10:20 (laughs)

Dr. Melissa Bar...: 10:20 ... is that I find that lens fitting is really intuitive, and once you, you know, see the patient with severe keratoconus and severe dry eye come in, I reach to my fitting set, and I go for the lens, and of course lenses are fit on sagittal depth not corneal curvature, and there're a lot of great technologies that we have too for these patients. So, don't be afraid. Get started, and if you're wondering, "Well, which company do I start with?" You know, look at what you do now. Do you fit corneal gas-permeable lenses with a certain company? You know, they likely have a scleral lens and wonderful consultants that can help you.

Leslie O'Dell: 10:59 So, what kind of testing do you need before you reach for the lens in your fit set?

Dr. Melissa Bar...: 11:05 So, there's a lot of advanced technology, such as scleral topography, you don't necessarily need that to fit scleral lenses. You can do a corneal topography or a Pentacam. I like to get some sort of information about specific elevations in the cornea. However, those who have, say, Sjogren syndrome, or even severe dry eye without a lot of corneal irregularity, their corneas are pretty normal. It's important to check the horizontal visible iris diameter, it's nice to see how much their cornea protrudes, if it comes out or not, and you know, and of course a slit lamp examination, checking the lids and lashes, the cornea conjunctiva, staining, of course prior to putting on a lens. But some people are really concerned because they don't have the fancy technology, and it's okay. It is still possible to fit scleral lenses very successfully.

Jackie Garlich: 12:04 That was, when I was fitting those, I had a corneal topographer is what we had, but I'll see, like, I will look at all these like pictures of people fitting scleral lenses, and then they have the scan of like you can see how that lens lays on conj, and like, I was like, "Oh, man, I don't have any of that." But you can actually do quite a bit with just your slit lamp beam as far as you know, guesstimating how much tear lake you have in there- you know what- you know what I mean?

Dr. Melissa Bar...: 12:35 Of course, you- if- if you have anterior segment OCT, it'll tell you exactly what that post-lens tear reservoir is, you know, it's 252 microns. However-

Jackie Garlich: 12:45 Right, right. (laughs)

Dr. Melissa Bar...: 12:47 ... if you're estimating it, and you say, "It's 250," that's okay.

Leslie O'Dell: 12:50 Yeah.

Dr. Melissa Bar...: 12:50 As long as it’s not touching the cornea. (laughs) You're really-

Leslie O'Dell: 12:52 Yeah, right.

Dr. Melissa Bar...: 12:53 ... you have a little room, you're fine. Some people use OCT for every single patient, and that's great. I use OCT as a problem solver or if I'm, you know, if something's not making sense, say it's Salzmann's nodular degeneration, and the patient is saying, "I feel the lens here, and it looks like it's clearing, but it's not." That would be an example. Or if it's a patient where I'm really trying to minimize the clearance for whatever reason just to prevent fogging or something like that, or if I want a closer look at the edge, so it's something that I have access to, but don't use on every single patient.

Leslie O'Dell: 13:35 So, in that patient with the Salzmann's nodular dystrophy, that has some lens awareness, is it- what is usually the problem that you find, you know, when you're using your anterior segment OCT?

Dr. Melissa Bar...: 13:47 I find in- that the lens is touching the nodule, because sometimes those nodules can be a little tricky, and so it's nice to have reverse geometry, or oblate designs, which we do have now, that are flatter centrally, and steeper peripherally, to vault over those nodules. So, the designs- scleral lens designs have improved so much in the last 20 years. It's absolutely incredible, and there are different designs that are based on research and studies, and now, we're moving into empirical fitting, where we can design off of the scleral topographers, and of course we have impression-based technology, like EyePrintPro, which takes a mold of the eye, and then a lens is made off of that. So, you know, some of my severe dry eye patients also have glaucoma, they could have a protruding bleb, or have had prior surgery, and an impression-based lens is really helpful for those patients.

Leslie O'Dell: 14:46 How long does that take to have manufactured, the impression type of lens?

Dr. Melissa Bar...: 14:51 Yeah, it can take a week or two, just like any other-

Leslie O'Dell: 14:54 Yeah, mm-hmm (affirmative).

Dr. Melissa Bar...: 14:54 ... lens design. So, the mold actually sent to the manufacturer, they scan it, and then a lens is made, within 2 microns.

Leslie O'Dell: 15:03 And so, when you're doing the fit, you know, with that patient initially, and you're ha- you know, and you are having this emotional response, do they then not get to leave with the lens that first day, and you have to order it and then you have to have a dispense, I guess, kind of exam?

Dr. Melissa Bar...: 15:19 Yes, at this time. It's very hard. (laughs)

Leslie O'Dell: 15:22 Yeah, I can imagine.

Dr. Melissa Bar...: 15:23 They want to leave with the diagnostic lens.

Leslie O'Dell: 15:26 Yeah.

Dr. Melissa Bar...: 15:27 But it does not provide a lot of oxygen, and would not be healthy to wear. But there are some companies that can rush lenses, so they get to me pretty quickly.

Jackie Garlich: 15:37 You bringing up oxygen kind of brings up a good point. Can you talk, about like oxygen transmissibility and specifically like the, you know, like the tear reservoir, like that was one of the things I was not totally clear on when I started fitting, like, oh, just- if we need vault, just like vault it a ton, and then we'll be like good, and that's also not the answer, you know, for fitting scleral lenses, but maybe could you touch on that, like the oxygen-

Dr. Melissa Bar...: 16:05 Sure. Sure, so, you know, there are a lot of highly debated topics of scleral lenses, and there's still a lot of unknowns. We don't have 50-year or 100-year research on scleral lenses. But hypoxia is a highly debated topic, so yes, I will touch on it. There are many theoretical models of what sort of clearance you should actually have. And whenever someone is fitting scleral lenses, I always like to know what they're fitting. So I'll tell you what I fit. So, I fit from a 15 mm from a normal cornea up to about a 21 for a very highly irregular cornea.

Dr. Melissa Bar...: 16:43 So, that's a very wide range. I would say the majority of patients can do really well in that 16 to 18 mm range. Now, when we're asking, you know, how much clearance do you actually want, it really depends on what you're fitting. So are you fitting a normal eye in a smaller diameter, I want less clearance, so it could be 100 to 150. If I'm fitting a really highly irregular eye, it could be much more. For that middle of the road, about 200, 250. But the patients who have keratoconus that you think might progress, if they have not had cross-linking, I do wanna fit those patients with a little more space.

Dr. Melissa Bar...: 17:28 Now, for many years, we were fitting patients with, you know, excessive, I would say, excessive clearance at this point prior to the studies, and many patients have really done just fine. But there are great new materials this year with a DK of 200, which is wonderful. So, for our patients who have had, say, a corneal transplant, those whose corneas are really fragile, I'm using this high DK material with great success, and so getting more oxygen to the cornea. Now, ways to kind of get the most oxygen, you can go smaller in diameter, however, for our patients who have dry eye, we wanna go a little bit larger because the scleral lens is gonna cover the cornea conjunctiva, the area that it covers, will be the area that it protects, and so we do tend to wanna go a little bit larger for those patients. We can of course reduce the sagittal depth, we can do that independently in most lens designs, we can even decrease the center thickness of the lens, and of course we can use really high DK materials.

Leslie O'Dell: 18:36 So tell me a little bit about your, you know, if you have a new patient that you're going to be doing scleral lenses on, how many visits does it typically take, and then once you have them where they need to be in lens, comfort-wise, you've ordered and dispensed that product to them, how often are you seeing them? I guess it- I guess that part may depend on what underlying disease you're monitoring as well. But just kinda walk me through a little bit of your typical, you know, patient care follow-up schedule.

Dr. Melissa Bar...: 19:08 Sure. So, I'll see a patient initially for a fitting, and the fitting could be done either diagnostically or empirically at this time, and then I'll see the patient back a few weeks later for the dispense and training appointment. And there are typically three to four visits, so we do pre-appoint all of these visits to make sure that the patient is fit successfully. So, in those, say, with dry eye and those I might be a little bit more concerned about, a typical follow-up could be 3 to 4 months, and a patient who has moderate keratoconus, for example, that I don't think is progressing a lot, a typical follow-up would be about 6 months. So, it really depends on the individual patient, it depends on their condition, it depends on, you know, how they're doing as well.

Jackie Garlich: 20:02 So, how does this person, this dry eye person, get in your chair to do a scleral lens? Is this a patient that you said, like, "We need to do this," or is this referred into you? What's- how does it work for you?

Dr. Melissa Bar...: 20:15 It's a combination, actually. So, I have a lot of referrals for dry eyes, so I work with our corneal specialist at UC Davis, I work with referring specialists from the greater area as well.

Jackie Garlich: 20:31 (laughing)

Dr. Melissa Bar...: 20:32 And I get a lot, yes, really trying to get, a lot of people in Nevada to fit- they're doing better- they're doing better for fitting scleral lenses. But I see a lot of patients from the greater area for dry eyes specifically for scleral lenses. So, this could be a patient who's tried sort of everything that has not worked, who comes to me. There are patients within my clinic as well, so since I see a lot of patients with Sjogren's, I talk to them about scleral lenses, I let them know that they exist.

Dr. Melissa Bar...: 21:05 I think it's important even to do an in-office trial of scleral lenses, just trying it on if you can, if you have that ability, because that gives the patient a really good idea, "Wow, this is really comfortable." And then they can go ahead. We do have an option as well to do like a trial fitting, which I think is helpful because maybe a patient is unsure if they want to even wear contact lenses at all, specifically scleral lenses. We do it- a fitting in the office, and they- there's no commitment, they can decide not to go with it, but that's another option there for our patient. So it's definitely a huge combination of the two.

Jackie Garlich: 21:52 Can you, like if you're fitting a patient for dry eye, and I understand this'll probably vary between patients, but how soon do patients really start to feel better when you're treating this dry eye patient with a scleral lens?

Dr. Melissa Bar...: 22:08 It really depends on the patient, so some can be-

Jackie Garlich: 22:10 Yeah.

Dr. Melissa Bar...: 22:10 ... within a day. They instantly feel better, um, others I'd say it takes a week or two, and then it is important for the patients to continue doing whatever they're doing, even when they're fit with scleral lenses, so continue eyelid treatments, continue prescription eyedrops, even with scleral lens use, of course prescriptions are used prior to scleral lens insertion, and after scleral lens removal. And one thing that's really important for our dry eye patients who wear scleral lenses are solutions. Actually, it's important for every single patient-

Jackie Garlich: 22:47 (laughing)

Dr. Melissa Bar...: 22:47 ... who wears scleral lenses, but especially those with dry eye because they can have a lot of surface debris on the lens, and so recommending specific solutions, like a specific hydrogen peroxide or multi-purpose solution, recommending specific solutions for application in the bowl of the lens, we have Nutrifill, ScleralFil, and LacriPure as FDA-approved options. And sometimes for these patients we wanna go a little thicker, a more viscous drop, like 2 drops of Celluvisc or Oasis Plus in the bowl of the lens with their scleral lens as well.

Jackie Garlich: 23:25 So this is a topic that is like not as fun to talk about, but the billing aspect of scleral lenses was one piece that I- we sort of struggled with at my other office getting the proper like reimbursements for the scleral lenses. Do- that is a whole other podcast probably that we could talk about maybe the billing, but do you have any like tips on that or good resources to like even help like the billing department when someone's gonna start doing that?

Dr. Melissa Bar...: 23:54 Sure. So, there's an excellent resource on the GPLI website about-

Jackie Garlich: 23:58 Mm-hmm (affirmative).

Dr. Melissa Bar...: 23:59 ... about billing and also charging for specific services. The National Keratoconus Foundation has great resources on letters to write to patients when they're asking for letter of medical necessity. But as far as billing, I agree, that would probably be another podcast.

Jackie Garlich: 24:21 (laughing)

Dr. Melissa Bar...: 24:21 However, I'll state, that we do bill for dry eye specifically under either their vision or their medical, and it is really important to obtain authorization prior to the patient coming into the practice for their condition. And also to know, you know, what is that specific diagnosis that you are billing, getting authorization for it, and informing the patient prior to the appointment. Of course, we do bill the fit and material as self-pay as well. That's the really short answer.

Jackie Garlich: 24:59 (laughs) I knew it was a loaded question, but... (laughs)

Dr. Melissa Bar...: 25:02 But an important one.

Jackie Garlich: 25:04 Yeah.

Dr. Melissa Bar...: 25:04 The one that we- that we work on every day.

Leslie O'Dell: 25:07 So Dr. Barnett, you are definitely the expert in the field, you've written the book about scleral lenses, so you're getting all these referrals from, you know, outside physicians in- you know, eye care providers and, I'm assuming, other type of providers, like you mentioned early on with rheumatology. But what tip would you have for, you know, the general optometrist that isn't you know, isn't the expert with scleral lenses getting these practices to really let them know that that service is available? 'Cause I think that sometimes that bridge between different professions can be a little bit challenging, even, you know, to make the relationship, did you go through like the Sjogren's Foundation or, you know, is it a work in progress?

Dr. Melissa Bar...: 25:50 So, yes, great question. There's a wonderful resource on the Scleral Lens Education Society. Now, membership is free for everyone, there's a fellowship program, please become a Fellow so I can refer my patients to you when they move.

Leslie O'Dell: 26:07 (laughs)

Dr. Melissa Bar...: 26:07 ... that's where I look to send patients. But on the Scleral Lens website, there's a specific section of information about scleral lenses with literature references that you can use. You can print this out, you can put it in a folder along with your bio, bring it to whoever you want to refer scleral lenses to you, the general ophthalmologist, corneal specialist, rheumatologist, oncologist, whoever it might be. And this is for many, many conditions, so that is the best way. And, you know, once you develop this relationship, you're gonna get more, and more, and more referrals, so that's really helpful.

Jackie Garlich: 26:50 So, one thing that I did wanna touch on is the Hydra-PEG, the- the Tangible Hydra-PEG. That came out, I think it was a couple of years ago now, am I correct in saying that? But that was like a big- a big game changer in scleral lenses. Can you talk about that?

Dr. Melissa Bar...: 27:08 Sure, so Tangible Hydra-PEG did come out a few years ago, and I started using it on patients who wore scleral lenses, and really, it's amazing. So, it's a surface coating on the lens, it reduces debris and deposits, it improves wettability, and it helps not only with the front surface fogging, but the post-lens tear reservoir fogging. So it's an amazing technology that is great for everyone, no fit changes or parameter changes need to be made, and really helps my patients with dry eye.

Dr. Melissa Bar...: 27:43 So prior to Hydra-PEG, I was using all sorts of extra cleaners for these patients, alcohol-based cleaners, like MiraFlow, Lobob Extra Strength Cleaner on their lenses, even Menicon Progent, a super duper cleaner, and the only tricky thing with Tangible Hydra-PEG is that you have to keep it simple-

Leslie O'Dell: 28:02 Yeah. (laughing)

Dr. Melissa Bar...: 28:03 ... so no alcohol-based cleaners, no abrasive cleaners, and just a simple hydrogen peroxide or multi-purpose and application solution, and of course not rinsing lenses with water because water's abrasive and it can remove the coating. So not only has Hydra-PEG been great for my scleral lens patients, but those corneal GPs I've been so incredibly impressed, and it's also available on hybrid and some soft cleanses.

Leslie O'Dell: 28:39 And now for the To the Point wrap-up. Thanks to Dr. Melissa Barnett for her great insights. Scleral lens fitting is rewarding to both the patients and the doctors. There are many great resources to help you get started. Some of them include ScleralLens.org, and a book written by Dr. Barnett.

Jackie Garlich: 29:01 The book is called Contemporary Scleral Lenses: Theory and Application, and she wrote this book with Dr. Lynette Johns.

Leslie O'Dell: 29:08 Really, the tips are don't be afraid to get your hands dirty, get started, and really make the difference for the patients we serve.

6/25/2020 | 29:35