What Is Binocular Vision Dysfunction (BVD)?

TRANSCRIPT

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Do you often feel dizzy? Does reading or doing any kind of close work, which requires visual focusing,

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leave you with a headache? Do you often bump into things and have trouble judging distances?

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You might be experiencing binocular vision dysfunction. If you want to learn more about the condition, don't click away,

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because today I'm speaking once again with Paul Graham. Paul is a leading Gold Coast optometrist with over 30 years of experience.

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He's also the owner of Harmony Vision Care. In this interview, we're going to be talking about BVD,

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how it's diagnosed and how it's treated. But first, who am I? My name is Paul Sallaway. I'm the owner of Optics Digital Marketing, an agency that helps independent

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optometrists to grow their practice. So hello, Paul. Good to see you again. Hey, Paul. Good to see you again.

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So there's been a lot happening since we last talked. So some major weather events happening on the Gold Coast there,

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but it sounds like you pulled through that reasonably okay. Pull through it okay.

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Yeah, we were quite fortunate. It was a lot worse for a lot of other people out there. All right. Well, binocular vision dysfunction.

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So to put this in layperson's terms. So if I have BVD, and I understand there are some different

1:23

types of that condition, but if I have some form of BVD,

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what symptoms would I typically be experiencing? Yeah, look, I think that's something that's

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important to understand is that BVD is a fairly broad term that we can then subcategorize into different parts.

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I like to break it into three types groups of symptoms. We've got what we call eye-related symptoms, performance symptoms,

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and spatial organization symptoms. And so if we're talking and we're not optometrists, and we want to talk about

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the symptoms that might make us go, that sounds like an eye problem. They're the eye-related symptoms. So things might be going blurry.

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The print might be moving around, I might get some sore eyes, some tired eyes. And even sometimes people might make the connection that their headaches

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seem to be triggered by doing near work. So a lot of those eye-related symptoms relate to doing concentrated work,

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particularly near reading screen devices, those sorts of things. Certainly, some eye-related symptoms could happen from BVD when driving

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and doing other things. The key part is it's when you're trying to concentrate. Your performance-related symptoms are those things, where again,

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if we use near work as an example, you might have trouble concentrating. You're finding that you get to the bottom of the page and have to read things again,

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or you feel like you've got to force your Self to focus. You might find that you're starting to avoid reading, just feeling

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tired at the end of the day. And so they're the kind of symptoms that you could blame on lots of other things.

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And that's the nature of BVD. Sometimes it goes unnoticed because you can't look at someone and go,

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oh, you've got BVD. And we call it a hidden vision problem a lot of the time. And if I'm talking to parents, then kids will sometimes divide

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into either more eye related symptoms category or more performance related symptoms. And the reasoning around that is that the kids who push on and keep engaged

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in the near work and the devices are more likely to get the direct eye strain and blur because they keep pushing and pushing until you hit that point.

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Whereas performance related symptoms are almost like that subconscious trying to back out of the work or escape from it.

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so you don't push yourself to the point where you get physically uncomfortable in your visual system.

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You tune out instead And then if we get to the third group, you've got

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your spatial organization symptoms. So this starts to become beyond just what's happening with near work.

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So you might have trouble perceiving or judging depth. So And that's going to result in adults might complain that they don't

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judge parking in the car very well. They don't like busy roads because they can't be completely sure

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where the other cars are. They might trip upstairs, bump into people a lot, bump into doorways is a common one.

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And you can also get people who might get some dizziness or vertigo. And that's because what I like to talk to people about is our spatial,

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our triangle of understanding where we are in space is the coordination

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of our binocular vision. So that's our whole visual field, two eyes working together to create one

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stable image of the world out there. And that needs to communicate with your balance systems here.

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And it also needs to coordinate with your brain's understanding of where

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your head is relative to your trunk and the rest of your body. So it's your body awareness from feet up.

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But effectively, we like to talk a lot about the head positioning because we use our head and our eyes together as part of looking.

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And if you have any difficulties matching the information between those systems,

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then you get this vertigo or dizziness response. And the way I like to explain it to my patients, it's almost your

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brain's way of saying, will you stop? Because I'm not sure of the world out there. And if I make you dizzy or get vertigo, then you start to freeze your movement

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so that your brain can protect itself. And so you can get that wide scale of symptoms anywhere from eye strain

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right through to, for some people, debilitating dizziness and vertigo in extreme cases.

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Let's talk about headaches for a second, because people experience all different types of headaches.

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Sometimes, not so much these days, but I used to get headaches at the back of the head, but I think that was more of a posture thing and maybe

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not sitting properly. But with people who have binocular vision dysfunction, does that headache

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manifest itself in a particular way? Yeah, the classic eye-related headaches are typically frontal, along the front,

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behind the eyes, can be the classic one. You're right, the back of the head headaches are often from neck and posture.

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They can sometimes refer through to an eye pain. And so I'll often get into the nitty-gritty of what

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does the eye pain feel like? And that's where I'll often make a referral to a physiotherapist or some other physical therapist, osteopath, chiropractors, depends on what the

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patient's preferred modality is, because they are often referred pain. But you can indirectly get some neck tightness and neck pain

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from a focusing problem. There's been plenty of studies to show that when you force your eyes to work, your neck muscles tighten.

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So over time, this back of head headache can be a combination of being frozen

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in your posture doing near work, but also because you're forcing your eyes to work as well. But the classic one for kids, as an example, is the headaches that start

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during school or after school, and they're typically the head. And often, they won't complain about until you ask.

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I like to say to my parents is that I keep the questions open.

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I ask open questions. Kids can't answer yes or no, so I can get an honest appraisal of what they're doing.

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And so I ask, how often do you get headaches? And they go, a lot. Show me where.

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And they point to their head and what part of the day. And so you can see them ticking the boxes for the classic

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asthenopic eye strain or binocular visual dysfunction-related headache. Could this be something that

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comes on at any point in your life? I mean, if you got binocular vision dysfunction,

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is that something that you would be aware of early in life, or is it just something that could start to impact your well-being in your 70s, out of the blue?

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Yeah, well, look, there's a number of different things that might trigger it. Sometimes it can be this steady build-up of demand on the visual system

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during the school years. Some people might find they just get more performance-related symptoms

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that they don't think is a vision problem. They just say, look, I'm not a reader and I didn't enjoy it, so they didn't do it. And then the problem sits there below the surface, and then they go and get

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a job where they might be on the tools for most of their career, and then they get a supervisor's role or a management role,

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and they're placed in a position where they're doing the work that might trigger some more of those headaches.

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Binocular visual dysfunction can occur from mild brain injury, whiplash, concussions. So you may have some other events in your life that then result in a headache.

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So it can happen at every age is the short answer.

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Absolutely. So it depends on the task you're doing and what other events have happened to you. So let's say that I feel like there's something going wrong with the way I

9:00

I deal with my visual world. So I come to see you and I say, Paul, there's something not

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quite right with my eyes. What questions would you ask me? So I gave an example of the headaches.

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We'll get an idea of what task you do, what devices are you using,

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understanding your study, your occupation, what's changed recently. Have you had any concussions in the last six months?

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Have you had any illnesses or viruses? How clearly are you seeing distance and near?

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We'll ask questions of how often do you get headaches? How often do you find that you might get sore eyes, tired eyes, eye strain?

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How do you find yourself concentrating when you read? How often do you lose your place? How often do you use your finger to keep your place?

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And we can also get a bit of an insight into the things that your visual

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dysfunction might stop you from doing or make it less enjoyable. So we might ask questions about what you like to do and what you don't like to do,

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because in the background, sometimes the vision problem can shape the activities that you prefer doing without you realizing.

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If you find something uncomfortable, then you unconsciously may stop doing it and reading. So classic example.

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So I often meet adults where I'll say, did you find reading uncomfortable,

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something you didn't like doing when you were younger? And they go, how did you know? And it's like, well, you've got binocular visual dysfunction.

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And for a lot of people, it sits since childhood. And often they'll just become reading avoiders without realizing it.

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We need to know about general history, visual history, like I said, and I think we covered the illness and injury that might relate to it.

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So concussions, whiplash, those sorts of things. A lot of that sounds like it's a subjective diagnosis.

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You're asking the patients to describe how they feel. But I guess that there are some also So there's a lot of objective

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tests and diagnostic approaches that you can take as well. So tell us about those. Absolutely.

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So most people who have had an eye exam are probably pretty familiar with the sight test. Cover one eye, read the letters on the chart,

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And we're looking to see if you can get to 20/20, which is the Imperial version. We call it 6: 6 in Australia and other countries.

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That's often then related to whether you have a prescription or not. So we do the test, the machine behind me on the wall there, of finding out what's

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the lens that gets you the clearest distance vision? And then we have a whole bunch of eye health checks in terms of front of eye,

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interior eye, pressure, those sorts of things. So they're your classic test that most people would know about.

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Standard in our practice that we All the optometrists do in our practice is a very comprehensive test of how you actually use your two eyes together.

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So we're very interested in the quality of your eye movements, how well your two eyes are working together.

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So that'll come under various names of the convergence testing or convergence,

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divergence, or binocular vision. We want to look at how well you're able to... The flexibility of your focusing system, that's also called accommodation.

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So how easily do you adjust your focusing? And the important thing is that focusing has to occur and be

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coordinated with your binocular vision. So we're looking at how those two systems interrelate as well. We'll do tests of your ability to just pick up fine 3D vision.

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We'll test whether your eyes are maybe suppressing or inhibiting some of the information, which is a sign that you're under stress.

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And so that makes up a good part of a routine exam. And for the most part between what we find out in your case history in those exams,

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we were able to identify most binocular visual dysfunctions from that.

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We have a couple of other more advanced instruments that we might use if

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we start to either just need to tease out some of the specifics a bit more or Or if your symptoms are strongly indicating that you

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have some binocular visual dysfunction, but you're getting through the regular

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test in an okay fashion, because in the background, someone can force their way through the test and pass the numbers.

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And so we have some other tests to try and highlight where the problem might be.

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How long does a typical session last for? It sounds like a lot there. Yeah.

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So the first time we see somebody is It's a 45 minute exam. So if we're dealing with someone who's got maybe a more complex history,

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where there may be some other neurological events or signs, so someone who's had a concussion or a brain injury or is

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suffering with static and visual snow. And so our staff will triage it.

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So if it's one of those cases where it sounds like we need to spend a bit more time, then we will book an hour for that one.

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So a good part of the time we spend is, yes, we do ask a lot of questions. We do a lot of measurements, but it's also making sure we've got plenty

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of time to discuss and explain what we found, go through the various alternatives of how we manage it.

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And if you're dealing with people with concussion or brain injury, sometimes we just need to take measurements slowly because the measurements we use, we need to just gently go

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in and understand that maybe a measurement might trigger some symptoms. And so we just want to go in carefully when we're dealing

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with some of these cases. So any new patient who comes into your practice, do you go through this

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process of just checking? Maybe you have BVD, you ask the questions and just do the

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quality of life check up front. Yes. So we have questionnaires as part of the entry in.

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So that has a symptom checklist. Depending on the case, we might use a scored

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Quality of Life questionnaire. And they call it Quality of Life questionnaires because it recognizes the impact that a vision problem has on your ability to do

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things outside just vision. But we do have a core part of what we

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consider a normal exam is measuring your binocular visual function.

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One of the quotes is every patient, every day. So every patient gets that test every day that we're practicing.

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So if I've been a patient of yours for 10 years and I'm just coming in for my annual

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checkup, is that would I have to fill in one of those questionnaires to give you a hint that maybe something's occurred

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that would require testing? There are some cases, but it's been a little Well,

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it's been a while since we've seen one, then we may redo some of those questionnaires. Someone who's a regular patient practice, those consultations are a little shorter.

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We tend to go half an hour. But again, if there's something that the patient has been discussing with the staff on the phone and they identify that potentially we need to spend

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a bit more time, then we'll allocate more time. Often between our just verbal case history

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and also looking at their binocular vision findings, And if something flags up and change, we can go, hey,

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I've noticed something's changed here. And you can deeper dive into the case history.

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Most people will come in and mention that something's changed, particularly if you've been seeing for a while, then you get educated on it's

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not just about seeing clearly. There's so much more to what's going on with your visual system than just

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the bottom line on a letter chart. Yeah, the continual patient education and making People are

16:45

aware of all these different aspects of vision are certainly an important part

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of what you do there at Harmony Vision Care, aren't there? Absolutely. And I've been able to pick up patients come in for their routine exam.

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I haven't seen them for a couple of years, and everything It seems to be okay. And then I go, Hey, this has changed.

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And what's been gone? I went, Oh, okay. Well, actually, no, I had a concussion 12 months ago. And you go, Okay, well, there it is.

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And it just got on with life, even though... And then you start asking questions, or what's changed since then? I can't do this now.

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I find that I used to be able to do an eight-hour day on the computer, and now I can only do a couple of hours.

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So it opens up those conversations and an opportunity to get them, hopefully,

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back to what they used to be able to do. Yeah. Well, let's That's a really good segue on my next question.

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So we talked about symptoms, and we talked about the diagnosis and questions and tests that you run.

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So what would be some of the causes of this? And you've mentioned concussion, you've mentioned injuries.

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Are there any other things that might cause a binocular vision

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dysfunction to come into your life? Yeah, you can look at them in a couple of different categories.

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You might, developmental is you might... Developmental is one where you might find that some people never quite

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developed good enough oculomotor binocular visual dysfunction, or binocular function

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skills prior to engaging in school and those sorts of things. And so you might identify There's a delay in the development of those visual skills.

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And so when they're placed in a situation where their skills don't match the demands, then it creates symptoms.

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So a body of evidence that indicates that focusing problems and binocular vision problems can occur over time.

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And the expert opinion is that it's a cumulative stress from doing near work.

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We've got this, the binocular visual system is really designed for us to survive and move through a three-dimensional world.

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And instead, in modern life, we sit still as we are right now, looking at relatively

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two-dimensional things at a near distance. And so our vision is immobile, we're immobile.

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That's not what our visual system is designed to do. And so I use the same analogy that we get stress and strain in other parts of our

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body from sitting still and not doing much. Why would the visual system be any different? And if you have the opportunity of tracking kids over time, and we've

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seen this in the research, but we get to do it in this practice as well. You can see kids coming in at preschool. Everything's great.

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It's not so great at grade two and three, probably more three and four,

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because the near work demands have really increased. The volume of reading that they're doing has increased, the need to read small

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but print, the need to comprehend what you're doing places a lot more strain on the visual system.

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So you You've got that vision problem to develop over time from what we do with them. 80% of computer users have some eye strain symptoms.

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And then you've got injury and illness like we're talking about. So brain injury, post viral, those sorts of things can also result

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in a binocular visual dysfunction. I think something like 50 % of concussions and whiplash have

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a form of binocular visual dysfunction afterwards. So you talked about developmental causes.

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So amblyopia or lazy eyes, that's commonly called.

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If that's untreated, does that often lead to BVD as well?

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Amblyopia and strabismus is a form of BVD. It's probably on the I don't like the use of extreme end, but it's at the end where

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you've really shut down the functioning of one channel to try and maintain some limited form of binocular vision.

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And you get a wide variety of symptoms depending on the nature

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of the eye turn in the amblyopia. Sometimes it goes unnoticed because the symptoms are very, very subtle in terms

20:54

of, again, you avoid what you can't do. At the extreme, you know people with iterns and lazy eyes,

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strabismus and amblyopia, do have problems with depth judgment. There's some research to indicate the reading speed.

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It's not as good as in people who have normal binocular function. So they tend to present with different symptoms.

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All right, just to keep going. All right. So Paul, we've talked about the symptoms that I might have.

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We talked about the questions that you would ask me, the tests you might do. Talked about maybe the causes and the underlying reasons for those things.

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So what's next? What treatments or therapies are you going to discuss with me while I'm

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in your consultation room? The tools that optometrists have are obviously lenses.

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And so we can use lenses not just for correcting sight. There are ways of using lenses to reduce eye strain, reduce headaches,

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reduce those symptoms. For people who's binocular visual dysfunction is related to other

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hypersensitivities around flicker and light and movement and those sorts of things. Sometimes, tints become a useful thing to help them cope with those symptoms.

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We may occasionally use prisms in in our lens prescribing. Vision therapy is one that we go to because lenses can't treat everything.

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And so it's a combination of rehabilitation, but also desensitizing.

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So if you We've got someone who's got binocular dysfunction where they're getting the dizziness and the vertigo.

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So part of our vision therapy is trying to desensitize them to the triggers that create that dizziness and vertigo.

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And then the other part of what we're doing in vision therapy is actually improving the function of binocular vision and its relationship to focusing.

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And then there's just counseling around good hygiene habits. And so trying to use a bigger screen further away, taking regular breaks,

23:12

what distance are you holding the book, what lighting What posture? So there's a lot of that visual habit counseling that forms part of it as well,

23:20

particularly in maybe the early stages where we start to see signs of it. The symptoms aren't too bad.

23:27

They're not quite prepared to maybe wear some glasses at this particular stage. And so the habit counseling goes across regardless of whether you're

23:35

needing treatment a lot. It's good advice to try and avoid some of these issues as well. With regards to tints.

23:41

So if I understand this correctly, everyone's vision is individual. So it's like some tints might help some people, but a different tint

23:49

might help a different person. Is that right? Yeah. And you'll get people where the tint makes no difference.

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You'll get some people where it's a very specific tint, seems to create the greatest relief for them.

24:02

And there's another group where just any tint provides some relief. And so this is where it gets quite individual.

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So I'll often say to patients, there are some people, we're just a light gray So I think that's the way it is enough just

24:16

to take the edge of things. And there's others where it needs to be of a specific wavelength or color for them to feel like they're getting relief.

24:23

Slack me down if I'm incorrect in saying this, but I get the impression from hearing you talk about prisms that you're not or maybe you're a bit

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ambivalent about the whole idea of prisms in lenses. Would you like to talk about that. Well, and look, I'm certainly ambivalent about the way tints

24:39

are prescribed as well. So people need to be careful that prisms and tints can become a bit of a cure roll.

24:45

And so if all you've got a hammer, everything looks like a nail. And so I tend to take the approach that my preference is

24:53

to use the simplest device possible. So if I have to start using prisms or tints, then that's a more

25:01

complex lens than what you might need. And there might be some situations where we've got no choice.

25:07

That is the best thing for you, but it's not something I necessarily rush into. Some of the challenges with prism is You're actually sometimes treating

25:17

a symptom rather than the cause, where there are other ways to prescribe that try to get to cause of the stress on the visual system.

25:25

And some people may redevelop the problem through the prism.

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And so you get this thing called the eating prism. Some people will say that doesn't occur, but I've certainly seen

25:35

it happen often enough. It certainly makes me cautious around the describing of it. I don't see people needing...

25:41

Tints tend to be a little bit more stable. You got to be careful with tints because they're The effectiveness of them may be

25:48

different under different light sources. So what works under a flutter may not work so well in the incandescent lighting or outdoors.

25:54

So I think there's just a little bit of care that needs to be taken into describing them.

25:59

And like I said, if I can give someone the opportunity of developing better vision without having to use these additional things on a lens,

26:08

then that's my preferred approach. But not everyone can commit to vision therapy. And that's part of the discussion.

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It's why we leave so much time because we want to talk through all these different

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pathways of this is what you could do, this is what you would do, and these are the outcomes that we might expect from.

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So this is something that I'm a little bit unclear about. So I think I understand what what tints are and how prism lenses work.

26:32

And I can understand that adjusting lifestyles, that could work. But I don't really quite understand the vision therapy and what that is.

26:40

Can you go a little bit deeper on that for me? Yeah. At a simple level, people think of it as an eye exercise, but we're

26:46

not exercising muscles. We're providing an environment where people can pay attention to where they are

26:53

in space relative, so where their body is in space relative to other things.

27:00

How do they change the way they look at something to make it easier and more comfortable? So we like to call it OT or physiotherapy for the eyes.

27:08

So you're developing more awareness of how you use your visual system, and then you're practicing more efficient ways of getting the two eyes to work

27:18

together, more efficient ways of focusing. So it's not something that you have to concentrate on. It becomes more and more automatic.

27:24

And then we also want to develop what we call generalization, where you're now able to use those new skills while doing other things so you don't

27:33

have to concentrate on. So basically, it's activities designed for you, first of all,

27:38

to become aware of how you're currently using your eyes, then developing better,

27:44

more efficient ways So it's using your eyes, and then repeating those until that becomes the new way you see.

27:50

So can you give me some practical example of that? I mean, are we talking here about the good old pencil push-ups,

27:57

or is there something that... You have something else that you might give people to do as an exercise to improve their visual. Yeah.

28:04

And if we have a look at where pencil push-ups came from is that you can see someone has the inability to track and the eyes stop looking at it.

28:12

And pencil push-ups is trying to force the two eyes work together. Whereas if we look at the loss of convergence you have when you're doing

28:21

this, it's either because it's painful to do or you've lost the awareness of where it is in space.

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And so we will do activities with some things So we use things that generate 3D targets and ask people to get a real sense of where in space these 3D targets are.

28:36

We might be using feedback mechanisms where they can actually get some feedback on where their eyes are pointing, so they really get a sense of being able

28:45

to change and control that, whereas this tends to be just forcing the two pens together. So there's a lot of the activities of making sure you're paying attention

28:53

to what you're looking at, but also things in space around it. So in the office, we use a lot of things where it might be a red and blue glasses

29:02

or Polaroid glasses to produce this sense of 3D so that we're amplifying your

29:07

understanding of how your two eyes are working together. And then that provides lots of feedback for then working on it.

29:15

We might be using lenses that change how you focus. And so you get a sense and a feel of how you make that lens clear or blurry.

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And so we're using these tools so you become aware of trying to change how

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you're seeing and getting some feedback that way. And because it's a different path for each person, because it's not just

29:33

a matter of moving muscles around, it's really learning to understand what your vision is doing. It's really like, I call it personalized coaching for the visual system.

29:40

It's a one on one thing that you do with a therapist. It's the ideal environment to be successful and that you're doing it

29:46

regularly enough that it becomes a new habit. So I'm assuming that there are some exercises that people can do at home

29:54

on a regular basis to do all this. Yes. So in our practice, we do a 45 minute vision therapy session.

30:01

So you're working with the therapist doing what we call office-based activities. So there's things that we're using equipment in the office to, like I said,

30:08

generate these 3D images or to allow you to just move and see what's happening to your visual system at the same time.

30:15

And then we'll send them home with some more basic exercises to reinforce

30:21

the things that you're learning to do, things where you're shifting your focus or getting the two eyes to work together.

30:26

And so you have this 15, 20 minutes home practice to make stick. All right.

30:31

So let's say we've had this consultation and we've agreed that I

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need to do some practice at home. Maybe you've prescribed some tints or prisms or whatever.

30:44

So what does the follow-up process look like? Does it mean that I probably need to come back to you every month,

30:50

every three months, every six months? What would that typically look like? It will vary from person to person.

30:56

So if we take the case of a child who might If they're able to benefit from some glasses to help with eye strain and things like that,

31:03

then we want to follow up in a couple of months after they start wearing them to make sure that everything's improving, that they're reinforced

31:11

how they're wearing them. And that might be three months, then six months and then every year

31:17

for a little while until things are looking fairly stable. For adults, where sometimes it can be fairly simple, you need a pair of reading

31:25

glasses, then that might be a year or two if we're fairly confident that that's all they need. If someone One's engaged in a vision therapy program that takes a couple

31:33

of months to roll out in completion. So we're seeing them every week. I'm doing a review every couple of months.

31:39

And so it's obviously a more regular visit. So it really depends on on a particular situation.

31:47

But if we've prescribed something, we at least want to see them within someone within a year. And then we determine from that point of how well they've responded to it

31:54

as to what the follow-up then is. And once they hit a stable point, it might be a year or two before when you see them.

32:01

All right. Well, this has been very informative. So from what I understand, not all optometrists

32:07

do this this vision therapy work. Just as some optometrists, maybe they do a lot more dry eye treatment.

32:14

Others may do like, specialists, contact lens fitting. Not all optometrists do vision therapy, do they?

32:21

So where you are, are there many other optometrists doing it, or are you fairly unique on the Gold Coast there?

32:32

Look, I think there are some who might do some basic activities or computerized

32:39

therapy, which I'm not a big fan of. I haven't found them quite successful. We're probably the only one in our part of the Gold Coast that has a dedicated

32:49

vision therapy where we're doing clinic-based therapy. I think the next practice is probably somewhere in the northern Rivers

32:55

of New South Wales or the Southern parts of Brisbane. Okay. Well, on that note, so how can people get in touch with you

33:02

there at Harmony Vision Care for? We certainly find out a lot more through our website, which is harmonyvisioncare.

33:09

Com. Au, and you can find out more. You can ask questions through that one.

33:15

You can book appointments through it. You can call us on 07-5520-5900 if you

33:22

want to ring and talk to the team. But the website is probably a great place to get some of that

33:27

additional information. This is I've brought up some things where you go, Hey, that sounds like me.

33:32

So there's some good resources there. And also, don't forget, you can follow Paul's Facebook business

33:38

page and follow his YouTube account. Once again, hit the like button, hit subscribe.

33:45

So he's always releasing helpful content like this. All right.

33:51

Well, anything else you want to add, Paul, before we wrap up? No, just know that not a lot.

33:57

I shouldn't say no, not a lot. The binocular vision problem is, we call it a hidden vision problem.

34:03

So it's not obvious. And so it really does need asking the right questions,

34:08

doing the right tests in order to find it. So that's what we're here for. Yeah.

34:13

All right. Okay, well, let's call it a wrap then. So thanks very much, Paul.

34:18

Until next time. Until next time, everyone. Have a great day. Bye-bye. Thank you..