An air embolism means air bubbles have entered the bloodstream and are blocking blood flow the way a cork blocks a bottle. In OVAE, the air enters through veins connected to the eye—especially the vortex veins, which drain blood from the choroid (the eye’s spongy, blood-rich layer)—and then travels through the ophthalmic veins → cavernous sinus → jugular veins → right side of the heart → lungs. When enough air gets in, the bubbles can choke the outflow from the right ventricle to the lungs, suddenly lowering the oxygen getting to the body and dropping blood pressure. In the operating room, the very first machine sign is often a sudden drop in end-tidal CO₂ (ETCO₂) on the anesthesia monitor, followed by oxygen desaturation and cardiovascular collapse if not stopped immediately. OVAE is rare but can be catastrophic; case series show it has been fatal in a large share of reported cases, particularly during air infusion steps of vitreoretinal surgery. EyeWikiPubMedResearchGate
During retina surgery, surgeons sometimes infuse air under pressure into the eye to flatten a detached retina or to clear fluid (an “air–fluid exchange”). If the infusion cannula slips into the suprachoroidal space or the eye has a large choroidal wound (e.g., trauma or tumor endoresection), pressurized air can tear the vortex vein ampullae and rush into the venous system. Because the eye is close to the heart and the air is pressurized, a large bolus can reach the heart very quickly. Clinically, a sudden ETCO₂ drop, a “mill-wheel” heart murmur on the chest, rapid oxygen desaturation, and shock can follow within seconds to minutes. EyeWikiResearchGate
It’s important to note that air can also enter the orbital and cranial venous system from non-ocular sources (for example, a routine intravenous bolus that inadvertently introduces air), and imaging has documented air within the superior ophthalmic vein in such settings. That observation helps confirm the pathway by which venous air can reach ocular venous structures. PubMed
Types
By circulation path
Venous OVAE (classic): Air enters via the eye’s venous outflow and lodges in the right heart/lungs. This is the entity discussed here.
Paradoxical (venous → arterial) OVAE: Venous air crosses to the arterial side through a patent foramen ovale (PFO) or other right-to-left shunt and can cause brain or heart ischemia. (The starting point is still venous air from the eye.) NCBI
By timing and setting
Intraoperative: Happens during eye surgery, especially pars plana vitrectomy when air is infused. This is the most reported context.
Peri-/post-procedural: Shortly after eye surgery or after procedures involving veins near the orbit (or even non-ocular IV injections that propagate air into orbital/cerebral veins). EyeWikiPubMed
By the source of air
Pressurized intraocular infusion (air–fluid exchange, gas tamponade).
Large choroidal wound (trauma or tumor endoresection) acting as an “open door” to torn vortex veins. EyeWiki
By severity
Massive OVAE: Large, sudden bolus with hemodynamic collapse.
Subclinical/minor: Small amounts cause ETCO₂ changes and transient hypoxemia with limited or no symptoms.
Causes
Slipped infusion cannula during vitrectomy — The tip slips from the vitreous cavity into the suprachoroidal space and pressurized air dissects to torn vortex veins. EyeWiki
High infusion pressure during air–fluid exchange — Turning up the air pressure can force air through a choroidal detachment into veins. ResearchGate
Sutureless transconjunctival ports — Unsecured ports are more prone to slippage than sutured 20-gauge ports. EyeWiki
Large choroidal wounds from trauma — An open path for air to enter the choroid and then the veins. EyeWiki
Choroidal melanoma endoresection — Resection creates big choroidal defects; air used for visualization can entrain. SAGE Journals
Intentional choroidotomy or drainage procedures — Similar mechanism: an opening into the choroid near large veins. ResearchGate
Inadequate team check (“time-out”) before gas infusion — A preventable setup error where the line isn’t confirmed secure. EyeWiki
Nitrous oxide anesthesia in the presence of intraocular gas — Expands trapped gas; can worsen any ongoing air problem (general VAE principle). NCBI
Positive-pressure ventilation with high PEEP — Can raise venous pressure gradients and influence air movement (general VAE risk context). NCBI
Orbital fracture with compressed air exposure — Rare industrial injuries can drive air into orbital/cranial veins.
Improperly vented infusion lines — Microbubbles or larger boluses can be delivered inadvertently.
Loose connections or leaking valves on infusion systems — Air can be sucked into the line and pushed into the eye.
IV injections with residual air — Air can propagate retrograde into cranial venous sinuses and ophthalmic veins; has been imaged in the superior ophthalmic vein. PubMed
Use of air–gas mixing errors — Wrong concentration or incorrect gas chosen for tamponade increases risk. EyeWiki
Rapid patient position changes with open venous pathways — Postural shifts can favor air entrainment (general VAE principle). NCBI
Open globe repair followed by early air infusion in a second surgery — Pre-existing choroidal tears make a later air step risky. ResearchGate
Large retinal detachment repairs needing high flow — Bigger cases tempt higher pressures and longer air steps. ResearchGate
Inadequate monitoring during known high-risk steps — Missing the early ETCO₂ drop delays response. EyeWiki
Lack of precordial Doppler in very high-risk cases — Fewer early detections; faster progression. ResearchGate
Right-to-left shunt (e.g., PFO) present — Converts a venous event into a paradoxical arterial one with brain/heart injury risk. NCBI
Symptoms and signs
Remember: early signs in the operating room are often machine clues before human symptoms.
Sudden drop in end-tidal CO₂ — The first and most sensitive intraoperative clue that air is blocking blood flow to the lungs. EyeWikiPubMed
Drop in oxygen level — Pulse oximeter dives because the lungs can’t exchange gases well. PubMed
Fast heartbeat (tachycardia) — The heart races to compensate for low oxygen and low blood pressure. PubMed
“Mill-wheel” heart murmur — A churning sound over the chest classic for significant venous air. PubMedNCBI
Low blood pressure (hypotension) — Pumping against air lowers forward blood flow. NCBI
Irregular heart rhythm (arrhythmia) — The right heart is strained and irritable. NCBI
Bluish discoloration of head/neck (cephalic cyanosis) — In massive events with venous outflow “jammed,” the head looks persistently blue. ResearchGate
Shortness of breath or apnea — When ventilating, the machine may alarm; breathing stops in extreme cases. NCBI
Coughing or wheeze — Lung irritation from trapped air. NCBI
Chest pain or sense of doom — If awake, the patient may feel this just like with a pulmonary embolism. NCBI
Confusion or loss of consciousness — Low oxygen and low blood flow to the brain. NCBI
Seizure or focal deficits — If paradoxical arterial spread happens to the brain. NCBI
Visible air bubbles in retinal vessels — Rare but reported on eye exam in venous gas embolism. NCBI
Neck vein distention — Pressure effects on venous return. NCBI
Cool, clammy skin with poor capillary refill — Shock pattern as circulation fails.
Diagnostic tests
How clinicians think about testing: OVAE is a clinical diagnosis in context (e.g., during vitrectomy with air), anchored by a sudden ETCO₂ drop, supportive exam/monitor findings, and imaging or bedside confirmation when feasible. Early recognition is critical because seconds matter. EyeWikiNCBI
A) Physical Exam
Precordial auscultation (stethoscope over the chest)
A “mill-wheel” murmur—like liquid churning—supports a significant venous air burden. It’s not always present, but when heard during an air-infusion step, it is highly suggestive. NCBIPulse and blood pressure check in real time
Sudden tachycardia, hypotension, and shock patterns point to obstructed right-heart outflow from air. NCBIOxygenation check at the bedside
Rapid bluish discoloration (especially head/neck) and falling pulse oximetry warn of impaired lung gas exchange. In massive OVAE, cephalic cyanosis has been recorded. ResearchGateBedside fundus examination (if possible)
Rarely, clinicians can see tiny air bubbles in retinal vessels, which directly supports a gas embolism picture. NCBI
B) Manual (bedside) tests/procedures
Immediate stop of air infusion as a “diagnostic maneuver”
If the ETCO₂ and hemodynamics rebound promptly after stopping intraocular air, that change strongly supports OVAE as the cause. PubMedPatient positioning (left-lateral/Trendelenburg/Durant) and observe response
Rapid repositioning can trap air in the right heart and sometimes improves vitals; improvement supports the diagnosis in the right context (also part of early management). NCBIAspiration through a pre-placed central venous catheter near the right atrium
With the catheter already in place (not inserted emergently), drawing back and seeing frothy air is both supportive and therapeutic. NCBIIntraoperative wound/cannula check (surgeon’s bedside check)
Securing the infusion line and compressing/opening sites that could entrain air, then noting stabilization of ETCO₂ and vital signs, helps confirm the ocular source. EyeWiki
C) Lab & Pathological tests
Arterial blood gas (ABG)
Shows hypoxemia (low PaO₂), hypercapnia or mixed changes, and sometimes metabolic acidosis from shock. ResearchGateNCBISerum lactate
Elevated lactate indicates poor tissue perfusion from the low-output state created by air in the right heart/lungs.Cardiac injury markers (e.g., troponin)
May rise if there is myocardial strain/ischemia from prolonged hypotension or paradoxical embolism.Pathological confirmation in fatal cases (forensic)
Post-mortem techniques (e.g., opening the right heart under water or confirming air in key venous structures) can verify lethal venous air embolism when the clinical course fits. ResearchGate
D) Electrodiagnostic/monitoring tests
Continuous capnography (ETCO₂)
Most sensitive early intraoperative sign—a sudden, sustained drop in ETCO₂ during air steps should trigger immediate action. EyeWikiElectrocardiography (ECG)
Shows tachycardia, right heart strain, or arrhythmias in significant venous air embolism. NCBIPrecordial Doppler ultrasound
Very sensitive, noninvasive detector of venous air; characteristic sounds appear even for small volumes, allowing earlier response in high-risk eye cases. NCBITransesophageal echocardiography (TEE)
The most sensitive test to directly visualize air in the right heart and outflow tract; not always available during eye surgery but definitive when present. NCBI
E) Imaging tests
CT of the orbits/head (CT angiography when indicated)
Can show air in the superior ophthalmic vein, cavernous sinus, or other venous pathways—direct anatomical proof of the route. PubMedChest CT (or targeted CT)
May reveal air within central venous structures or secondary lung findings after a suspected embolic event. NCBIChest X-ray
Less sensitive, but in some cases may show abnormal radiolucent lines or other supportive changes; mainly rules out other causes like pneumothorax.Ocular ultrasound (B-scan) or fundus photography
May show suprachoroidal air or secondary signs of choroidal detachment that fit the mechanism; fundus photos can capture intravascular bubbles if present. EyeWiki
Non-pharmacological treatments
These are immediate, team-based steps. Many start within seconds of suspicion.
Stop the air: immediately halt air infusion, clamp lines, and secure all ports. Purpose: remove the source. Mechanism: prevents more gas from entering veins. bsir.org
Call for help and announce “air embolism” so roles are clear. Purpose: mobilize airway, anesthesia, and surgical teams. Mechanism: coordinated resuscitation. sarasotaanesthesia.com
100% oxygen via circuit or bag-valve while preparing definitive airway if needed. Purpose: raise blood oxygen and shrink bubbles (nitrogen washout). Mechanism: oxygen replaces nitrogen inside bubbles, making them smaller. Medscapebsir.org
Durant maneuver: position left lateral decubitus with head down (Trendelenburg). Purpose: float air into the right atrium, away from the RV outflow tract. Mechanism: gravity and buoyancy. PMC+1
Manual ventilation and lung-protective settings: avoid excessive PEEP if it worsens RV output. Purpose: optimize oxygen/CO₂ and hemodynamics. Mechanism: reduces RV afterload. PMC
Central venous aspiration (if a multi-lumen CVC in place or can be placed quickly by an expert). Purpose: suck out air from the right atrium. Mechanism: direct bubble removal. sarasotaanesthesia.com
CPR if arrest occurs: chest compressions can help break up/move bubbles while providing circulation. Mechanism: mechanical propulsion and perfusion. sarasotaanesthesia.com
TEE or precordial Doppler monitoring to confirm diagnosis and guide therapy. Mechanism: detects intracardiac air and RV function. sarasotaanesthesia.com
Avoid nitrous oxide (turn it off). Mechanism: prevents bubble expansion. sarasotaanesthesia.com
Aggressive IV fluid resuscitation (crystalloid). Purpose: support venous return and cardiac output. Mechanism: increases preload to push bubbles forward. sarasotaanesthesia.com
Lower eye infusion pressure and seal ocular wounds immediately. Purpose: shut the venous air entry point. Mechanism: reduces pressure gradient. BMJ Open Gastroenterology
Direct ocular measures (e.g., temporary gentle external pressure / wound closure by the surgeon). Purpose: block choroidal/venous channels. Mechanism: tamponade. BMJ Open Gastroenterology
Early hyperbaric oxygen therapy (HBOT) in selected severe cases (especially neurologic deficits or suspected arterial gas embolism). Purpose: shrink bubbles, improve oxygen delivery. Mechanism: high-pressure oxygen reduces bubble size and treats ischemia. The Oxford Center
Vasopressor/inotrope support (see drug section) paired with the above maneuvers. Purpose: stabilize blood pressure and RV output. PMC
Percutaneous cardiopulmonary support/ECMO in refractory collapse in experienced centers. Mechanism: bypasses the lungs, maintains oxygenation while the embolism resolves. ekja.org
Trendelenburg during line placement to avoid additional IV air. Mechanism: increases venous pressure and reduces air entrainment. sarasotaanesthesia.com
Capnography and continuous SpO₂ watching for recovery or re-deterioration. Mechanism: early detection. sarasotaanesthesia.com
Team debrief and equipment check after stabilization to prevent recurrence. Mechanism: systems fix. Patient Safety Movement Foundation
Document nitrous-oxide allergy-like precaution (institutional flag) for future surgeries if gas embolism occurred. Mechanism: default to air/O₂ only. sarasotaanesthesia.com
Early ICU admission for observation after any significant event. Mechanism: continuous monitoring for delayed effects. PMC
Drug treatments
Important: Drug therapy supports the core maneuvers above; it does not dissolve venous air. Doses below are typical adult ranges; clinicians adjust for weight, comorbidities, and guidelines.
Oxygen (medical gas) – Class: medical gas. Dose/time: 100% FiO₂ immediately via tight mask, circuit, or ETT. Purpose: shrink bubbles and raise blood oxygen. Mechanism: nitrogen washout; increases diffusion gradient. Side effects: absorption atelectasis if prolonged, dry airways. Medscapebsir.org
Epinephrine – Class: catecholamine (α/β agonist). Dose: ACLS for arrest; for shock, titrate IV infusion (e.g., 0.02–0.1 µg/kg/min). Purpose: raise BP, support cardiac output. Mechanism: ↑contractility, vasoconstriction. Risks: arrhythmias, ischemia. PMC
Norepinephrine – Class: vasopressor (α>β agonist). Dose: start ~0.05–0.1 µg/kg/min, titrate. Purpose: counteract hypotension from RV failure. Mechanism: systemic vasoconstriction with some inotropy. Risks: ischemia, arrhythmias. PMC
Vasopressin – Class: non-adrenergic vasopressor. Dose: e.g., 0.01–0.04 units/min. Purpose: add-on pressor in refractory shock. Mechanism: V1 vasoconstriction. Risks: ischemia, hyponatremia. PMC
Dobutamine – Class: inotrope (β1 agonist). Dose: 2–10 µg/kg/min. Purpose: support RV contractility if output low. Mechanism: ↑inotropy, ↓PVR modestly. Risks: tachyarrhythmias, hypotension. PMC
Phenylephrine – Class: pure α-agonist. Dose: bolus 50–100 µg or infusion 0.2–1 µg/kg/min. Purpose: raise MAP if vasodilated and tachycardic. Mechanism: arterial constriction. Risks: reflex bradycardia, perfusion issues. PMC
Crystalloid IV fluids (e.g., balanced saline) – Class: volume expander. Dose: guided by hemodynamics (e.g., 500–1000 mL boluses). Purpose: improve venous return. Mechanism: ↑preload. Risks: fluid overload. sarasotaanesthesia.com
Heparin (selected cases only) – Class: anticoagulant. Use: not routine for VAE; may be considered if concurrent thrombosis is suspected or vascular access manipulation requires it—specialist decision only. Risks: bleeding. sarasotaanesthesia.com
Amiodarone – Class: antiarrhythmic. Dose: per ACLS for unstable ventricular arrhythmias. Purpose: treat serious arrhythmias triggered by RV strain. Risks: hypotension, bradycardia. PMC
Bronchodilator (e.g., albuterol) – Class: β2-agonist inhaled. Use: bronchospasm if present to improve ventilation. Risks: tremor, tachycardia. sarasotaanesthesia.com
Also: Avoid nitrous oxide—it expands intravascular gas. sarasotaanesthesia.com
Dietary molecular supplements
There are no supplements that treat or reverse OVAE. Any supplement should only be considered after you are medically stable and with your doctor’s approval, mainly for general recovery, not as a cure.
For general cardiopulmonary recovery (examples with conservative, commonly used doses for adults unless otherwise directed):
Protein (whey or plant) – Dose: enough to reach ~1.0–1.2 g/kg/day total protein. Function/mechanism: supports tissue repair and immune proteins.
Omega-3 fatty acids (EPA/DHA) – Dose: ~1 g/day combined EPA+DHA (food first). Function: may support endothelial function and lower inflammation.
Vitamin C – Dose: 200–500 mg/day short term. Function: antioxidant for collagen and vessel healing.
Vitamin D – Dose: only if deficient; typical 800–2000 IU/day under supervision. Function: immune modulation and muscle function.
Magnesium – Dose: 200–400 mg/day (avoid in kidney disease). Function: supports rhythm stability and muscle function.
Coenzyme Q10 – Dose: 100–200 mg/day. Function: mitochondrial energy support.
B-complex (esp. B12/folate if low) – Dose: per labs. Function: red-blood-cell and nerve support.
Zinc – Dose: 10–20 mg/day briefly if low. Function: wound healing and immune enzymes.
Citrulline or L-arginine (caution in hypotension) – Dose: citrulline 3 g/day. Function: nitric-oxide precursor; vascular support.
Electrolyte solution – Dose: as directed. Function: hydration to support circulation.
Again: these do not treat air embolism; they’re general recovery nutrients. Talk to your clinician first, especially if you have heart, kidney, or eye-pressure issues.
Regenerative / stem-cell drugs
There are no approved “hard immunity boosters,” regenerative drugs, or stem-cell drugs that treat OVAE. Using such drugs outside a clinical trial can be harmful. What is relevant:
Hyperbaric Oxygen Therapy (HBOT) – not a drug but a regenerative-adjacent therapy that improves oxygen delivery and shrinks bubbles; may be considered in severe gas embolism or neurologic compromise. Dosing is by protocols in specialized centers—not something to self-dose. The Oxford Center
ECMO/PCPS – again not a drug; organ-support technology that can save life in refractory collapse. ekja.org
Investigational cytoprotective agents (e.g., neuroprotective strategies studied in ischemia) are experimental and not standard for OVAE; any use should be trial-based only.
Stem-cell therapies – no evidence or approvals for OVAE; avoid outside regulated trials.
Erythropoietin, N-acetylcysteine, or similar “tissue protectants” – occasionally studied for ischemia but not established for air embolism.
“Immune boosters” marketed online – not recommended; they do not remove air or prevent the hemodynamic effects of OVAE.
Bottom line: stick to oxygen, positioning, airway/breathing/circulation, and expert procedures. Those save lives. PMCsarasotaanesthesia.com
Procedures/surgeries
Emergent ocular wound exploration and closure – Why: stop venous air entry from choroidal/sclerotomy sites. What: surgeon closes leaks and lowers infusion pressures. BMJ Open Gastroenterology
Central venous catheter placement for air aspiration – Why: remove air from the right atrium/right ventricle. What: skilled operator threads a catheter and aspirates air under imaging. sarasotaanesthesia.com
Hyperbaric Oxygen Therapy session – Why: reduce bubble size and rescue ischemic tissue in severe/neurologic cases. What: patient enters a pressure chamber for protocolized treatments. The Oxford Center
Percutaneous cardiopulmonary support/ECMO – Why: life support for refractory shock or arrest. What: large cannulas circulate and oxygenate blood outside the body. ekja.org
Cardiopulmonary resuscitation and advanced life support – Why: treat arrest and maintain circulation until air clears and definitive measures work. What: compressions, defibrillation if indicated, airway management, drugs per ACLS. sarasotaanesthesia.com
Ways to prevent OVAE
Use valved cannulas and secure ports during vitrectomy. BMJ Open Gastroenterology
Set conservative air-infusion pressures with alarms and hard limits. BMJ Open Gastroenterology
Confirm cannula tip location is intraocular before turning on air. JAMA Network
Stop air before instrument withdrawal or exchanges. BMJ Open Gastroenterology
Avoid nitrous oxide for cases using intraocular gas. sarasotaanesthesia.com
Continuous capnography (ETCO₂) and pulse oximetry, consider precordial Doppler/TEE in high-risk cases. sarasotaanesthesia.com
Promptly close any leaky sclerotomies; test for leaks at the end. BMJ Open Gastroenterology
Air-eliminate and filter IV lines; use air-in-line alarms. sarasotaanesthesia.com
Team drills and checklists for “suspected air embolism.” Patient Safety Movement Foundation
Post-op monitoring when air was used for tamponade or when anatomy was complex. SAGE Journals
When to see a doctor
During surgery: the team will act immediately.
After surgery: seek emergency care at once if you notice sudden shortness of breath, chest pain, fainting, blue lips/skin, severe dizziness, or confusion. These are medical emergencies.
Any new or severe vision loss after eye surgery also needs urgent evaluation (for other causes such as central retinal artery occlusion). NCBI
What to eat — and what to avoid
Eat more of:
Lean proteins (fish, eggs, legumes) to rebuild tissue.
Fruits and vegetables of many colors for antioxidants and fiber.
Whole grains for steady energy.
Healthy fats (olive oil, nuts; oily fish for omega-3s).
Adequate fluids (water or oral rehydration) unless on fluid restriction.
Avoid or limit:
Alcohol (worsens dehydration and blood pressure control).
Smoking/vaping (harms lungs and healing).
Very salty foods if you have heart or blood-pressure issues.
Large caffeine doses if you’re tachycardic or anxious post-op.
Unregulated “booster” supplements that promise rapid recovery.
(Diet supports recovery; it does not treat an air embolism.)
Frequently asked questions
Is OVAE the same as a stroke in the eye?
No. OVAE is air in the veins from the eye to the lungs/heart. A retinal “stroke” (CRAO) usually involves arterial blockage and is a different problem, though both are emergencies. NCBIHow often does OVAE happen?
Very rarely, but most cases are serious. Reports link it mainly to vitrectomy with air infusion. JAMA NetworkSAGE JournalsWhat’s the first thing the team does?
Stop the air, give 100% oxygen, position left-side head-down, support breathing and blood pressure. MedscapePMCWhy does the ETCO₂ drop suddenly?
Because air blocks lung blood flow, less CO₂ returns to the lungs, so the monitor number plummets. PMCWhy is nitrous oxide avoided?
It diffuses into bubbles and enlarges them, making things worse. sarasotaanesthesia.comCan air be sucked out of the heart?
Sometimes, through a central venous catheter placed by an expert. Not always possible or successful, but it can help. sarasotaanesthesia.comIs hyperbaric oxygen always used?
No. It’s considered in severe or neurologic cases or when arterial gas embolism is suspected. Decision is case-by-case. The Oxford CenterCould OVAE cause cardiac arrest?
Yes. A large venous air load can cause RV failure and arrest. Immediate resuscitation is essential. SAGE JournalsWhat monitors help catch it early?
Capnography (ETCO₂), precordial Doppler, and TEE are sensitive. sarasotaanesthesia.comCan this happen after I leave the operating room?
It’s much less likely, but if there were leaky wounds or pressurized air left in systems, it’s possible. That’s why closure and monitoring matter. SAGE JournalsIs it the same as air from IV lines?
Mechanism similar (venous air). In eye surgery, the entry point is ocular venous channels. Both are dangerous in large volumes. sarasotaanesthesia.comWhat’s the prognosis?
Depends on speed of recognition and response and the volume of air. Rapid, skilled care markedly improves outcomes; delayed recognition can be fatal. SAGE JournalsIf I had intraocular gas, can I fly?
Flying with intraocular gas can expand the bubble and cause arterial ocular problems—you must follow your surgeon’s instructions and avoid altitude until cleared. (This is a different risk than OVAE.) ResearchGateDo blood thinners fix OVAE?
No—they don’t remove air. Anticoagulants are not routine and are used only for other indications decided by specialists. sarasotaanesthesia.comWhat can surgical teams do to prevent OVAE?
Use valved ports, safe pressures, vigilant monitoring, and tight wound closure, and stop air before instrument changes. BMJ Open GastroenterologyJAMA Network
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Last Updated: August 17, 2025.


