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The Eye in the Community ED

namethatsmell

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    I'll be working in a rural community shop when I graduate. I'm going to have very limited ophthalmology coverage and I'll admit that eye stuff is probably my weakest link as the eye guys at my current shops are great about coming into the ED or seeing patients in their clinic the same day.

    For those of you who don't have easy access to eye docs, how did you improve your eye knowledge?

    Any online lectures, EM-oriented eye books, CME-style courses or anything else out there help you improve your eye toolbox?

    What eye dx do you insist on having seen the same day (transfer if necessary) vs 1-2 days?

    Thanks in advance for your thoughts.
     
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    DrDrummer

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      This is more for med students, but still good to have the fundamentals:

      http://www.ophthobook.com

      This guy is great. His slit lamp exam video was very helpful for me in terms of understanding how the microscope actually works and the different components of the exam.

      In my (limited) experience as a resident, I found great value in following a couple patients over to the ophthalmology clinic who I had sent over when my shift wrapped up around the same time. They were super into teaching and showing me how they do their exam and what they were looking for -- maybe you could spend an afternoon or two hanging out in a local optho clinic or with one of your colleagues on their service, and see their most common chief complaints? In my experience, when we as EM Docs take an active interest in the workdays of other specialties, they're usually pretty cool about trying to help educate us about how to manage their most common ED phone calls/referrals on our own, or what red flags we should look out for that necessitate urgent/emergent intervention or consultation.
       
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      The White Coat Investor

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        I learned almost everything I know about eye emergencies in residency. The following I have seen same day:

        1) Globe rupture
        2) Monocular loss of vision
        3) Concern for retinal detachment (although if suspicion is very low, perhaps the next morning)
        4) Ulcers (occasionally seen next morning)
        5) Iritis- I want ophtho to see before steroids start

        That said, I was once "the eye guy" for an entire country of military members. I was the only doc who knew how to use the slit lamp. My ophtho back-up was in Iraq. Needless to say, I didn't ship much there.
         
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        n2b8me

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          I think starting with practicing a lot using the slit lamp, tonopen and dilating peoples eyes for fundoscopic exams will help a ton. You could just start doing it on all the corneal problems and basic eye stuff.

          For me being in the country I would think about what eye emergencies would need to be admitted. There aren't that many really:
          1. Orbital cellulitis for iv abx. mostly its a medicine admit anyway.
          2. acute angle glaucoma: sometimes the pressures are difficult to correct and they also may need IV analgesics.
          3. Globe rupture. CT can help for these too if it is from trauma like a bullet/pellet/metallic object.

          The challenging cases are the people that have total vision loss. Ideally all these cases can be discussed with the Ophthamoligst over the phone prior to discharge. For the retinal detachments, aqueous detatchments, vitreous hemorhage, CRVO: they can all be managed as outpatients without much needed ER treatment. Trying to sort out one from the other is challenging without imaging, but because we can't fix any of it... The rare one is central retinal artery occlusion and because it is more like a stroke we can manage these acutely.

          In a place without any ophtho back up I would CT all of the eyes with sudden vision loss (and r/o globe rupture, and cellulitis) then go from there.

          I wouldn't stress so much on the rest of the anterior chamber stuff: corneal ulcers/abrasions, uveitis/iritis, hyphema. all outpatient mgmt.
           
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          namethatsmell

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            I learned almost everything I know about eye emergencies in residency. The following I have seen same day:

            1) Globe rupture
            2) Monocular loss of vision
            3) Concern for retinal detachment (although if suspicion is very low, perhaps the next morning)

            Interesting--I've picked up a couple of these on bedside sono and when I talk with our eye guys they always say just have them follow up in a few days (doesn't have to be next day) since they often won't repair them for 1-2 weeks. Maybe this is an anomaly?
             

            namethatsmell

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              I think starting with practicing a lot using the slit lamp, tonopen and dilating peoples eyes for fundoscopic exams will help a ton. You could just start doing it on all the corneal problems and basic eye stuff.

              For me being in the country I would think about what eye emergencies would need to be admitted. There aren't that many really:
              1. Orbital cellulitis for iv abx. mostly its a medicine admit anyway.
              2. acute angle glaucoma: sometimes the pressures are difficult to correct and they also may need IV analgesics.
              3. Globe rupture. CT can help for these too if it is from trauma like a bullet/pellet/metallic object.

              The challenging cases are the people that have total vision loss. Ideally all these cases can be discussed with the Ophthamoligst over the phone prior to discharge. For the retinal detachments, aqueous detatchments, vitreous hemorhage, CRVO: they can all be managed as outpatients without much needed ER treatment. Trying to sort out one from the other is challenging without imaging, but because we can't fix any of it... The rare one is central retinal artery occlusion and because it is more like a stroke we can manage these acutely.

              In a place without any ophtho back up I would CT all of the eyes with sudden vision loss (and r/o globe rupture, and cellulitis) then go from there.

              I wouldn't stress so much on the rest of the anterior chamber stuff: corneal ulcers/abrasions, uveitis/iritis, hyphema. all outpatient mgmt.

              This is gold. Thanks!
               

              DrZeke

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                Interesting--I've picked up a couple of these on bedside sono and when I talk with our eye guys they always say just have them follow up in a few days (doesn't have to be next day) since they often won't repair them for 1-2 weeks. Maybe this is an anomaly?

                Timing of RD repair is based on:

                1) is the macula on or off? Visual acuity can be very helpful in giving you a hint.

                2) how long they have been detached.

                1-2 weeks not always appropriate.
                 
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                DrZeke

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                  Interesting, helpful to know. Thanks.

                  Also, diagnosing an RD on b scan/ultrasound requires training and a dynamic exam. You need to appreciate the orientation of things. I personally think if not trained vitreous hemorrhage can be confused for detachment...

                  Standard of care for diagnosing RD is not ultrasound.

                  I think it's great to hear how many of you are interested in learning about our exams and rule out techniques. I've had several occasions where I've offered to show a couple of residents a few things in the ER, but the interest has been impressively low...
                   

                  Eyefixer

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                    Hi guys, practicing ophthalmologist here. Feel free to PM with any questions.

                    1. RDs- when a patient shows up complaining of NEW sudden onset flashes/floaters/curtain/loss of vision, suspect vitreous detachment vs retinal tear or detachment. VAST majority of the time, its vitreous detachment without any retinal pathology. Some patients are at higher risk for RD/RT- high myopes (thick glasses, can not see distance but have very good near vision without glasses), h/o previous RD, family history of RD, h/o cataract or any other eye surgery, trauma. If patient's vision at presentation is "good" ex., 20/40 macula is likely on, if it "poor" ex., 20/200 or worse, macula may be off. Macula on RDs should be fixed in 24 hours, macula off- within a week. The reality of the situation though in a community setting is that even if you get you on call general ophtho guy to come in at 2 am on a Friday night to see flashes/floaters patient and he/she does dx an RD, a retina specialist will NOT come in in the middle of the night to fix it. It's just not done. My advice: if you highly suspect an RD- tell patient to be NPO overnight and go see retina specialist in am. Call them and document conversation/name. You are done.

                    2. Corneal ulcers- red painful eye most commonly in a contact lens wearer who abuses them (sleeps in them, etc), ONE eye is usually involved, you see a white spot on the cornea with Woods lamp. The bigger the spot, the more pain, the more worried you should be. Small peripheral ulcers- usually Staph, give 4th generation Floroquinolone (Vigamox, etc), every hour while awake until seen by ophtho, Bacitracin ointment for QID and cycloplegia with Cyclopentalate 1% BID if a lot of pain. If large central ulcers- you should be more worried, may be Strep, Klebsiela, Pseudomonas, can chew through cornea quickly and cause endophthalmitis. Need to see ophtho or better yet cornea specialist ASAP and may need fortified antibiotics and close follow up. If no ophtho available for those, send to ivory tower. NEVER GIVE STEROIDS. You are done.

                    3. Orbital cellulitis- in young kids (less then 5), a bad conjunctivitis may look like orbital cellulitis, need CT orbits WITH contrast to differentiate. In older, look at eye movements and ask about loss of vision and double vision. Look for proptosis. These are orbital signs distinguishing preseptal and orbital cellulitis. Have low threshold for admission and IV antibiotics. If there is an abscess on CT, need ENT or oculoplastcs involved. General ophtho guys won't help with that. You are done.

                    4. Glaucoma- that's a tough one. Ideally, learn how to use tonopen (needs to be calibrated, need to use a cover). If this thing is not properly calibrated, it will show pressure of 92 (max reading) and you will be calling your ophtho guys in panic :). Learn signs and symptoms of angle closure- mid dilated pupil, steamy cornea, lethargic patient that may be vomiting if pressure is very high, decreased vision. Need to send to ophtho who has access to a YAG laser or send to university. You are done.

                    5. Trauma- CT is helpful in ruptured globe diagnosis, look for globe deformity, vitreous heme, ask about mechanism of injury (grinding metal on metal? high velocity object?- suspect intra ocular foreign body). If you see "black stuff" on the cornea, that may be iris plugging up cornea rupture. Don't touch, put a shield on the eye, give anti-emetics and 400 mg of IV gatifloxacin, send to university (honestly, if I had a globe rupture, I'd want it repaired in an academic setting and not by a general ophtho who did one five years ago). All trauma patient should eventually see an ophthalmologist, even if not the same day.

                    Lastly, for red eyes, please do not give Tobramycin or Sulfacetamide. That stuff is toxic to the cornea. You can do Ofloxacin or if really high suspicion for bacterial infection- 4th generation fluoroquinolone. Don't give steroids.

                    Cheers!
                     
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                    BJJVP

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                      Hi guys, practicing ophthalmologist here. Feel free to PM with any questions.

                      1. RDs- when a patient shows up complaining of NEW sudden onset flashes/floaters/curtain/loss of vision, suspect vitreous detachment vs retinal tear or detachment. VAST majority of the time, its vitreous detachment without any retinal pathology. Some patients are at higher risk for RD/RT- high myopes (thick glasses, can not see distance but have very good near vision without glasses), h/o previous RD, family history of RD, h/o cataract or any other eye surgery, trauma. If patient's vision at presentation is "good" ex., 20/40 macula is likely on, if it "poor" ex., 20/200 or worse, macula may be off. Macula on RDs should be fixed in 24 hours, macula off- within a week. The reality of the situation though in a community setting is that even if you get you on call general ophtho guy to come in at 2 am on a Friday night to see flashes/floaters patient and he/she does dx an RD, a retina specialist will NOT come in in the middle of the night to fix it. It's just not done. My advice: if you highly suspect an RD- tell patient to be NPO overnight and go see retina specialist in am. Call them and document conversation/name. You are done.

                      2. Corneal ulcers- red painful eye most commonly in a contact lens wearer who abuses them (sleeps in them, etc), ONE eye is usually involved, you see a white spot on the cornea with Woods lamp. The bigger the spot, the more pain, the more worried you should be. Small peripheral ulcers- usually Staph, give 4th generation Floroquinolone (Vigamox, etc), every hour while awake until seen by ophtho, Bacitracin ointment for QID and cycloplegia with Cyclopentalate 1% BID if a lot of pain. If large central ulcers- you should be more worried, may be Strep, Klebsiela, Pseudomonas, can chew through cornea quickly and cause endophthalmitis. Need to see ophtho or better yet cornea specialist ASAP and may need fortified antibiotics and close follow up. If no ophtho available for those, send to ivory tower. NEVER GIVE STEROIDS. You are done.

                      3. Orbital cellulitis- in young kids (less then 5), a bad conjunctivitis may look like orbital cellulitis, need CT orbits WITH contrast to differentiate. In older, look at eye movements and ask about loss of vision and double vision. Look for proptosis. These are orbital signs distinguishing preseptal and orbital cellulitis. Have low threshold for admission and IV antibiotics. If there is an abscess on CT, need ENT or oculoplastcs involved. General ophtho guys won't help with that. You are done.

                      4. Glaucoma- that's a tough one. Ideally, learn how to use tonopen (needs to be calibrated, need to use a cover). If this thing is not properly calibrated, it will show pressure of 92 (max reading) and you will be calling your ophtho guys in panic :). Learn signs and symptoms of angle closure- mid dilated pupil, steamy cornea, lethargic patient that may be vomiting if pressure is very high, decreased vision. Need to send to ophtho who has access to a YAG laser or send to university. You are done.

                      5. Trauma- CT is helpful in ruptured globe diagnosis, look for globe deformity, vitreous heme, ask about mechanism of injury (grinding metal on metal? high velocity object?- suspect intra ocular foreign body). If you see "black stuff" on the cornea, that may be iris plugging up cornea rupture. Don't touch, put a shield on the eye, give anti-emetics and 400 mg of IV gatifloxacin, send to university (honestly, if I had a globe rupture, I'd want it repaired in an academic setting and not by a general ophtho who did one five years ago). All trauma patient should eventually see an ophthalmologist, even if not the same day.

                      Lastly, for red eyes, please do not give Tobramycin or Sulfacetamide. That stuff is toxic to the cornea. You can do Ofloxacin or if really high suspicion for bacterial infection- 4th generation fluoroquinolone. Don't give steroids.

                      Cheers!

                      This was indeed an awesome post.

                      Eyefixer, how do you feel about oral steroids for iritis? For example, a pt with a hx of recent trauma to the eye. Initially he was asymptomatic for several days. But he now presents with eye pain, photophobia and mild blurry vision. I've never been good enough to confidently identify cell and flare but on exam, but let's say the patient has mild injection, no significant symptomatic improvement with topical anesthetics, and pain with light to the opposite eye. Would oral prednisone be of any benefit? Any potential harm other than the usual with oral steroids? I rx oral prednisone so often from the ED for asthma and COPD without issue. I've actually been told that since I'm more comfortable with oral prednisone, I could do that until the pt follows up in the eye clinc. The reasoning is that oral steroids would have less potential harm to the eye than topical steroids if misused (though with obviously more risk for systemic side effects). Does that seem reasonable to you?
                       

                      Eyefixer

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                        This was indeed an awesome post.

                        Eyefixer, how do you feel about oral steroids for iritis? For example, a pt with a hx of recent trauma to the eye. Initially he was asymptomatic for several days. But he now presents with eye pain, photophobia and mild blurry vision. I've never been good enough to confidently identify cell and flare but on exam, but let's say the patient has mild injection, no significant symptomatic improvement with topical anesthetics, and pain with light to the opposite eye. Would oral prednisone be of any benefit? Any potential harm other than the usual with oral steroids? I rx oral prednisone so often from the ED for asthma and COPD without issue. I've actually been told that since I'm more comfortable with oral prednisone, I could do that until the pt follows up in the eye clinc. The reasoning is that oral steroids would have less potential harm to the eye than topical steroids if misused (though with obviously more risk for systemic side effects). Does that seem reasonable to you?

                        What you are describing is likely traumatic iritis. This is usually is self limiting condition (imagine how many people get punched in the eye and never go to ER or see an ophthalmologist. Eye gets red and hurts for a while, but eventually symptoms resolve). If the patient does come in, it should be treated. Treatment is not oral steroids- too big of a gun. We use topical steroids and cycloplegia. I would never advise ER docs to use topical steroids for anything- for med legal reasons, etc. A patient on topical steroids always needs to be monitored for eye pressure spikes, cataract development, etc. In ER setting, for patient with traumatic iritis give them Cyclogyl 1 percent BID which gives them symptomatic relief (pain and photophobia) and refer to ophtho. They need a full eye exam due to trauma anyway. If there is still inflammation, Ophtho will add steroids. You are done :).
                         
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                        Angry Birds

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                          This was indeed an awesome post.

                          Eyefixer, how do you feel about oral steroids for iritis? For example, a pt with a hx of recent trauma to the eye. Initially he was asymptomatic for several days. But he now presents with eye pain, photophobia and mild blurry vision. I've never been good enough to confidently identify cell and flare but on exam, but let's say the patient has mild injection, no significant symptomatic improvement with topical anesthetics, and pain with light to the opposite eye. Would oral prednisone be of any benefit? Any potential harm other than the usual with oral steroids? I rx oral prednisone so often from the ED for asthma and COPD without issue. I've actually been told that since I'm more comfortable with oral prednisone, I could do that until the pt follows up in the eye clinc. The reasoning is that oral steroids would have less potential harm to the eye than topical steroids if misused (though with obviously more risk for systemic side effects). Does that seem reasonable to you?

                          Hot damn, I thought I was the only one who still couldn't confidently identify f***in cells and flare.
                           
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                          deleted547339

                            What you are describing is likely traumatic iritis. This is usually is self limiting condition (imagine how many people get punched in the eye and never go to ER or see an ophthalmologist. Eye gets red and hurts for a while, but eventually symptoms resolve). If the patient does come in, it should be treated. Treatment is not oral steroids- too big of a gun. We use topical steroids and cycloplegia. I would never advise ER docs to use topical steroids for anything- for med legal reasons, etc. A patient on topical steroids always needs to be monitored for eye pressure spikes, cataract development, etc. In ER setting, for patient with traumatic iritis give them Cyclogyl 1 percent BID which gives them symptomatic relief (pain and photophobia) and refer to ophtho. They need a full eye exam due to trauma anyway. If there is still inflammation, Ophtho will add steroids. You are done :).

                            What do you think about a single dose of PO/IM steroids in the ED?
                             
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                            Eyefixer

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                              Hot damn, I thought I was the only one who still couldn't confidently identify f***in cells and flare.

                              I for one would not expect an ER doc to be able to identify/grade cell/flare. If you can, great. Truthfully, i started to be able to REALLY see and grade cell/flare probably by the end of my first year ophtho residency.
                               
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                              Old Grunt

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                                This thread is great. Thanks to all the people who have contributed and especially the practicing ophthalmologists.

                                I wanted to throw a plug in here for an ap: "eyehandbook" for your smartphone. Lots of good info on it and also some cool tools (i.e. an kinetic drum). I don't have any financial interest in the ap.
                                 

                                canigetawhatwhat

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                                  i respect the **** out of ophtho. Most of their diagnosis is based on physical exam. Wildly different pathologies with subtle exam findings that they are trained to pick up. Its incredible, really.

                                  I am an eye ball hater. I got pretty good at slit lamps (flare, cells, looking for aac, etc.) but I realized it only helped me minimally and i still needed to get ophto on board for definitive care. And because i was wrong a lot.

                                  Question about corneal foreign bodies.

                                  I often flick them out with a 25 g and there is often a rust ring. I never image. Should i even flick them out? There is always likely residual fb from the rust ring and i send them all the ophtho anyway. Should I image em?

                                  Thanks eyefixer
                                   
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                                  DrZeke

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                                    i respect the **** out of ophtho. Most of their diagnosis is based on physical exam. Wildly different pathologies with subtle exam findings that they are trained to pick up. Its incredible, really.

                                    I am an eye ball hater. I got pretty good at slit lamps (flare, cells, looking for aac, etc.) but I realized it only helped me minimally and i still needed to get ophto on board for definitive care. And because i was wrong a lot.

                                    Question about corneal foreign bodies.

                                    I often flick them out with a 25 g and there is often a rust ring. I never image. Should i even flick them out? There is always likely residual fb from the rust ring and i send them all the ophtho anyway. Should I image em?

                                    Thanks eyefixer

                                    If you're comfortable removing it I would remove the FB and start antibiotics ASAP. Less likelihood that way of developing corneal ulcer and delaying treatment and healing. Rust ring can be dealt with by Ophtho if indicated. Some rust rings if peripheral enough and asymptomatic can be left.


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                                    Eyefixer

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                                      Sorry I just saw this. Flicking off metallic foreign bodies with a 30g needle is ok as long as you have a slit lamp ( and know how to use it ) AND it's not central (over the pupil). Central ones create a danger of permanent visual axis scaring so better handled by Ophtho. In either case, these are not true emergency and may be sent to ophtho next day with lots of ointment. Do not dig into the cornea to get every last bit of rust ring, even I don't. They tend to come out on their own with time. And of course make sure it's not an open globe- leaking from the wound or iris plugging up the wound etc. You can always ask radiologist to make sure there is no iofb on CT scan or if the globe is mishapen.


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                                      DrZeke

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                                        eyefixer, thanks for posting and hopefully we'll be doing less nuisance phone calls.
                                        should we be dilating eyeballs ?
                                        what's your take on bedside u/s?

                                        there's 3 apps I use for eyes
                                        eyemanual
                                        eyehandbook
                                        eyemd

                                        In our hospital with a large residency bedside U/S by ER usually results in more headache than help. We often gets calls:

                                        1) vitreous syneresis/floaters = retinal detachment

                                        2) find "disc edema" when there isn't or say there is none when there actually is, resulting in confused neurologist.

                                        3) I've had to repeated ask for people not to scan a globe that they cannot see as it may be open.

                                        4) we have had people ultrasound open globe resulting in "all this brown stuff came out" AKA ultrasound induced evisceration

                                        Maybe others have different experience


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                                        Eyefixer

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                                          eyefixer, thanks for posting and hopefully we'll be doing less nuisance phone calls.
                                          should we be dilating eyeballs ?
                                          what's your take on bedside u/s?

                                          there's 3 apps I use for eyes
                                          eyemanual
                                          eyehandbook
                                          eyemd

                                          No dilating eyeballs. Bedside US may be helpful in diagnosing retinal detachment, vitreous hemorrhage, etc. IF you know what you are looking at. If open globe is suspected, do not push on the eyeball with anything including ultrasound. If suspecting open globe- put a plastic shield on it ASAP, give anti emetics, give IV moxi or gatifloxacin X1 dose (good intraocular penetration). Ship out to your friendly tertiary referral center.

                                          Wills eye manual is all you will ever need for emergency eye care.


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