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Biomedical subjects

M X Repka

Publications and source records attributed to M X Repka.

At least 37 records · Page 2Linked to original sources
PubMed1998

Prevalence of myopia between 3 months and 5 1/2 years in preterm infants with and without retinopathy of prematurity. Cryotherapy for Retinopathy of Prematurity Cooperative Group.

PURPOSE: The purpose of the study was to examine spherical equivalent refractive errors, especially myopia, at six ages between 3 months and 5 1/2 years post-term in preterm children with birth weights of less than 1251 g. DESIGN: A cohort study. PARTICIPANTS: There were a total of 827 participants in the multicenter study of cryotherapy for retinopathy of prematurity (ROP). Approximately one third of the eyes did not develop ROP, whereas two thirds developed mild-to-severe ROP. None of the eyes underwent cryotherapy. INTERVENTION: Refractive error was measured at 3 months, 1 year, and 5 1/2 years term due date at the five long-term follow-up centers. In most eyes, refractive error also was measured at 2, 3 1/2, and 4 1/2 years. MAIN OUTCOME MEASURE: Myopia was defined as 0.25 diopter (D) or greater with high myopia as 5 D or greater. RESULTS: The proportion of eyes with myopia in this preterm population was increased compared to published data on full-term children and was related to severity of both acute-phase and cicatricial-phase ROP. The percentage of eyes with myopia varied little across ages, ranging from 21.2% at 1 year to 15.7% at 4 1/2 years. The percentage of eyes with high myopia doubled from 1.8% to 3.9% between 3 months and 1 year and remained stable thereafter. The distribution of refractive errors in eyes with mild acute-phase ROP was similar to that of eyes with no ROP. In contrast, eyes with moderate or severe acute-phase ROP showed an increased prevalence of high myopia. The distribution of refractive errors changed between 3 months and 1 year with little change after 1 year. This pattern of refractive development differs from that of full-term infants. Birth weight, severity of ROP, and degree of myopia at 3 months predicted the presence of myopia and high myopia at 5 1/2 years of age. CONCLUSIONS: The distribution of refractive errors in preterm infants from age 3 months to 5 1/2 years varies with severity of acute-phase ROP and cicatricial disease. Changes in refractive error distribution occur primarily between 3 months and 1 year and involve a decrease in the proportion of eyes with hyperopia and an increase in the proportion with high degrees of myopia.

Acute Disease↗
PubMed1998

The incidence of ophthalmologic interventions in children with birth weights less than 1251 grams. Results through 5 1/2 years. Cryotherapy for Retinopathy of Prematurity Cooperative Group.

OBJECTIVE: This study aimed to report the frequency of ophthalmologic surgical and medical therapies provided to children with birth weights less than 1251 g who had all stages of retinopathy of prematurity (ROP). In addition, this study aimed to report the initial age at which such procedures are provided and to report the frequency of cerebrospinal fluid shunts. DESIGN: Observational case series with prospective data collection. PARTICIPANTS: Children from the Multicenter Trial of Cryotherapy for Retinopathy of Prematurity (CRYO-ROP) with birth weights less than 1251 g served as subjects. Group A included 257 children from all 23 CRYO-ROP study centers who had threshold ROP, who had participated in the randomized trial of cryotherapy, and who had survived to age 1 year. Group B included 1208 children from 5 of the 23 study centers who had varying severity of ROP (69 had threshold ROP) and who had participated in a 5 1/2-year study of the natural history of ROP. MAIN OUTCOME MEASURES: Investigators documented medical and surgical ophthalmologic interventions through age 5 1/2 years as well as cerebrospinal fluid shunting surgery for hydrocephalus through age 2 years. RESULTS: Group A was composed of 257 children with threshold ROP who underwent 226 ocular interventions in addition to cryotherapy (0.9 intervention per child). The most common treatments performed on the randomized cohort of children were vitrectomy (26% of patients), lensectomy (18%), amblyopia therapy (20%), and strabismus surgery (10%). Cataract surgery not associated with vitrectomy was performed infrequently (2%) and was performed equally often in treated and control eyes. Amblyopia therapy was prescribed as often for treated as for control eyes. Cerebrospinal fluid shunts were placed in 11% of these children. Group B was composed of 1208 natural history patients who underwent 239 ophthalmologic interventions (0.4 intervention per child). Strabismus surgery was the most commonly performed procedure for the natural history cohort of children (6% of the children). Amblyopia therapy was prescribed for 7% of the natural history patients. Cerebrospinal fluid shunts were required by 3% of the natural history infants, more often in children with more severe ROP. CONCLUSIONS: These premature infants underwent a large number of ophthalmologic treatments during the first 5 1/2 years of life. The long-term costs of both extreme prematurity and ROP include not only the initial ablative therapy for ROP and societal loss due to blindness that still occurs in some cases, but also the ongoing costs of caring for eye problems.

Amblyopia↗
PubMed1998

Pediatric Horner syndrome.

INTRODUCTION: The purpose of this study was to define the etiologies of Horner syndrome in the pediatric population. METHODS: A retrospective review was performed of the medical records of all pediatric Horner syndrome patients (< 18 years old) examined by the pediatric ophthalmology services at two large referral centers. RESULTS: Seventy-three pediatric Horner syndrome patients were identified. Of these, 31 (42%) were congenital, 11 (15%) were acquired without surgical intervention, and 31 (42%) were acquired after a surgical procedure of the thorax, neck, or central nervous system. Of the congenital Horner syndrome patients, a history of delivery with the use of forceps, vacuum extraction, shoulder dystocia, fetal rotation, or postterm delivery was elicited in 16 patients (53%). Concomitant brachial plexus injury was identified in only 3 patients. Two patients had congenital varicella syndrome and 1 patient was diagnosed with neuroblastoma. This patient had a palpable supraclavicular mass and stridor. Diagnosis of the patients with acquired Horner syndrome included neuroblastoma (2), trauma (1), rhabdomyosarcoma (1), brainstem vascular malformation (1), disseminated sclerosis (1), and not determined (5). CONCLUSION: In children with congenital Horner syndrome, a history of forceful manipulation of the infant during birth may reduce the need for extensive systemic evaluation. Without such history, a decision to proceed with further evaluation is made with consideration of the relative incidence of neuroblastoma by age and the physical findings. All acquired pediatric Horner syndrome patients without a known etiology require thorough evaluation because of the frequent association of serious underlying disease.

Birth Injuries↗
PubMed1998

Pseudotumor cerebri in children.

PURPOSE: Demographic and outcome data in the era of modern neuroimaging are needed to describe pseudotumor cerebri in children. METHODS: We reviewed the medical records of children less than 18 years old who were diagnosed with pseudotumor cerebri between 1977 and 1997. We defined pseudotumor cerebri as (1) increased intracranial pressure, (2) normal or small ventricles, and (3) normal cerebrospinal fluid composition. The condition might be idiopathic or the result of a nontumor etiology. RESULTS: Thirty-seven patients had an initial diagnosis of pseudotumor cerebri. Two patients were subsequently diagnosed with a central nervous system malignancy and were excluded from further analysis. The remaining 35 patients included 10 patients with idiopathic pseudotumor cerebri and 25 patients with disorders reported to be associated with pseudotumor cerebri. The mean age was 10.6 years with a range of 3 to 17 years. Twenty patients (57%) were female and 13 patients (37%) were obese. At presentation 4 patients had a visual acuity less than 20/40 in the best eye and 10 patients had visual field deficits. Seventeen patients (49%) had cranial nerve deficits, all of which resolved with normalization of the intracranial pressure. Follow-up data were obtained on 30 patients. Only one patient had a final visual acuity less than 20/40 in the best eye, whereas six patients had residual visual field deficits. Ten patients (33%) had optic nerve atrophy. CONCLUSIONS: There was no gender predominance, and associated etiologic factors were common in these children with pseudotumor cerebri. Permanent visual loss occurs in some children with pseudotumor cerebri. Quantitative perimetry and optic nerve examination were more sensitive than visual acuity determination in detecting damage to the visual sensory system. In rare instances the patient diagnosed with pseudotumor cerebri will be found after extended follow-up to harbor an intracranial neoplasm.

Adolescent↗
PubMed1998

Pituitary adenoma in children.

Pituitary adenoma is an uncommon intracranial tumor of children. The authors retrospectively reviewed the records of 10 patients younger than 17 years of age with pituitary adenoma. Five patients had visual loss at presentation. Four of these five patients with visual loss and extrasellar tumor extension were adolescents (12-15 years of age). Seven of 10 patients underwent neurosurgery. Of the five patients with visual loss, three patients experienced visual improvement, one patient was unchanged, and one patient did not have follow-up. The visual loss in these patients tended to be more severe and more likely to be associated with optic atrophy than adult patients. Although they are relatively uncommon, ophthalmologists should be aware that pituitary adenomas may occur in children and that these tumors when present in the pubertal period may be more likely to exhibit extrasellar extension or invasiveness.

Adenoma↗
PubMed1997

Early treatment of posterior retinopathy of prematurity: a controlled trial.

OBJECTIVE: The purpose of the study is to assess the possible benefits of early laser treatment for posterior retinopathy of prematurity (ROP) and to provide data concerning the natural history of posterior ROP. DESIGN: The study design was a prospective, multicenter, randomized trial. PARTICIPANTS: A total of 19 infants with prethreshold posterior ROP were studied. INTERVENTION: Randomization to immediate indirect laser photocoagulation or observation, with application of laser photocoagulation for those control eyes reaching threshold disease, was performed. MAIN OUTCOME MEASURES: Patients were assessed at 3 months and the anatomic outcome recorded along with any adverse treatment effects. RESULTS: An unfavorable structural outcome developed in 3 (16%) of 19 early treatment eyes compared with 3 (18%) of 17 for those treated only if threshold disease was reached. Of the 17 control eyes, 15 (88%) reached threshold disease. Progression to threshold occurred within 1 week in all but two eyes. All 12 control eyes with posterior ROP and any amount of extraretinal fibrovascular proliferation progressed to threshold disease. CONCLUSIONS: Although the number of patients studied is too small to reach statistical significance, the likelihood of a favorable outcome for eyes with prethreshold posterior ROP treated immediately with laser photocoagulation is comparable to that obtained by withholding treatment until threshold disease is reached. There is a high probability of progression from prethreshold to threshold disease, usually within 1 week or less.

Disease Progression↗
PubMed1997

Strabismus surgery among aged medicare beneficiaries.

OBJECTIVES: The purpose of this study was to investigate the incidence of strabismus surgery among aged patients in the United States. METHODS: The Medicare Part B claims experience (physician professional fee billing) for 1995 was reviewed for the number of times each strabismus surgical procedure recognized in Physicians' Current Procedural Terminology (CPT) was performed. To determine the indications for the procedures that were performed, a 5% sample of claims was reviewed for the pertinent International Classification of Diseases, Ninth Revision, Clinical Modification, diagnostic codes. RESULTS: There were 27 million aged Medicare beneficiaries eligible for Part B benefits in 1995 in a fee-for-service setting. During that year physicians reported 9497 strabismus physician services. These represented 6585 separate procedures (CPT codes 67311 to 67343) and 277 botulinum toxin (Botox) injections for strabismus (CPT 67345) performed during 1995. Sixty-nine percent of the surgical procedures were for horizontal correction and 28% were for vertical correction. Adjustable sutures were used for only 1240 cases (1 9%). The add-on procedural code for reoperation surgery or surgery in the presence of restriction of the extraocular muscles was used in just 930 cases (14%). The most common diagnosis for horizontal surgery was exotropia. Paralytic strabismus and thyroid disease were identified for 17% of cases. Three percent of the diagnoses were inappropriate for the procedures performed and may have been reported in error. CONCLUSIONS: These data confirm a very low incidence of strabismus surgical procedures (2/10,000) and injections (1/100,000) among aged Medicare beneficiaries. The strabismus surgery was most often performed to repair a horizontal deviation. The adjustable suture technique was used infrequently. These data may be extrapolated into the future to aid in determining the strabismus services that will be needed early in the next century.

Aged↗
PubMed1996

The one-year surgical outcome after prism adaptation for the management of acquired esotropia.

PURPOSE: To report the 1-year motor and sensory outcomes for patients with acquired comitant esotropia managed with preoperative prism adaptation. METHODS: Patients entered a multicenter randomized prospective evaluation of prism adaptation before strabismus surgery. Prism responders were randomized to surgery with the target angle based on either the entry angle or the adapted angle of esotropia. Three hundred five patients (92 percent of cohort) completed 1-year postoperative follow-up. RESULTS: The overall motor success rate for all patients in the study was 74 percent. Prism responders operated on for the adapted esotropic target angle had a satisfactory motor outcome more often than those operated on for the entry angle, 90 percent compared with 75 percent (P = 0.04). Significant predictors of a satisfactory motor outcome after surgery were prism adaptation, female sex, and hyperopia greater than or equal to +3.00 D. Prism responders operated on for the adapted angle showed fusion of the Worth 4-dot at substantially more often than did those operated on for the entry angle, 75 percent compared with 60 percent (P = 0.12). CONCLUSION: Prism adaptation significantly improves the 1-year motor outcome after esotropia surgery in prism responders. There is no increase in the number of overcorrections. These results confirm the value of allotting the extra time and potential expense needed for this technique.

Adaptation, Ocular↗
PubMed1995

Regulation of static and dynamic ocular alignment in patients with trochlear nerve pareses.

Ocular alignment and saccades were studied in seven patients with trochlear nerve pareses, before and after strabismus surgery. Prior to surgery, a position-dependent vertical ocular misalignment was present, and downward saccades were hypometric in the paretic eye. Strabismus surgery reduced the magnitude and position-dependence of the static misalignment. Saccade conjugacy improved in the patients with congenital pareses, and in the patient with a gradual-onset acquired paresis, but less improvement occurred in subjects with traumatic pareses. The post-operative change in saccade conjugacy relative to the change in static alignment correlated with pre-operative vertical vergence, suggesting that changes in saccade yoking depend on an interaction between saccades and vertical vergence.

Adaptation, Ocular↗
PubMed1995

Refractive error and axial length in a primate model of strabismus and congenital nystagmus.

PURPOSE: To evaluate the development of refractive error and axial length in a primate model of sensory strabismus and nystagmus. METHODS: Four macaque monkeys had alternating tarsorraphy beginning within 24 hours of birth. One eye was closed for 25 days, and when it opened, the second eye immediately was closed for the next 25 days. Cycloplegic refractions and axial lengths were determined prospectively for three animals for 1 year or more. These data were compared to those of three unsutured control macaques raised under otherwise similar conditions. RESULTS: Each experimental animal developed exotropia and nystagmus. The first occluded eyes were significantly more hypermetropic than the control eyes at 1 month of age (+7.25 D +/- 1.95 D versus +1.92 D +/- 1.27 D; P < 0.02) and remained significantly more hypermetropic throughout the study. The second occluded eyes were more hypermetropic than the control eyes at 1 month (+2.42 D +/- 2.13 D versus +1.92 D +/- 1.27 D; P = 0.20), but less hypermetropic than the first occluded eyes. The rate of emmetropization was slightly faster for the first occluded eyes than for the control eyes (-0.12 D/month compared to -0.03 D/month). The mean axial length measurements of the experimental and control eyes were the same at 1 month, and their rates of change over time were identical. CONCLUSIONS: Persistent hypermetropia was produced by a brief period of reverse neonatal eyelid closure in a model of congenital-like nystagmus. It is suggested that infantile lid closure, nystagmus, or amblyopia after neonatal visual disruption may be associated with a failure of normal emmetropization.

Animals↗
PubMed1994

Treatment of acquired nystagmus with botulinum neurotoxin A.

OBJECTIVE: Acquired nystagmus may cause oscillopsia and in some cases decreased visual acuity. Such symptoms may be debilitating. We evaluated the efficacy of retrobulbar botulinum neurotoxin A in the visual rehabilitation of patients with acquired symptomatic nystagmus. PATIENTS: Adults with acquired nystagmus from multiple sclerosis or brain-stem hemorrhage were recruited for this treatment study. Eligible patients were unable to perform visual tasks that they had performed prior to the onset of the nystagmus. DESIGN AND INTERVENTION: A prospective study evaluated the results of the retrobulbar injection of 25 to 30 U of botulinum neurotoxin A. Patients underwent testing of visual function, including eye movement recordings before and after initial injections. Patients were followed up for changes in their visual function for at least 6 months following the last injection. RESULTS: Six patients (nine eyes) with acquired nystagmus were treated with a series of 17 injections of retrobulbar botulinum neurotoxin A. Each patient had subjective and objective improvement in distance visual acuity following the injection. A reduction in the amplitude of the nystagmus was seen following each of the injections, but the frequency of the nystagmus was generally unchanged. Visual improvement usually lasted no more than 8 weeks. However, improvement persisted for 6 months after injection in two patients with oculopalatal myoclonus. CONCLUSION: Botulinum neurotoxin A transiently improves the visual function of patients with acquired nystagmus. For patients with oculopalatal myoclonus the improvement seems to last longer, about 6 months in two patients.

Adult↗
PubMed1994

Ketorolac versus acetaminophen or ibuprofen in controlling postoperative pain in patients with strabismus.

PURPOSE: Ketorolac is a new, parenteral, nonsteroidal, anti-inflammatory agent. The authors compare the effectiveness of a single intravenous dose of ketorolac with a single oral dose of either acetaminophen or ibuprofen in controlling postoperative pain in patients with strabismus. METHODS: A prospective, randomized, double-masked study was performed on 60 patients older than 12 years of age who were undergoing strabismus surgery. The patients were randomized into one of three single-dosage treatment groups: group 1 received oral acetaminophen (650 mg); group 2 received oral ibuprofen (600 mg); and group 3 received intravenous ketorolac (60 mg) intraoperatively and placebo capsules postoperatively. Pain and sedation levels were assessed at 2 and 5 hours after surgery by having the patient mark a standard 100-mm visual analog scale. RESULTS: The ketorolac-treated patients had significantly less pain at both the 2- and 5-hour intervals after surgery compared with either the acetaminophen or ibuprofen groups (P = 0.001). There was no difference in the level of sedation among any of the three treatment groups. CONCLUSION: Intravenous ketorolac given at the conclusion of surgery was more effective than either oral acetaminophen or oral ibuprofen given 30 to 45 minutes after strabismus surgery in controlling postoperative pain. Pain relief was achieved earlier by intravenous delivery than by oral agents. Greater pain relief with ketorolac was sustained 5 hours after surgery. This facilitates suture adjustment and earlier discharge. Similar pain control is possible for other ophthalmologic surgery. Because the oral medications used in this study were administered in capsules, the results may have been different if clinically available preparations had been tested.

Acetaminophen↗
PubMed1993

Surfactant prophylaxis and retinopathy of prematurity.

OBJECTIVE: The use of exogenous surfactant has led to a decrease in mortality of low-birth-weight infants. In some instances, use of this drug has also led to a reduction in neonatal morbidity, such as respiratory distress syndrome. This study was undertaken to determine whether prophylactic surfactant therapy has an effect on the incidence and severity of retinopathy of prematurity. DESIGN: The authors reviewed the findings of sequential prospective ophthalmologic examinations performed in two neonatal intensive care units that participated in randomized trials of prophylactic exogenous mammalian surfactant. PATIENTS: There were 43 patients in the control group (no prophylactic surfactant) and 43 patients in the prophylactic surfactant group. These groups did not differ on the basis of birth weight, gestational age, race, or gender. RESULTS: The incidence and severity of retinopathy of prematurity did not vary between the control and surfactant-treated infants. Only birth weight appeared to be significantly related to the incidence and severity of retinopathy of prematurity. CONCLUSIONS: These results suggest that the widespread use of prophylactic surfactant therapy will not change the incidence of retinopathy of prematurity in extremely low-birth-weight infants. However, the absolute number of affected patients will likely increase because of the decrease in mortality of extremely low-birth-weight patients, the patients most at risk for retinopathy of prematurity.

Female↗
PubMed1993

Common pediatric neuro-ophthalmologic conditions.

Neuro-ophthalmologic problems are some of the most distressing ocular conditions to affect children. In this article the author discusses the differential diagnosis and management of blindness during the first year of life. Nystagmus or 'jiggling eyes' tumors of the visual pathways and acquired ocular motor neuropathies comprise the balance of the article.

Blindness↗
PubMed1993

Timing of amblyopia therapy relative to strabismus surgery.

BACKGROUND: It is taught that amblyopia must be fully reversed before surgery for esotropia is undertaken to achieve the best surgical outcome. In some cases, this means delaying surgery for many months. The alternative of operating early, before the completion of amblyopia therapy, and continuing to treat the amblyopia postoperatively has not been evaluated previously. METHODS: Forty-seven children younger than 8 years of age were identified with a history of both amblyopia and esotropia. They had no other ocular, medical, or neurologic abnormalities. They had no prior strabismus surgery. Of these 47 patients, 26 had their amblyopia fully treated before surgery, and 21 underwent surgery before completing amblyopia therapy. Five of the latter group did not require amblyopia therapy after surgery even though they were still amblyopic before operation. The motor outcome was assessed by comparing the motor alignment at 6 and 0.33 m using accommodative targets in primary position before surgery, at 6 months after surgery, and at the child's most recent visit. Motor success was defined in this study as a postoperative deviation at distance fixation of 8 prism diopters or less. The sensory result was assessed by comparing the frequency of detectable stereoacuity. RESULTS: The treatment groups did not differ significantly in age, depth of amblyopia, refractive error, or preoperative angle. There was no significant difference detected in motor or sensory outcome whether amblyopia was fully or only partially treated before surgery. CONCLUSION: Performing corrective surgery in children with esotropia before full resolution of amblyopia is safe and efficient if the amblyopia therapy is continued after surgery. This strategy permits earlier surgery without postponing the operation until full resolution of amblyopia. The finding that five patients did not require amblyopia therapy after surgery suggests that eye re-alignment itself can help reverse amblyopia in some cases.

Accommodation, Ocular↗
PubMed1993

The efficacy of optical and pharmacological penalization.

PURPOSE: Optical and pharmacological penalization of sound eyes are infrequently used alternatives to occlusion for treating amblyopia. The authors evaluated the efficacy of penalization as their primary treatment of amblyopia. METHODS: One hundred sixty-six patients underwent penalization treatment for strabismic or anisometropic amblyopia for a minimum of 3 months. Both atropine and optical penalization methods were used. RESULTS: Visual acuity improved in 67 (77%) of 87 patients treated with optical penalization. There was a significant improvement of the geometric mean visual acuity of the amblyopic eyes from 20/38 to 20/28 (P < 0.001). Visual acuity of 60 (76%) of 79 patients treated with pharmacological penalization improved. There was a significant improvement of mean visual acuity of the amblyopic eyes from 20/61 to 20/40 (P < 0.001). Neither therapy produced an instance of occlusion amblyopia. Thirteen patients discontinued therapy because of blur or discomfort. CONCLUSION: This study demonstrates that penalization methods are effective methods for the treatment of amblyopia, with a low risk of occlusion amblyopia. Patient acceptance of these methods was excellent. Penalization should be considered more often for the primary treatment of amblyopia.

Amblyopia↗
PubMed1993

Diode laser photocoagulation for threshold retinopathy of prematurity. A randomized study.

BACKGROUND: Although peripheral cryotherapy decreases the incidence of unfavorable anatomic outcomes in threshold retinopathy of prematurity (ROP), apnea, bradycardia, and lid edema can occur. Argon laser indirect ophthalmoscope photocoagulation has been used as an alternative to cryotherapy, with fewer adverse effects. Retinal lesions placed with diode lasers are deeper than similar argon laser lesions, and it is not known whether this difference could influence the response to ablative therapy. METHODS: Patients were enrolled under a prospective, randomized protocol. One eye of each patient with symmetric, threshold ROP was treated with an 814/815 nm diode laser, while the other eye was treated with cryotherapy. Patients with asymmetric diseases also were randomized for treatment in the threshold eye. RESULTS: Nineteen infants (33 eyes) were treated, ranging from 485 to 863 g birth weight (23 to 27 weeks gestational age); 18 patients (32 eyes) were followed for 3 months or longer. Four patients (8 eyes) had bilateral zone 1 disease. Postconceptional age was 36 to 45 weeks at the time of treatment. The diode laser treatment was better tolerated than cryotherapy, and the treatment apparatus was more easily transported. Apneic episodes requiring intubation resulted from two cryotherapy sessions but no diode laser sessions. Five cryotherapy-treated eyes required retreatment because of persistent disease with adjacent skip areas. In the group followed for 3 to 15 months, 1 cryotherapy-treated eye and 1 diode laser-treated eye progressed to stage 5 retinal detachment. CONCLUSION: Compared with cryotherapy, the diode laser was more convenient, technically easier to administer, and better tolerated by the patient. Although the number of patients was too small for meaningful statistical analysis of outcome, diode laser peripheral retinal ablation appeared to be as effective as cryotherapy for the treatment of threshold ROP.

Cryosurgery↗