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PubMed1995

Clinical electroretinography in the dog with ganzfeld stimulation: a practical method of examining rod and cone function.

We used a simple and reproducible technique with full-field electroretinography and a special-purpose computer system to test and evaluate outer retinal function in dogs. The standardized protocol included the following five basic responses: (1) a stable initial light-adapted, mainly cone derived response, (2) a dark-adapted rod response, (3) chromatically separated rod and cone responses, (4) a maximal rod and cone response and (5) an isolated cone flicker response. For evaluating the electroretinographic responses, a graphic-presentation was used that included data from the tested animal as well as normative data from dogs of the specific breed and age group, presented as the percentage of the median in which limits of normality were depicted in percentiles.

Adaptation, Ocular↗

PubMed1993

Experiences with the international standard for clinical electroretinography: normative values for clinical practice, interindividual and intraindividual variations and possible extensions.

The international Standard for Clinical Electroretinography requires a minimum of 5 standard response types. In a sample of 20 healthy subjects, the normative values according to this standard were established. Since the distribution of amplitude and implicit time does not follow a Gaussian distribution, we have found the median value and the 1st to 99th percentile or the 5th to 95th percentile useful for determination of abnormality, presented here separately for intraindividual and interindividual variation. To improve quality and reliability, we propose that individual laboratories extend the minimum standard and record the standard responses as parts of a stimulus series of increasing intensity. The normal value of the b/a ratio can easily be established from the maximum response to the Standard for Clinical Electrophysiology standard flash, pointing to abnormalities especially in circulatory disturbances and in degenerative diseases of the retina. The b/a ratio is between 1.5 and 1.7. If flicker responses are recorded at the 1st and 10th minutes after the onset of the rod saturating adaptation light (25 cd/m2), an increase in amplitude can be observed, which in our sample has a relative value of 1.3. A reduced increase in cone response amplitudes during light adaptation might point to abnormality within the rod/cone interaction. Responses from the cone system can be further differentiated by the use of chromatic stimuli. With appropriate filters, short-wavelength cone-sensitive and long-wavelength cone-sensitive responses can be differentiated also in clinical daily practice, which might be helpful for further differentiation of cone disorders. Regular measurements of intraindividual variability can help to improve the quality of electroretinogram recordings. Medians and ranges between the 1st and 99th and the 5th and the 95th percentiles were determined for all recordings for interindividual, as well as for intraindividual variations.

Adult↗

PubMed1989

Electroretinography in central retinal vein occlusion. Correlation of electroretinographic changes with pupillary abnormalities.

In 149 eyes with central retinal vein occlusion (CRVO), we prospectively investigated the role of routine, clinical electroretinography (ERG) in differentiating ischemic (60 eyes) from nonischemic CRVO (89 eyes). Single-flash photopic and scotopic ERGs were recorded. Data for the amplitudes and implicit times of a- and b-waves and for the b-/a-wave amplitude ratio were analyzed in detail. The study revealed that the best ERG parameter (for both photopic and scotopic ERG) for differentiating ischemic from nonischemic CRVO was a subnormal b-wave amplitude (reduced to less than or equal to 60% or by greater than or equal to 1 SD from the normal mean value, or less than or equal to 64%-69% of that in the fellow normal eye), with a sensitivity of 80%-90% and a specificity of 70%-80%. ERG findings were correlated with the relative afferent pupillary defect (RAPD). An RAPD of greater than or equal to 0.7 log units showed a sensitivity of 88% and a specificity of 90% in differentiating ischemic from nonischemic CRVO. ERG and RAPD findings showed a good correlation. The combined ERG and RAPD tests could differentiate 97%-100% of ischemic from nonischemic CRVO cases, with a specificity of about 70%.

Aged↗

PubMed1978

The influence of coating agents on the electrode circuit in electroretinography.

In electroretinography, coating agents are usually applied to improve the contact between the contact-lens electrode and the eye. These agents influence electroretinographic responses. In this experimental study we show that the characteristic properties of the electrode circuit are not influenced by the coating agent. Thus we conclude that these coating agents influence the eye itself. The mechanism of this interaction may be physical, or may be an unknown pharmacologic drug side effect.

Cellulose↗

PubMed2003

[Scanning laser ophthalmoscope multifocal electroretinography and microperimetry in patients with Stargardt's disease].

PURPOSE: We used a scanning laser ophthalmoscope (SLO) evoked multifocal electroretinography (mf-ERG) to evaluate retinal function in patients with Stargardt's disease. SLO microperimetry could demonstrate the size of central retinal scotoma very well in these patients. The aim of the examination was to correlate the results of SLO mf-ERG and SLO microperimetry. METHODS: In four patients with Stargardt's disease SLO mf-ERG and SLO microperimetry were performed. The area of measurement in the SLO mfERG had a 24 degrees diameter (12 degrees visual angle) at the posterior pole of the eye. Stimulation was done using a helium-neon laser (632.8 nm). Simultaneous control of fixation was made using a infrared laser (730 nm). SLO microperimetry was performed with stimuli having the size of Goldmann III stimuli and the intensities 0 dB, 12 dB and 20 dB. In this study the reduction of SLO mfERG amplitudes was correlated to graded stimulus intensities in the SLO microperimetry. RESULTS: The area of reduced retinal function in the SLO mf-ERG measurement could be well correlated to the size of the scotoma in the SLO microperimetry, using the stimulus Goldmann III with the intensity 20 dB. CONCLUSION: SLO mfERG and SLO microperimetry are sensitive methods for quantifying functional deficits and are therefore useful for performing a detailed examination of the retina.

Adult↗

PubMed2003

[Testing central retinal function with multifocal electroretinography before and after photodynamic therapy].

BACKGROUND: Photodynamic therapy (PDT) is applied for certain forms of choroidal neovascular membrane (CNV). The aim of this study was to investigate the effect of PDT on central retinal function as assessed by multifocal electroretinography (ERG). METHODS: 24 patients (25 eyes) with CNV (>50% classic 12 eyes) or occult (9 eyes) in age related macular degeneration (AMD) and CNV with pathological myopia (4 eyes) were treated by PDT using Verteporfin((R)). Before and a median of 6 weeks after therapy, central retinal function was examined using multifocal ERG (RetiScan, 61 hexagons, first-order response). RESULTS: In the area of treatment,we found a tendency of the amplitude of the first positive deflection (P1) to decrease and of the implicit time to increase, but both effects were not statistically significant. These alterations were more pronounced in eyes with occult CNV and in myopia-related CNV. Amplitude reduction and implicit time prolongation could also be found in the areas represented by the multifocal ERG but not treated. There was no significant correlation between change in visual acuity after PDT and amplitude of the multifocal ERG. CONCLUSION: The effects of PDT on retinal function seem to be moderate as assessed by multifocal ERG. An inherent problem of this investigation was the recruitment of nontreated patients as controls. Future goals are investigations of patients with repeated PDT and of long-term alterations in multifocal ERG after PDT.

Adult↗

PubMed2003

[Multifocal steady-state pattern-reversal electroretinography in glaucoma patients].

AIM: This study was designed to answer the question of whether multifocal steady-state pattern-reversal electroretinography (ERG) is capable of detecting glaucomatous visual field defects. METHOD: Sixteen patients (28 eyes) and ten normal subjects (20 eyes) were examined. Multifocal pattern ERGs were recorded with the RETIscan system and DTL electrodes. We stimulated with a steady-state checkerboard pattern reversal (three reversals during 171 ms sweep length, congruent with 17.5 reversals/s). The multifocal pattern ERG amplitudes were evaluated using discrete Fourier transformation (DFT) across three reversals. In cases of advanced glaucoma, the DFT-calculated amplitudes were combined in hemispheres and checked for correlations with corresponding visual field defects. In all binocularly examined persons, side comparisons ("worse" eye vs "better" eye), and interindividual comparisons (glaucoma vs normal) were carried out. RESULTS: In interindividual comparisons and interocular side comparisons, significant amplitude reductions of the "worse" eyes were seen in the foveal records. No topographical correlation between multifocal pattern ERG amplitudes and visual field defects could be found. CONCLUSIONS: In glaucomatous visual field defects, multifocal steady-state pattern-reversal ERG using the present stimulation was significantly reduced in its foveal records but seems to be incapable of detecting them topographically.

Adult↗

PubMed2002

Monitoring retinal function in neovascular maculopathy using multifocal electroretinography - early and long-term correlation with clinical findings.

PURPOSE: To objectively investigate and longitudinally monitor retinal function in patients with choroidal neovascularization (CNV) due to exudative age-related macular degeneration (AMD) and myopia using multifocal electroretinography (mfERG). METHODS: Patients with classic and occult subfoveal CNV secondary either to AMD or to myopia were enrolled in the study. The mfERGs were performed at the beginning of the study and every 3 months subsequently during a follow-up period of 15 months. In addition, standardized visual acuity testing, ophthalmologic examinations, color fundus photographs and fluorescein angiography were performed. The mfERG records were derived with the VERIS-System (Electro-Diagnostic Imaging, San Mateo, Calif., USA); 103 locations within the central 50 degrees in diameter were stimulated concurrently by means of the m-sequence technique. Fixation stability was monitored throughout the recording session with an infrared eye monitoring system (VERIS Refractor/Camera unit). The first-order response component was extracted for each stimulated retinal location. The response densities of the first-order kernel were evaluated as a function of eccentricity from the center (ring 1) to the periphery of the stimulated area (ring 6). The results were compared to those derived from age-matched normal control groups. For each patient mfERG responses measured on follow-up visits were compared to each other to evaluate and monitor changes in retinal function. These changes were tested for correlation with those observed in other clinical and electroretinographic findings. Statistical analysis was performed using the Pearson coefficient. RESULTS: Subfoveal neovascular maculopathy was associated with a reduction in response density most prominent within the central 5 degrees over the area affected by CNV detected either at the beginning of the study or at the follow-up recordings. During the follow-up period patients 1 and 4 showed stabilization or a slight increase in response densities over the neovascular lesion-complex and a corresponding stabilization or slight increase in visual acuity accompanied by a decrease in the activity of the neovascular lesion as determined by fluorescein angiography. Patient 2 revealed an increase in response density correlating with an increase in visual acuity and decrease in lesion size. In the contralateral eye of this patient the response density dropped in the area of new subfoveal CNV. In patient 3 continuous progression of the disease was documented by fluorescein angiography and visual acuity. It correlated well with a continuous decrease in retinal response densities during the follow-up. CONCLUSIONS: Objective monitoring of retinal function and correlation with morphological and psychophysical findings was at least in part possible in patients suffering from AMD and myopia. In all of four patients whose subfoveal CNV was documented by fluorescein angiography. Response densities were reduced particularly in the central 5 degrees and in visual acuity. The mfERG data showed a moderate to high statistical correlation with visual function as measured by visual acuity. On the other hand, the greatest linear dimension of the lesion size showed only a weak to moderate statistical correlation with both the response densities of the mfERG and the visual acuity. We conclude that the size of the CNV complex does not represent an accurate measure of retinal function in neovascular maculopathy. The good correlation of the mfERG data with visual acuity suggests that it may serve for objective assessment of retinal function, of the areas overlying the CNV. It shows potential as a valuable tool for longitudinal monitoring of AMD patients.

Aged↗

PubMed2006

Assessment of macular function by multifocal electroretinography following epiretinal membrane surgery with indocyanine green-assisted internal limiting membrane peeling.

PURPOSE: To evaluate the changes in macular function and potential retinal toxicity in epiretinal membrane (ERM) surgery with indocyanine green (ICG)-assisted internal limiting membrane (ILM) peeling using multifocal electroretinography (mfERG). METHODS: Thirteen eyes of 13 patients were randomly assigned to have ERM surgery with ILM peeling using 0.5 mg/ml or 1.25 mg/ml ICG staining. Patients were examined at baseline and at 3 and 6 months postoperatively. The postoperative mfERG N1 and P1 response amplitudes and peak latencies of various ring eccentricities were assessed and compared with baseline to determine any serial changes. RESULTS: After surgery, the median best-corrected visual acuity improved from 20/70 at baseline to 20/30 at 6 months postoperatively (Wilcoxon signed-ranks test, P=0.004). At 3 months postoperatively, the 0.5 mg/ml group showed no significant changes in N1 and P1 response amplitudes and peak latencies, whereas the 1.25 mg/ml ICG group showed significant reductions in N1 and P1 response amplitudes compared with baseline. No significant changes in mfERG responses were observed in either group at 6 months after surgery. CONCLUSIONS: Our mfERG findings suggested that the use of a higher concentration of ICG for ILM staining might result in transient retinal functional impairment postoperatively. The lowest possible concentration of ICG should be used intraoperatively to minimize potential retinal toxicity.

Aged↗

PubMedDate not supplied

Multifocal electroretinography (mfERG) in insulin dependent diabetics with and without clinically apparent retinopathy.

PURPOSE: To study the retinal function, using multifocal electroretinography (mfERG), in diabetic patients with mild and moderate retinopathy, and in diabetics without clinically apparent retinopathy. METHODS: Thirty-one patients with insulin dependent diabetes mellitus, eleven without any clinically apparent retinopathy, twelve with mild retinopathy and eight with moderate retinopathy, were studied. Ophthalmologic examination included testing of visual acuity, fundus inspection, fundus photography and mfERG. Sixteen subjects without eye disease and with normal visual acuity were used as controls for comparison of mfERG results. RESULTS: The patients had a mean diabetes duration of 23+/-9 years. All patients and controls had a visual acuity of 1.0. In the first order component of the mfERG there were significantly higher ring amplitudes in the diabetics compared to the controls (p=0.001). In the second-order component of the mfERG, there was a significantly prolonged implicit time in the diabetics who had retinopathy compared to those without any retinopathy (p=0.026). The third positive waveform in the ring amplitudes of the second-order component, were absent in 15/31 of patients with diabetes, but were easily distinguished in all the controls; p<0.001. This waveform was absent in 6/11 patients without retinopathy. CONCLUSION: Patients with insulin dependent diabetes have specific abnormalities in both the first and the second-order component of the mfERG. These abnormalities reflect both vascular changes in the retina and, probably simultaneously, pathology in inner retinal function, also in the diabetics without clinically apparent retinopathy.

Diabetes Mellitus, Type 1↗

PubMed2006

The changes of pattern electroretinography at the early stage of photodynamic therapy.

PURPOSE: To evaluate the short-term changes in pattern electroretinography (PERG) after photodynamic therapy (PDT). METHODS: Thirty eyes of 30 patients (17 males, 13 females) with choroidal neovascularization secondary to age related macular degeneration were included in this study. Standard PDT with verteporfin was performed on each patient. Serial PERG recordings were performed before, 1 week, and 1 month after PDT. RESULTS: Mean age of the patients was 69.6+/-8.4 years (range 56 and 90 years). One month after PDT, the visual acuity improved in 16 eyes, remained unchanged in 12 eyes and deteriorated in two eyes. New hemorrhages were seen in two eyes in the first week after PDT and visual acuity was decreased in those patients. No other patient complained of ocular and systemic adverse events. There was a statistically significant reduction in the amplitudes of P50 and N95 waves at the first week recordings after PDT. At 1 month after PDT, no significant differences in the P50 and N95 amplitudes were observed compared with pre-PDT PERG recordings. There were no significant changes in the latencies of P50 and N95 at the first week and first month recordings when compared with pre-treatment PERG values. CONCLUSIONS: Reduction in P50 and N95 amplitudes suggests that transient impairments in macular function occur at the first week after PDT.

Aged↗

PubMed2006

Visual field and multifocal electroretinography and their correlations in patients on hydroxychloroquine therapy.

PURPOSE: To evaluate the effects of hydroxychloroquine on visual field and multifocal electroretinography (mfERG) and their correlations in patients taking hydroxychloroquine. METHODS: This was a cross-sectional study in which patients on hydroxychloroquine therapy underwent automated 10-2 threshold static visual field examination and mfERG recordings. Non-parametric unadjusted and age-adjusted Spearman correlation coefficients rho were calculated between the cumulative dose of hydroxychloroquine and the visual field mean deviation (MD) and pattern standard deviation (PSD) values; and the mfERG response amplitudes and peak latencies. Correlation analysis was also performed between the visual field MD and PSD values and the mfERG response amplitudes and peak latencies. RESULTS: A total of 26 eyes in 13 patients were analyzed. The mean duration of hydroxychloroquine therapy was 4.9 years and the mean cumulative dose was 574 g. No significant correlation was found between the cumulative dose of hydroxychloroquine and the visual field MD and PSD values. There were significant correlations between the cumulative dose of hydroxychloroquine and mfERG N1 and P1 response amplitudes for the central rings (ring 1-3). The correlations between the dose of hydroxychloroquine and mfERG N1 and P1 response amplitudes were strongest for the paracentral ring 2 (rho =-0.63 and rho =-0.62, respectively, P = 0.001). Significant correlations were also found between the visual field MD values and mfERG response amplitudes of various ring eccentricities. CONCLUSIONS: In patients on hydroxychloroquine, mfERG response amplitude correlated with both the 10-2 visual field MD values and with the cumulative dose of hydroxychloroquine used. The use of mfERG can provide objective measurement of retinal function in patients on hydroxychloroquine and may provide supplementary quantitative information to visual field findings.

Adult↗

PubMed1992

Electroretinography in seasonal affective disorder.

Retinal mechanisms have been hypothesized in the pathophysiology of seasonal affective disorder (SAD). Electroretinography (ERG) is a noninvasive electrophysiologic test that provides an objective measure of photoreceptor and retinal function. We conducted dark-adapted ERG examinations with a bright white light stimulus in a group of depressed, drug-free patients with seasonal affective disorder (6 men, 18 women) diagnosed by DSM-III-R criteria, and a group of sex- and age-matched control subjects (6 men, 16 women) during the winter. A significant difference was found between SAD patients and controls, but female SAD patients had lower ERG b-wave amplitudes than female controls, while male SAD patients had higher amplitudes than the matched controls. The ERG b-wave implicit times (times from onset of stimulus to peak of b-wave) were significantly longer in the left eyes of the male control subjects. These data may indicate subtle retinal changes in patients with SAD, but the results must be considered preliminary because of the small number of subjects studied and the large intersubject variability in the ERG procedure.

Adult↗

PubMed2005

Training a learning vector quantization network using the pattern electroretinography signals.

In this study, the pattern electroretinography (PERG) signals derived from evoked potential across retinal cells of subjects after visual stimulation were analyzed using artificial neural network (ANN) with 172 healthy and 148 diseased subjects. ANN was employed to PERG signals to distinguish between healthy eye and diseased eye. Supervised network examined was a competitive learning vector quantization network. The designed classification structure has about 94% sensitivity, 90.32% specifity, 5.94% false negative, 9.67% false positive and correct classification is calculated to be 92%. Testing results were found to be compliant with the expected results that are derived from the physician's direct diagnosis. The end benefit would be to assist the physician to make the final decision without hesitation.

Adult↗

PubMed2006

Pattern electroretinography and visual evoked potentials in optic nerve diseases.

BACKGROUND: To evaluate transient pattern electroretinography (PERG) and pattern visual evoked potential (VEP) for the diagnosis, differential diagnosis and follow-up of optic nerve diseases. METHODS: Twenty-nine consecutive patients (14 female, 15 male) with the diagnosis of ischaemic optic neuropathy (n=14) and optic neuritis (n=15) were included in this study. Mean age of the patients with ischaemic optic neuropathy was 63.3+/-3.3 (60-78) years and the mean age of the patients with optic neuritis was 28.3+/-8.4 (19-43) years. In each patient ophthalmological examination and systemic evaluation were done and VEP and PERG were recorded. As a control group, VEP recordings of 35 healthy subjects were included. RESULTS: In the ischaemic optic neuropathy group (group 1), mean VEP amplitude (+/-SD) (1.96+/-0.95 microV) was found to be decreased significantly in the affected eyes in comparison to the control group and the unaffected eyes. The delay in latency (116.3+/-20.14 msec in the affected eyes compared with 101.31+/-6.19 msec in unaffected eyes) was statistically significant when compared with the healthy subjects. In the optic neuritis group (group 2), VEP amplitude was decreased (4.13+/-4.04 microV vs 6.97+/-3.35 microV and 6.97+/-4.43 microV) and latency was increased (122.59+/-20.09 msec vs 101.31+/-6.19 msec and 108.76+/-13.57 msec) in affected eyes significantly in comparison to the unaffected eyes and control group, respectively. Even though there were no significant differences for P50 latency and N95/P50 ratios between affected and unaffected eyes in both groups, N95 amplitude decreased significantly in the affected eyes of the ischaemic optic neuropathy patients and N95 latency was found to be decreased in optic neuritis patients. There was no correlation between VEP and PERG findings in both groups. CONCLUSION: VEP amplitude decreased significantly in ischaemic optic neuropathies while latency delay was more significant in patients with optic neuritis. PERG findings showed decreased N95 amplitude in ischemic optic neuropathy without associated latency changes.

Adult↗

PubMedDate not supplied

The clinical applications of multifocal electroretinography: a systematic review.

Multifocal electroretinography (mfERG) is an investigation that can simultaneously measure multiple electroretinographic responses at different retinal locations by cross-correlation techniques. mfERG therefore allows topographic mapping of retinal function in the central 40-50 degrees of the retina. The strength of mfERG lies in its ability to provide objective assessment of the central retinal function at different retinal areas within a short duration of time. Since the introduction of mfERG in 1992, mfERG has been applied in a large variety of clinical settings. This article reviews the clinical applications of mfERG based on the currently available evidence. mfERG has been found to be useful in the assessment of localized retinal dysfunction caused by various acquired or hereditary retinal disorders. The use of mfERG also enabled clinicians to objectively monitor the treatment outcomes as the changes in visual functions might not be reflected by subjective methods of assessment. By changing the stimulus, recording, and analysis parameters, investigation of specific retinal electrophysiological components can be performed topographically. Further developments and consolidations of these parameters will likely broaden the use of mfERG in the clinical setting.

Electroretinography↗

PubMed1998

Multifocal electroretinography in retinitis pigmentosa.

PURPOSE: To investigate the diagnostic potential of multifocal electroretinography for the evaluation of retinal affection by retinitis pigmentosa in a clinical setting. METHODS: For this prospective study, multifocal electroretinograms were obtained from 38 patients who matched the inclusion criteria of either a detectable photopic Ganzfeld response or visual fields of 10 degrees or more, and from 30 normal volunteers. Recordings were performed with the visual evoked response imaging system, using a resolution of 61 hexagonal elements within a 30-degree visual field. The results of the left eye of each patient and control subject were used for statistical evaluation by the Mann-Whitney U test. RESULTS: The 38 eligible patients included those with Usher syndrome types I and II (one patient and six patients, respectively) and those with autosomal-recessive (18), X-recessive (two), and autosomal-dominant (11) forms of retinitis pigmentosa. In 27 (71%) of these 38 patients, at least a central response of the multifocal electroretinogram was detectable. Loss of multifocal electroretinogram response density in patients with retinitis pigmentosa was significant (P < .00001) in all five eccentricity groups (concentric rings), with a progression from center to periphery. Implicit time was significantly elevated in the third eccentricity group (P < .0038) and increased further toward the periphery (P < .00001). The results did not differ notably between retinitis pigmentosa subgroups. CONCLUSIONS: Because the multifocal electroretinogram differentiates between affected and nonaffected retinal areas, eccentricity-dependent changes in both amplitude and implicit time were found. It can therefore add to the diagnostic information of many patients with retinitis pigmentosa.

Adolescent↗

PubMed2000

Visual pathway abnormalities Wilson's disease: an electrophysiological study using electroretinography and visual evoked potentials.

The pathogenesis of the pattern reversal visual evoked potential (PRVEP) abnormalities in patients with Wilson's disease (WD) has not been investigated earlier. Since electroretinography (ERG) assesses the functional integrity of the retina, it was used along with PRVEP to localize the abnormalities in PRVEP in Wilson's patients. Ten newly diagnosed Wilson's disease patients underwent PRVEP and flash ERG soon after the diagnosis was established. The PRVEP latencies were prolonged in comparison with the controls (P<0.001). Photopic and scotopic A waves and oscillatory potentials were prolonged (P<0. 02) with reduction in amplitudes of photopic A and B waves (P<0.001). Six of these patients were subjected to repeat PRVEP and flash ERG after the clinical improvement with specific therapy. Comparison of the pre and post-treatment visual electrophysiological studies revealed significant reduction in latencies of PRVEP and flash ERG A wave (P<0.05) with increase in amplitudes of P100 of PRVEP (P<0.05), A and B waves of flash ERG (P<0.01). These findings confirm the reported PRVEP changes in WD and in addition demonstrate the reversibility of the retinal dysfunction which partially contributes to the PRVEP abnormalities. To the best of our knowledge this is the first study of ERG in patients with Wilson's disease in the literature. Further, there have been no earlier reports in the literature evaluating the effect of specific treatment on the PRVEP and ERG in Wilson's disease.

Adolescent↗