Skip Navigation
PrintDownload PDFGet Adobe ReaderDownload to WordDownload as HTMLDownload as XMLCitation Manager
Save to Favorites
Guideline Summary
Guideline Title
Dry eye syndrome. Limited revision.
Bibliographic Source(s)
American Academy of Ophthalmology Cornea/External Disease Panel. Dry eye syndrome. Limited revision. San Francisco (CA): American Academy of Ophthalmology (AAO); 2011. 28 p. [119 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American Academy of Ophthalmology Cornea/External Disease Panel, Preferred Practice Patterns Committee. Dry eye syndrome. San Francisco (CA): American Academy of Ophthalmology (AAO); 2008. 28 p. [99 references]

All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. To ensure that all Preferred Practice Patterns are current, each is valid for 5 years from the "approved by" date unless superseded by a revision.

Scope

Disease/Condition(s)

Dry eye syndrome

Guideline Category
Counseling
Diagnosis
Evaluation
Management
Treatment
Clinical Specialty
Ophthalmology
Intended Users
Physicians
Guideline Objective(s)

To preserve and/or improve vision, prevent or minimize structural damage to the ocular surface, and improve patient comfort, by addressing the following goals:

  • Establish the diagnosis of dry eye, differentiating it from other causes of irritation and redness
  • Identify the causes of dry eye
  • Establish appropriate therapy
  • Relieve discomfort
  • Prevent complications, such as loss of visual function, infection, and structural damage
  • Educate and involve the patient in the management of this disease
Target Population

Individuals of all ages who present with symptoms and signs suggestive of dry eye, such as irritation, redness, fluctuating vision, and decreased tear meniscus

Interventions and Practices Considered

Diagnosis

  1. Medical and ocular history
  2. Physical examination
    • Visual acuity
    • External examination
    • Slit-lamp biomicroscopy
  3. Diagnostic tests
    • Assessment of corneal sensation, when indicated
    • Laboratory and clinical evaluation for autoimmune disorders, when indicated

Management/Treatment

  1. Education and environmental modifications
  2. Elimination of offending topical or systemic medications where feasible
  3. Topical medication (e.g., artificial tear substitutes, gels/ointments; cyclosporine and corticosteroids; mucolytic agents; autologous serum tears)
  4. Systemic medication (e.g., omega-3 fatty acids, tetracyclines, cholinergic agonists, anti-inflammatory agents)
  5. Surgical treatment (e.g., punctal plugs, permanent punctual occlusion, tarsorrhaphy, correction of eyelid abnormalities)
  6. Other treatment (e.g., warm compresses and eyelid hygiene, contact lenses, moisture chamber spectacles)
  7. Follow-up
  8. Counseling and referral
Major Outcomes Considered
  • Effectiveness of therapies
    • Reduction or alleviation of signs and symptoms
    • Maintenance and improvement visual function
    • Reduction or prevention of structural damage
  • Adverse effects of therapies

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

In the process of revising this document, a detailed literature search of articles in the English language was conducted in December 2007 in PubMed and the Cochrane Library on the subject of dry eye for the years 2002 to 2007. To complete this limited revision, PubMed and the Cochrane Library were searched on January 27, 28, February 4, 11, and 15, 2011 on the subject of dry eye, limited to English language and publication date from 2008 to the date of the search. Details of the literature search are available at www.aao.org/ppp External Web Site Policy.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Ratings of Strength of Evidence

Level I includes evidence obtained from at least one properly conducted, well-designed randomized, controlled trial. It could include meta-analyses of randomized controlled trials.

Level II includes evidence obtained from the following:

  • Well-designed controlled trials without randomization
  • Well-designed cohort or case-control analytic studies, preferably from more than one center
  • Multiple-time series with or without the intervention

Level III includes evidence obtained from one of the following:

  • Descriptive studies
  • Case reports
  • Reports of expert committees/organization (e.g., Preferred Practice Patterns [PPP] panel consensus with external peer review)
Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The results of a literature search on the subject of dry eye were reviewed by the Cornea/External Disease Panel and used to prepare the recommendations, which they rated in two ways. The panel first rated each recommendation according to its importance to the care process. This "importance to the care process" rating represents care that the panel thought would improve the quality of the patient's care in a meaningful way. The panel also rated each recommendation on the strength of the evidence in the available literature to support the recommendation made.

Rating Scheme for the Strength of the Recommendations

Ratings of Importance to Care Process

Level A, defined as most important

Level B, defined as moderately important

Level C, defined as relevant but not critical

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

These guidelines were reviewed by Council and approved by the Board of Trustees of the American Academy of Ophthalmology (September 2008).

The guidelines were reviewed and updated for currency in September 2011.

Recommendations

Major Recommendations

The ratings of importance to the care process (A-C) and the ratings of strength of evidence (I-III) are defined at the end of the "Major Recommendations" field.

Diagnosis

The initial evaluation of a patient who presents with symptoms suggestive of dry eye should include those features of the comprehensive adult medical eye evaluation relevant to dry eye (see the National Guideline Clearinghouse [NGC] summary of the American Academy of Ophthalmology [AAO] Preferred Practice Pattern Comprehensive adult medical eye examination). [A:III]

Patient History

Questions about the following elements of the patient history may elicit helpful information:

  • Symptoms and signs: [A:III] e.g., irritation, tearing, burning, stinging, dry or foreign body sensation, mild itching, photophobia, blurry vision, contact lens intolerance, redness, mucous discharge, increased frequency of blinking, eye fatigue, diurnal fluctuation, symptoms that worsen later in the day
  • Exacerbating conditions: [B:III] e.g., wind, air travel, decreased humidity, prolonged visual efforts associated with decreased blink rate such as reading and computer use
  • Duration of symptoms [A:III]
  • Topical medications used, their frequency, and their effect on symptoms: [A:III] e.g., artificial tears, "eyewash," antihistamines, glaucoma medications, vasoconstrictors, corticosteroids
  • Contact lens wear, schedule, and care [A:III]
  • Allergic conjunctivitis [B:III]
  • Ocular surgical history: [A:III] e.g., prior keratoplasty, cataract surgery, keratorefractive surgery
  • Ocular surface disease [A:III] e.g., herpes simplex virus, varicella zoster virus, ocular mucous membrane pemphigoid, Stevens-Johnson syndrome, aniridia, graft versus host disease (GVHD)
  • Punctal surgery [A:III]
  • Eyelid surgery: [A:III] e.g., prior ptosis repair, blepharoplasty, entropion/ectropion repair
  • Bell palsy [A:III]
  • Smoking or exposure to second-hand smoke [A:III]
  • Dermatological diseases: [A:III] e.g., rosacea
  • Technique and frequency of facial washing including eyelid and eyelash hygiene [A:III]
  • Atopy [A:III]
  • Menopause [A:III]
  • Systemic inflammatory diseases: [A:III] e.g., Sjögren syndrome, GVHD, rheumatoid arthritis, systemic lupus erythematosus, scleroderma
  • Other systemic conditions: [A:III] e.g., lymphoma, sarcoidosis
  • Systemic medications: [A:III] e.g., antihistamines, diuretics, hormones and hormonal antagonists, antidepressants, cardiac antiarrhythmic drugs, isotretinoin, diphenoxylate/atropine, beta-adrenergic antagonists, chemotherapy agents, any other drug with anticholinergic effects
  • Trauma: [B:III] e.g., chemical
  • Chronic viral infections: [B:III] e.g., hepatitis C, human immunodeficiency virus (HIV)
  • Nonocular surgery: [B:III] e.g., bone marrow transplant, head and neck surgery, trigeminal neuralgia surgery
  • Radiation of orbit [B:III]
  • Neurological conditions: [B:III] e.g., Parkinson disease, Bell palsy, Riley-Day syndrome, trigeminal neuralgia
  • Dry mouth, dental cavities, oral ulcers [B:III]

Examination

The physical examination includes a visual acuity measurement, [A:III] an external examination, [A:III] and slit-lamp biomicroscopy. [A:III]

The external examination should pay particular attention to the following:

  • Skin: [A:III] e.g., scleroderma, facial changes consistent with rosacea
  • Eyelids: [A:III] incomplete closure/malposition, incomplete or infrequent blink, eyelid lag, erythema of eyelid margins, abnormal deposits or secretions, entropion, ectropion
  • Adnexa: [A:III] enlargement of the lacrimal glands
  • Proptosis [B:III]
  • Cranial nerve function: [A:III] e.g., cranial nerve V (trigeminal), cranial nerve VII (facial)
  • Hands: [B:III] joint deformities characteristic of rheumatoid arthritis

The slit-lamp biomicroscopy should focus on the following:

  • Tear film: [A:III] height of the meniscus, debris, increased viscosity, mucus strands, and foam
  • Eyelashes: [A:III] trichiasis, distichiasis, deposits
  • Anterior and posterior eyelid margins: [A:III] abnormalities of meibomian glands (e.g., orifice metaplasia, reduced expressible meibum, atrophy), character of meibomian gland secretions (e.g., turbid, thickened, foamy, deficient), vascularization crossing the mucocutaneous junction, keratinization, scarring
  • Puncta: [A:III] patency, position, presence, and position of plugs
  • Conjunctiva
    • Inferior fornix and tarsal conjunctiva: [A:III] e.g., mucous threads, scarring, erythema, papillary reaction, follicle enlargement, keratinization, foreshortening, symblepharon
    • Bulbar conjunctiva: [A:III] e.g., punctate staining with rose bengal or fluorescein dyes; hyperemia; localized drying; keratinization
  • Cornea: [A:III] localized interpalpebral drying, punctate epithelial erosions, punctate staining with rose bengal or fluorescein dyes, filaments, epithelial defects, mucous plaques, keratinization, pannus formation, thinning, infiltrates, ulceration, scarring, neovascularization, evidence of corneal or refractive surgery

Diagnostic Tests

Corneal sensation should be assessed when trigeminal nerve dysfunction is suspected (Heigle & Pflugfelder, 1996). [A:III] A laboratory and clinical evaluation for autoimmune disorders should be considered for patients with significant dry eyes, other signs and symptoms of an autoimmune disorder (e.g., dry mouth), or a family history of an autoimmune disorder. [A:III]

Treatment

Specific treatment recommendations depend on the severity and source of the dry eye. The sequence and combination of therapies should be determined on the basis of the patient's needs and preferences and the treating ophthalmologist's medical judgment. [A:III] The table below lists treatments for dry eye syndrome based on the severity level of the disease. Specific therapies may be chosen from any category regardless of the level of disease severity, depending on physician experience and patient preference.

Treatment Recommendations for Dry Eye Syndrome by Disease Severity Level*

Mild
  • Education and environmental modifications [A:III]
  • Elimination of offending topical or systemic medications [A:III]
  • Aqueous enhancement using artificial tear substitutes, gels/ointments [A:III]
  • Eyelid therapy (warm compresses and eyelid hygiene) [A:III]
  • Treatment of contributing ocular factors such as blepharitis or meibomianitis [A:III] (see the NGC summary of the AAO Preferred Practice Pattern Blepharitis)
Moderate In addition to above treatments:
  • Anti-inflammatory agents (topical cyclosporine [U.S. Food and Drug Administration, 2003; Sall et al., 2000] [A:I] and corticosteroids [Pflugfelder et al., 2004; Marsh & Pflugfelder, 1999; Prabhasawat & Tseng, 1998; Sainz De La Maza Serra, Simon Castellvi, & Kabbani, 2000], [A:II] systemic omega-3 fatty acids supplements [Creuzot et al., 2006; Miljanovic et al., 2005]) [A:II]
  • Punctal plugs [A:III]
  • Spectacle side shields and moisture chambers [A:III]
Severe In addition to above treatments:
  • Systemic cholinergic agonists (Vivino et al., 1999; Petrone et al., 2002; Nelson et al., 1998) [A:I]
  • Systemic anti-inflammatory agents [A:III]
  • Mucolytic agents [A:III]
  • Autologous serum tears (Tsubota et al., 1999; Chiang et al., 2007) [A:III]
  • Contact lenses [A:III]
  • Correction of eyelid abnormalities [A:III]
  • Permanent punctal occlusion [A:III]
  • Tarsorrhaphy [A:III]

*Adapted with permission from Pflugfelder SC (Chair). Management and therapy Subcommittee of the International Dry Eye Workshop. Management and therapy of dry eye disease: report of the Management and Therapy Subcommittee of the International Dry Eye Workshop (2007). Occul Surf 2007;5:174.

Follow-Up

The frequency and extent of the follow-up evaluation will depend on the severity of disease, the therapeutic approach, and response to the therapy. For example, patients with sterile corneal ulceration associated with dry eye may require daily follow-up. [A:III]

Provider and Setting

Patients with dry eye who are evaluated by non-ophthalmologist health care providers should be referred promptly to the ophthalmologist if any of the following occurs: [A:III]

  • Visual loss
  • Moderate or severe pain
  • Lack of response to the therapy
  • Corneal infiltration or ulceration

Counseling/Referral

The most important aspects of caring for patients with dry eye are to educate them about the chronic nature of the disease process and to provide specific instructions for therapeutic regimens. It is helpful to reassess periodically the patient's compliance and understanding of the disease, the risks for associated structural changes, and to re-inform the patient as necessary. [A:III] The patient and physician together can establish realistic expectations for effective management.

Patients with pre-existing dry eye should be cautioned that refractive surgery, particularly laser-assisted in situ keratomileusis (LASIK), may worsen their dry eye condition (Nettune & Pflugfelder, 2010). [A:III] Patients who have dry eye and are considering refractive surgery should have the dry eye treated before surgery (American Academy of Ophthalmology Basic and Clinical Science Course Subcommittee, 2011).

Definitions:

Ratings of Importance to Care Process

Level A, defined as most important

Level B, defined as moderately important

Level C, defined as relevant but not critical

Ratings of Strength of Evidence

Level I includes evidence obtained from at least one properly conducted, well-designed randomized, controlled trial. It could include meta-analyses of randomized controlled trials.

Level II includes evidence obtained from the following:

  • Well-designed controlled trials without randomization
  • Well-designed cohort or case-control analytic studies, preferably from more than one center
  • Multiple-time series with or without the intervention

Level III includes evidence obtained from one of the following:

  • Descriptive studies
  • Case reports
  • Reports of expert committees/organization (e.g., Preferred Practice Patterns [PPP] panel consensus with external peer review)
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for most recommendations (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Accurate and timely diagnosis and appropriate treatment and management will preserve and/or improve vision, prevent or minimize structural damage to the ocular surface, and improve patient comfort.

Potential Harms
  • While topical cyclosporine 0.05% is typically well tolerated, ocular burning was reported in 17% of the patients in one study.
  • Patients prescribed corticosteroids for dry eye should be monitored for adverse effects such as increased intraocular pressure, corneal melting, and cataract formation.
  • The most common side effect from taking cholinergic agonist pilocarpine in a clinical study was excessive sweating that occurred in over 40% of patients. Two percent of the patients taking oral pilocarpine withdrew from the study because of this and other drug-related side effects. Cevimeline (another oral cholinergic agonist) may have fewer adverse systemic side effects than oral pilocarpine.
  • Soft contact lenses are effective in preventing recurrence of filamentary keratopathy but are poorly tolerated if the patient has severe dry eyes. If the patient has associated neurotrophic keratopathy, contact lenses should be avoided.
  • Punctal plugs that are displaced into the lacrimal system may pass through the entire system, but blockage with secondary infection has been reported. Rarely, surgical removal is necessary. Intracanalicular plugs may offer ease of insertion and a decreased chance of extrusion, but they have been associated with the occurrence of epiphora, canaliculitis, and dacryocystitis.

Qualifying Statements

Qualifying Statements
  • The Preferred Practice Pattern® (PPP) guidelines are based on the best available scientific data as interpreted by panels of knowledgeable health professionals. In some instances, such as when results of carefully conducted clinical trials are available, the data are particularly persuasive and provide clear guidance. In other instances, the panels have to rely on their collective judgment and evaluation of available evidence.
  • Preferred Practice Patterns provide guidance for the pattern of practice, not for the care of a particular individual. While they should generally meet the needs of most patients, they cannot possibly best meet the needs of all patients. Adherence to these Preferred Practice Patterns will not ensure a successful outcome in every situation. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. It may be necessary to approach different patients' needs in different ways. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice.
  • Preferred Practice Pattern guidelines are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or other information contained herein.
  • References to certain drugs, instruments, and other products are made for illustrative purposes only and are not intended to constitute an endorsement of such. Such material may include information on applications that are not considered community standard, that reflect indications not included in approved U. S. Food and Drug Administration (FDA) labeling, or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use, and to use them with appropriate patient consent in compliance with applicable law.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Chart Documentation/Checklists/Forms
Foreign Language Translations
Patient Resources
Quick Reference Guides/Physician Guides
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
American Academy of Ophthalmology Cornea/External Disease Panel. Dry eye syndrome. Limited revision. San Francisco (CA): American Academy of Ophthalmology (AAO); 2011. 28 p. [119 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
1998 Sep (revised 2011 Sep)
Guideline Developer(s)
American Academy of Ophthalmology - Medical Specialty Society
Source(s) of Funding

American Academy of Ophthalmology

Guideline Committee

Cornea/External Disease Panel; Preferred Practice Patterns Committee

Composition of Group That Authored the Guideline

Cornea/External Disease Panel Members: Robert S. Feder, MD (Chair); Steven P. Dunn, MD; Matthew R. Jones, MD; Francis S. Mah, MD; Leslie A. Olsakovsky, MD; Audrey R. Talley-Rostov, MD; Andrew J. Velazquez, MD; David C. Musch, PhD, MPH, Methodologist

Preferred Practice Patterns Committee Members: Christopher J. Rapuano, MD (Chair); David F. Chang, MD; Emily Y. Chew, MD; Robert S. Feder, MD; Stephen D. McLeod, MD; Bruce E. Prum, Jr., MD; C. Gail Summers, MD; David C. Musch, PhD, MPH, Methodologist

Academy Staff: Flora C. Lum, MD; Nancy Collins, RN, MPH; Doris Mizuiri; Jessica Ravetto

Medical Editor: Susan Garratt

Financial Disclosures/Conflicts of Interest

In compliance with the Council of Medical Specialty Societies' Code for Interactions with Companies (available at www.cmss.org/codeforinteractions.aspx External Web Site Policy), relevant relationships with industry occurring from January 2011 to September 2011 are listed. The Academy has Relationship with Industry Procedures to comply with the Code (available at http://one.aao.org/CE/PracticeGuidelines/ppp.aspx External Web Site Policy).

David F. Chang, MD: Alcon Laboratories, Inc. – Consultant/Advisor; Allergan, Inc. – Lecture fees

Emily Y. Chew, MD: No financial relationships to disclose

Steven P. Dunn, MD: No financial relationships to disclose

Robert S. Feder, MD: No financial relationships to disclose

Matthew R. Jones, MD: No financial relationships to disclose

Francis S. Mah, MD: Alcon Laboratories, Inc. – Consultant/Advisor; Allergan, Inc. – Consultant/Advisor

Stephen D. McLeod, MD: No financial relationships to disclose

David C. Musch, PhD, MPH: No financial relationships to disclose

Leslie A. Olsakovsky, MD: No financial relationships to disclose

Bruce E. Prum, Jr., MD: Allergan, Inc. – Consultant/Advisor

Christopher J. Rapuano, MD: Alcon Laboratories, Inc. – Lecture fees; Allergan, Inc. – Consultant/Advisor, Lecture fees; EyeGate Pharma – Consultant/Advisor

C. Gail Summers, MD: No financial relationships to disclose

Audrey R. Talley-Rostov, MD: No financial relationships to disclose

Andrew J. Velazquez, MD: No financial relationships to disclose

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American Academy of Ophthalmology Cornea/External Disease Panel, Preferred Practice Patterns Committee. Dry eye syndrome. San Francisco (CA): American Academy of Ophthalmology (AAO); 2008. 28 p. [99 references]

All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. To ensure that all Preferred Practice Patterns are current, each is valid for 5 years from the "approved by" date unless superseded by a revision.

Guideline Availability

Electronic copies: Available from the American Academy of Ophthalmology (AAO) Web site External Web Site Policy.

Print copies: Available from American Academy of Ophthalmology, P.O. Box 7424, San Francisco, CA 94120-7424; Phone: (415) 561-8540.

Availability of Companion Documents

The following is available:

  • Summary benchmarks for preferred practice patterns guidelines. San Francisco (CA): American Academy of Ophthalmology; 2011 Oct. 3 p. Electronic copies: Available in Portable Document Format (PDF) from the American Academy of Ophthalmology (AAO) Web site External Web Site Policy. Also available in a variety of foreign languages from the AAO Web site External Web Site Policy.

Print copies: Available from American Academy of Ophthalmology, P.O. Box 7424, San Francisco, CA 94120-7424; Phone: (415) 561-8540.

In addition, the appendices External Web Site Policy to the original guideline document contain various resources, including dry eye severity scales and information diagnostic tests and association diseases.

Patient Resources

The following is available:

Print copies: Available from American Academy of Ophthalmology, P.O. Box 7424, San Francisco, CA 94120-7424; Phone: (415) 561-8540.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI on February 20, 1999. The information was verified by the guideline developer on April 23, 1999. This summary was updated by ECRI on April 9, 2004. The information was verified by the guideline developer on May 20, 2004. This NGC summary was updated by ECRI Institute on April 22, 2009. The updated information was verified by the guideline developer on May 15, 2009. This NGC summary was updated by ECRI Institute on May 17, 2012.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Information about the content, ordering, and copyright permissions can be obtained by calling the American Academy of Ophthalmology at (415) 561-8500.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

Read full disclaimer...