in-practice (in-office) optometric research

VIRTUAL ISSUE EDITORIAL

This editorial fronts the second virtual issue for Ophthalmic & Physiological Optics. Virtual issues are a collection of papers

from previously published issues of the journal that are brought together in a single, online issue. All the OPO papers in this

virtual issue are free to access on the OPO website - http://www.wiley.com/bw/vi.asp?ref=0275-5408&site=1

In-practice (in-office) optometric research

Introduction

It is important that the work of the community optome-

trist is evidence-based1 and this virtual issue seeks to

explore the role that community optometrists can play in

gathering this evidence. This virtual issue contains a col-

lection of recent papers from Ophthalmic & Physiological

Optics involving in-practice (in-office) research, mostly by

community optometrists.

The papers in this virtual issue highlight the many ways

in which community optometrists can become involved

in research. A classic approach is for research-trained

optometrists to carry out research in their own prac-

tices,2–8 sometimes as part of a Masters, Professional Doc-

torate, or PhD degree.9–12 Some studies are collaborations

between community optometrists and research-trained

collaborators,13–15 sometimes with the community

optometrists providing data from their practice records.2

Other approaches are for community optometrists to

allow data to be gathered in their practices,16–24 to collect

normative data for clinical tests,9,12 to allow additional

services to be offered from their practices,25,26 or to col-

laborate with questionnaires or surveys.27–35 The College

of Optometrists’ initiative in setting up iPRO (Innovation

in Practice-based Research for Optometrists)36 is a wel-

come development to encourage in-practice optometric

research.

Methods and norms for optometric tests

Many commonplace optometric tests would benefit from

investigation using in-practice research and a good exam-

ple of this is the work by Adler and colleagues13 assessing

the influence of target type and test method on the mea-

surement of the near point of convergence. Various tar-

gets for assessing the near point of convergence were

compared in 51 patients seen in community optometric

practice. The authors found that free-space methods gave

better (closer near point of convergence) results than

using a penlight or an RAF rule. For children of school

age the results were not influenced by age and the results

might indicate that a finger tip or pencil tip are more

suitable targets than those on an RAF rule. The most

important conclusion was that practitioners should be

consistent in their method of measurement, especially if

reassessing after treatment.

It is perhaps surprising for a profession that relies so

much on subjective reports that very little attention has

been given to the precise wording of patient instructions

in optometric tests. Karania and Evans12 investigated the

effect of the wording of test instructions with the Mallett

near fixation disparity test. The precise wording was

found to be important, and in particular to ask not just

whether the Nonius markers are aligned but also whether

the markers move. The latter question identified more

cases of fixation disparity, and was associated with an

improved ability to detect symptomatic patients.

Tang and Evans9 obtained norms in a community

optometric practice for another binocular vision test, the

Mallett Foveal Suppression Test. The authors recom-

mended that the test should be carried out first with both

eyes viewing through the polarised filters (measuring

monocular acuities under dichoptic viewing whilst binoc-

ularly fused) and then still with the polarised filters in

place but with each eye in turn occluded. Based on 131

patients consulting a community optometric practice,

they found that statistically significant foveal suppression

occurs when a patient can read approximately one line

further in the test monocularly compared to under fused

dichoptic conditions.

The Pattern Glare Test is a test that is used to detect

and quantify pattern glare, which is suggestive of Meares-

Irlen Syndrome/Visual Stress (MISViS). Evans and

Stevenson11 obtained norms for this test from patients

consulting a community optometric practice. As in previ-

ous work, pattern glare was correlated with migraine and

a novel finding was that pattern glare decreases with age.

The CCLRU redness grading scales are commonly used

to grade the appearance of limbal and bulbar hyperaemia.

Pult and colleagues8 assessed the right eyes of 120 healthy

non-contact lens wearing patients seen in an optometry

practice in Germany. Normal results were specified indi-

cating that for similar populations a limbal redness above

2.5 or a bulbar redness above 2.6 (quadrant averaged) or

3.0 (overall) may be considered abnormal.

A technical note by Harle et al.14 described a clinical

evaluation of a new ophthalmoscope of a very basic

design which might make it affordable in developing

Ophthalmic & Physiological Optics ISSN 0275-5408

Ophthalmic & Physiological Optics 32 (2012) 83–88 ª 2012 The College of Optometrists 83

countries. Six community optometrists graded the instru-

ment and found that, although the instrument did not

perform to the same level as conventional ophthalmo-

scopes, it achieved clinically acceptable results in a high

proportion of cases.

Studies using practice databases

One resource that all optometric practices have is the

practice database and this can be a valuable resource for

research, especially in a practice with state of the art

instrumentation. Coleman and Barnard6 reported a retro-

spective analysis from 1745 consecutive patients of images

obtained with an ultra wide field scanning laser ophthal-

moscope. The prevalence of congenital hypertrophy of

the retinal pigment epithelium was 1.2%.

The data in a practice database can be valuable for

demonstrating effects that might to an optometrist seem

well established, but which require evidence-based sup-

port to gain more widespread acceptance. In an analysis

of clinical records from an independent optometric prac-

tice Pointer4 showed that updating spectacles improves

visual acuity. This defines the essence of optometry:

improving sight. The improvement is greater in the sixth

decade of life than before, perhaps supporting the com-

monplace practice of examining older patients more fre-

quently than younger adults. The study results also

support the benefit of regular eye examinations. A further

analysis of these data investigated the relationship

between improvement in visual acuity and refractive

error.3

Another study by Pointer highlights the benefits of col-

laboration between an experienced in-practice researcher

and a leading academic researcher.2 The starting point for

this study, by Pointer and Gilmartin, was the clinical

observation that some myopic patients when they reach

the incipient phase of presbyopia require an abrupt

increase in their negative-powered prescription. In a preli-

minary study an audit of 39 optometric clinic records

indicate that this effect may occur in about 20% of the

study population of myopic incipient presbyopes. The

authors propose a theory to explain this phenomenon

and note that refractive surgeons should be aware that

adult myopia is not necessarily a fixed characteristic.

Steele and colleagues24 investigated a topic that

deserves more attention in community optometric prac-

tices: error classification as a part of risk management

strategy. Ten community optometric practices used note-

books (about three per practice) to records errors using a

classification that had already been used in general medi-

cal practice. Staff were encouraged to record all errors, no

matter how seemingly trivial. Communication errors were

most commonly recorded, often for missing case notes,

but optical prescription errors (e.g. transposition errors

and illegible forms) accounted for 18% of errors.

Access to NHS-funded community optometriceyecare

Shah and colleagues27 carried out a telephone survey of

the availability of state funded primary eyecare in the UK.

Of 200 practices telephoned, 199 provided NHS sight

tests but the survey revealed that just over half of prac-

tices were unwilling to carry out an eye examination of a

1 year old child. However, nearly all (93%) were willing

to see an older patient with dementia. People on low

income in the UK are entitled to state-funded (NHS)

support to assist with the cost of spectacles via an NHS

Optical Voucher. Jessa et al.28 found that 30% of optical

practices in South London did not provide spectacles

whose cost is fully funded by the NHS voucher. However,

all practices did provide eyecare that is funded by the

NHS for eligible patients.

Spectacle prescribing

The prescribing of spectacles remains a core function of

community optometrists and the scientific basis for this

activity has for some time been lagging behind clinical

practice. A crucial question is what is the repeatability of

refractive error determination? Research to evaluate this is

most relevant when it occurs in community optometric

practices (where most refractive errors are corrected) and

when the practitioner is unaware that the patient is pre-

senting as part of a research study. Two recent studies in

the UK have adopted this approach.16,17 In MacKenzie’s16

study an asymptomatic 29 year old patient presented to

40 optometric practices and the 95% limits of agreement

for the spherical element were ±0.55 D. In the study by

Shah et al.17 three different patients each presented unan-

nounced to about 100 community optometrists. The

spherical power was within ±0.50 D 98% of the time and

the cylindrical power within ±0.50 D 100% of the time

(but all three patients had low astigmatism).

Freeman and Evans10 investigated non-tolerances in a

busy optometric practice. Once problems that could be

resolved by opticians had been excluded, those that

required an appointment with an optometrist accounted

for 1.8% of eye examinations,10 which has been estimated

to be 2.8% of patients who were prescribed spectacles.29

Gender was not a relevant factor, but presbyopes

accounted for 88% of non-tolerances.10 In every case, the

final prescription was within 1.00 D of the not tolerated

prescription, and 84% were within ±0.50 D.

The finding that refractive error assessment is repeat-

able to within ±0.50 D and yet most non-tolerances only

Virtual issue editorial BJW Evans

84 Ophthalmic & Physiological Optics 32 (2012) 83–88 ª 2012 The College of Optometrists

require an adjustment within ±0.50 D highlights the

challenging nature of optical prescribing. No doubt, it is

in an attempt to reduce the risk of non-tolerance that

practitioners make modifications to their measurements

of refractive error in order to arrive at an optical pre-

scription. Howell-Duffy and colleagues29 surveyed 426

community optical practices to discover, via eight case

scenarios (vignettes), the frequency and type of modifica-

tions made to the subjective refraction before prescrib-

ing. Depending on the clinical presentation, between

36% and 86% of practitioners reported prescribing

the subjective findings. Those who modified their find-

ings before prescribing employed a wide variety of

approaches, some of which were not in keeping with

conventional teaching.

In a follow-up study this team surveyed nearly 600

optometrists and found that the probability of a practi-

tioner modifying their clinical findings with ‘partial pre-

scribing’ increased with years of experience.30 The authors

speculate that it may be increasing exposure to patients

who return dissatisfied with their spectacles that leads to

a greater appreciation of partial prescribing.

Disease detection in community optometricpractice

In April 2009 the UK National Institute for Clinical

Excellence (NICE) published guidelines on glaucoma and

the integration of these guidelines with the current model

of state funding for much community optometric eyecare

has been problematic. Myint and colleagues31 carried out

a survey of UK community optometrists before the NICE

guidelines were published. The authors evaluated 1293

responses on perceived barriers to the detection of pri-

mary open angle glaucoma. The most frequently per-

ceived barriers were time constraints limiting the options

for repeat testing and lack of financial remuneration to

perform the additional tests required. This was related to

NHS funding since barriers were less frequently reported

in Scotland where there is more appropriate NHS funding

of eyecare by community optometrists. Since the NICE

guidelines many schemes have been developed that

involve community optometrists re-checking raised pres-

sures using Goldman tonometry. Parkins and Edgar15

compared two such schemes and showed that it was far

more cost effective for the referring optometrist to repeat

tonometry using applanation than for this to be carried

out by a small team of specially accredited optometrists.

Another survey by Myint and colleagues32 showed that

UK community optometrists are well equipped to carry

out case finding for chronic open angle glaucoma,

although there is a lack of standardisation with respect to

equipment used.

One of the most important roles of the optometrist is

the detection of sight and life-threatening ocular tumours

and Hemmerdinger and colleagues35 assessed an online

referral guide for melanocytic fundus lesions. They sent

images of 400 different melanocytic lesions to 55 optome-

trists, most of whom were in community optometric

practice (there was a bias with a disproportionate number

in independent practice).35 There was substantial agree-

ment between optometrists and an ocular oncologist, and

indeed between different optometrists. The authors

believe that this online tool could be helpful to commu-

nity optometrists.

The content of optometric eyecare

In a series of publications, Shah and colleagues investi-

gated the content of eye examinations provided by com-

munity optometrists in the UK. A review revealed that

the best approach to measuring clinical practice is to use

standardised patients, actors who are rigorously trained to

recognise and report relevant clinical procedures.1 This

approach was used to define the typical content of eye

examinations for a myope with headaches suspicious of

migraine,22 a patient at risk of glaucoma,20 and a patient

with symptoms suggestive of retinal detachment19. This

research has identified areas where optometric practice

has progressed in recent years (e.g. greater use of binocu-

lar indirect ophthalmoscopy) and topics that need greater

emphasis in continuing professional development (e.g.

awareness of racial risk factors for glaucoma). The work

has also been used to assist equitable outcomes in several

clinico-legal cases. In particular, the finding that practitio-

ners often carry out tests whose results are not

recorded18,21 has important implications for clinico-legal

cases, and for optometric further training.

Needle and colleagues33 used a survey to investigate

therapeutic practice by UK optometrists and received

1288 replies, with over 90% from community optome-

trists. This study revealed that most optometrists are

already involved in some form of therapeutic practice,

with common non-sight-threatening conditions being

managed frequently or occasionally by 69–96% of optom-

etrists. Blepharitis and dry eye were most commonly

managed, although 14% reported supplying chloramphe-

nicol or fusidic acid frequently. Relatively few respondents

(14%) expressed no interest in undertaking further train-

ing for extended prescribing.

Additional services from community optometry

Two recent studies have indicated that community

optometrists may be able to play a wider role in health-

care monitoring. Thompson and colleagues25 surveyed

BJW Evans Virtual issue editorial


509 community optometrists and found that few asked

about smoking habits, but that two-thirds would like to

improve their knowledge of smoking and its ocular com-

plications. The authors argued that community optome-

trists are an untapped opportunity for promoting

smoking cessation services.

Howse and colleagues26 suggested that community

optometrists could play a greater role in the detection of

diabetes by testing blood glucose levels. A screening service

was offered in five community optometric practices and a

questionnaire survey of 939 patients who had been screened

suggested a high level of acceptance of the screening service.

One way in which many community optometrists

enhance the service they provide to patients is to use rou-

tine eye examinations as an opportunity of disseminating

eyecare-related information to their patients. Pointer5 sur-

veyed 480 motorists attending an optometric practice to

discover how many were aware of the UK statutory vehicle

number plate viewing distance. Only 5% were able to state

correctly the current distance (20 m) and the author rec-

ommended better publicity of the information that this

distance is approximately equivalent to five car lengths.

Contact lenses

Another area of optometric activity that is amenable to

in-practice research is contact lens practice. Santodomingo-

Rubido7 carried out a randomised, controlled, and inves-

tigator-masked clinical study comparing two multipur-

pose contact lens solutions. This was carried out in a UK

community optometric practice using 41 existing contact

lens wearers. Both care regimes performed in a similar

clinical manner. Dry eye is a common problem that can

be especially problematic for contact lens wearers and

Michel et al.23 evaluated two symptom based methods of

evaluating dry eye: the Ocular Comfort Index and the

more established McMonnies Dry Eye Index. Participants

were contact lens wearers from eyecare clinics, including

a community optical practice. The authors found that the

McMonnies index performed better than the Ocular

Comfort Index.

Gill and colleagues34 surveyed 1000 randomly selected

UK optometrists and contact lens opticians to discover

attitudes to fitting rigid gas permeable contact (RGP)

lenses. Practitioners were deterred from fitting RGP lenses

because of initial patient discomfort. It is perhaps surpris-

ing that although 30% felt that it is clinically acceptable

to use topical anaesthetic during RGP fitting, this was

used regularly only by 1% of the sample.

International perspective

This virtual issue concentrates on recent papers published

in Ophthalmic & Physiological Optics, but the interna-

tional nature of much practice-based optometric research

should be acknowledged. Some of the papers described

above have involved international collaborations,8,23 and

selected international papers from other journals that

highlight certain aspects of in-practice research now will

be briefly mentioned.

Cheng and colleagues used the database of an optomet-

ric practice in Canada which included 40% (1489) of the

children in that city who were of Chinese racial origin.37

In ethnic Chinese children living in Canada the preva-

lence and magnitude of myopia is similar to those living

in urban East Asian countries. A paper published in

North America from a team in Wales investigated

patients attending eight optometric practices in the Vale

of Glamorgan.38 Court and colleagues used a pre-exami-

nation questionnaire to obtain measures of anxiety and

found that patients who do not wear spectacles may be

more anxious when attending for eye examinations.Two

papers by Efron and colleagues described a survey of 756

Australian community optometrists to investigate how

they recorded corneal staining and contact lens complica-

tions.39,40 Although grading scales were used extensively,40

serious deficiencies in the recording of corneal staining

were common.39 Kennedy and colleagues used focus

groups of community optometrists and optometry stu-

dents to investigate attitudes to contributing to a smoking

cessation program.41 It was felt that optometrists could

play a useful role.

Conclusion

This virtual issue includes a wide range of research

involving community optometrists. There is an ongoing

need for practice-based research involving community

optometrists to better underpin everyday optometric

activities with a sound evidence-base. As the scope of

community optometry continues to expand it is hoped

that there will be a commensurate expansion of practice-

based research.

Bruce Evans

Institute of Optometry,

City University, and London South Bank University,

London, UK

References

1. Shah R, Edgar D & Evans BJ. Measuring clinical practice.

Ophthalmic Physiol Opt 2007; 27: 113–125.

2. Pointer JS & Gilmartin B. Patterns of refractive change in

myopic subjects during the incipient phase of presbyopia: a

preliminary study. Ophthalmic Physiol Opt 2011; 31: 487–

493.



3. Pointer JS. Spectacle prescription change encountered with

an optimization of visual acuity. Ophthalmic Physiol Opt

2010; 30: 405–407.

4. Pointer JS. Habitual vs optimal distance visual acuity.


5. Pointer JS. Poor recognition of the UK minimum driving

vision standard by motorists attending optometric prac-

tice. Ophthalmic Physiol Opt 2007; 27: 238–244.

6. Coleman P & Barnard NA. Congenital hypertrophy of the

retinal pigment epithelium: prevalence and ocular features

in the optometric population. Ophthalmic Physiol Opt

2007; 27: 547–555.

7. Santodomingo-Rubido J. The comparative clinical perfor-

mance of a new polyhexamethylene biguanide- vs a

polyquad-based contact lens care regime with two silicone

hydrogel contact lenses. Ophthalmic Physiol Opt 2007; 27:

168–173.

8. Pult H, Murphy PJ, Purslow C, Nyman J & Woods RL.

Limbal and bulbar hyperaemia in normal eyes. Ophthalmic

Physiol Opt 2008; 28: 13–20.

9. Tang STW & Evans BJW. The Near Mallett Unit Foveal

Suppression Test: a cross-sectional study to establish test

norms and relationship with other optometric tests.

Ophthal Physiol Opt 2007; 27: 31–43.

10. Freeman C & Evans BJW. Investigation of the causes of

non-tolerance to optometric prescriptions for spectacles.

Ophthal Physl Opt 2010; 30: 1–11.

11. Evans BJW & Stevenson SJ. The Pattern Glare Test: a

review and determination of normative values. Ophthal

Physiol Opt 2008; 28: 295–309.

12. Karania R & Evans BJ. The Mallett Fixation Disparity Test:

influence of test instructions & relationship with symp-

toms. Ophthal Physiol Opt 2006; 26: 507–522.

13. Adler PM, Cregg M, Viollier AJ & Margaret Woodhouse J.

Influence of target type and RAF rule on the measurement

of near point of convergence. Ophthalmic Physiol Opt

2007; 27: 22–30.

14. Harle DE, Davies K, Shah R et al. Technical Note: a com-

parison of a novel direct ophthalmoscope, the OptyseTM,

to conventional direct ophthalmoscopes. Ophthalmic Phys-

iol Opt 2007; 27: 100–105.

15. Parkins DJ & Edgar DF. Comparison of the effectiveness

of two enhanced glaucoma referral schemes. Ophthalmic

Physiol Opt 2011; 31: 343–352.

16. MacKenzie GE. Reproducibility of sphero-cylindrical pre-

scriptions. Ophthalmic Physiol Opt 2008; 28: 143–150.

17. Shah R, Edgar DF, Rabbetts R, Harle DE & Evans BJW.

Standardised patient methodology to assess refractive error

reproducibility. Optom Vis Sci 2009; 86: 517–528.

18. Shah R, Edgar DF & Evans BJW. A Comparison of stan-

dardised patients, record abstraction and clinical Vignettes.

Ophthal Physiol Opt 2010; 30: 209–224.

19. Shah R, Edgar DF, Harle DE et al. The content of opto-

metric eye examinations for a presbyopic patient present-

ing with flashing lights. Ophthalmic Physiol Opt 2009; 29:

105–126.

20. Shah R, Edgar DF, Spry PG et al. Glaucoma detection: the

content of optometric eye examinations for a presbyopic

patient of African racial descent. Br J Ophthalmol 2009; 93:

492–496.

21. Shah R, Edgar DF & Evans BJW. How well does record

abstraction quantify the content of an optometric eye

examination in the UK? Ophthal Physiol Opt 2009; 29:

383–396.

22. Shah R, Edgar DF, Rabbetts R et al. The content of opto-

metric eye examinations for a young myope with head-

aches. Ophthalmic Physiol Opt 2008; 28: 404–421.

23. Michel M, Sickenberger W & Pult H. The effectiveness of

questionnaires in the determination of Contact Lens

Induced Dry Eye. Ophthalmic Physiol Opt 2009; 29:

479–486.

24. Steele CF, Rubin G & Fraser S. Error classification in com-

munity optometric practice – a pilot project. Ophthalmic

Physiol Opt 2006; 26: 106–110.

25. Thompson C, Harrison RA, Wilkinson SC, Scott-Samuel

A, Hemmerdinger C & Kelly SP. Attitudes of community

optometrists to smoking cessation: an untapped opportu-

nity overlooked? Ophthalmic Physiol Opt 2007; 27: 389–

393.

26. Howse JH, Jones S & Hungin AP. Screening for diabetes

in optometry practices: acceptability to users. Ophthalmic

Physiol Opt 2011; 31: 367–374.

27. Shah R, Edgar DF & Evans BJW. A survey of the availabil-

ity of state funded primary eyecare in the UK. Ophthal

Physiol Opt 2007; 27: 481.

28. Jessa Z, Evans BJW, Thomson WD & Rowlands G. Provi-

sion of NHS-funded spectacles in South London. Ophthal

Physiol Opt 2009; 29: 641–647.

29. Howell-Duffy C, Umar G, Ruparelia N & Elliott DB. What

adjustments, if any, do UK optometrists make to the sub-

jective refraction result prior to prescribing? Ophthalmic

Physiol Opt 2010; 30: 225–239.

30. Howell-Duffy C, Scally AJ & Elliott DB. Spectacle prescrib-

ing II: practitioner experience is linked to the likelihood of

suggesting a partial prescription. Ophthalmic Physiol Opt

2011; 31: 155–167.

31. Myint J, Edgar DF, Kotecha A, Murdoch IE & Lawrenson

JG. Barriers perceived by UK-based community optome-

trists to the detection of primary open angle glaucoma.


32. Myint J, Edgar DF, Kotecha A, Murdoch IE & Lawrenson

JG. A national survey of diagnostic tests reported by UK

community optometrists for the detection of chronic open

angle glaucoma. Ophthalmic Physiol Opt 2011; 31: 353–359.

33. Needle JJ, Petchey R & Lawrenson JG. A survey of the

scope of therapeutic practice by UK optometrists and their

attitudes to an extended prescribing role. Ophthalmic Phys-

iol Opt 2008; 28: 193–203.

BJW Evans Virtual issue editorial


34. Gill FR, Murphy PJ & Purslow C. A survey of UK practi-

tioner attitudes to the fitting of rigid gas permeable lenses.


35. Hemmerdinger C, Beech M, Groenewald C & Damato B.

Validation of an online referral guide for melanocytic

fundus lesions. Ophthalmic Physiol Opt 2011; 31: 574–579.

36. College of Optometrists. Applied research – iPRO.

2011. http://www.college-optometrists.org/en/research/

Applied_research/index.cfm (Accessed January 2012).

37. Cheng D, Schmid KL & Woo GC. Myopia prevalence in

Chinese-Canadian children in an optometric practice.

Optom Vis Sci 2007; 84: 21–32.

38. Court H, Greenland K & Margrain TH. Predicting state anxi-

ety in optometric practice. Optom Vis Sci 2009; 86: 1295–

1302.

39. Efron N, Pritchard N, Brandon K et al. How opto-

metrists record corneal staining. Clin Exp Optom 2011;

94: 82–86.

40. Efron N, Pritchard N, Brandon K et al. A survey of the

use of grading scales for contact lens complications

in optometric practice. Clin Exp Optom 2011; 94: 193–199.

41. Kennedy RD, Spafford MM, Schultz AS, Iley MD & Zawada

V. Smoking cessation referrals in optometric practice: a

canadian pilot study. Optom Vis Sci 2011; 88: 766–771.

Bruce Evans started his research career with a College of

Optometrists PhD Scholarship at Aston University. For

the last 20 years he has divided his time between clinical

research at the Institute of Optometry and working as a

community optometrist. He is a strong advocate for evi-

dence-based optometry and for the important role that

community optometrists can play in carrying out clinical

research. He is Director of Research at the Institute of

Optometry, where is he involved in the Doctor of Opto-

metry programme which the Institute jointly runs with

London South Bank University. Bruce Evans is a Visiting

Professor to City University and London South Bank

University.

Bruce Evans



in-practice (in-office) optometric research

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