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BACKGROUND Hyperactive cranial neuropathies refractory to medical management can often be debilitating to patients. While microvascular decompression (MVD) surgery can provide relief to such patients when an aberrant vessel is compressing the root entry zone (REZ) of the nerve, the arteries of elderly patients over 65 years of age can be less amenable to manipulation because of calcifications and other morphological changes. A dolichoectatic vertebral artery (DVA), in fact, can lead to multiple cranial neuropathies; therefore, a strategy for MVDs in elderly patients is useful. OBSERVATIONS A 76-year-old man presented with medically refractory trigeminal neuralgia (TN) and hemifacial spasm (HFS). A DVA was the conflicting vessel at the left REZs of the trigeminal and facial nerves. The authors performed a retrosigmoid craniotomy for MVD of the DVA with Teflon padding at both REZs in approximately 1 hour of operative time. The patient was free of facial pain and spasm immediately after surgery and at follow-up. LESSONS The authors described the case of an elderly patient with both TN and HFS caused by compression of a DVA. Simultaneous MVD with Teflon padding at both REZs provided symptomatic relief with limited surgical time. This can be a particularly useful and straightforward surgical strategy in the elderly population.

Arachnoid cysts (ACs) are the most common space-occupying lesions in the human brain and present significant challenges for clinical management. While most cases of ACs are sporadic, nearly 40 familial forms have been reported. Moreover, ACs are seen with increased frequency in multiple Mendelian syndromes, including Chudley–McCullough syndrome, acrocallosal syndrome, and autosomal recessive primary ciliary dyskinesia. These findings suggest that genetic factors contribute to AC pathogenesis. However, traditional linkage and segregation approaches have been limited in their ability to identify causative genes for ACs because the disease is genetically heterogeneous and often presents asymptomatically and sporadically. Here, we comprehensively review theories of AC pathogenesis, the genetic evidence for AC formation, and discuss a different approach to AC genomics that could help elucidate this perplexing lesion and shed light on the associated neurodevelopmental phenotypes seen in a significant subset of these patients.

Supplementary motor area (SMA) syndrome is a typically transient condition resulting from damage to the medial premotor cortex. The exact mechanism of recovery remains unknown but is traditionally described as a process involving functional compensation by the contralateral SMA through corpus callosal fibers. The purpose of this case study is to highlight a distinct extra-callosal mechanism of functional recovery from SMA syndrome in a patient with agenesis of the corpus callosum (ACC). We present the clinical presentation and perioperative functional neuroimaging features of a 16-year-old patient with complete ACC who exhibited recovery from an SMA syndrome resulting from surgical resection of a right-sided low-grade glioma. Preoperative functional MRI (fMRI) revealed anatomically concordant activation areas during finger and toe tapping tasks bilaterally. Three months following surgery, the patient had fully recovered, and a repeat fMRI revealed shift of the majority of the left toe tapping area from the expected contralateral hemisphere to the ipsilateral left paracentral lobule and SMA. The fMRI signal remodeling observed in this acallosal patient suggests that within-hemisphere plasticity of the healthy hemisphere may constitute an alternative critical process in SMA syndrome resolution and challenges the traditional view that transcallosal fibers are necessary for functional recovery.

Although established marketing techniques have been applied to design more effective health campaigns, more often than not, the same message is broadcasted to large populations, irrespective of unique characteristics. As individual digital device use has increased, so have individual digital footprints, creating potential opportunities for targeted digital health interventions. We propose a novel precision public health campaign framework to structure and standardize the process of designing and delivering tailored health messages to target particular population segments using social media-targeted advertising tools. Our framework consists of five stages: defining a campaign goal, priority audience, and evaluation metrics; splitting the target audience into smaller segments; tailoring the message for each segment and conducting a pilot test; running the health campaign formally; and evaluating the performance of the campaigns. We have demonstrated how the framework works through 2 case studies. The precision public health campaign framework has the potential to support higher population uptake and engagement rates by encouraging a more standardized, concise, efficient, and targeted approach to public health campaign development.

OBJECTIVE Pediatric idiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure despite normal cerebrospinal fluid and neuroimaging findings. Initial management is typically medical; however, nearly 10% of children will eventually require surgery for persistent headache and/or vision loss. External lumbar drainage, which is a considerably safer treatment option, has not been adequately analyzed in children with medically refractory IIH. METHODS The authors conducted a single-institution retrospective analysis of children with medically refractory IIH who had undergone external lumbar drain (ELD) placement because of worsening papilledema, reflected as increased retinal nerve fiber layer (RNFL) thickness on optical coherence tomography (OCT) testing. The main outcome measures were effects of external lumbar drainage on papilledema resolution, symptoms, and vision. RESULTS The authors analyzed the medical records of 13 children with IIH (11 girls, mean age 15.0 ± 2.3 years) whose mean CSF opening pressure was 45.5 ± 6.8 cm H2O. In all children, the average global RNFL thickness in both eyes significantly increased at ELD placement (right eye 371.8 ± 150.2 μm, left eye 400.3 ± 96.9 μm) compared with presentation thickness (right eye 301.6 ± 110.40 μm, left eye 350.2 ± 107.7 μm) despite acetazolamide medical therapy (20–30 mg/kg/day), leading to ELD placement after 9.5 ± 6.9 days (range 3–29 days). After ELD insertion, there was headache resolution, gradual and continuous improvement in optic disc thickness, and preservation of good vision. CONCLUSIONS ELD placement in children with medically refractory IIH who demonstrated worsening papilledema with increased RNFL thickening on OCT testing typically results in symptom relief and disc edema resolution with good visual outcome, often preventing the need for additional definitive surgeries that carry greater failure and morbidity risks.

Purpose: To evaluate the prevalence of strabismus in neurofibromatosis type 1 (NF-1) by comparing children with normal neuroimaging to those with optic pathway glioma. Methods: A retrospective data collection of all children with NF-1 with neuroimaging studies examined at a single medical center between 2000 and 2016. Results: Of the 198 children with NF-1 reviewed, 109 (55%) were male, 121 (61%) had normal neuroimaging, and 77 (39%) had an optic pathway glioma. Mean age at presentation was 6.3 ± 4.7 years and mean follow-up was 4.8 ± 3.1 years. Strabismus was present in 29 (15%) children and was significantly more prevalent in children with NF-1 with optic pathway glioma (21 of 77 [27%]) than in those with normal neuroimaging (8 of 121 [7%], P < .001). Sensory strabismus was only found in children with optic pathway glioma, accounting for most cases (12 of 21 [57%]). A strong association between strabismus and optic pathway glioma is demonstrated by an odds ratio of 5.29 ( P < .001). Children with NF-1 with optic pathway glioma have a 4.13 times higher relative risk of developing strabismus than children with NF-1 without it ( P = .001). The direction of ocular misalignment in children with NF-1 with optic pathway glioma was not significantly different than that observed in children without optic pathway glioma ( P = .197, Fisher's exact test). Only 5 (17%) children with NF-1 with strabismus (3 with optic pathway glioma) underwent corrective surgery to align their eyes. Conclusions: Optic pathway glioma in children with NF-1 is associated with an increased risk of strabismus that is often sensory. Although exotropia is the most common ocular misalignment associated with optic pathway glioma, the direction of strabismus cannot be used as an accurate predictor for its presence. [ J Pediatr Ophthalmol Strabismus . 2019;56(1):19–22.]

Purpose To report on the characteristics, accomplishments, and past experiences of current academic ophthalmology department chairs. Design Cross-sectional study. Methods Setting: A confidential online survey. Study Population: Total of 111 chairs of US academic ophthalmology departments. Main Outcome Measures: Chairs' general characteristics, training/former positions held, academic accomplishments, previous organization/committee involvement, motivation/insight, and overall work satisfaction. Results Fifty-five chair responses were received (96% male, mean age 57 years, mean term 7 years). The majority were American medical graduates (93%), full professors of ophthalmology (93%), and permanent chairs (96%). All completed their residency in the US and 96% completed a fellowship (25% vitreoretinal surgery, 22% cornea and external disease, and 20% glaucoma). On average, chairs authored 98 peer-reviewed articles, 2 books, and 11 book chapters. They were also significantly involved in peer-reviewed journal literature, serving as editors (20%), associate editors (18%), or editorial board members (60%). The majority of chairs indicated they decided to seek their position late in their career, having already become a full (33%) or associate professor (26%), primarily owing to a desire to build and promote an academic ophthalmology department (61%). Chairs regarded their experience as head of service as most important for their current performance as department heads. Their principal advice to aspiring ophthalmology chairs was to focus on developing skills as a clinician, researcher, and educator ("triple threat"). Conclusions Overall, academic department chairs are accomplished leaders in ophthalmology and prolific authors with an established academic record. Chairs regarded their previous leadership roles within the department as invaluable to their effectiveness as chair.

Background Acute acquired comitant esotropia (AACE) is a relatively rare type of pediatric strabismus, often described as a possible presentation of intracranial pathology. The risk of having neurological disease in isolated AACE is not clear, because many previously published cases had other neurological or ophthalmological abnormalities. The purpose of this study was to analyze the incidence of neurological abnormalities in children presenting with AACE and otherwise normal neurological and ophthalmological evaluations. Methods The medical records of consecutive patients >4 years of age with AACE examined by a single practitioner from 2014 to 2018 were reviewed retrospectively. The main outcome measure was the presence of neurological disease. Children with duction deficits, incomitant esodeviations, and hyperopia of >2.00 D were excluded. Results A total of 20 children (11 males; mean age, 9.8 ± 4.1 years) were included. Mean esodeviation was 29.5Δ ± 14.8Δ (range, 10Δ-55Δ). All had an otherwise normal ophthalmological and neurological evaluations. Of the 20, 19 (95%) had normal brain neuroimaging. One child that did not have neuroimaging was followed over 2 years without developing any neurological sequelae. Conclusions In our study cohort, pediatric AACE not accompanied by other ophthalmic and neurological abnormalities was not a manifestation of intracranial pathology. In such cases, the decision to perform neuroimaging should take into account other factors, including caregivers' preferences and availability for close monitoring.

Purpose To determine the effect of horizontal rectus muscle surgery on distance-near incomitance. Design Prospective, comparative, interventional case series. Methods Prospective evaluation of patients >7 years old who had medial or lateral rectus muscle surgery at the University of Arkansas Medical Center or Arkansas Children's Hospital between December 2009 and January 2012. Prism and alternate cover testing was performed at distance (6 m) and near (0.3 m) fixation after >1 hour of monocular occlusion at preoperative and postoperative examinations within 1 week, and closest to 1 year after surgery. The change in distance-near incomitance was calculated. Patients with extraocular muscle fibrosis or paralysis were excluded. Results Forty-five patients met inclusion criteria. Twenty-five patients had medial rectus muscle surgery, and 20 patients had lateral rectus muscle surgery. Postoperative examinations showed a change in distance-near incomitance ≤10 prism diopters (PD) in 42 of 44 patients evaluated within 1 week after surgery and in all 28 patients evaluated 6-24 months after surgery. Horizontal rectus muscle surgery did not induce a clinically significant change in distance-near incomitance (±2 PD equivalence, TOST confidence interval, −1.8 +1.6 PD, P value = 0.014). Contrary to traditional teaching, medial rectus muscle surgery was not more likely to induce a greater effect at near fixation (P = 0.80) and lateral rectus muscle surgery was not more likely to induce a greater effect at distance fixation (P > 0.99). Conclusion Horizontal rectus muscle surgery does not induce a clinically significant effect on distance-near incomitance. Contrary to traditional teaching, medial rectus muscle surgery does not induce a greater effect on ocular alignment at near fixation and lateral rectus muscle surgery does not induce a greater effect on ocular alignment at distance fixation. It is not necessary to consider distance-near incomitance when choosing between medial rectus and lateral rectus muscle surgery.

OBJECTIVE: To assess the effect of reduced contrast sensitivity on three commonly used colour vision tests in order to establish key discrepancies that may be relevant for clinical practice. METHODS: A prospective non-interventional clinical study of colour vision testing using three commonly used devices: Ishihara and Hardy–Rand–Rittler (H-R-R) pseudoisocochromatic plate tests, and Farnsworth D-15 arrangement test performed under progressively reduced contrast sensitivity conditions achieved with a neutral density filter bar. RESULTS: The Pelli–Robson contrast sensitivity (PRCS) at which 5% of the population should first experience a 10% reduction in colour vision testing from baseline was calculated for each of the three colour vision devices: Farnsworth D-15 test: 1.81 log contrast sensitivity (CS), H-R-R test: 1.69 log CS, and Ishihara test: 1.34 log CS. Single factor repeated measures analyses, conducted separately at each contrast sensitivity level, revealed no difference between the colour vision testing devices at PRCS ≥1.80 log CS (P ≥ 0.367). However, in all PRCS ≤1.65 log CS, the differences were statistically significant (all P ≤ 0.004), demonstrating a significantly lower percentage of errors in the Ishihara test compared with both the Farnsworth D-15 (P

Purpose To characterize and analyze the profile of United States (US) academic ophthalmology department chairs. Design Cross-sectional study. Methods Setting : Web search of publicly accessible sources. Study Population : One hundred and eleven US ophthalmology chairs. Main Outcome Measures : Demographic and academic data. Results Of the 111 chairs reviewed, 90% are male. Mean age of chairs is 59 years, and mean age at time of appointment is 47 years. Ninety-two percent of chairs graduated from an American medical school. Twenty-eight percent of chairs also have additional graduate degrees: 8% a Doctor of Philosophy (PhD) degree, 15% a master's degree, and 5% both. Ninety-five percent of chairs completed a clinical fellowship, most frequently in cornea (25%), vitreoretinal surgery (23%), and glaucoma (21%). The 3 programs that trained the largest number of chairs are Massachusetts Eye and Ear Infirmary, Wilmer Eye Institute, and Bascom Palmer Eye Institute. Thirty-two percent of chairs were previously trained in the program they currently head, more commonly as a resident (28%) than as a fellow (5%). The estimated mean number of publications per chair is 108 (range, 0-850) and the mean h-index is 24. Twenty-seven programs exchanged chairs from 2014 to 2017. The characteristics of appointed chairs are no different than those of recently retired chairs. Conclusions Ophthalmology chairs remain predominately male, most often specializing in cornea, vitreoretinal surgery, or glaucoma. Most chairs tend to be prolific authors whose careers have placed an emphasis on research; however, a lack of demonstrated research experience does not preclude chairmanship in certain US programs.

Purpose To determine whether unilateral strabismus surgery creates lateral incomitance in patients with exotropia. Methods Patients >7 years of age with intermittent or constant exotropia who underwent unilateral horizontal rectus muscle surgery between December 2009 and January 2012 were prospectively evaluated. Prism and alternate cover testing was performed with distance fixation in primary position, right gaze, and left gaze after 1 hour of monocular occlusion. Measurements were obtained within 1 month prior to surgery, within 1 week after surgery, and >3 months after surgery. The surgical procedure varied according to the surgeon's discretion. The change in deviation induced by strabismus surgery in lateral gaze was expressed as a percentage of the change in deviation induced in primary position. Results A total of 12 patients met inclusion criteria. Of the 11 patients with postoperative examinations within 1 week after surgery, 10 (91%) had greater surgical effect with gaze toward the operated eye ( P = 0.007). All 9 patients with >3 months' follow-up had greater surgical effect with gaze toward the operated eye ( P = 0.003). On average, the surgical effect in gaze toward the operated eye was 120% of that achieved in primary position; in gaze away from the operated eye, 75% ( P 6 months after surgery. Conclusions Unilateral strabismus surgery induces lateral incomitance that may cause diplopia >6 months after surgery in patients with exotropia. This should be considered when planning strabismus surgery and counseling patients.

Purpose: To analyze postoperative instructions provided to patients and families after strabismus surgery. Methods: In April 2012, a 12-question electronic survey was sent to all members of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) regarding their instructions to patients undergoing strabismus surgery. The questions specifically addressed patients’ daily activities, such as their resumption of school and work, sports, swimming, normal showering and bathing, and contact lens use. Results: One hundred two responses were completed; 96% were from pediatric ophthalmologists regularly performing strabismus surgery. Participation was greater by North American members (86%) and respondents with more than 10 years of experience (75%). Fifty percent of the respondents advised patients to resume normal showering and bathing 24 hours after surgery. Conversely, respondents recommended that children wait 3 to 4 days before resuming schoolwork (52%) and at least 2 weeks before playing in a sandbox (47%). Furthermore, respondents indicated that patients should refrain from participating in sports-related activities for at least 1 week (43%) and should not go swimming for at least 2 weeks (56%). Finally, 47% advised their patients not to wear contact lenses for 2 weeks after surgery. Conclusions: Overall, the responses indicated a high regard among AAPOS members for promoting normal healing and prevention of infection and other postoperative complications; however, certain trends, such as the recommendation regarding normal showering, may intimate a lack of further infection prevention. [ J Pediatr Ophthalmol Strabismus. 2015;52(3):142–146.]