Self-Trephination in Cranial Excoriation Disorder.

BACKGROUND AND IMPORTANCE: Trephination is a procedure in which a small hole is made in the skull. Rare cases of self-trephination by individuals seeking medical benefit have been reported. Excoriation disorder is a compulsive skin-picking condition in which an individual self-inflicts cutaneous lesions. Left untreated, severe excoriation disorder can pose significant health risks. CLINICAL PRESENTATION: Here, we describe 5 patients who presented with self-trephination due to a severe form of compulsive cranial excoriation at 2 neighboring academic medical centers over a 4-year period. We review the clinical presentation of self-trephination in cranial excoriation disorder and associated risk factors, surgical and nonsurgical interventions, complications of the disease, treatments, and mortality. Defining clinical characteristics include repetitive self-induced destruction of the scalp and skull with entry into the intracranial compartment, frequent psychiatric comorbidities, infection or injury of the brain with consequent neurological morbidity or mortality, and frequent treatment failures because of poor adherence. CONCLUSION: Self-trephination in cranial excoriation disorder is a severe neuropsychological disorder and neurosurgical emergency that exposes the brain and is often life-threatening. Appropriate therapy requires antibiotics, surgical debridement and repair of the wound, and concomitant effective psychiatric management of the underlying compulsion, including the use of antidepressants and behavioral therapy.

Frailty and postoperative outcomes in brain tumor patients: a systematic review subdivided by tumor etiology.

PURPOSE: Frailty has gained prominence in neurosurgical oncology, with more studies exploring its relationship to postoperative outcomes in brain tumor patients. As this body of literature continues to grow, concisely reviewing recent developments in the field is necessary. Here we provide a systematic review of frailty in brain tumor patients subdivided by tumor type, incorporating both modern frailty indices and traditional Karnofsky Performance Status (KPS) metrics. METHODS: Systematic literature review was performed using PRISMA guidelines. PubMed and Google Scholar were queried for articles related to frailty, KPS, and brain tumor outcomes. Only articles describing novel associations between frailty or KPS and primary intracranial tumors were included. RESULTS: After exclusion criteria, systematic review yielded 52 publications. Amongst malignant lesions, 16 studies focused on glioblastoma. Amongst benign tumors, 13 focused on meningiomas, and 6 focused on vestibular schwannomas. Seventeen studies grouped all brain tumor patients together. Seven studies incorporated both frailty indices and KPS into their analyses. Studies correlated frailty with various postoperative outcomes, including complications and mortality. CONCLUSION: Our review identified several patterns of overall postsurgical outcomes reporting for patients with brain tumors and frailty. To date, reviews of frailty in patients with brain tumors have been largely limited to certain frailty indices, analyzing all patients together regardless of lesion etiology. Although this technique is beneficial in providing a general overview of frailty's use for brain tumor patients, given each tumor pathology has its own unique etiology, this combined approach potentially neglects key nuances governing frailty's use and prognostic value.

Multiomic analyses implicate a neurodevelopmental program in the pathogenesis of cerebral arachnoid cysts.

Cerebral arachnoid cysts (ACs) are one of the most common and poorly understood types of developmental brain lesion. To begin to elucidate AC pathogenesis, we performed an integrated analysis of 617 patient-parent (trio) exomes, 152,898 human brain and mouse meningeal single-cell RNA sequencing transcriptomes and natural language processing data of patient medical records. We found that damaging de novo variants (DNVs) were highly enriched in patients with ACs compared with healthy individuals (P = 1.57 × 10-33). Seven genes harbored an exome-wide significant DNV burden. AC-associated genes were enriched for chromatin modifiers and converged in midgestational transcription networks essential for neural and meningeal development. Unsupervised clustering of patient phenotypes identified four AC subtypes and clinical severity correlated with the presence of a damaging DNV. These data provide insights into the coordinated regulation of brain and meningeal development and implicate epigenomic dysregulation due to DNVs in AC pathogenesis. Our results provide a preliminary indication that, in the appropriate clinical context, ACs may be considered radiographic harbingers of neurodevelopmental pathology warranting genetic testing and neurobehavioral follow-up. These data highlight the utility of a systems-level, multiomics approach to elucidate sporadic structural brain disease.

Familial and syndromic forms of arachnoid cyst implicate genetic factors in disease pathogenesis.

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.

Simultaneous microvascular decompression for trigeminal neuralgia and hemifacial spasm involving a dolichoectatic vertebral artery in an elderly patient: illustrative case.

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.

Factors influencing the decision to receive seasonal influenza vaccination among US corporate non-healthcare workers.

Influenza causes significant mortality and morbidity in the United States (US). Employees are exposed to influenza at work and can spread it to others. The influenza vaccine is safe, effective, and prevents severe outcomes; however, coverage among US adults (50.2%) is below Healthy People 2030 target of 70%. These highlights need for more effective vaccination promotion interventions. Understanding predictors of vaccination acceptance could inform vaccine promotion messages, improve coverage, and reduce illness-related work absences. We aimed to identify factors influencing influenza vaccination among US non-healthcare workers. Using mixed-methods approach, we evaluated factors influencing influenza vaccination among employees in three US companies during April-June 2020. Survey questions were adapted from the WHO seasonal influenza survey. Most respondents (n = 454) were women (272, 59.9%), 20-39 years old (n = 250, 55.1%); white (n = 254, 56.0%); had a college degree (n = 431, 95.0%); and reported receiving influenza vaccine in preceding influenza season (n = 297, 65.4%). Logistic regression model was statistically significant, X (16, N = 450) = 31.6, p = .01. Education [(OR) = 0.3, 95%CI = 0.1-0.6)] and race (OR = 0.4, 95%CI = 0.2-0.8) were significant predictors of influenza vaccine acceptance among participants. The majority had favorable attitudes toward influenza vaccination and reported that physician recommendation would influence their vaccination decisions. Seven themes were identified in qualitative analysis: "Protecting others" (109, 24.0%), "Protecting self" (105, 23.1%), "Vaccine accessibility" (94, 20.7%), "Education/messaging" (71, 15.6%), "Policies/requirements" (15, 3.3%), "Reminders" (9, 2.0%), and "Incentives" (3, 0.7%). Our findings could facilitate the development of effective influenza vaccination promotion messages and programs for employers, and workplace vaccination programs for other diseases such as COVID-19, by public health authorities.

Influenza causes significant mortality and morbidity in the United States (US).The US working-age group (18­64-year-old) bears a huge burden of influenza annually.Influenza vaccination coverage in the working-age group is low.Physicians and employers can influence vaccine acceptance of working adults.Employers can consider practical steps, e.g., incentivizing, or offering vaccine onsite.

Child Neurology: Functional Reorganization Mediating Supplementary Motor Area Syndrome Recovery in Agenesis of the Corpus Callosum.

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.

Correction: Precision Public Health Campaign: Delivering Persuasive Messages to Relevant Segments Through Targeted Advertisements on Social Media.

[This corrects the article DOI: 10.2196/22313.].

Precision Public Health Campaign: Delivering Persuasive Messages to Relevant Segments Through Targeted Advertisements on Social Media.

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.

Respiratory Syncytial Virus-Associated Mortality Among Young Infants in Karachi, Pakistan: A Prospective Postmortem Surveillance Study.

BACKGROUND: Respiratory syncytial virus (RSV) is an important cause of infant morbidity and mortality and a potential target for maternal immunization strategies. However, data on the role of RSV in young infant deaths in developing countries are limited. METHODS: We conducted a community-based mortality surveillance from August 2018-March 2020 for infants ≤6 months in Karachi, Pakistan. We tested (reverse transcription-polymerase chain reaction) nasopharyngeal swabs from deceased infants for presence of RSV. We performed verbal autopsies and calculated odds of RSV-associated mortality with 95% CIs and used multivariable logistic regression to evaluate associations. RESULTS: We collected 490 nasopharyngeal specimens from 1280 eligible infant deaths. There were 377/490 (76.9%) live births and 14/377 (3.7%; 95% CI: 1.8-5.6) were RSV positive. Most deaths occurred in neonates (254/377; 67.4%), males (226/377; 59.9%), and respiratory illnesses (206/377; 54.6%). Postneonatal age (10/14, 71.4%; OR: 5.5; 95% CI: 1.7-18.0), respiratory symptoms (12/14, 85.7%; OR: 5.2; 1.2-23.7), and high RSV season (9/14, 64.3%; OR: 4.4; 1.4-13.3) were associated with RSV mortality. In multivariable logistic regression analysis, respiratory symptoms (OR: 6.6; 95% CI: 1.3-32.5), RSV seasonality (6.1; 1.8-20.4), and age (9.2; 2.6-33.1) were significant predictors of RSV-associated mortality. CONCLUSIONS: RSV has a significant mortality burden in early infancy in Karachi, Pakistan. Age, RSV seasonality, and respiratory symptoms were significant predictors of RSV-associated mortality. Our findings have implications for clinical management of young infants with cold-like symptoms, policy development, and research regarding maternal immunization against RSV during pregnancy, in resource-constrained, low-income, and vaccine-hesitant populations.

External lumbar drainage in progressive pediatric idiopathic intracranial hypertension.

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.

When pediatric acute acquired comitant esotropia is not caused by a neurological disease.

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.

The effect of reduced contrast sensitivity on colour vision testing.

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 < 0.023) and H-R-R (P < 0.035) tests. CONCLUSIONS: At high contrast sensitivities, all colour vision tests function almost equally; however, at decreased levels of contrast sensitivity, H-R-R and Farnsworth D-15 are more greatly affected.

Prevalence of Strabismus Among Children With Neurofibromatosis Type 1 Disease With and Without Optic Pathway Glioma.

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.].

Chairs of United States Academic Ophthalmology Departments: A Descriptive Analysis and Trends.

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.

Leadership of United States Academic Departments of Ophthalmology: Chairperson Characteristics, Accomplishments, and Personal Insights.

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.

Instructions to Patients and Families Following Strabismus Surgery.

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.

Unilateral strabismus surgery in patients with exotropia results in postoperative lateral incomitance.

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 < 0.001). Three patients had diplopia in lateral gaze toward the operated eye that remained >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.