The status of women in academic ophthalmology: Authorship of papers, presentations, and academic promotions.

As the field of ophthalmology has evolved in the last several decades, so has the gender distribution of ophthalmologists. We conducted a narrative review to further characterise the status of women in the realm of publication, presentations, editorial positions, grants, academic promotion, and financial compensation. While the proportion of women publishing, presenting, and filling academic and editorial roles has increased over time, it still does not match that of men. Women are more likely to be first authors instead of senior authors, have lower average h-indices, and are awarded fewer grants. The magnitude of some of these differences is smaller when adjusted for women's shorter career duration on average. Despite increased representation of women in ophthalmology, women continue to receive less compensation for the same work. This review highlights that more can be done to improve gender parity in ophthalmology.

Assessing an Exposure Keratopathy Prevention Strategy in Mechanically Ventilated Patients: A Retrospective Study.

OBJECTIVE: Patients who are intubated and sedated are at risk for developing exposure keratopathy, which can lead to permanent vision loss. This retrospective study assesses the incidence of exposure keratopathy (EK) in intensive care unit (ICU) patients before and after implementation of an EK Prevention Order Set. METHODS: At one tertiary care hospital (Bronx, NY), an "Exposure Keratopathy Prevention Order Set" was implemented to ameliorate this risk which included the application of white petrolatum-mineral oil lubricating ointment every 6 hours in both eyes. This retrospective chart review study analyzed the incidence of EK diagnosis before and after implementation of this EK Prevention Order Set. Patients who were on mechanical ventilation at the time of ophthalmology consult request between January 1, 2021, and December 31, 2021, were included. Ophthalmology consult notes of patients with EK diagnosis were reviewed for details regarding the consult request, examination findings, diagnosis, and treatment plan. RESULTS: There were 247 and 361 ventilated ICU patients before and after the order set, respectively. The number of ophthalmology consults decreased slightly after the order set from 15 of 247 to 20 of 361 ventilated patients. In addition, the rate of EK among ventilated patients decreased from 4.5% (11 of 247 patients over 151 days) to 2.2% (8 of 361 patients over 212 days; P =0.154) with a risk ratio of 0.50 (95% CI 0.20-1.22). CONCLUSION: The number of patients diagnosed with EK trended down after implementation of the EK Prevention Order Set.

Types of materials for frontalis sling surgery for congenital ptosis.

BACKGROUND: Congenital ptosis is a drooping of one or both eyelids at birth, often due to poor development of the levator palpebrae superioris muscle. This can result in amblyopia, astigmatism, and ocular torticollis and therefore may necessitate surgical intervention in early childhood if visual development is compromised. Patients may have varied levels of levator function. Those with moderate to good function may elect to first attempt ptosis repair with external levator advancement or mullerectomy/Fasanella-Servat procedures. For those with poor function, those procedures are less likely to be effective, so they may undergo frontalis sling surgery, in which the tarsal plate is coupled to the frontalis muscle, so that movement of the brow and forehead result in movement of the eyelid. The optimal material to use in this surgery is unknown. OBJECTIVES: To evaluate the comparative effectiveness and safety of various materials used in frontalis sling surgery for congenital ptosis. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (June 2018), Ovid MEDLINE, Ovid MEDLINE E-pub Ahead of Print, Ovid Medline In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily (January 1946 to 20 June 2018), Embase (January 1947 to 20 June 2018), PubMed (1948 to 20 June 2018), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to 20 June 2018), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 20 June 2018. SELECTION CRITERIA: We included randomized trials that compared one material to another for the treatment of congenital ptosis. DATA COLLECTION AND ANALYSIS: Two review authors independently completed eligibility screening, data abstraction, 'Risk of bias' assessment, and grading of the evidence. MAIN RESULTS: We identified three randomized trials that had compared four different materials, two materials in each trial. The studies included a total of 160 participants. The surgical procedures compared were polytetrafluoroethylene (Gore-Tex), Ethibond suture, Mersilene mesh, and autogenous fascia lata.We judged all studies to be at unclear risk of bias due to incomplete reporting of methods and other methodological deficiencies.Because the three included studies compared different types of implants, we were unable to combine data in a meta-analysis. The limited data preclude any conclusion regarding the optimal implant for frontalis sling surgery.In terms of the primary outcome of functional success, this was defined as widening of the opening between eyelids, assessed either by grade or by millimeter measurement. Bajaj 2004 showed that 93% of the Gore-Tex group and 83% of the Ethibond group had a good or satisfactory outcome (as defined by investigators). Elsamkary 2016 reported that 78.1% of the autogenous fascia group and 61.8% of the Gore-Tex group had a very good or good outcome. Salour 2008 did not include this type of grading system; they showed that the lid fissure increased 4.0 mm ± 1.46 mm in the Mersilene group and 3.13 mm ± 1.72 mm in the fascia lata group.In terms of adverse events, Bajaj 2004, which included 15 patients per group, showed no recurrence in the Gore-Tex group and 1 in the Ethibond group; no need for removal in the Gore-Tex group and 1 in the Ethibond group; and no infections in the Gore-Tex group and 1 in the Ethibond group. Elsamkary 2016, which included 55 patients per group, had 3 recurrences in the fascia group and 6 in the Gore-Tex group; no need for removal in either group; and 1 infection in the fascia group and 2 in the Gore-Tex group. Salour 2008, which included 10 patients per group, had no recurrence, removals, or infections in either the Mersilene or the fascia group. AUTHORS' CONCLUSIONS: The three trials included in this review evaluated four materials for frontalis sling surgery. Assessment of these three studies does not allow us to identify the optimal material. Future randomized trials should be rigorously designed so as to identify the best treatment for this condition.

Interventions for orbital lymphangioma.

BACKGROUND: Orbital lymphangiomas are a subset of localized vascular and lymphatic malformations, which most commonly occur in the head and neck region. Orbital lymphangiomas typically present in the first decade of life with signs of ptosis, proptosis, restriction of ocular motility, compressive optic neuropathy, and disfigurement. Therefore, early and effective treatment is crucial to preserving vision. Due to proximity to vital structures, such as the globe, optic nerve, and extraocular muscles, treatment for these lesions is complicated and includes a large array of approaches including observation, sclerotherapy, systemic therapy, and surgical excision. Of these options, there is no clear gold standard of treatment. OBJECTIVES: To assess the evidence supporting medical and surgical interventions for the reduction/treatment of orbital lymphangiomas in children and young adults. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 5); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 22 May 2018. SELECTION CRITERIA: We planned to include randomized controlled trials (RCTs) comparing at least two of the following interventions with each other for the treatment of orbital lymphangiomas: observation; sildenafil therapy; sirolimus therapy; sclerotherapy; surgery (partial or complete resection). We planned to include trials that enrolled children and adults up to 32 years of age, based on a prior clinical trial protocol. There were no restrictions regarding location or demographic factors. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the titles, abstracts, and full articles to assess their suitability for inclusion in this review. No risk of bias or data extraction was performed because we did not find any trials for inclusion. If there had been RCTs, two authors would have assessed the risk of bias and abstracted data independently with discrepancies being settled by consensus or consultation with a third review author. MAIN RESULTS: There were no RCTs that compared any two of the mentioned interventions (medical or surgical) for treating orbital lymphangiomas in children and young adults. AUTHORS' CONCLUSIONS: Currently, there are no published RCTs of orbital lymphangioma treatments. Without these types of studies, conclusions cannot be drawn regarding the effectiveness of the medical and surgical treatment options for patients with orbital lymphangiomas. The presence of only case reports and case series on orbital lymphangiomas makes it clear that RCTs are needed to address the differences between these options and help guide treatment plans. Such trials would ideally compare outcomes between individuals randomized to one of the following treatment options: observation, sclerotherapy, systemic sirolimus therapy, systemic sildenafil therapy, and surgical excision.

Gender-based differences in letters of recommendation written for ophthalmology residency applicants.

BACKGROUND: To determine whether gender-based differences may be present in letters of recommendation written for ophthalmology residency applicants. METHODS: All applications submitted through SF Match to the UCLA Stein Eye Institute Residency Training Program from the 2017-2018 application cycle were analyzed using validated text analysis software (Linguistic Inquiry and Word Count (Austin, TX)). The main outcome measures were differences in language use in letters of recommendation by gender of applicant. RESULTS: Of 440 applicants, 254 (58%) were male and 186 (42%) were female. The two gender groups had similar United States Medical Licensing Exam (USMLE) Step 1 scores, undergraduate grade point averages (uGPA's), proportions of underrepresented minority (URM) applicants and Gold Humanism Honor Society members, numbers of academic and service activities listed, and gender distributions of their letter writers (all P values > 0.05). However, letters written for male applicants were determined to use more "authentic" words than those written for female applicants (mean difference, 0.800; 95% CI, 0.001-1.590; P = 0.047). Letters written for male applicants also contained more "leisure" words (mean difference, 0.056; 95% CI, 0.008-0.104; P = 0.023) and fewer "feel" words (mean difference, 0.033; 95% CI, 0.001-0.065; P = 0.041) and "biological processes" words (mean difference, 0.157; 95% CI, 0.017-0.297; P = 0.028). CONCLUSIONS: There were gender differences detected in recommendation letters in ophthalmology consistent with prior studies from other fields. Awareness of these differences may improve residency selection processes.

Proptosis Reduction Using Sirolimus in a Child With an Orbital Vascular Malformation and Blue Rubber Bleb Nevus Syndrome.

A 15-month-old boy with left congenital proptosis presented to the emergency department with melena. Upper GI endoscopy and magnetic resonance angiography revealed vascular lesions, consistent with gastrointestinal tract manifestations of blue rubber bleb nevus syndrome. MRI revealed vascular malformations in both orbits, with mass effect on the left side. The patient was started on a trial of the antiangiogenic agent sirolimus (also known as rapamycin), and after 6 months of treatment showed clinical improvement in proptosis supported by radiologic evidence of regression in the larger, left orbital mass, with stability of the smaller, right orbital mass. There are 11 published cases of orbital blue rubber bleb nevus syndrome in the English literature. To our knowledge, this is the first reported case of successful, long-term treatment with sirolimus causing a reduction in the size of an orbital vascular malformation.

A case of congenital myofibroma of the orbit presenting at birth.

PURPOSE: The purpose of this report is to highlight a rare cause of congenital proptosis. METHODS: This is a case report. RESULTS: We present a case of a baby girl born with a large myofibroma in the right retrobulbar space. This case is unusual because it presented from birth and was in a critical location. A prenatal ultrasound performed two days prior to birth did not reveal this mass to the technician or obstetrician. At birth, the tumor induced severe proptosis, with the eyelids unable to close around the globe. Deterioration of the ocular surface secondary to exposure was evident immediately after birth. One week after birth, the mass was excised by the Oculoplastics service in conjunction with a Neurosurgical team using a transcranial approach. The tumor was diagnosed by histopathology and immunologic staining as a myofibroma, a rare condition. CONCLUSIONS: Orbital myofibroma is a rare cause of congenital proptosis presenting at birth.

The Significance of Female Faculty and Department Leadership to the Gender Balance of Ophthalmology Residents.

PURPOSE: To examine the gender balance of academic ophthalmology departments by determining the association between the rates of female residents in ophthalmology programs and department chair/residency program director (PD) gender and rate of female faculty within the department. DESIGN: Retrospective cross-sectional study. METHODS: Demographic information on ophthalmology programs, including size, location, and gender distribution of leadership, faculty, and residents was collected from public online resources. Departments with residency programs were included for analyses if they were both Accreditation Council Graduate Medical Education accredited and available for application through the San Francisco Match for the 2020-2021 application cycle. For analyses, a binomial regression was fitted to identify factors associated with the female faculty and resident proportions. RESULTS: In 117 total programs, 16.7% of chairs and 37.7% of PDs were female. There were more female residents at programs with female PDs (P = .02), with more female faculty (P < .001), and at larger departments (P = .001) and residency programs (P = .04). In multivariate analysis, more female faculty members increased the odds of having more female residents (P < .001). Chair gender did not correlate with the proportion of female faculty or residents. There were the most female residents in the Northeast and the fewest in the Southwest (P = .003). CONCLUSIONS: Although gender of department chair did not correlate with proportion of female faculty or residents, programs with more female faculty members had more female residents. Deans and programs should strive for departmental diversity and the recruitment and success of female residents to ensure the use of their full academic capital.

Refractive surgery: a treatment for and a cause of strabismus.

PURPOSE OF REVIEW: The purpose of this article is to review refractive surgery as a means of treatment for strabismus and as a potential cause of strabismus and binocular diplopia. RECENT FINDINGS: Numerous studies have reported that refractive surgery is effective in correcting certain types of strabismus such as accommodative and partially accommodative esotropia. Studies on the treatment of exotropia related to anisometropia have demonstrated less favorable outcomes. In patients without manifest strabismus preoperatively, recent studies have shown that strabismus and diplopia can occur after refractive surgery. Appropriate clinical testing and risk stratification are essential to determine whether a patient is at increased risk for postoperative strabismus and diplopia. SUMMARY: Refractive surgery can be useful in patients with accommodative and partially accommodative esotropia. A thorough history and clinical examination is extremely important to expose potential risk factors in all patients undergoing refractive surgery. Based on the designated risk level, more advanced testing may be warranted.

Non-invasive methods of estimating intracranial pressure.

Non-invasive measurement of intracranial pressure can be invaluable in the management of critically ill patients. We performed a comprehensive review of the literature to evaluate the different methods of measuring intracranial pressure. Several methods have been employed to estimate intracranial pressure, including computed tomography, magnetic resonance imaging, transcranial Doppler sonography, near-infrared spectroscopy, and visual-evoked potentials. In addition, multiple techniques of measuring the optic nerve and the optic nerve sheath diameter have been studied. Ultrasound measurements of the optic nerve sheath diameter and Doppler flow are especially promising and may be useful in selected settings.

Comparison between Medical Student Educators and Program Directors in 2010 and 2019.

Objective Over the last decade, prominence of the Directors of Medical Student Education in Ophthalmology (DMSEs) within the Association of University Professors of Ophthalmology (AUPO) has increased. With increased recognition of this important leadership position, an examination of the trending demographic differences between DMSEs and the Ophthalmology Program Directors (PDs) may be helpful, especially in regard to the potential for academic promotion from each track. Design Present study is a database study. Methods The AUPO directory was used to ascertain the DMSE and the PD members between 2010 and 2019. The demographic profile for each member was determined using publicly available resources. Chi-square analysis of the data was performed. Main Outcome Measures Number of DMSE and PD AUPO from 2010 to 2019 in AUPO Directory, sex, geographic location, and graduation year were measured through this study. Results There has been a steady increase in the number of DMSEs from 2010 to 2019, whereas the number of PDs have remained stable. The number of DMSEs have increased in all regions of the United States. The year of ophthalmology residency graduation was similar in the DMSE and PD cohorts in 2010 and 2019. The number of women have increased in the DMSEs in 2019 compared with 2010; the number of women who were PDs in 2019 were similar to 2010. Finally, more PDs in 2010 became Chairs in 2019, whereas no DMSEs in 2010 became Chair in 2019. Conclusion There are a growing number of DMSEs, overall, with an increasing proportion of women in the 2019 DMSE group compared with 2010. In contrast, the overall number of PDs have remained stable, as has the proportion of female PDs in 2019 compared with 2010. DMSEs, compared with PDs, are less likely to become Chairs. The increased opportunity for academic leadership with the growing DMSE group may help change leadership patterns overall in academic ophthalmology.

Complication and Management of Optic Nerve Edema Resulting From Nasal Transposition of the Split Lateral Rectus Muscle.

A 9-year-old boy with partial third nerve palsy underwent medial transposition of the left lateral rectus muscle and left inferior oblique myectomy. He developed optic nerve compression, which improved after a superior oblique tenotomy. A primary superior oblique tenotomy or a maximum lateral rectus muscle split may help avoid this complication. [J Pediatr Ophthalmol Strabismus. 2021;58(3):e12-e15.].

Current Scope of Online Ophthalmology Education and Curriculum Impact Due to COVID-19.

Objective Abrupt changes in ophthalmology education caused by the COVID-19 pandemic have resulted in novel online curriculum development. The aims of this study were to identify (1) the scope of online curricula implemented both prior to and during the COVID-19 pandemic; (2) perception of educators on these online modalities; and (3) early lessons from online implementation that may guide future curricular planning. Methods Implementation of online curricula was evaluated by using a national online survey of Ophthalmology Directors of Medical Student Education (DMSE) via Qualtrics software. Participants Medical Student Educators of the Association of University Professors of Ophthalmology (AUPO) were surveyed. Results Fifty responses were collected, representing a 64.9% response rate. Prior to the COVID-19 pandemic, 44% of institutions had no online components in their courses, but 78.3% of institutions reported increasing online components in response to the pandemic. Required courses were significantly associated both with having implemented online components before the pandemic and implementing online-only versions of these courses in response to the pandemic. The three most popular modalities used for online teaching were lectures, interactive cases, and problem-based learning, with a median satisfaction of 4.0, 4.32, and 4.35, (out of five) respectively. The least popular modalities used were online teaching of physical exam skills and telemedicine, both with a median satisfaction of 2.5. Median overall educator satisfaction with online teaching was four (out of five). The most common weakness related to online teaching was the lack of effective physical exam skills training. Conclusion Our data demonstrate that most institutions successfully shifted their ophthalmology curriculum to a virtual and online version in response to the COVID-19 pandemic. DMSEs adapted quickly, transitioning in-person clinical courses, and extracurricular activities to online formats. Overall, educator satisfaction with online curricula was high. Integration of online curricula provides the opportunity to enrich institutional curriculums and overcome limitations imposed by decreasing curriculum time. This study reveals an early window into the utilization, strengths, and weaknesses of online ophthalmology education, which can serve as a guiding point to enhance ophthalmology curriculum development.