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Corneal Reflex

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421. Blepharospasm, Benign Essential (Follow-up)

to their preinjection level of function. Some have suggested that the development of antitoxin antibodies or the progressive atrophy of muscle may account for variations in the dose response curve, but no studies have supported these findings. Tear breakup time (TBUT), lissamine green staining, and Ocular Surface Disease Index (OSDI) scores have all been shown to be improved after botulinum toxin injection. [ ] Complications of botulinum toxin injections include ptosis (7-11%), corneal exposure/lagophthalmos (5-12 (...) Scand . 2008 Jun 5. . Morrison DA, Mellington FB, Hamada S. Schwartz-Jampel syndrome: surgical management of the myotonia-induced blepharospasm and acquired ptosis after failure with botulinum toxin A injections. Ophthal Plast Reconstr Surg . 2006 Jan-Feb. 22(1):57-9. . Quartarone A, Sant'Angelo A, Battaglia F. Enhanced long-term potentiation-like plasticity of the trigeminal blink reflex circuit in blepharospasm. J Neurosci . 2006 Jan 11. 26(2):716-21. . Defazio G, Hallett M, Jinnah HA, Conte

2014 eMedicine.com

422. Glaucoma, Complications and Management of Glaucoma Filtering (Follow-up)

result in serious consequences. According to a recent study, most eyes in which a flat anterior chamber with hypotonia developed after glaucoma surgery eventually acquired late cataract. This finding confirms a previous clinical impression that hypotonia is a cause of late cataract. When the anterior chamber is flat, contact can occur between the cornea and the lens. Contact between the corneal endothelium and the anterior lens capsule usually results in damage to the cornea. Corneal damage can (...) , which is most common with large nasal blebs extending onto the cornea. Tear film abnormalities with dellen formation and superficial punctate keratopathy may occur. Corneal astigmatism, visual field defects, and monocular diplopia have been described in patients in whom large filtering blebs migrated onto the cornea. Artificial tears and ocular lubricants can be helpful, especially in patients with abnormal tear film. Several chemical and thermal methods have been used to shrink blebs. A temporary

2014 eMedicine.com

423. Endophthalmitis, Bacterial (Follow-up)

inflammation and hypopyon Increased red reflex Retraction of any fibrin Improved visual acuity If no improvement occurs in 48-72 hours, consider the following: Repeat tap/biopsy and antibiotic injections Vitrectomy and injection of antibiotics, if no previous vitrectomy exists If view is poor, B-scan ultrasound is useful to rule out retinal detachment. Previous Next: Further Inpatient Care Patients may be admitted or may be treated as outpatients depending on the following: Severity of endophthalmitis (...) , D'Amico DJ, Baker AS. Endogenous bacterial endophthalmitis. Report of a ten-year retrospective study. Ophthalmology . 1994 May. 101(5):832-8. . Donahue SP, Kowalski RP, Jewart BH, Friberg TR. Vitreous cultures in suspected endophthalmitis. Biopsy or vitrectomy?. Ophthalmology . 1993 Apr. 100(4):452-5. . Hariprasad SM, Shah GK, Chi J, Prince RA. Determination of aqueous and vitreous concentration of moxifloxacin 0.5% after delivery via a dissolvable corneal collagen shield device. J Cataract Refract

2014 eMedicine.com

424. Esotropia, Pseudo (Follow-up)

children previously diagnosed with pseudoesotropia. Am Orthopt J . 2013. 63:103-6. . Media Gallery Note the cross-eyed appearance of the right eye in the top image that corrects with elimination of the prominent epicanthal fold. In these photos of the same child as in the previous image, note the cross-eyed appearance of the left eye in the top image that corrects with elimination of the prominent epicanthal fold. Also, note that corneal light reflex demonstrates straight alignment. of 2 Tables (...) of Medicine Simon K Law, MD, PharmD is a member of the following medical societies: , , Disclosure: Nothing to disclose. J James Rowsey, MD Former Director of Corneal Services, St Luke's Cataract and Laser Institute J James Rowsey, MD is a member of the following medical societies: , , , , , , , Disclosure: Nothing to disclose. Chief Editor Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences Hampton Roy, Sr, MD is a member

2014 eMedicine.com

425. Esotropia, Infantile (Follow-up)

== processing > Infantile Esotropia Follow-up Updated: Feb 09, 2017 Author: Vicente Victor D Ocampo, Jr, MD; Chief Editor: Donny W Suh, MD, FAAP Share Email Print Feedback Close Sections Sections Infantile Esotropia Follow-up Further Outpatient Care The infant typically is seen 3-14 days after the surgery. Visual acuity is checked, an afferent pupillary defect is ruled out, and a good red reflex is elicited from both fundi. Furthermore, conjunctival incisions are inspected with a penlight for dehiscence (...) Scleral perforation Foreign body granuloma at the suture site Allergic reaction to suture material Conjunctival inclusion cyst Conjunctival scarring Anterior segment ischemia Change in eyelid position Lost muscle Slipped muscle Oculocardiac reflex Previous Next: Prognosis It is accepted that better ocular alignment and visual prognosis can be achieved if surgical correction is performed before age 2 years. Long-term follow-up studies on esotropic infants who underwent surgical alignment by age 2 years

2014 eMedicine.com

426. Inherited Metabolic Disorders (Follow-up)

, consistent outlines for taking histories and doing physical examinations. Scientific methods were applied to pathology and clinical medicine because of discoveries in physics and chemistry (both organic and inorganic). The discoveries led to knowledge of the organic chemistry of dyes, tissue staining, and improved microscopy. [ , ] The blood pressure apparatus, thermometer, stethoscope, tuning fork, and later, the reflex hammer were added to the clinician's armamentarium. [ ] With these tools, physicians (...) substances in various tissues and organs. Manifestations generally include neurologic impairment, skeletal deformities, intellectual and cardiac abnormalities, and gastrointestinal problems. Ocular complications often cause severe reduction in visual acuity and can affect any part of the eye including cataract, vitreous degeneration, retinopathy, optic nerve swelling and atrophy, ocular hypertension, and glaucoma. Corneal opacification of varying severity is frequently seen. Most of these patients have

2014 eMedicine.com

427. Lasers in Urology (Follow-up)

. With any laser, all intraoperative personnel should wear proper eye protection that blocks the specific laser's wavelength to avoid corneal or retinal damage should an optical delivery fiber crack or break. This especially is true with Nd:YAG, which penetrates deeply and can burn the retina faster than the blink reflex can protect it. Ho:YAG, which does not penetrate as deeply, may cause corneal defects if aimed at the unprotected eye. Finally, strategic and adequate draping should be used around

2014 eMedicine.com

428. Hyperopia, Phakic IOL (Follow-up)

chamber. This injection is started at the opposite limbus. As the aqueous drains, it should be replaced with viscoelastic agent. The depth of the anterior chamber is not reduced at any time. For iris claw lens implantation, 2 side ports are needed to introduce the instruments, which fix the iris to the claw. Making the larger incision to insert the IOL The size of this incision depends on the type of IOL to be implanted. For a soft precrystalline lens, make a 3.0- to 3.2-mm 3-plane clear corneal (...) incision at the temporal area (0° for the left eye or 180° for the right eye). For an iris claw lens, the width of the incision depends on the diameter of the optic (5 mm). The incision may be made at the limbus or in the clear cornea. If a pocket section is made, it will allow a wound closure without sutures. Insertion of foldable lens in the precrystalline space The lens is introduced with angled-suture forceps, then it is positioned behind the iris on a horizontal axis with a cyclodialysis spatula

2014 eMedicine.com

429. Brain Death in Children (Treatment)

Cerebral functions are absent (ie, unresponsiveness) The following brainstem functions are absent: pupillary light reflex, corneal reflex, oculocephalic/oculovestibular reflex, oropharyngeal reflex, and respiratory (apnea using an accepted apnea testing procedure) [ ] Irreversibility of brain function cessation is recognized The cause of coma is established and is sufficient to account for the loss of brain function The possibility of recovery of any brain function is excluded Cessation of brain (...) brainstem function - Fixed and dilated or midposition pupils; absent spontaneous and oculocaloric/oculovestibular eye movements; absent movement of facial and oropharyngeal muscles; and bsent corneal, gag, cough, sucking, and rooting reflexes Spinal cord reflex withdrawal not included Consistent examination throughout the observation period (see Table 1, below) Table 1. Age-Dependent Observation Period Age Hours Between 2 Examinations Recommended Number of EEGs 7 days-2 months 48 2 2 months-1 year 24 2

2014 eMedicine.com

430. Cerebellar Hemorrhage (Treatment)

systolic blood pressure greater than 200 mm Hg Pinpoint pupils and abnormal corneal and oculocephalic reflexes Hemorrhage extending into the cerebellar vermis Hematoma diameter greater than 30 mm Brainstem distortion Intraventricular hemorrhage Upward herniation Acute hydrocephalus Clot evacuation and direct fibrinolysis of the hematoma has been reported in small numbers of carefully selected patients. [ , , , ] Endoscopic hematoma evacuation has also been reported to have been effective in a small (...) agree that a patient who is comatose, flaccid, and without brainstem reflexes with a large midline hemorrhage has a poor prognosis. For such patients, supportive care without surgery may be the only indicated therapy. For infratentorial hemorrhages, the GCS has been shown to be a predictor of outcome. [ ] However, clear consensus does not exist regarding many patients who fall between these extremes. Variation in surgical treatment exists even within a geographic region. Immediate management

2014 eMedicine.com

431. Cavernous Sinus Syndromes (Treatment)

hypertension Optic disc edema or pallor; retinal hemorrhages Anesthesia in the ophthalmic division of the trigeminal nerve (V1) and/or decreased or absent corneal reflex and possibly anesthesia in the maxillary or V2 branch Pupil in mid-position and nonreactive if both sympathetic and parasympathetic fibers of the third nerve are affected Cavernous sinus tumors Metastatic lesions: Isolated or combined ophthalmoplegia, painful ophthalmoplegia, anesthesia in the ophthalmic nerve Pituitary tumors: Isolated

2014 eMedicine.com

432. Catatonia (Treatment)

; specifically, neuroleptic malignant syndrome (NMS), encephalitis, and focal status epilepticus must be ruled out Ophthalmologic consultation is recommended to rule out Kayser-Fleischer rings (pigmented rings at the edge of the cornea that are characteristic of Wilson disease) Hematologic consultation is appropriate to prevent thromboembolic disease if people with catatonia demonstrate evidence of early coagulation activation [ ] Consultation with a psychiatrist is indicated to rule out acute psychosis (...) N, Nielsen NB. [Malignant neuroleptic syndrome in a 15-year old girl after a single injection of a high-dose neuroleptic]. Ugeskr Laeger . 1991 Aug 5. 153(32):2239-40. . Winzeler RL. Latah in Southeast Asia: the history and ethnography of a culture-bound syndrome . Cambridge, Great Britain: Cambridge University Press; 1995. Simons RC. Latah: a culture-specific elaboration of the startle reflex [film] . Bloomington, Indiana: Indiana University Audiovisual Center; 1983. Tanner CM, Chamberland J

2014 eMedicine.com

433. Cataract, Congenital (Treatment)

development when compliance with CL wear is moderate to poor or when a cataract is extracted in a patient older than 1 year. A study with promising preliminary results concerns the primary implantation of flexible IOLs in infants younger than 1 year. [ ] The population studied includes infants aged 3-11 months who have different forms of unilateral congenital cataracts. A 2008 study by Capozzi et al showed that, in the first 42 months of age, corneal power (Km) and axial length (AL) values (...) not affect corneal clarity in the long run. [ ] Goggin et al found in a publicly funded hospital study that the manufacturer seems to underestimate the corneal plane effective cylinder power of its toric IOLs. By estimating the effective corneal plane cylinder power of the IOL, as altered by the anterior chamber depth and pachymetry and by the IOL sphere power, a better outcome could be achieved; however, this is not currently addressed by the manufacturer. [ ] Previous Next: Consultations

2014 eMedicine.com

434. Cataract, Senile (Treatment)

after the operation include the following: Flat or shallow anterior chamber due to wound leak Choroidal detachment Pupillary block Ciliary block Suprachoroidal hemorrhage Stromal and epithelial edema Hypotony Brown-McLean syndrome (peripheral corneal edema with a clear central cornea most frequently seen following ICCE) Vitreocorneal adherence and persistent corneal edema Delayed choroidal hemorrhage Elevated intraocular pressure (often due to retained viscoelastic) Cystoid macular edema - Studies (...) be evident, as well as some conjunctival injection. The cornea is normally clear with minimal edema and striae. The anterior chamber should be deep with mild cellular and flare reaction. It is important to check whether the posterior capsule is intact and whether the IOL is positioned properly. The red reflex must be strong and clear and the intraocular pressures should be within normal limits. Transient intraocular pressure elevations may be observed and are often attributed to retained viscoelastic

2014 eMedicine.com

435. Chorea in Children (Treatment)

disturbance, cerebellar dysfunction, and occasionally seizures. Impaired ocular motility may also be an early sign of HD in the pediatric patient and resembles oculomotor apraxia. The patient may appear to be primarily clumsy, rather than either rigid or choreiform. Reflexes are usually brisk, and pyramidal signs with extensor plantar responses are common. Seizures occur in about 30-50% of patients and are difficult to control. Diagnosis The availability of a DNA-based testing (to reliably identify the HD (...) tendon reflexes also occurs. Seizures occur in about one third of patients. MRI may demonstrate atrophy of the caudate nucleus or T2-weighted hyperintensities in the striatum. Diagnosis Identify characteristic clinical features, a positive family history, the presence of acanthocytes on peripheral blood smear, and a normal plasma lipid profile. Treatment Treatment is symptomatic. Antidopaminergic agents may suppress the chorea, but they may worsen concomitant parkinsonism. Seizures should be treated

2014 eMedicine.com

436. Duane Syndrome (Treatment)

, contraction of the palpebral fissure and oblique movements of the eye. 1905. Arch Ophthalmol . 1996 Oct. 114(10):1255-6; discussion 1257. . Brown HW. Congenital structural anomalies of the muscles. Allen JH, ed. Strabismus Ophthalmic Symposium 11 . St. Louis: CV Mosby Co; 1958. 391. Lyle TK, Bridgeman GJO. Worth and Chavasse’s Squint. The Binocular Reflexes and the Treatment of Strabismus . 9th ed. London: Bailliere Tindall and Cox; 1959. 251-5. Malbran J. Estrabismos y paralysis. Clinica y terapeutica (...) : Nothing to disclose. Specialty Editor Board Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. J James Rowsey, MD Former Director of Corneal Services, St Luke's Cataract and Laser Institute J James Rowsey, MD is a member of the following medical societies: , , , , , , , Disclosure: Nothing to disclose. Chief Editor

2014 eMedicine.com

437. Down Syndrome (Treatment)

with Down syndrome may have nasolacrimal duct obstruction. [ ] Anterior segment assessment Evaluate corneas carefully for keratoconus, keratoglobus, or corneal hydrops. Scissoring of the retinoscopic reflex is an early finding in patients with keratoconus. Placido disks, keratometers, or topographies can be used to evaluate cooperative patients with Down syndrome who have keratoconus. Rizzuti and Munson signs appear later. Iris' Brushfield spots may occur in up to 90% of patients with trisomy 21 (...) . . Rossi R, Blonna D, Germano M, Castoldi F. Multidisciplinary investigation in Down syndrome: bear in mind. Orthopedics . 2008 Mar. 31(3):279. . Sabti S, Tappeiner C, Frueh BE. Corneal Cross-Linking in a 4-Year-Old Child With Keratoconus and Down Syndrome. Cornea . 2015 Sep. 34(9):1157-1160. . . Media Gallery of 0 Tables Contributor Information and Disclosures Author Natalio J Izquierdo, MD Associate Professor, Medical Sciences Campus, University of Puerto Rico School of Medicine Natalio J Izquierdo

2014 eMedicine.com

438. Myasthenia Gravis (Treatment)

with local cooling Prism measurements and margin reflex distance-1 should be documented in patients who have diplopia or ptosis with a facial photo on a cell phone camera. The patient is asked to lie supine with eyes closed in an examination chair for up to twenty minutes. A supplemental cool compress or small amount of ice in an examining glove is placed over the closed lids, as tolerated. Upon re-examination with the patient sitting up, the lid height and alignment are often improved in patients (...) desire. Successful muscle surgery for selected patients with a stable course of MG and persistent diplopia has been reported. [ , , ] Blepharoptosis surgery Ptosis surgery for myasthenia is complicated by variable lid height, possible corneal exposure due to concomitant orbicularis weakness, and the possible unmasking of diplopia in patients with unilateral ptosis. Ptosis surgery in patients with stable ptosis that has failed to respond to medical therapy for MG has been described. The surgical

2014 eMedicine.com

439. Myopia, Radial Keratotomy (Treatment)

likely stray light will become a problem, especially at night. 4. Marking the location of the incisions: A marker with ridges imprints the location of the incisions in the epithelium as it is depressed on the cornea. The meridian for astigmatic surgery may be marked using a circular protractor and linear marker. 5. Measuring corneal thickness with an ultrasonic pachymeter: The fluid-filled probe tip is held perpendicular to the corneal surface, and the instruments obtain paracentral measurements just (...) knife blade: Double-pronged forceps fixate the globe at the limbus, and the knife is held perpendicular to the corneal surface at the edge of the clear zone, commencing a centrifugal incision. 11. Centripetal incision with a vertical knife blade: The globe is fixated at the limbus with a forceps, and the knife blade is inserted into the cornea adjacent to the limbus. 12. Transverse incision with a vertical knife blade: A knife with a vertical blade cuts a transverse incision for astigmatism, while

2014 eMedicine.com

440. Myopia, LASIK (Treatment)

. Patients with irregular corneas and a history of contact lens wear should be observed with serial refractions and topography until both stabilize. Finally, ultrasonic pachymetry is necessary to determine if enough corneal thickness is present to create a flap, ablate the cornea, and still leave enough tissue behind to prevent structural weakening and ectasia. Current guidelines recommend leaving at least 250 µm of cornea untouched. Next: Intraoperative Details The procedure usually is performed under (...) in an incomplete or partial ablation and correction of the desired refractive error. Microkeratome-created flaps depend on corneal curvature measurements, that is, the steeper the cornea, the more cornea that is exposed to the microkeratome during the forward pass, resulting in a larger diameter flap. The flatter the cornea curvature, the smaller the flap diameter. Very steep corneas (>48-49 D) are prone to button hole flaps, while very flat corneas (< 41-42 D) are prone to free flaps. Femtosecond flap

2014 eMedicine.com

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