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Corneal Reflex

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441. Adult Physiatric History and Examination (Treatment)

and stability of joints; inspection of muscle mass; and assessment of muscle strength and tone Neurologic - Inspection of general appearance including attention to grooming, assessment of mental status (eg, orientation, memory, attention and concentration, language and naming, fund of knowledge, insights into current condition), and assessment of cranial nerves I - Smell II - Visual acuity, and visual fields III, IV, and VI - Pupil and eye movements V - Facial sensation and corneal reflex VII - Facial (...) symmetry and strength VIII - Hearing with tuning fork IX - Palate movement XI - Shoulder shrug XII - Tongue protrusion Neurologic examination also includes assessment of (1) sensation to pinprick, vibration, and proprioception, (2) assessment of sphincter tone and reflexes (eg, bulbocavernosus), (3) assessment of deep tendon reflexes in upper and lower extremities, including pathologic reflexes (eg, Babinski, Hoffman), and (4) assessment of coordination (eg, finger/nose, heel/shin, rapid, alternating

2014 eMedicine.com

442. Endophthalmitis, Bacterial (Treatment)

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

443. Esotropia, Pseudo (Treatment)

epicanthal fold. Also, note that corneal light reflex demonstrates straight alignment. of 2 Tables Contributor Information and Disclosures Author Kalpana K Jatla, MD Private Practice, Clarity Eye Center Kalpana K Jatla, MD is a member of the following medical societies: Disclosure: Nothing to disclose. Coauthor(s) S Anna Kao, MD Comprehensive Ophthalmologist, Emory Clark Holder Clinic; Staff Physician, Department of Ophthalmology, West Georgia Medical Center S Anna Kao, MD is a member of the following (...) of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School 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

2014 eMedicine.com

444. Facial Soft Tissue Injuries (Treatment)

because this may delay reepithelialization and suppress the normal blink reflex. Note: Emergent consultation with an ophthalmologist is warranted for suspected retained intraocular foreign bodies. Urgent consultation is needed for suspected corneal ulcerations (microbial keratitis). These injuries require close follow-up, and referral to an ophthalmologist should also be made for any athlete with continued pain after 48 hours or inadequate healing by 72 hours. Epistaxis Epistaxis typically does (...) to keep the patient comfortable and achieve adequate cleaning. Lubrication of the wound using an antibiotic ointment and covering with a sterile bandage may encourage healing. Corneal abrasion Corneal abrasions result from loss of the surface epithelium. Disruption near the central visual axis interferes with visual acuity. Such abrasions should be treated with a course of ophthalmic topical antibiotics. Topical analgesics may be used initially, but avoid prescribing them to the athlete for home use

2014 eMedicine.com

445. Glaucoma, Complications and Management of Glaucoma Filtering (Treatment)

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

446. Marcus Gunn Jaw-winking Syndrome (Treatment)

in an exaggeration of the aberrant eyelid movement to a level well above the superior corneal limbus, which would be unacceptable to the patient. If the jaw-wink is significant, ablation of the levator and resuspension of the eyelid to the brow are necessary. Several techniques have been suggested to obliterate levator function, which effectively dampens the aberrant eyelid movement, as follows: Bullock advocated complete excision of the levator aponeurosis and muscle all the way to the orbital apex. [ ] Dillman (...) . . Beard C. Ptosis . 3rd ed. St. Louis: CV Mosby; 1981. 46-9. Duke Elder S. Normal and abnormal development; congenital deformities. System of Ophthalmology . St. Louis: CV Mosby; 1963. Vol 3, pt 2: 900-5. Pandey M, Baduni N, Jain A, Sanwal MK, Vajifdar H. Abnormal oculocardiac reflex in two patients with Marcus Gunn syndrome. J Anaesthesiol Clin Pharmacol . 2011 Jul. 27(3):398-9. . . Conte A, Brancati F, Garaci F, Toschi N, Bologna M, Fabbrini G, et al. Kinematic and diffusion tensor imaging

2014 eMedicine.com

447. Metabolic Disease &amp (Treatment)

of the involvement of a number of organ systems. The diagnosis and treatment of Fabry disease can be challenging. The signs and symptoms of Fabry disease may be nonspecific, and if manifestations in different organs are considered in isolation, the unifying diagnosis may be missed. [ , ] The National Society of Genetic Counselors recommends testing for any patient with a family history of Fabry disease or corneal verticillata ("whorls") on slit lamp exam. In the absence of these factors, it is recommended (...) and rhythm abnormalities may be evident on chest palpation and auscultation. Acroparesthesia is a reflection of peipheral neuropathy with complaints of pain in hands and feet typically manifesting in childhood and adolescence. This pain may be both episodic and chronic. Acute episodes may be triggered by exposure to extremes of temperature, stress, emotion, and/or fatigue. Palms and soles of feet appear affected without change in color, preserved deep tendon reflexes, and NCV can be normal due to small

2014 eMedicine.com

448. Brain Death in Children (Diagnosis)

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

449. Blepharospasm, Benign Essential (Diagnosis)

, implying an impairment in cortical processing of sensory input, with a resultant loss of blink reflex inhibition. [ ] If the central control center fails to regulate blinking in blepharospasm, it is believed to be only one component of an overloaded, defective circuit. This circuit forms a blepharospasm vicious cycle, which has a sensory limb, a central control center located in the midbrain, and a motor limb. The sensory limb responds to multifactorial stimuli, including light, corneal or eyelid (...) . . 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 A, Berardelli A. Blepharospasm 40 years later. Mov Disord . 2017 Apr. 32 (4):498-509. . Peterson DA, Sejnowski TJ. A Dynamic Circuit Hypothesis for the Pathogenesis of Blepharospasm. Front Comput Neurosci . 2017. 11:11. . Fayers T, Shaw SR, Hau SC, Ezra DG. Changes in corneal

2014 eMedicine.com

450. Bell Palsy (Diagnosis)

. Several procedures are aimed at protecting the cornea from exposure and achieving facial symmetry. These procedures reduce the need for constant use of lubrication drops or ointments, may improve cosmesis, and may be needed to preserve vision on the affected side. (See Treatment.) Patient education To prevent corneal abrasions, patients should be instructed about eye care. They also should be encouraged to do facial muscle exercises using passive range of motion, as well as actively close their eyes (...) test Nerve excitability test Computed tomography Magnetic resonance imaging See for more specific information on testing and imaging modalities for Bell palsy. Management Goals of treatment: (1) improve facial nerve (seventh cranial nerve) function; (2) reduce neuronal damage; (3) prevent complications from corneal exposure Treatment includes the following: Corticosteroid therapy (prednisone) [ , ] Antiviral agents [ , ] Eye care: Topical ocular lubrication is usually sufficient to prevent corneal

2014 eMedicine.com

451. Bell Palsy (Diagnosis)

. Several procedures are aimed at protecting the cornea from exposure and achieving facial symmetry. These procedures reduce the need for constant use of lubrication drops or ointments, may improve cosmesis, and may be needed to preserve vision on the affected side. (See Treatment.) Patient education To prevent corneal abrasions, patients should be instructed about eye care. They also should be encouraged to do facial muscle exercises using passive range of motion, as well as actively close their eyes (...) test Nerve excitability test Computed tomography Magnetic resonance imaging See for more specific information on testing and imaging modalities for Bell palsy. Management Goals of treatment: (1) improve facial nerve (seventh cranial nerve) function; (2) reduce neuronal damage; (3) prevent complications from corneal exposure Treatment includes the following: Corticosteroid therapy (prednisone) [ , ] Antiviral agents [ , ] Eye care: Topical ocular lubrication is usually sufficient to prevent corneal

2014 eMedicine.com

452. Aniridia (Diagnosis)

but is a panocular disorder with macular and optic nerve hypoplasia, cataract, and corneal changes that are other anomalies that lead to decreased vision and nystagmus. Visual acuity is generally low but is unrelated to the degree of iris hypoplasia. Glaucoma is a secondary problem causing additional visual loss over time. [ ] Patients with aniridia usually lack a foveal reflex, indicating poor macular development. True aplasia of the optic nerve also can occur. All these patients need specialized management (...) of each individual problem. Because of poor visual acuity and nystagmus, low vision aids are very helpful. Lifelong regular follow-up care is necessary for the early detection of any new problems, especially glaucoma, lens, and systemic problems, so that timely treatment is given. [ ] Since the condition has a dominant transmission, proper genetic counseling should be obtained. Aniridia is shown in the images below. Aniridia with a vascularized corneal opacity in a young patient. Centrally placed

2014 eMedicine.com

453. Diabetic Neuropathy (Diagnosis)

along with sensory neuropathy (sensorimotor neuropathy) Autonomic – Neuropathy that may involve the cardiovascular, gastrointestinal, and genitourinary systems and the sweat glands Physical examination should include the following assessments: Peripheral neuropathy testing – Gross light touch and pinprick sensation; vibratory sense; deep tendon reflexes; strength testing and muscle atrophy; dorsal pedal and posterior tibial pulses; skin assessment; Tinel testing; cranial nerve testing Autonomic (...) and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology. Prepublished online April 11, 2011. . Tavakoli M, Kallinikos P, Iqbal A, et al. Corneal confocal microscopy detects improvement in corneal nerve morphology with an improvement in risk factors for diabetic neuropathy. Diabet Med . 2011 Oct. 28(10):1261-7. . . Possidente CJ, Tandan R. A survey of treatment practices in diabetic peripheral neuropathy. Prim Care Diabetes . 2009 Nov. 3(4):253-7. . Backonja M

2014 eMedicine.com

454. Diabetic Neuropathy (Diagnosis)

along with sensory neuropathy (sensorimotor neuropathy) Autonomic – Neuropathy that may involve the cardiovascular, gastrointestinal, and genitourinary systems and the sweat glands Physical examination should include the following assessments: Peripheral neuropathy testing – Gross light touch and pinprick sensation; vibratory sense; deep tendon reflexes; strength testing and muscle atrophy; dorsal pedal and posterior tibial pulses; skin assessment; Tinel testing; cranial nerve testing Autonomic (...) and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology. Prepublished online April 11, 2011. . Tavakoli M, Kallinikos P, Iqbal A, et al. Corneal confocal microscopy detects improvement in corneal nerve morphology with an improvement in risk factors for diabetic neuropathy. Diabet Med . 2011 Oct. 28(10):1261-7. . . Possidente CJ, Tandan R. A survey of treatment practices in diabetic peripheral neuropathy. Prim Care Diabetes . 2009 Nov. 3(4):253-7. . Backonja M

2014 eMedicine.com

455. Dermatochalasis (Diagnosis)

for dermatochalasis has been found to provide significant improvement in vision, peripheral vision, and quality-of-life activities. Predictors of improvement in quality of life include superior visual-field loss of at least 12°, a chin-up posture, symptoms of eye fatigue due to droopy lids, a marginal reflex distance 1 (MRD-1) of 2 mm of less, and down-gaze ptosis impairing reading. [ ] Race Race does not seem to play a role in dermatochalasis; however, patients of Asian origin frequently note fullness (...) in midfacial rejuvenation. Arch Facial Plast Surg . 2009 Jan-Feb. 11(1):24-8. . Brown MS, Siegel IM, Lisman RD. Prospective analysis of changes in corneal topography after upper eyelid surgery. Ophthal Plast Reconstr Surg . 1999 Nov. 15(6):378-83. . Zinkernagel MS, Ebneter A, Ammann-Rauch D. Effect of upper eyelid surgery on corneal topography. Arch Ophthalmol . 2007 Dec. 125(12):1610-2. . Ghabrial R, Lisman RD, Kane MA, Milite J, Richards R. Diplopia following transconjunctival blepharoplasty. Plast

2014 eMedicine.com

456. Hyperopia, Phakic IOL (Diagnosis)

definition. The authors no longer advocate the use of laser refractive corneal surgery because of the possibility of regression in such a surgical (hyperopia) profile. Laser hyperopic corneal corrections results in loss of effect over time because of the natural or sometimes hyperplastic healing response of the cornea to fill in this ablated step between the treated and untreated zones. Next: History of the Procedure In 1977, Worst designed and used a pure iris support lens. This iris claw lens was fixed (...) == processing > Phakic Intraocular Lens (IOL) for the Treatment of Hyperopia Updated: May 02, 2018 Author: Manolette R Roque, MD, MBA, FPAO; Chief Editor: Michael Taravella, MD Share Email Print Feedback Close Sections Sections Phakic Intraocular Lens (IOL) for the Treatment of Hyperopia Overview Background Many corneal refractive procedures, including automated lamellar keratoplasty, photorefractive keratectomy (PRK), laser in situ keratomileusis (LASIK), holmium:YAG (Ho:YAG) laser, and conductive

2014 eMedicine.com

457. Chorea in Children (Diagnosis)

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

458. Chloroquine/Hydroxychloroquine Toxicity (Diagnosis)

, neurologic symptoms, such as vertigo, tinnitus, irritability, cranial nerve palsies, and myasthenialike muscle weakness Findings on eye examination include the following: Corneal deposits Posterior subcapsular lens opacity (chloroquine) Irregularity in the macular pigmentation and blunting of the foveal reflex (early) Bull’s eye maculopathy (classic finding in non-Asian patients) Peripheral pigment irregularity and bone spicule formation, vascular attenuation, and optic disc pallor (end stage) See (...) and/or daily dose above the recommended threshold. [ ] Older patients are believed to be at a higher risk because of the higher rate of retinal comorbidities. Previous Next: Prognosis If the maximum daily dosage recommendations are followed, the likelihood of toxicity from chloroquine or hydroxychloroquine is less than 1% the first five years of treatment. [ ] Corneal epithelial changes are usually reversible, but retinopathy caused by these agents are not. If diagnosed early, before RPE damage

2014 eMedicine.com

459. Cavernous Sinus Syndromes (Diagnosis)

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

460. Cataract, Senile (Diagnosis)

structures - May provide clues to the patient's cataract etiology, concomitant disease, and eventual visual prognosis Swinging flashlight test - Detects a Marcus Gunn pupil or a relative afferent pupillary defect (RAPD) indicative of optic nerve lesions or severe diffuse retinal involvement Slit lamp examination - Should concentrate on the evaluation of not only lens opacity but also other ocular structures (eg, conjunctiva, cornea, iris, anterior chamber) Examination of nuclear size and brunescence (...) staging of senile cataract is traditionally based on the appearance of the lens on slit-lamp examination, as follows: Hypermature cataract: This is a dense white opacity that obscures the red reflex and contains milky fluid within the capsule, a result of degenerated lens cortex. The capsule if often tense or wrinkled. A morgagnian cataract is a type of hypermature cataract in which the nucleus sinks within the fluid cortex. Mature cataract: This is a cataract that is opaque, totally obscuring the red

2014 eMedicine.com

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