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Corneal Reflex

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461. Myopia, Phakic IOL (Diagnosis)

> Phakic Intraocular Lens (IOL) for Myopia Correction Updated: Sep 22, 2016 Author: Arun Verma, MD; Chief Editor: Hampton Roy, Sr, MD Share Email Print Feedback Close Sections Sections Phakic Intraocular Lens (IOL) for Myopia Correction Overview Background Myopia can be corrected by 3 different means, as follows: Optical devices (ie, glasses, contact lenses) Corneal refractive procedures (ie, radial keratotomy [RK], automated lamellar keratoplasty [ALK], photorefractive keratoplasty [PRK], laser (...) have hypermetropia or astigmatism, patients with an unusually thin or irregularly shaped cornea, and patients with eye conditions such as keratoconus, pellucid marginal dystrophies, or dry eye. Phakic IOL is preferable over LASIK surgery in most patients with severe myopia. In such patients, outcomes of phakic IOLs are superior to those of LASIK surgery in terms of both postoperative visual acuity and contrast sensitivity. All the various phakic IOLs, whether angle supported, iris supported

2014 eMedicine.com

462. Myopia, LASIK (Diagnosis)

keratectomy/photorefractive keratectomy with adjunctive mitomycin-C for complicated LASIK flaps. J Cataract Refract Surg . 2005 Feb. 31(2):291-6. . Solomon R, Donnenfeld ED, Perry HD. Photorefractive keratectomy with mitomycin C for the management of a LASIK flap complication following a penetrating keratoplasty. Cornea . 2004 May. 23(4):403-5. . Pande M, Hillman JS. Optical zone centration in keratorefractive surgery. Entrance pupil center, visual axis, coaxially sighted corneal reflex, or geometric (...) performed worldwide. According to the American Society of Cataract and Refractive Surgery, about 700,000 procedures a year are currently performed in the United States. Spherical aberration: a schematic diagram for the human eye. Next: History of the Procedure Jose Barraquer is generally credited with much of the early work leading to corneal lamellar refractive procedures as they are currently practiced. He noted that refractive change could be accomplished in the cornea by tissue addition

2014 eMedicine.com

463. Neuropathy of Leprosy (Diagnosis)

and distribution of sensory/motor signs. Sensory and motor abnormalities Facial nerve palsy due to involvement of branches to the frontalis or orbicularis oculi leads to frontalis weakness or lagophthalmos. It may be unilateral or bilateral but spares other muscles innervated by the facial nerve. Sensory loss may occur in the malar region and cornea. Wasting and weakness usually progress pari passu (ie, at the same rate). In some patients, however, wasting is more prominent than weakness. These signs involve (...) predominantly the ulnar nerve at the elbow, median nerve at the wrist, and common peroneal nerve at the fibular head. With respect to sensory modalities, thermal sensation is affected first, followed by pain and touch. Proprioception and vibration modalities are often preserved. Topographical distribution of sensory loss is variable. Graded sensory testing with standardized nylon microfilaments or computer-assisted sensory examination (CASE) may be helpful to detect early sensory loss. Deep tendon reflexes

2014 eMedicine.com

464. Neurological History and Physical Examination (Diagnosis)

of the frontal lobes (hence the term frontal-lobe release signs). Superficial reflexes These are segmental reflex responses that indicate the integrity of cutaneous innervation and the corresponding motor outflow. These include the corneal, conjunctival, abdominal, cremasteric, anal wink, and plantar (Babinski) reflexes. The corneal and conjunctival reflexes may be elicited by gently touching the appropriate structure with a sterile wisp of cotton. The normal response is bilateral winking. Absence (...) the following: Higher functions Cranial nerves (CNs) Sensory system Motor system Reflexes Cerebellum Meninges System survey Tools required In addition to the stethoscope and the usual office supplies (eg, gloves, tongue depressors), the neurologist should have an ophthalmoscope, a reflex hammer, and a tuning fork. A pin (Wartenberg) wheel was once a favorite tool of many neurologists because it was easy to use for sensory (pinprick) testing. Unless it is disposable (commercially available), this wheel

2014 eMedicine.com

465. Stroke, Ischemic (Treatment)

is not recommended for patients older than 60 years Clinical evidence of deterioration in swollen supratentorial hemispheric ischemic stroke includes new or further impairment of consciousness, cerebral ptosis, and changes in pupillary size In patients with swollen cerebellar infarction, level of consciousness decreases because of brainstem compression; this decrease may include early loss of corneal reflexes and the development of miosis Standardized definitions are needed to facilitate studies of incidence

2014 eMedicine Emergency Medicine

466. Snake Envenomation, Cobra (Treatment)

of the proper antivenom to be administered. If the patient is bitten by a wild snake, identification may be equally problematic and important, particularly if there is more than one antivenom option for the region. Attempts to capture or kill the snake could result in additional bites or delay in transporting the victim to medical care. If possible, a digital photo of the snake may be a better choice. If the snake is killed, it must be handled with care as it may have a prolonged bite reflex after death (...) ophthalmic anesthetic agent may reduce pain and aid in irrigation. The topical use of 1:1000 epinephrine solution is reported to relieve pain promptly. A fluorescein-aided slit lamp examination helps to find evidence of corneal damage. A brief course of topical ophthalmic antibiotics and preservative-free lubricating drops may be prescribed. Previous Next: Inpatient Care Admit all cobra snakebite patients to closely monitored settings, whether or not antivenom is given. Observe asymptomatic patients

2014 eMedicine Emergency Medicine

467. Ultraviolet Keratitis (Treatment)

. MMWR Morb Mortal Wkly Rep . 2016 Mar 25. 65 (11):282-5. . Contín MA, Benedetto MM, Quinteros-Quintana ML, Guido ME. Light pollution: the possible consequences of excessive illumination on retina. Eye (Lond) . 2015 Nov 6. . Podskochy A. Protective role of corneal epithelium against ultraviolet radiation damage. Acta Ophthalmol Scand . 2004 Dec. 82 (6):714-7. . Parrish CM, Chandler JW. Corneal trauma. Kaufman HE, et al, eds. The Cornea . New York: Churchill Livingstone; 1988. Schein OD. Phototoxicity (...) == processing > Ultraviolet Keratitis Treatment & Management Updated: Mar 14, 2019 Author: Alex Koyfman, MD; Chief Editor: Liudvikas Jagminas, MD, FACEP Share Email Print Feedback Close Sections Sections Ultraviolet Keratitis Treatment Prehospital Care If ultraviolet (UV) keratitis is suspected, flush eyes for several minutes with water or saline solution. Next: Emergency Department Care Administration of a short-acting cycloplegic drop (eg, cyclopentolate 1%) may help relieve the pain of reflex ciliary

2014 eMedicine Emergency Medicine

468. Facial Trauma, Sports-Related Injuries

with a sports arena. Airway Patients with sports-related facial injuries are usually able to maintain protective oral and pharyngeal reflexes and can clear their own airway of saliva, blood, or vomitus. However, dislodged tooth fragments, dental appliances, or mandibular structural collapse may compromise the airway and should be noted. Emergent tracheostomy is seldom needed, even in severe facial fractures, unless a concomitant injury to the cranium, neck, or chest exists. Control bleeding Extensive (...) to look for pupillary symmetry and light response, as well as for an afferent pupillary defect. Epiphora, pain, or photophobia may indicate corneal abrasion. Palpate the infraorbital rims for stability. Look for discrepancy of globe position in the bony orbit (exophthalmos, enophthalmos, hypoglobus, telecanthus), which suggests a fracture involving the orbit. Gently press over closed eyelids to feel for the turgidity of the globes. A flaccid globe may indicate rupture, while a tense or proptotic globe

2014 eMedicine Surgery

469. Facial Nerve Paralysis, Static Reconstruction

, or neurologic deficits or anomalies. The condition of the ipsilateral eye must be carefully inspected to assess for excursion and ability to fully close, ectropion, lower-lid laxity, corneal irritation or ulceration, and tear production. The cornea can be inspected by using fluorescein dye and a Wood lamp to identify exposure keratitis or corneal ulcerations. The surgical team must record objective measures of facial motion and movement with digital images (either photographs or video recordings (...) lacrimal sac, and a patent nasolacrimal duct are essential for normal tear drainage. Management strategy Supportive therapy Management of the eye in a patient with facial paralysis centers on corneal protection. The patient should use artificial tears during the day and lubricating ointment at night. Taping the eyelids can assist with eye closure. Patching is not recommended, because it does not protect the cornea from trauma or ulceration. The surgeon must examine the cornea frequently to rule out

2014 eMedicine Surgery

470. Facial Nerve Paralysis, Dynamic Reconstruction

, spontaneous facial movements Oral competence and eyelid closure with corneal protection Absence or limitation of synkinesis and mass movement Limitations of surgery The facial nerve innervates a total of 23 paired muscles and the orbicular oris, but only 18 of these muscles, working in a delicate balance, produce facial animation and expression. No current reconstructive stratagem can reproduce every facial expression and movement. The patient and the surgeon should thoroughly discuss the patient's (...) operations, the results of which do not manifest for 2-3 years postoperatively. Previous Next: Physical Examination The surgeon must perform a comprehensive physical examination of the patient with facial paralysis, scrutinizing the face at rest and during voluntary and reflex emotional movement. The physician must determine the involvement of unilateral or bilateral facial nerves, facial asymmetries, and synkinesis. The degree of brow ptosis, ectropion, lid laxity, and oral competence must also be noted

2014 eMedicine Surgery

471. Facial Nerve Anatomy

initiated as emotional responses and reflexes. With nuclear and infranuclear lesions, loss of involuntary and voluntary facial movement occurs. The facial nerve nuclei also receive afferent input from other brainstem nuclei. Input from the trigeminal nerve and nucleus form the basis of the trigeminofacial reflexes; eg, the corneal reflex. Input from the acoustic nuclei to the facial nerve nucleus forms part of the stapedial reflex response to loud noises. Extrapyramidal system The extrapyramidal system (...) to facial hiatus Ipsilateral facial paresis, ipsilateral abducens (CN VI) palsy Parkinson disease Extrapyramidal pathways Masked facies Pseudobulbar palsy Pontine Bilateral facial paresis with other CN defects, hyperactive gag reflex, hyperreflexia associated with hypertension, emotional lability Weber syndrome Upper midbrain Ipsilateral loss of direct and consensual pupillary light reflexes, ipsilateral external strabismus, oculomotor paresis Previous Next: Cerebellopontine Angle and the Internal

2014 eMedicine Surgery

472. General Approach to the Trauma Patient

, examine the patient for step-off fractures, entry and exit wounds, or lacerations. A frontal sinus fracture may be accompanied by significant swelling and may be discovered only by radiographic examination. Orbit examination The orbit examination is the next important step. Note diplopia, proptosis, enophthalmos, and orbital rim fractures. Suspect corneal injury in the painful eye with ciliary injection. Lack of corneal reflex can be observed with injury to the sensory division of CN V or the motor (...) division of CN VII. A sharply demarcated red area on the sclera appears with subconjunctival hemorrhage and is often associated with orbital rim fractures. Additionally, check the lacrimal apparatus for obstruction. The pupils were assessed earlier but should be reexamined for hyphema. Loss of the red reflex may suggest a retinal detachment. Check CN II by assessing gross vision and visual fields because unilateral blindness suggests a lesion of the optic nerve. Such a lesion provides no direct

2014 eMedicine Surgery

473. Bell Palsy (Overview)

. 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 Emergency Medicine

474. Tetanus (Diagnosis)

muscle rigidity with intermittent reflex spasms in response to stimuli (eg, noise, touch). Tonic contractions cause opisthotonos (ie, flexion and adduction of the arms, clenching of the fists, and extension of the lower extremities). During these episodes, patients have an intact sensorium and feel severe pain. The spasms can cause fractures, tendon ruptures, and acute respiratory failure. Patients with localized tetanus present with persistent rigidity in the muscle group close to the injury site (...) . Tetanus can also develop as a complication of chronic conditions such as abscesses and gangrene. It may infect tissue damaged by burns, frostbite, middle ear infections, dental or surgical procedures, abortion, childbirth, and intravenous (IV) or subcutaneous drug use. In addition, possible sources not usually associated with tetanus include intranasal and other foreign bodies and corneal abrasions. Underimmunization is an important cause of tetanus. Tetanus affects nonimmunized persons, partially

2014 eMedicine Emergency Medicine

475. Smoke Inhalation (Diagnosis)

size. [ ] Smoke inhalation may produce injury through several mechanisms. Heated air from a fire can cause significant thermal injury to the upper airway. Particulate matter produced during combustion (soot) can mechanically obstruct and irritate the airways, causing reflex bronchoconstriction. Noxious gases released from burning materials include carbon monoxide (CO) and hydrogen cyanide (CN). Smoke may also contain aldehydes from combustion of furniture and cotton, and a variety of chemicals (...) reflexes help protect the lower lung areas from direct thermal injury. Animal experiments have shown that 142°C inhaled air cools to 38°C by the time it reaches the carina. Steam, volatile gases, explosive gases, and the aspiration of hot liquids provide some exceptions, as moist air has a much greater heat-carrying capacity than dry air. Asphyxiation Tissue hypoxia can occur via several mechanisms. Combustion in a closed space can consume significant amounts of oxygen, decreasing the ambient

2014 eMedicine Emergency Medicine

476. Tick-Borne Diseases, Lyme (Diagnosis)

if the initial test is negative, Lyme titers should always be ordered with a reflex confirmatory test. Most commercial laboratories will perform both IgG and IgM Western blots. If the patient has been in Europe, where different strains of Borrelia are more common, a C6 peptide ELISA is a more accurate confirmatory test than the Western blots, which have been developed to B burgdorferi , which is the most common strain found in the United States. The C6 peptide is less expensive than the Western blots

2014 eMedicine Emergency Medicine

477. Herpes Zoster Oticus (Follow-up)

brainstem reflex pathways through intersynaptic transmission in an anterograde direction. [ ] Previous Next: Clinical Manifestations of Herpes Zoster Oticus Patient history Typically, patients present with severe otalgia. Complaints include the following: Painful, burning blisters in and around the ear, on the face, in the mouth, and/or on the tongue (see the image below) Herpes zoster oticus. Image courtesy of Manolette Roque, MD, Ophthalmic Consultants Philippines Co, EYE REPUBLIC Ophthalmology Clinic (...) . Associated findings include the following: Dysgeusia (alteration in taste) Inability to fully close the ipsilateral eye, which may lead to the occasional presentation of drying and irritation of the cornea. Standardized assessment of facial function The following House-Brackmann facial nerve grading scale provides a standardized way to quantify facial nerve function and objectively track recovery [ , ] : Grade I - Normal function Grade II - Mild dysfunction Grade III - Moderate dysfunction Grade IV

2014 eMedicine Emergency Medicine

478. 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 Emergency Medicine

479. Anesthesia, General

reflexes are lost, so providers must be very careful to position the patient. The primary concerns of positioning are ocular injuries, peripheral nerve injuries, musculoskeletal injuries, and skin injuries. [ ] Initially after induction of anesthesia, eyelids should be gently taped down in a closed position. This helps prevent corneal injury by accidental scratching of the cornea. Another ocular injury that can be made less likely during surgical positioning is to prevent ocular venous congestion (...) surgical site dressings, adequate pain control, normothermia, ambulation ability, absence of nausea, and omitting and stable vital signs. All patients undergoing a general anesthetic at minimum must have a post-operative note that documents many of these items (institution dependent). Ideally, the patient should be queried after return to baseline cognition when more clandestine issues may be addressed (e.g., corneal abrasions and extremely rarely, awareness under anesthesia). Previous References

2014 eMedicine Surgery

480. Bell Palsy

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 and smile. For patient (...) 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 drying, abrasion

2014 eMedicine Surgery

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