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Corneal Reflex

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461. Inhalation Injury (Overview)

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 Pediatrics

463. Heart Preservation (Overview)

respirations (apnea) No oculovestibular reflexes No oculocephalic reflexes No corneal and pupillary reflexes No cough and gag reflexes Identifiable cause for the coma Irreversibility over a 12- to 24-hour observation period Cause of death In patients who become cardiac donors in urban United States, the usual mechanism of brain death is penetrating or blunt head trauma. Most deaths in these patients are secondary to motor vehicle collisions, gunshot wounds to the head, or . Intracranial bleeding, drug

2014 eMedicine Pediatrics

464. Inhalation Injury (Treatment)

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 Pediatrics

465. Heart Preservation (Treatment)

respirations (apnea) No oculovestibular reflexes No oculocephalic reflexes No corneal and pupillary reflexes No cough and gag reflexes Identifiable cause for the coma Irreversibility over a 12- to 24-hour observation period Cause of death In patients who become cardiac donors in urban United States, the usual mechanism of brain death is penetrating or blunt head trauma. Most deaths in these patients are secondary to motor vehicle collisions, gunshot wounds to the head, or . Intracranial bleeding, drug

2014 eMedicine Pediatrics

466. Lyme Disease (Overview)

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 Pediatrics

467. Trigeminal Neuralgia (Diagnosis)

sensation over a portion of the face or mouth. Occasionally, patients may suffer jaw weakness and/or corneal anesthesia. Corneal ulceration can result because of trophic disturbances from nerve deafferentation. After any invasive treatments, reactivation of a herpes simplex infection is not uncommon. The worst complication is anesthesia dolorosa, an intractable facial dysesthesia, which may be more disabling than the original trigeminal neuralgia. This dysesthesia may be caused by procedures (...) . Diagnostic accuracy of trigeminal reflex testing in trigeminal neuralgia. Neurology . 2006 Jan 10. 66(1):139-41. . Eller JL, Raslan AM, Burchiel KJ. Trigeminal neuralgia: definition and classification. Neurosurg Focus . 2005 May 15. 18(5):E3. . Blom S. Trigeminal neuralgia: its treatment with a new anticonvulsant drug (G-32883). Lancet . 1962 Apr 21. 1:839-40. . Dalessio DJ. Trigeminal neuralgia. A practical approach to treatment. Drugs . 1982 Sep. 24(3):248-55. . Campbell FG, Graham JG, Zilkha KJ

2014 eMedicine.com

468. Vertebrobasilar Stroke (Diagnosis)

the following: Ataxia and dysmetria, due to damage to the inferior cerebellar peduncle and cerebellum Horner syndrome (eg, ptosis, miosis, hypohidrosis or anhidrosis, enophthalmos), due to damage to descending sympathetic fibers Facial pain and temperature loss Reduced corneal reflex, from damage to the descending spinal tract and nucleus of CN V Nystagmus Hypoacusis (cochlear nucleus) Dysarthria Dysphagia Paralysis of the pharynx, palate, and vocal cord Loss of taste from the posterior third of the tongue (...) prognosis with reasonable functional recovery. See the images below regarding vertebrobasilar stroke. Lesion of the medial longitudinal fasciculus (MLF) resulting in internuclear ophthalmoplegia (INO). (Courtesy of BC Decker Inc.) Illustration of afferent (CN V) and efferent (CN VII) limbs of the blink reflex. (Courtesy of BC Decker Inc.) Visceral motor component of CN III and pathways involved in pupillary constriction. (Courtesy of BC Decker Inc.) Note the horizontal eye movement. Also note

2014 eMedicine.com

469. 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

470. Myasthenia Gravis (Diagnosis)

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

471. Metabolic Disease &amp (Diagnosis)

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

472. 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

473. Posterior Polar Cataract (Diagnosis)

to the posterior capsule. Duke-Elder mentions stationary as well as progressive cataracts. [ ] Posterior polar cataract is easily seen and often clearly delineated. In its early stages, it can be seen interfering with the normal light reflex. Fully formed, it presents as a dense, circular plaque in the central posterior part of the lens. It can be surrounded by vacuoles and smaller areas of degenerated lens material. Often, the only benefit to the surgeon is that the defect is so clearly visible. This entity (...) , MD Anderson Cancer Center and Texas Children's Hospital Disclosure: Nothing to disclose. Specialty Editor Board Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department 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

2014 eMedicine.com

474. 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

475. Marcus Gunn Jaw-winking Syndrome (Diagnosis)

eyelid ptosis. Patients with Marcus Gunn jaw-winking syndrome have variable degrees of blepharoptosis in the resting, primary position. Although Marcus Gunn jaw-winking syndrome is usually unilateral, it can present bilaterally in rare cases. [ , ] The wink reflex consists of a momentary upper eyelid retraction or elevation to an equal or higher level than the normal fellow eyelid upon stimulation of the ipsilateral pterygoid muscle. This response is followed by a rapid return to a lower position (...) U K . 1957. 77:181-5. . Kirkham TH. Familial Marcus Gunn phenomenon. Br J Ophthalmol . 1969 Apr. 53(4):282-3. . 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

2014 eMedicine.com

476. Lyme Disease (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.com

477. Lyme Disease (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.com

478. Lyme Disease (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.com

479. Lyme Disease (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.com

480. 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

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