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Corneal Reflex

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481. Blepharoplasty, Upper Lid Ptosis Surgery

of the upper limbus of the cornea. When the ptotic lid covers enough of the upper limbus or pupil it can result in both functional and aesthetic deformities. The severity of ptosis is classified by determining how much of the upper limbus is covered by the lid margin: mild is 2 mm, moderate is 3 mm, and severe is 4+ mm. Levator function is classified based on the distance of lid margin excursion: excellent is 12-15 mm, good is 8-12 mm, fair is 5-7 mm, and poor is 2-4 mm. Previous Next: Epidemiology (...) , and unilateral or bilateral. True ptosis can be congenital or acquired. Congenital ptosis is associated with neurogenic or myogenic origins. In a study of patients with unilateral congenital upper eyelid ptosis, Bagheri et al reported a direct correlation between levator muscle function, lid fissure height, and margin reflex distance, which, according to the investigators, demonstrates the association of levator muscle dysfunction with the development and severity of congenital ptosis. [ ] Acquired causes

2014 eMedicine Surgery

482. Blepharoplasty, Ptosis Surgery

, exercise extreme caution in patients with processes (eg, thyroid myopathy, progressive external ophthalmoplegia) or dystrophies in which a poor Bell phenomenon, decreased random eye movements during sleep, and poor orbicularis muscle function may exist and produce lagophthalmos and corneal exposure. Loss of the blink reflex or corneal sensitivity, paralysis of the orbicularis, and significant keratitis sicca are definite contraindications to surgery. Previous References Khooshabeh R, Baldwin HC (...) warrant individual consideration. Probably the most common and one of the most difficult to manage forms of ptosis is the jaw-winking syndrome (Marcus Gunn phenomenon). All patients with jaw-winking syndrome exhibit a variable degree of ptosis of the involved lid when the eyes are at rest in the primary position. The wink reflex consists of a rapid elevation and retraction of the lid to a higher level than that of the normal fellow lid and an almost equally rapid return to a less elevated level

2014 eMedicine Surgery

483. Blepharoplasty, Lower Lid Transconjunctival

be evaluated for the presence of Bell phenomenon, as patients with poor response may have increased postoperative corneal dryness. These patients and any patient with a history of dry eyes require preoperative tear film evaluation, including a Schirmer test. The Schirmer test uses paper strips inserted into the eye for several minutes to measure the production of tears. [ ] Previous Next: Indications Transconjunctival blepharoplasty has been recognized as useful in patients with fat excess and fine skin (...) and should be cleared for further surgery by their refractive eye surgeon. Patients wearing contact lenses pose a particular risk when blepharoplasty is considered. Eyes may dry out as a patient ages, and this process is often hastened by chronic contact lens use. Additionally, eyelid surgery such as blepharoplasty, canthopexy, or other lid altering procedures may subtly affect the curvature of the cornea, making use of contact lenses uncomfortable or even dangerous. Patients should discontinue the use

2014 eMedicine Surgery

484. Blepharoplasty, Subciliary Approach

tangential to the cornea or covers the cornea by 1 mm. If the lower eyelid margin is located inferior to the cornea, then the white sclera, or scleral show, is seen. Scleral show greater than 1 mm frequently indicates significant eyelid laxity. Scleral show present prior to surgery remains after surgery. Ophthalmologic examination Evaluate visual acuity for near and distant vision in both eyes independently using standard tests for this purpose. If the patient wears glasses or contact lenses, visual (...) acuity is measured with the corrective device. Also, an eye fundus evaluation is advisable, as is a test for Bell phenomenon and lagophthalmos. Further, evaluate facial nerve function, corneal reflux, and extraocular motor function and perform visual-field defect testing. Identify persons with deficiencies in tearing production or dry eye syndrome. Ask screening questions about burning eye sensations, tearing, and excessive blinking. If a patient has these conditions, a referral to an ophthalmologist

2014 eMedicine Surgery

485. Blepharoplasty, Lower Eyelid Laxity

as the examiner's eyes. The distance from the corneal light reflex to the lower lid is normally 5.5 mm but will be increased in patients with ectropion. The difference between the normal MRD2 and the measured MRD2 may give an indication of how much skin is needed to correct an ectropion caused by anterior lamella deficiency. Presence of hypertrophied orbicularis muscle: Hypertrophied muscle may manifest as a noticeable band in the lower lid. Tone of the lid: Assess lid tone with the snap test and by evaluating (...) to the lower limbus: To measure for lower lid retraction, evaluate the lateral, central, and medial relationship of the lower lid to the inferior limbus while the patient is in neutral gaze. Ideally, no scleral show should be beneath the inferior limbus. In certain individuals, scleral show may be normal but should not be increased surgically. Margin reflex distance-2 (MRD2): This is an objective measurement that may be taken by shining a light in the patient's eyes when they are at the same level

2014 eMedicine Surgery

486. Blepharoplasty, Lower Lid Arcus Marginalis Release

from the orbital rim via a transcutaneous approach. The study involved 56 patients, 54 of whom expressed satisfaction with the cosmetic result. [ ] Postoperative details Infection of the lid following blepharoplasty is rare, making systemic antibiotic prophylaxis unnecessary. Nonetheless, antibiotic ophthalmic ointment may be applied to the incision line and cornea immediately after surgery and daily thereafter. After a few days, the patient may switch to Lacri-Lube ophthalmic ointment or its (...) . Ophthalmologic consultation is imperative in this situation. Oculocardiac reflex The oculocardiac reflex manifests in approximately 25% of blepharoplasty patients but is almost exclusive to those undergoing local anesthesia. Characterized by intraoperative bradycardia or dysrhythmia, any ocular manipulation, including traction on the orbital fat pads, can trigger this reflex. Most patients demonstrating this reflex experience a heart rate change of less than 30%; however, profound bradycardia and even arrest

2014 eMedicine Surgery

487. Cold Injuries

not be mistaken for intoxication, although these two states can coexist. In severe hypothermia, mental status is further impaired, leading to hallucinations, stupor, and even coma. Atrial and ventricular arrhythmias are common with moderate hypothermia. The Osborn (J) point, an upward deflection at the junction of the QRS complex and the ST segment, can usually be seen on the ECG. The patient may appear clinically dead, with nonpalpable peripheral pulses, fixed and dilated pupils, loss of ocular reflexes

2014 eMedicine Surgery

488. Brow Lift, Mid Forehead

of racial and genetic variation is present. Whether a patient has a high forehead and whether the anterior hairline should be brought forward and downward should be determined for each patient individually. In general, men benefit from bringing their anterior hairlines forward, as do some women. Conversely, most women and many men do not do well with forehead scars that result from mid forehead lifts. Inherent in the brow evaluation is an assessment of the upper eyelid. Assess the corneal reflex-lid (...) malposition (eg, medial droop), extent of forehead rhytides (eg, transverse lines, glabellar lines, temporal lines, crow's feet), and position of the upper eyelid margin. Determine if brow ptosis is present. No objective standard allows accurate assessment of the presence or absence of brow ptosis. However, a useful measurement is the distance between the inferior limbus of the cornea and the center of the brow. This distance is usually 22 mm or more. Anything less than 22 mm suggests brow ptosis

2014 eMedicine Surgery

489. Electronystagmography

the power of analysis by allowing horizontal recording of each eye and vertical recording of one. Finally, some newer systems provide acquisition of both horizontal and vertical movements of each eye. Electrodes Traditional ENG includes the use of electro-oculography to objectively measure eye movements. This recording is possible because of the corneal-retinal potential difference; the cornea is electropositive relative to the retina. With a fixed recording site, voltage differences can be recorded (...) with the visual system and spinal afferents in the brain stem to produce the vestibuloocular reflex. [ ] Essentially, the standard ENG test battery consists of the following 3 parts: Oculomotor evaluation Positioning/positional testing Caloric stimulation of the vestibular system Indications Although ENG is the most widely used clinical laboratory test to assess vestibular function, normal ENG test results do not necessarily mean that a patient has typical vestibular function. ENG abnormalities can be useful

2014 eMedicine Surgery

490. Eyelid Anatomy

: Bhupendra C K Patel, MD, FRCS; Chief Editor: Arlen D Meyers, MD, MBA Share Email Print Feedback Close Sections Sections Eyelid Anatomy Overview Overview The act to protect the anterior surface of the globe from local injury. Additionally, they aid in regulation of light reaching the eye; in tear film maintenance, by distributing the protective and optically important tear film over the cornea during blinking; and in tear flow, by their pumping action on the conjunctival sac and lacrimal sac. Structures (...) . The Müller muscle may function as a large, serial muscle spindle. The stretching of the Müller muscle by the initial eye opening action of the levator may initiate a reflex via the mesencephalic trigeminal nucleus, which subsequently is routed through the ipsilateral or bilateral levator muscle, evoking involuntary tonic contraction to maintain an adequate visual field. The peripheral vascular arcade of the upper eyelid lies adherent to the lower border of the anterior surface of the Müller muscle, just

2014 eMedicine Surgery

491. Herpes Zoster Oticus (Treatment)

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

492. Ultraviolet Keratitis (Follow-up)

. 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

493. Lung Transplantation (Follow-up)

is determined by clinical criteria when two separate examinations are performed 24 hours apart or by ancillary studies to assess brain activities. An absence of drugs, hypothermia, or metabolic derangements must be confirmed. Clinical criteria for brain death are as follows: Known cause of condition Temperature higher than 95°F No drug intoxication or neuromuscular blocking agent No significant metabolic derangement No gag, cough, or corneal reflexes Absence of dull-eye reflex Pupils fixed and dilated

2014 eMedicine Surgery

494. Preblepharoplasty Facial Analysis

be necessary. Clinically, in these cases, the upper lid appears vertically elongated. Blepharoptosis is determined by measuring the marginal reflex distance (MRD)-1. While the patient remains in neutral gaze, the MRD-1 is measured from the corneal light reflex to the eyelid margin at the midpupillary line. The reference range for MRD-1 is 4-4.5 mm. Values below the reference range suggest ptosis, whereas values above the reference range suggest upper eyelid retraction. Abnormalities should alter surgical (...) is the MRD-2, which is measured from the corneal light reflex to the margin of the lower eyelid in neutral gaze. The reference range for MRD-2 is 5-5.5 mm. Ectropion, a pulling away of the lower lid from the globe, should be noted preoperatively and is generally a contraindication to cosmetic blepharoplasty unless concomitant lateral canthoplasty is contemplated. In equivocal situations, conservative intervention is recommended. Lower-eyelid laxity is measured by means of the snap test and the lower-lid

2014 eMedicine Surgery

495. Skull Base, Acoustic Neuroma (Vestibular Schwannoma)

numbness occurs in about 25% of patients and is more common at the time of presentation than facial weakness. Objective hypoesthesia involving the teeth, buccal mucosa, or skin of the face is associated with larger tumors, but a subjective reduction in sensation that cannot be documented on objective examination occurs commonly with medium-sized and small tumors. Decrease in the corneal reflex generally occurs earlier and more commonly than objective facial hypoesthesia. Although approximately 50-70

2014 eMedicine Surgery

496. Malignant Tumors of the Palate

trigeminal nerve involvement in the sphenopalatine foramen or pterygopalatine fossa extension. An absent corneal reflex is indicative of skull-base extension through the foramen rotundum, foramen ovale, or inferior orbital fissure. Dental numbness may indicate perineural invasion. Middle ear effusion is suggestive of nasopharyngeal extension or invasion of the tensor veli palatini muscle. Involvement of the mandibular division of the trigeminal nerve may manifest as hypesthesia along the mandible

2014 eMedicine Surgery

497. Organ Procurement Considerations in Trauma

brain death, the physician must demonstrate the following: Correction of potentially reversible causes of coma Hypothermia Sedating medications Metabolic disturbances Endocrine disturbances Hypoxia or hypercarbia Absence of brainstem reflexes (eg, cornea, pupillary light, oculovestibular, gag, oculocephalic) Lack of respiratory effort (apnea test, ie, absence of respiratory movement after disconnection from respirator for sufficient duration to have pCO 2 rise to >50-60 mm Hg) To confirm

2014 eMedicine Surgery

498. Orbit Anatomy

ophthalmopathy has been linked to thyroid-stimulating hormone and a factor that causes increased deposition of mucopolysaccharides into orbital fat. Malignant exophthalmos is most commonly associated with Graves disease, but it can be caused by other endocrine disorders. [ ] Exophthalmos can lead to corneal abrasion, chemosis, ophthalmoplegia, and retinal venous congestion. Several procedures have been developed that involve removing a portion of the bony orbit to decompress the orbital contents. Previous (...) The trigeminal nerve, which supplies general sensory innervation to the orbit and surrounding structures, originates at the lateral and ventral portion of the pons. The nerve enters the Meckel cave, which is formed by a split in the dura along the petrous temporal bone in the middle cranial fossa. The trigeminal ganglion rests in the Meckel cave posterior and lateral to the cavernous sinus and the internal carotid artery. The surgeon must be aware of the oculocardiac reflex when manipulating the contents

2014 eMedicine Surgery

499. Herpes Zoster Oticus (Overview)

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

500. Tick-Borne Diseases, Lyme (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 Emergency Medicine

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