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Corneal Reflex

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481. Adult Physiatric History and Examination (Follow-up)

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

482. Thyroid Ophthalmopathy (Diagnosis)

irritation, which some attribute to mechanical trauma transmitted from the upper eyelid to the superior bulbar and tarsal conjunctiva. Superior limbic keratoconjunctivitis has been a purported prognostic marker for severe thyroid-associated orbitopathy. The corneal light reflexes should be examined closely, because asymmetric proptosis and lid retraction may mask the true relative positions of the globes. Orbital muscle involvement Strabismus is common, and it often presents as hypotropia or esotropia (...) detection of visual loss. In patients with diplopia, prisms may be beneficial for those with small-angle or relatively comitant deviations. Tape occlusion of one lens or segment of the glasses may be helpful. If this is not effective, try using an occluder or vaulted eye patch (with care not to touch the cornea or compress the orbit). Patients with dry eye symptoms or corneal exposure should apply during the day and lubricating ointment at night, and they should consider the use of punctal plugs

2014 eMedicine.com

483. 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.com

484. Sjogren Syndrome (Diagnosis)

. . Aragona P, Di Pietro R. Is it safe to use topical NSAIDs for corneal sensitivity in Sjögren's syndrome patients?. Expert Opin Drug Saf . 2007 Jan. 6(1):33-43. . Mavragani CP, Moutsopoulos NM, Moutsopoulos HM. The management of Sjögren's syndrome. Nat Clin Pract Rheumatol . 2006 May. 2(5):252-61. . Murillo-Lopez F, Pflugfelder SC. Disorders of tear production and the lacrimal system. Krachmer JH. Cornea and External Disease: Clinical Diagnosis and Management . St Louis, Mo: Mosby Year Book;: 1997:663 (...) variables demonstrates increased mortality (purpura, mixed monoclonal cryoglobulinemia, and low C4 levels). This article will focus on the ophthalmologic manifestations of Sjögren syndrome. Severe dry eyes can cause corneal scarring, ulceration, infection, and even perforation; thus, although the prognosis is good for most patients with Sjögren syndrome and ophthalmologic features, individuals with complications have a much guarded prognosis. The differential diagnosis includes conditions

2014 eMedicine.com

485. Schwartz-Jampel Syndrome (Diagnosis)

of corneal reflexes, and paradoxical perspiration at low temperatures. Their tongues lacked fungiform papillae (in addition to showing ulcerations). Reither et al reported on a survivor aged 16 years with SJS type II. (See Prognosis.) [ ] Considerable justification can be made for dropping the term SJS type II and simply referring to the condition as Stuve-Wiedemann syndrome. The disease is not technically that which Schwartz and Jampel described. Nevertheless, the term SJS type II is included (...) than stiffness) is prominent. Frequent bouts of hyperthermia have been described (possibly related to mitochondrial dysfunction). (See Presentation.) [ ] A high infant mortality rate is associated with this condition. Long-term survivors are rare but do exist, including 2 survivors, ages 3 and 12 years, reported on by Di Rocco et al in 2003. [ ] In addition to problems with bone dysplasia, these 2 children manifested dysautonomic and neuropathic features, including reduced patellar reflexes, lack

2014 eMedicine.com

486. Tardive Dyskinesia (Diagnosis)

at rest and with voluntary movement. The presence of dementia in a patient in whom TD is suspected merits consideration of Huntington disease, Wilson disease, or a central nervous system (CNS) neoplasm. The presence of hemiparesis, asymmetric reflexes, and other focal deficits indicates the need for further assessment to exclude structural brain lesions. The presence of jaundice, hepatomegaly, abdominal pain, or Kayser-Fleischer rings in the cornea requires further assessment to exclude Wilson disease

2014 eMedicine.com

487. Keratopathy, Neurotrophic (Diagnosis)

Updated: Sep 13, 2018 Author: Robert H Graham, MD; Chief Editor: Hampton Roy, Sr, MD Share Email Print Feedback Close Sections Sections Neurotrophic Keratitis Overview Background Neurotrophic keratitis, also known as neurotrophic keratopathy, is a degenerative disease characterized by decreased corneal sensitivity and poor corneal healing. This disorder leaves the cornea susceptible to injury and decreases reflex tearing. Epithelial breakdown can lead to , infection, melting, and perforation secondary (...) and in the superior cornea Defect surrounded by a rim of loose epithelium Edges may become smooth and rolled Stromal swelling with folds in the Descemet membrane Sometimes associated with anterior chamber inflammatory action Stage 3 is characterized as follows: Stromal lysis/melting May result in perforation Patient education Educate all patients with corneal hypesthesia about their condition. Instruct patients to seek evaluation immediately if the eye becomes red or if their vision changes. Patients need

2014 eMedicine.com

488. Keratoconjunctivitis, Sicca (Diagnosis)

, and epidermal growth factor (EGF) helps maintain the normal ocular surface and promote corneal wound healing. Other components include albumin, transferrin, immunoglobulin A (IgA), immunoglobulin M (IgM), and immunoglobulin G (IgG). The secretion of the lacrimal gland is controlled by a neural reflex arc, with afferent nerves (trigeminal sensory fibers) in the cornea and the conjunctiva passing to the pons (superior salivary nucleus), from which efferent fibers pass in the nervus intermedius (...) and grittiness Hyperemia Mucoid discharge Ocular irritation Excessive tearing (secondary to reflex secretion) Photophobia Fluctuating or blurry vision See for more detail. Diagnosis Studies that may be used for diagnosis include the following: Vital staining of corneal and conjunctival epithelium with fluorescein, lissamine green, or rose bengal Tear film osmolarity Ocular surface matrix metalloproteinase 9 (MMP-9) Measurement of tear breakup time (TBUT) The Schirmer test Tear meniscus height Quantification

2014 eMedicine.com

489. Duane Syndrome (Diagnosis)

(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, Buenos Aires. Editorial Oftalmologia . 1949. 627. Huber A. Electrophysiology of the retraction (...) 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 Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences Hampton Roy, Sr

2014 eMedicine.com

490. Dry Eye Syndrome (Diagnosis)

, and epidermal growth factor (EGF) helps maintain the normal ocular surface and promote corneal wound healing. Other components include albumin, transferrin, immunoglobulin A (IgA), immunoglobulin M (IgM), and immunoglobulin G (IgG). The secretion of the lacrimal gland is controlled by a neural reflex arc, with afferent nerves (trigeminal sensory fibers) in the cornea and the conjunctiva passing to the pons (superior salivary nucleus), from which efferent fibers pass in the nervus intermedius (...) and grittiness Hyperemia Mucoid discharge Ocular irritation Excessive tearing (secondary to reflex secretion) Photophobia Fluctuating or blurry vision See for more detail. Diagnosis Studies that may be used for diagnosis include the following: Vital staining of corneal and conjunctival epithelium with fluorescein, lissamine green, or rose bengal Tear film osmolarity Ocular surface matrix metalloproteinase 9 (MMP-9) Measurement of tear breakup time (TBUT) The Schirmer test Tear meniscus height Quantification

2014 eMedicine.com

491. Down Syndrome (Diagnosis)

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

492. Esotropia, Pseudo (Diagnosis)

-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. Next: Pathophysiology This condition most commonly occurs in infants when a flat nasal bridge and prominent epicanthal folds tend to obscure the nasal portion of the sclera. This optical illusion causes the patient to have an appearance of eyes deviated nasally, and it is most apparent when the eyes are in side gaze (...) in preverbal 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

2014 eMedicine.com

493. Hirschsprung Disease (Diagnosis)

regulation. Normal motility is primarily under the control of intrinsic neurons. In the absence of extrinsic signals, bowel function remains adequate, owing to the complex reflexive architecture of the enteric nervous system (ENS). For this reason, the ENS is often referred to as the “second brain.” Intestinal smooth muscle contraction and relaxation are under the control of enteric ganglia. Most enteric nervous activation causes muscle relaxation, mediated by nitric oxide and other enteric (...) neurotransmitters. Extrinsic neural afferents to the ENS contain cholinergic and adrenergic fibers. The cholinergic fibers generally cause contraction, whereas the adrenergic fibers mainly cause inhibition. In patients with Hirschsprung disease, both myenteric and submucosal plexuses are absent. The anus is invariably affected, and aganglionosis continues proximally for a variable distance. In the absence of ENS reflexes, control of the intestinal smooth muscle is overwhelmingly extrinsic. The activity of both

2014 eMedicine.com

494. Exotropia, Pseudo (Diagnosis)

: the visual axis and the pupillary axis. To construct the visual axis, extend a straight line from the viewing object through the nodal point. A straight line going through the center of the pupil and perpendicular to the corneal plane constructs the pupillary axis. Since fovea is displaced temporally, a small angle kappa (up to 5°) manifests as a nasally displaced corneal light reflex. Children may falsely appear to have an exotropia when they look to the side. Previous Next: Epidemiology Frequency (...) , 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 Institute J James Rowsey, MD is a member of the following medical societies: , , , , , , , Disclosure: Nothing to disclose. Chief Editor

2014 eMedicine.com

495. Endophthalmitis, Bacterial (Diagnosis)

Endophthalmitis Updated: Sep 20, 2018 Author: Robert H Graham, MD; Chief Editor: Hampton Roy, Sr, MD Share Email Print Feedback Close Sections Sections Bacterial Endophthalmitis Overview Practice Essentials Bacterial endophthalmitis (see the image below) is an inflammatory reaction of the intraocular fluids or tissues caused by microbial organisms. Bacteria may gain entry into the eye via corneal or scleral trauma (surgical or accidental) or hematogenously. If not properly treated, bacterial endophthalmitis (...) includes the following: Acute postoperative (< 6 wk postoperative) [ , ] ; usually occurs 2-10 days after surgery Delayed onset or chronic pseudophakic postoperative (>6 wk postoperative) [ ] Filtering bleb associated Posttraumatic– History of trauma is present, and infection usually progresses rapidly [ ] On physical examination, general findings in bacteria endophthalmitis are as follows: Visual acuity decreased below the level expected Lid edema Conjunctival hyperemia Corneal edema Anterior chamber

2014 eMedicine.com

496. Leprosy (Diagnosis)

/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 generally

2014 eMedicine.com

497. Horner Syndrome (Diagnosis)

dilates more slowly than the normal pupil does because the affected pupil lacks the pull of the dilator muscle (ie, dilation lag). Patients may have a loss of the ciliospinal reflex (ie, afferent C2, C3), in which the pupil fails to dilate when the skin on back of the neck is pinched. (Most authors, however, consider this finding unreliable.) Patients have dry skin (ie, anhidrosis) on the same side of their face as the affected pupil. The pattern of a patient’s inability to sweat may be helpful (...) 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 Edsel Ing, MD, MPH, FRCSC Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Active Staff, Michael Garron Hospital (Toronto East Health Network); Consulting Staff, Hospital for Sick Children and Sunnybrook Hospital, Canada

2014 eMedicine.com

498. Horner Syndrome (Diagnosis)

dilates more slowly than the normal pupil does because the affected pupil lacks the pull of the dilator muscle (ie, dilation lag). Patients may have a loss of the ciliospinal reflex (ie, afferent C2, C3), in which the pupil fails to dilate when the skin on back of the neck is pinched. (Most authors, however, consider this finding unreliable.) Patients have dry skin (ie, anhidrosis) on the same side of their face as the affected pupil. The pattern of a patient’s inability to sweat may be helpful (...) 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 Edsel Ing, MD, MPH, FRCSC Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Active Staff, Michael Garron Hospital (Toronto East Health Network); Consulting Staff, Hospital for Sick Children and Sunnybrook Hospital, Canada

2014 eMedicine.com

499. Abducens Nerve Palsy (Diagnosis)

and binocular fusion and to minimize diplopia. Congenital sixth nerve palsy (Duane syndrome) is a well-recognized entity. Examination for a sixth nerve palsy involves documenting the presence or absence of papilledema, examining the ocular motility, evaluating the eyelids and pupils, and excluding involvement of other cranial nerves (eg, V, VII, VIII). Occasionally checking deep tendon reflexes (DTRs) and motor function to exclude corticospinal tract involvement may be important. MRI is indicated for any (...) & Wilkins; 1999. Media Gallery of 0 Tables Contributor Information and Disclosures Author Michael P Ehrenhaus, MD Director, Department of Cornea, External Disease & Refractive Surgery, Assistant Professor, Department of Ophthalmology, State University of New York Downstate Medical Center Michael P Ehrenhaus, MD is a member of the following medical societies: , , , , Disclosure: Nothing to disclose. Coauthor(s) Mohammedyusuf E Hajee, MD Clinical Instructor, Staff Physician, Department of Ophthalmology

2014 eMedicine.com

500. Adult Physiatric History and Examination (Diagnosis)

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

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