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Corneal Reflex

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541. Hydroxychloroquine and ocular toxicity recommendations on screening

of hydroxychloroquine and chloroquine include disturbances in hepatic and renal function. Ocular side effects include retinal toxicity (which can lead to permanent visual impairment) and deposition of the drug in the cornea. The mechanism of retinal toxicity is not well understood, though it appears that the earliest changes occur in the cytoplasm of ganglion cells and photoreceptors with later involvement of the retinal pigment epithelium 2 , where it binds to melanin. Hydroxychloroquine has been used since (...) physician and the ophthalmologist. The Royal College of Ophthalmologists - Hydroxychloroquine and Ocular Toxicity Recommendations on Screening – October 2009 Page 3 of 9 Clinical features of ocular complications Quinolones can precipitate in the corneal epithelium in a diffuse punctate or whorl-like pattern which can sometimes result in visual haloes. This is much less common with hydroxychloroquine than with chloroquine 4,8 . The effect is reversible on stopping the drug. The earliest sign of retinal

2009 British Association of Dermatologists

542. Overview of Lysosomal Storage Disorders

disease Treatment: Supportive care Sialolipidosis (phospholipidosis; mucolipidosis IV, Berman disease; 252650) MCOLN1 (19p13.3-p13.2)* Onset: 1st yr Urine metabolites: No mucopolysaccharides Clinical features: Severe (Berman disease) and mild forms Developmental delay, corneal opacities, visual deficiency, strabismus, hypotonia, increased deep tendon reflexes; no radiographic skeletal abnormality, macrocephaly, or organomegaly Treatment: Supportive care Mannosidosis Onset: In type I, 3–12 mo In type (...) , corneal crystals and erosion, rickets, hepatosplenomegaly, pancreatic insufficiency, renal calculi, renal failure, renal Fanconi syndrome, decreased sweating, myopathy, dysphagia, cerebral atrophy, normal intelligence but neurologic deterioration in long-term survivors Cystine accumulation throughout reticuloendothelial system, WBC, and cornea Treatment: Replacement therapy for Fanconi syndrome, renal transplant for failure, cysteamine orally or as eyedrops, growth hormone Late-onset juvenile form

2013 Merck Manual (19th Edition)

543. Cataract

) Within the first week: (infection within the eye—very rare and could result in irreversible blindness) and glaucoma Within the first month: Cystoid macular edema Months later: (ie, swelling of the cornea due to damage to the corneal pump cells during cataract surgery), , and posterior capsular opacification (common but treatable with laser) After surgery, vision returns to 20/40 (6/12) or better in 95% of eyes if there are no preexisting disorders such as , , , and . If an intraocular lens (...) WESTERN OPHTHALMIC HOSPITAL/SCIENCE PHOTO LIBRARY Rarely, the cataract swells, pushing the iris over the trabecular drainage meshwork and causing its occlusion and thus secondary closed-angle glaucoma and pain. Diagnosis Ophthalmoscopy followed by slit-lamp examination Diagnosis is best made with the pupil dilated. Well-developed cataracts appear as gray, white, or yellow-brown opacities in the lens. Examination of the red reflex through the dilated pupil with the held about 30 cm away usually

2013 Merck Manual (19th Edition)

544. Tearing

: ). Obstruction of tear drainage can lead to stasis and infection. Recurrent infection of the lacrimal sac (dacryocystitis) can sometimes spread, potentially leading to . Anatomy of the lacrimal system. Etiology Overall, the most common causes of tearing are URI Allergic rhinitis Tearing can be caused by increased tear production or decreased nasolacrimal drainage. In many patients, the cause of tearing can be multifactorial. Increased tear production The most common causes are URI Dry eyes (reflex tearing (...) produced in response to dryness of the ocular surface) Any disorder causing conjunctival or corneal irritation can increase tear production (see ). However, most patients with corneal disorders that cause excess tearing (eg, corneal abrasion, corneal ulcer, corneal foreign body, keratitis) or with primary angle-closure glaucoma or anterior uveitis present with eye symptoms other than tearing (eg, eye pain, redness). Most people who have been crying do not present for evaluation of tearing. Decreased

2013 Merck Manual (19th Edition)

545. Floaters

affect entire visual field Loss of red reflex Indirect ophthalmoscopy by an ophthalmologist after pupillary dilation Vitreous inflammation (eg, cytomegalovirus, Toxoplasma , or fungal chorioretinitis) Pain Loss of visual acuity Loss of vision affecting the entire visual field Retinal lesions (sometimes cotton-like) that do not conform to an arterial or a venous territory Risk factors (eg, AIDS) Decreased red reflex May be bilateral Evaluation and testing as directed by an ophthalmologist, based (...) . The eyes are inspected for redness. Visual fields are assessed in all patients. However, recognition of visual field defects by bedside examination is very insensitive, so inability to show such a defect is not evidence that the patient has full visual fields. Extraocular movements and pupillary light responses are assessed. If patients have a red eye or eye pain, the corneas are examined under magnification after fluorescein staining, and slit-lamp examination is done if possible. Ocular pressure

2013 Merck Manual (19th Edition)

546. Diplopia

distorts light transmission through the eye to the retina. There may be > 2 images. One of the images is of normal quality (eg, brightness, contrast, clarity); the rest are of inferior quality. The most common causes of monocular diplopia are Corneal shape problems, such as keratoconus or surface irregularity Uncorrected , usually astigmatism Other causes include corneal scarring and dislocated lens. Complaints also may represent malingering. Binocular diplopia suggests disconjugate alignment (...) or MRI Tumors (near base of skull, in or near sinuses or orbit) Often pain (unrelated to eye motion), unilateral proptosis, sometimes other neurologic manifestations CT or MRI Neuromuscular transmission disorders (typically, pain is absent) Sometimes preceded by GI symptoms Descending weakness, other cranial nerve dysfunction, dilated pupils, normal sensation Serum and stool testing for toxin (Miller Fisher variant) Ataxia, decreased reflexes Lumbar puncture Intermittent, migratory neurologic

2013 Merck Manual (19th Edition)

547. Blurred Vision

by a small retinal detachment) may describe their symptoms as blurring. Podcast Etiology The most common causes of blurred vision (see ) include (the most common cause overall) Blurred vision has 4 general mechanisms: Opacification of normally transparent ocular structures (cornea, lens, vitreous) through which light rays must pass to reach the retina Disorders affecting the retina Disorders affecting the optic nerve or its connections Refractive errors Table Some Causes of Blurred Vision Cause (...) Suggestive Findings Diagnostic Approach Opacification of eye structures Gradual onset, often risk factors (eg, aging, corticosteroid use), loss of contrast, glare Lens opacification on ophthalmoscopy or slit-lamp examination Clinical evaluation Corneal opacification (eg, posttraumatic or postinfectious scarring) Corneal abnormalities on slit-lamp examination Clinical evaluation Disorders affecting the retina Gradual onset, central vision affected (central scotoma) without loss of peripheral vision

2013 Merck Manual (19th Edition)

548. Acute Vision Loss

to be the presence of optokinetic nystagmus). Red flags Acute loss of vision is itself a red flag; most causes are serious. Interpretation of findings Diagnosis of acute vision loss can be begun systematically. Specific patterns of help suggest a cause. Other clinical findings also help suggest a : Difficulty seeing the red reflex during ophthalmoscopy suggests opacification of transparent structures (eg, caused by corneal ulcer, vitreous hemorrhage, or severe endophthalmitis). Retinal abnormalities (...) their symptoms as blurred vision. Podcast Pathophysiology Acute loss of vision has 3 general causes: Opacification of normally transparent structures through which light rays pass to reach the retina (eg, cornea, vitreous) Retinal abnormalities Abnormalities affecting the optic nerve or visual pathways Etiology The most common causes of acute loss of vision are Vascular occlusions of the retina ( , ) Ischemic optic neuropathy (often in patients with ) Vitreous hemorrhage (caused by or trauma) Trauma

2013 Merck Manual (19th Edition)

549. Evaluation of the Ophthalmologic Patient

conjunctivae and the fornices can be inspected for foreign bodies, signs of inflammation (eg, follicular hypertrophy, exudate, hyperemia, edema), or other abnormalities. Corneal examination Indistinct or blurred edges of the corneal light reflex (reflection of light from the cornea when illuminated) suggest the corneal surface is not intact or is roughened, as occurs with a corneal abrasion or keratitis. Fluorescein staining reveals abrasions and ulcers. Before staining, a drop of topical anesthetic (eg (...) the thickness of the light reflex Silver wiring, a sign of hypertension in which thin, fibrotic arteriolar walls decrease the thickness of the light reflex Loss of venous pulsations, a sign of increased intracranial pressure in patients known to have had pulsations Slit-lamp examination A slit lamp focuses the height and width of a beam of light for a precise stereoscopic view of the eyelids, conjunctiva, cornea, anterior chamber, iris, lens, and anterior vitreous. With a handheld condensing lens, it can

2013 Merck Manual (19th Edition)

550. Overview of Coma and Impaired Consciousness

by the tentorium to form Kernohan notch) Contralateral dilated pupil and oculomotor paresis Ipsilateral hemiparesis Compression of the ipsilateral cerebral peduncle Contralateral hemiparesis Eventually, compression of the upper brain stem and the area in and around the thalamus Impaired consciousness Abnormal breathing patterns Fixed, unequal pupils Further compromise of the brain stem Loss of oculocephalic reflex Loss of oculovestibular reflex Loss of corneal reflexes Decerebrate posturing Subfalcine (...) be dysconjugate or absent (oculomotor paresis) or involve unusual patterns (eg, ocular bobbing, ocular dipping, opsoclonus). Homonymous hemianopia may be present. Other abnormalities include absence of blinking in response to visual threat (almost touching the eye), as well as loss of the oculocephalic reflex (the eyes do not move in response to head rotation), the oculovestibular reflex (the eyes do not move in response to caloric stimulation), and corneal reflexes. Autonomic dysfunction: Patients may have

2013 Merck Manual (19th Edition)

551. Rheumatoid Arthritis (RA)

your knowledge Sciatica Which of the following deficits is the most objective finding in sciatica? CNS Motor Reflex Sensory NEWS & VIDEOS FDA: Pulmonary Embolism Risk Up With Tofacitinib 10 mg for RA THURSDAY, Feb. 28, 2019 (HealthDay News) -- A safety clinical trial has revealed that tofacitinib (Xeljanz, Xeljanz XR) 10 mg twice daily is associated with an increased risk for pulmonary embolism... 3D Model The Foot Video How to Examine the Hand SOCIAL MEDIA Add to Any Platform Loading , MD (...) activity. Patients should be fully apprised of the risks of DMARDs and monitored closely for evidence of toxicity. Table Other Drugs Used to Treat Rheumatoid Arthritis Drug Dosage Adverse Effects Traditional disease-modifying antirheumatic drugs (DMARDs) Hydroxychloroquine 5 mg/kg po once/day (eg, with breakfast or dinner) or in 2 divided dosages (eg, 2.5 mg q 12 h) Usually mild dermatitis Myopathy Corneal opacity (generally reversible) Occasionally irreversible retinal degeneration Leflunomide 20 mg

2013 Merck Manual (19th Edition)

552. Sjögren Syndrome (SS)

SS often affects the eyes or mouth initially and sometimes exclusively. Dry eyes can cause a sandy, gritty sensation. In advanced cases, the cornea is severely damaged, epithelial strands hang from the corneal surface (keratitis filiformis), and vision can be impaired. Diminished saliva ( ) results in difficulty chewing and swallowing, secondary Candida infection, tooth decay, and calculi in the salivary ducts. Taste and smell may be diminished. Dryness may also develop in the skin and in mucous (...) knowledge Sciatica Which of the following deficits is the most objective finding in sciatica? CNS Motor Reflex Sensory NEWS & VIDEOS Autoimmune Disorders May Up Risk for Carpal Tunnel Syndrome FRIDAY, March 1, 2019 (HealthDay News) -- Common autoimmune disorders are associated with an increased risk for carpal tunnel syndrome (CTS), according to a study presented at the annual meeting... 3D Model The Foot Video Standing Gastrocnemius Stretch 1. Stand facing or next to wall with hands on the wall

2013 Merck Manual (19th Edition)

553. Brain Death

been done, brain death can be confirmed. Some states advise clinicians to do two separate examinations separated by at least 48 h in children; this approach is not consistently recommended or required for adult patients (see Table: ). Examination includes Assessment of pupil reactivity Assessment of oculovestibular, oculocephalic, and corneal reflexes Apnea testing Sometimes EEG or tests of brain perfusion are used to confirm absence of brain activity or brain blood flow and thus provide additional (...) ( 35 ° C), and hypotension (MAP 55 mm Hg) have been excluded. No neuromuscular blockers contribute to the neurologic findings. 3. Any observed movements can be attributed entirely to spinal cord function. 4. The cough reflex, pharyngeal reflexes, or both are tested and shown to be absent. 5. Corneal and pupillary light responses are absent. 6. Oculocephalic reflex testing that observes fixed eye movement with rotation of the head and caloric vestibulo-ocular reflexes that show no caloric response

2013 Merck Manual (19th Edition)

554. Strabismus

in Philadelphia. The university... 3D Model Cystic Fibrosis: Defective Chloride Transport Video How to do Neonatal Resuscitation SOCIAL MEDIA Add to Any Platform Loading Topic Resources Strabismus is misalignment of the eyes, which causes deviation from the parallelism of normal gaze. Diagnosis is clinical, including observation of the corneal light reflex and use of a cover test. Treatment may include correction of visual impairment with patching and corrective lenses, alignment by corrective lenses (...) difficulty in fusing images from misaligned eyes and to reduce diplopia. Some children with tropias have normal and equal visual acuity; however, amblyopia frequently develops with tropias and is due to cortical suppression of the image in the deviating eye to avoid confusion and diplopia. Diagnosis Physical and neurologic examinations at well-child checkups Tests (eg, corneal light reflex, alternate cover, cover-uncover) Prisms Strabismus can be detected during well-child checkups through the history

2013 Merck Manual (19th Edition)

555. Crying

, blood in the canal or behind the tympanic membrane) or infection (eg, red, bulging tympanic membrane). The corneas are stained with fluorescein and examined with a blue light to rule out corneal abrasion, and the fundi are examined with an ophthalmoscope for signs of hemorrhage. (If retinal hemorrhages are suspected, examination by an ophthalmologist is advised.) The oropharynx is examined for signs of thrush or oral abrasions. The skull is gently palpated for signs of fracture. Red flags (...) , or decreased breath sounds on auscultation Chest x-ray (UTI) Fever Possible vomiting Urinalysis and culture Trauma Corneal abrasion Crying with no other symptoms Fluorescein test Fracture ( ) Area of swelling and/or ecchymoses Favoring of a limb Skeletal survey x-rays to check for current and old fractures Hair tourniquet Swollen tip of a toe, finger, or penis with hair wrapped around the appendage proximal to the swelling Clinical evaluation Head trauma with intracranial bleeding Inconsolable, high

2013 Merck Manual (19th Edition)

556. Specific Poisons

, confusion, delirium, loss of corneal reflex, respiratory failure, drowsiness, ataxia, coma Charcoal up to 24 h after ingestion, supportive care, forced alkaline diuresis for phenobarbital (to aid in elimination) For severe cases, hemodialysis Barium compounds (soluble) Barium acetate Barium carbonate Barium chloride Barium hydroxide Barium nitrate Barium sulfide Depilatories Explosives Fireworks Rat poisons Vomiting, abdominal pain, diarrhea, tremors, seizures, colic, hypertension, cardiac arrest (...) HgCl) See Mercury, compounds of — Ammonium carbonate ([NH 4 ] 2 CO 3 ) See — Ammonium fluoride (NH 4 F) See Fluorides — Amobarbital See Barbiturates — Amphetamines Amphetamine sulfate or phosphate Dextroamphetamine Methamphetamine Phenmetrazine Synthetic cathinones (bath salts) Increased activity, exhilaration, talkativeness, insomnia, irritability, exaggerated reflexes, anorexia, diaphoresis, tachyarrhythmia, anginal chest pain, psychotic-like states, inability to concentrate or sit still

2013 Merck Manual (19th Edition)

557. Chemical Warfare Agents

doses also causes abrupt loss of consciousness with convulsions. Direct damage to myocardium may be prominent. Continued exposure to initially sublethal concentrations may induce eye irritation with conjunctivitis and corneal abrasions and ulcerations (gas eye), irritation of nasal and pharyngeal mucous membranes, headache, weakness, ataxia, nausea, vomiting, chest tightness, and hyperventilation. Some of these manifestations appear to be a reaction to the offensive odor of the compound. A green (...) , and blister formation after a latent period. The latent period is inversely correlated with dose but is usually at least a few hours (and up to 36 h). Blisters caused by sulfur mustard sometimes resemble a string of pearls around a centrally unaffected area; blisters caused by nitrogen mustard are less likely to show this pattern. Blisters may become large and pendulous. Painful chemical conjunctivitis causing reflex lid closure occurs earlier than skin symptoms but still after a delay often of hours

2013 Merck Manual (19th Edition)

558. General Principles of Poisoning

or respiratory arrest. Eye contact with toxins (solid, liquid, or vapor) may damage the cornea, sclera, and lens, causing eye pain, redness, and loss of vision. Some substances (eg, cocaine, phencyclidine, amphetamine ) can cause severe agitation, which can result in hyperthermia, acidosis, and rhabdomyolysis. Diagnosis Consideration of poisoning in patients with altered consciousness or unexplained symptoms History from all available sources Selective, directed testing The first step of diagnosis (...) except the mildest and most routine. Initial stabilization Maintain airway, breathing, and circulation IV naloxone IV dextrose and thiamine IV fluids, sometimes vasopressors Airway, breathing, and circulation must be maintained in patients suspected of a systemic poisoning. Patients without a pulse or BP require emergency . If patients have apnea or compromised airways (eg, foreign material in the oropharynx, decreased gag reflex), an endotracheal tube should be inserted (see ). If patients have

2013 Merck Manual (19th Edition)

559. Ocular Burns

. Bend involved knee and loop towel or band around the ankle. 3. Gently pull towel or band to stretch muscle on front of thigh pulling ankle toward buttocks... SOCIAL MEDIA Add to Any Platform Loading , MD, MPH, Wills Eye Emergency Department, Wills Eye Hospital Click here for Patient Education NOTE: This is the Professional Version. CONSUMERS: Topic Resources Thermal burns The blink reflex usually causes the eye to close in response to a thermal stimulus. Thus, thermal burns tend to affect (...) the eyelid rather than the conjunctiva or cornea. Eyelid burns should be cleansed thoroughly with sterile isotonic saline solution followed by application of an ophthalmic antimicrobial ointment (eg, bacitracin bid). Most thermal burns affecting the conjunctiva or cornea are mild and heal without significant sequellae. They are treated with oral analgesics ( acetaminophen with or without oxycodone ), cycloplegic mydriatics (eg, homatropine 5% qid), and topical ophthalmic antibiotics (eg, bacitracin

2013 Merck Manual (19th Edition)

560. Overview of Eye Trauma

, and tendons), and/or bones of the orbit. (See also .) General evaluation should include the following: Tests of visual acuity Range of extraocular motion Visual fields to confrontation Pupillary appearance and responses Location and depth of lid and conjunctival lacerations and of foreign bodies Depth of anterior chamber Presence of anterior chamber or vitreous hemorrhage, cataract, or red reflex Retinal examination Intraocular pressure determination Detailed examination of the sclera, anterior segment (...) (cornea, anterior chamber, ciliary body, iris), lens, and anterior vitreous is best done with a slit lamp. Although direct ophthalmoscopy can be used to examine the lens and posterior structures of the eye, indirect ophthalmoscopy, usually done by an ophthalmologist, provides a more detailed and binocular view of these structures. Indications for indirect ophthalmoscopy include clinical suspicion of vitreous abnormalities (eg, hemorrhage, foreign body) and retinal abnormalities; clinical suspicion may

2013 Merck Manual (19th Edition)

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