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Corneal Reflex

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561. examination of the patient with dizziness

for : signs of palsies and sensorineural hearing loss this includes particularly funduscopy for papilloedema or optic atrophy (II) eye movements (III, IV, and VI) corneal reflex (V) facial movement (VII) tuning folk tests for hearing loss(VIII) special attention is paid to those that pass through the cerebellopontine angle - the fifth to the seventh. nystagmus common in acute virtigo (2) vertical nystagmus (1) is commonly seen in vestibular nuclear or cerebellar vermis lesions horizontal nystagmus

2010 GP Notebook

562. keratitis (eye)

and later, corneal oedema blood vessel dilatation is typically concentrated around the limbus - circumcorneal injection often, the conjunctiva is also inflamed - keratoconjunctivitis discharge is usually present and may be watery, mucoid or purulent; notably, it is absent in keratoconjunctivitis sicca pupil may be small due to reflexive miosis; photophobia is common fluorescein readily demonstrates any ulceration (an epithelial breach) Keratitis an cause significant loss of vision from (1): scarring (...) astigmatism Complications leading to blindness (2) corneal perforation, choroidal detachment endophthalmitis, phthisis Corneal ulceration is an ophthalmologic emergency. the cause must be identified before treatment starts since some therapies are beneficial in one circumstance but are aggravating in another refer the same day for urgent ophthalmological review as delay in treatment may result in loss of sight. Notes: corneal ulceration may occur without keratitis e.g. when a corneal ulcer is secondary

2010 GP Notebook

563. cranial nerves

strength corneal reflex, if appropriate VII furrowing of brow on frowning, raising of eyebrows show teeth, smile, puff out cheeks screwing up of eyes facial movement VIII repeat number whispered into each ear Rinne's test Weber's test IX, X palatal movement, difficulty swallowing, gag reflex quality of speech: nasal guttural say "ee" XI sternocleidomastoid and trapezius bulk and strength XII tongue at rest and on movements to command, e.g. protrude say "la" and "ta"; quality of articulation Links

2010 GP Notebook

564. clinical examination of the dizzy patient

for : signs of palsies and sensorineural hearing loss this includes particularly funduscopy for papilloedema or optic atrophy (II) eye movements (III, IV, and VI) corneal reflex (V) facial movement (VII) tuning folk tests for hearing loss(VIII) special attention is paid to those that pass through the cerebellopontine angle - the fifth to the seventh. nystagmus common in acute virtigo (2) vertical nystagmus (1) is commonly seen in vestibular nuclear or cerebellar vermis lesions horizontal nystagmus

2010 GP Notebook

565. keratitis

, corneal oedema blood vessel dilatation is typically concentrated around the limbus - circumcorneal injection often, the conjunctiva is also inflamed - keratoconjunctivitis discharge is usually present and may be watery, mucoid or purulent; notably, it is absent in keratoconjunctivitis sicca pupil may be small due to reflexive miosis; photophobia is common fluorescein readily demonstrates any ulceration (an epithelial breach) Keratitis an cause significant loss of vision from (1): scarring astigmatism (...) Complications leading to blindness (2) corneal perforation, choroidal detachment endophthalmitis, phthisis Corneal ulceration is an ophthalmologic emergency. the cause must be identified before treatment starts since some therapies are beneficial in one circumstance but are aggravating in another refer the same day for urgent ophthalmological review as delay in treatment may result in loss of sight. Notes: corneal ulceration may occur without keratitis e.g. when a corneal ulcer is secondary to trauma non

2010 GP Notebook

566. inflammation of the cornea

acuity due to cellular infiltration and later, corneal oedema blood vessel dilatation is typically concentrated around the limbus - circumcorneal injection often, the conjunctiva is also inflamed - keratoconjunctivitis discharge is usually present and may be watery, mucoid or purulent; notably, it is absent in keratoconjunctivitis sicca pupil may be small due to reflexive miosis; photophobia is common fluorescein readily demonstrates any ulceration (an epithelial breach) Keratitis an cause (...) significant loss of vision from (1): scarring astigmatism Complications leading to blindness (2) corneal perforation, choroidal detachment endophthalmitis, phthisis Corneal ulceration is an ophthalmologic emergency. the cause must be identified before treatment starts since some therapies are beneficial in one circumstance but are aggravating in another refer the same day for urgent ophthalmological review as delay in treatment may result in loss of sight. Notes: corneal ulceration may occur without

2010 GP Notebook

567. Short Bowel Syndrome (SBS)

ridges in the nails. Poor growth performance in children is characteristic. Deficiency of essential fatty acids (linoleic and linolenic) - growth restriction, dermatitis, alopecia. Vitamin A deficiency - corneal ulcerations, growth delays. B complex vitamins in general - stomatitis, cheilosis and glossitis. Vitamin B1 deficiency - oedema, tachycardia, ophthalmoplegia, depressed deep tendon reflexes. Vitamin B6 deficiency - peripheral neuropathies (also a feature of B12 deficiency) and seizures (...) . Vitamin D depletion - poor growth, bowed extremities. Vitamin E deficiency - if severe, this can result in ataxia, oedema and depressed deep tendon reflexes. Vitamin K deficiency - petechiae, ecchymoses, purpura, or outright bleeding diatheses. Iron deficiency - pallor, spooned nails, glossitis. Zinc deficiency - angular stomatitis, poor wound healing, alopecia, scaly erythematous rash around the mouth, eye, nose and perineum. Differential diagnosis This may be wide-ranging and depending

2008 Mentor

568. Sudden Death

intra-arterial pressure monitoring. Absence of contractile activity using echocardiography. Any spontaneous return of cardiac or respiratory activity during this period of observation should prompt a further five minutes of observation from the next point of cardiorespiratory arrest. After five minutes of continued cardiorespiratory arrest the absence of the pupillary responses to light, of the corneal reflexes, and of any motor response to supra-orbital pressure should be confirmed The time (...) if the death is unexpected, an external examination of the deceased and their surroundings should be made, to look for any apparent factors which may be relevant to their death (bleeding, vomit, wounds, weapons, alcohol, pills, notes, etc). Other signs include: No response to painful stimuli. Absence of corneal reflexes. Cloudiness of the cornea. Examination of the trunk may show evidence of post-mortem staining as a result of hypostasis. Rigor mortis may have set in (begins approximately three hours after

2008 Mentor

569. Space-occupying Lesions

separate article. Cerebellopontine angle The most common pathology here is an . Common features include: Ipsilateral deafness. Tinnitus. Nystagmus. Reduced corneal reflex. Facial and trigeminal nerve palsies. Ipsilateral cerebellar signs. Corpus callosum This is an interesting part of the brain that communicates between the two sides. Lesions usually cause severe rapid intellectual deterioration with focal signs of adjacent lobes. There may be signs of loss of communication between the lobes

2008 Mentor

570. Tolosa-Hunt Syndrome

are the most commonly affected. The optic nerve and periarterial sympathetic nerves may also be involved. is common, as would be expected. Diplopia and cranial nerve lesions are discussed elsewhere. It may precede the pain by several days. Involvement of the ophthalmic division of the trigeminal nerve can cause paraesthesia over the forehead. The corneal reflex may be lost on that side. The lesion is usually unilateral but bilateral cases have been described. Symptoms may last any length of time from days

2008 Mentor

571. Squints

, strabismus or leukocoria as the presenting symptom of retinoblastoma was discovered by a family member in 75% of cases. The three screening methods needed to detect strabismus are: Gross inspection. Light reflex tests, including the Brückner test (inspection for a red reflex). Cover tests. In clinic, ophthalmoscopy and measurement of visual acuity are also crucial. A young baby should be examined for the presence of epicanthic folds (crescenteric folds of skin on each side of the nose) which could give (...) rise to pseudoesotropia (the impression that the eyes are turned inwards when in fact they are not). The corneal reflection test (Hirschberg's test) can help to rule this out. Hirschberg's test : this gives a rough estimate of the degree of strabismus. Hold a pen torch about an arm's length (c.33 cm) away from the patient and shine it in front of their eyes. If the patient is able to understand instructions, ask them to look at the light (babies will tend to look towards it anyway, even if briefly

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2008 Mentor

572. Ocular Local Anaesthetics

: they are toxic to the corneal epithelium. They also abolish the corneal reflex so increasing the risk of corneal damage. Topical non-steroidal anti-inflammatory drugs (NSAIDs), such as diclofenac eye drops, may have some role in pain management but their efficiency is uncertain and they should not be used as a substitute for oral analgesia (paracetamol, oral NSAIDs) [ ] . LAs work by blocking initiation and propagation of neuronal action potentials. Small-diameter, myelinated nerves are most susceptible (...) [ ] . Examples - lidocaine hydrochloride, oxybuprocaine hydrochloride, proxymetacaine hydrochloride, tetracaine hydrochloride (amethocaine hydrochloride) [ ] . Use - largely for initial assessment of minor trauma and for removal of conjunctival and corneal foreign bodies. There is some debate about their use in surgery, particularly cataract surgery, where some authors claim equal or better analgesia to injected LA [ ] . However, in the UK, injected LA is very much the norm for ocular surgery in the absence

2008 Mentor

573. Non-diabetic Retinal Vascular Disease

layer, outer plexiform layer, outer nuclear layer, external limiting membrane, rod and cone inner and outer segments and a single layer of cells called the retinal pigment epithelium (RPE). The only cells which are sensitive to light are the photoreceptor cells, comprising the rods and cones (for vision) and the photosensitive ganglion cells for entrainment and reflex responses to light. Neural signals from the rods and cones are processed by other nerve cells in the retina. The macula has a high (...) include a red eye, corneal oedema, a mid-dilated poorly reacting pupil and there may be rubeosis iridis. Fundoscopy shows venous dilatation, micro-aneurysms, neovascularisation and disc oedema. Management Urgent referral to ophthalmology : management involves a multidisciplinary team, including the cardiologist, neurologist and vascular and neurological surgeons. Patients will be treated with topical steroids and long-acting cycloplegic agents, with laser treatment to any new vessel growth. Any

2008 Mentor

574. Nystagmus

a small fixation target, observe the nystagmus in all positions of gaze. Ask the patient to comment on visual symptoms as the eyes move (eg, blurring, double vision). Enquire about the 'null' point: this is an angle which some patients find minimises their visual impairment - it often results in abnormal head positioning. Check oculocephalic reflex (doll's head phenomenon): This reflex is produced by moving the patient's head left to right or up and down. When the reflex is present, the eyes remain (...) stationary while the head is moved, moving in relation to the head. An alert patient normally does not have the doll's-eye reflex because it is suppressed. Inability to suppress the oculocephalic reflex suggests vestibular imbalance. The test may be performed by having the patient extend the arm out in front of the body and fixate on the outstretched thumb: Patients should be instructed to rotate their torso such that the thumb remains in front of the body at all times. Patients with the ability

2008 Mentor

575. Nelson's Syndrome

in the creases of the hands. Some patients develop hyperpigmentation after bilateral adrenalectomy but do not develop full-blown Nelson's syndrome. [ ] In adolescents there may be features of delayed puberty. Check eye movements, as the external ocular muscles will be affected if the III, IV or VI cranial nerves are involved. Damage to the ophthalmic division of the trigeminal nerve will impair sensation over the forehead and perhaps corneal reflex. Check the fundi, including looking for papilloedema

2008 Mentor

576. Vision Testing and Screening in Young Children

. The newborn examination and 6- to 8-week review [ ] This should include: The red reflex: use an ophthalmoscope about 30 cm from the infant's eyes. Dark spots in the red reflex can be due to cataracts, corneal abnormalities, or opacities in the vitreous. The red reflex may be absent with a dense cataract. [ ] Corneal light reflex to detect squint. Hold a penlight at arm's length in front of the child. When the child looks at the light, normally the light reflex is symmetrical and slightly nasal (medial (...) ) to the middle of each pupil. General inspection of the eyes may suggest other conditions. For example, one eye larger than the other may indicate glaucoma. Also at the 6- to 8-week examination, ask parents if they have any concerns about their child's vision. A specialist examination is indicated: When an abnormality is detected in the above routine examinations. In particular, an abnormal red reflex requires same-day referral as vision rapidly deteriorates week on week past six weeks and permanent severe

2008 Mentor

577. Vertebrobasilar Occlusion and Vertebral Artery Syndrome

cerebellar artery. Involvement of the vestibular system causes nausea, vomiting and vertigo. Ipsilateral features: Ataxia from cerebellar involvement. Horner's syndrome from damage to descending sympathetic fibres. Reduced corneal reflex from descending spinal tract damage. Nystagmus. Hypacusis. Dysarthria. Dysphagia. Paralysis of palate, pharynx and vocal cord. Loss of taste in the posterior third of the tongue. Contralateral findings: Loss of pain and temperature sensation in the trunk and limbs (...) and pulmonary oedema. Treatments for respiratory complications: Assess respiratory drive, gag reflex, cough reflex (to expel secretions). Consider endotracheal intubation (Glasgow Coma Scale less than 8). Sedation and muscle relaxation may be needed if agitated or resisting mechanical ventilation but these will have to be reversed before a full neurological assessment can be carried out. Thrombolysis (see also separate article): Local intra-arterial thrombolysis results in better recanalisation results than

2008 Mentor

578. Vegetative States

might include metabolic disturbances and treatable structural lesions. Careful and full assessment by a trained specialist in the correct environment using the appropriate criteria. Diagnosing a vegetative state The following must be present for a diagnosis: No awareness of self or environment. No purposeful behaviours. No comprehension or significant expression. There may, however, be some spontaneous movements (eg, shedding tears) or reflexive movements (eg, corneal reflex) and a number of other (...) . Spontaneous movements may occur, and the eyes may open in response to external stimuli. They may occasionally grimace, cry, or laugh. They do not speak and they are unable to respond to commands. There is no swallowing reflex and no control over bowels or bladder. This differs from brainstem death where there is loss of all brain function including the ability to breathe spontaneously. Minimally conscious state The patient has altered consciousness which is usually severe but there are aspects

2008 Mentor

579. Xeroderma Pigmentosum

). These are solar keratoses (premalignant), squamous cell carcinoma (SCC), basal cell carcinoma (BCC) and malignant melanoma. BCC and SCC occur most frequently. They are more prevalent in areas exposed to sun. The anterior tongue is also vulnerable. Eye features [ ] Eye features occur in the anterior, exposed part of the eye: Photophobia. Conjunctival inflammation and keratitis. Severe keratitis can lead to corneal opacification and vascularisation. Tumours of conjunctiva and eyelids - benign or malignant (...) . Eyelids may be pigmented, may lose lashes, or may atrophy - leading to ectropion or entropion. Neurological features [ ] 30% of affected individuals have neurological manifestations, including acquired microcephaly, diminished or absent deep tendon stretch reflexes, progressive sensorineural hearing loss and progressive cognitive impairment. Neurological problems can be mild or severe. Possible features are hyporeflexia, sensorineural deafness, spasticity, poor co-ordination, seizures, acquired

2008 Mentor

580. Glaucoma and Ocular Hypertension

, the pupillary reflex is lost and the eye has a stony appearance. The condition is very painful and is treated by destructive processes. Pathophysiology of glaucoma [ , ] The primary problem in glaucoma is disease of the optic nerve. The pathophysiology is not fully understood, but there is a progressive loss of retinal ganglion cells and their axons. In its early stages it affects peripheral visual field only but as it advances it affects central vision and results in loss of visual acuity, which can lead (...) between the cornea and the iris to assess whether the glaucoma is open-angle or closed-angle. A mirror is placed on the surface of the numbed eye to allow the operator to measure the angle directly. Corneal thickness - this influences the IOP reading. If it is thicker than usual, it will take greater force to indent the cornea and an erroneously high reading will be obtained. (The opposite is true for a thin cornea.) Corneal thickness is measured by pachymetry. Tonometry - this is the objective

2008 Mentor

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