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Corneal Reflex

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581. 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

582. Gradual Loss of Vision

? Are there implications with regard to their work or driving? Will this mark the loss of their independent living? Examination Important points to note on examination are: The visual acuity of both eyes. Note whether this improves using a pinhole. The red reflex: a media opacity (appears black against the red reflex) suggests a corneal, lens or vitreous problem. To localise the site of the opacity with respects to the pupil (lens): Slowly shift the direction of your ophthalmoscope light. Look at the direction (...) in which the opacity appears to move in relationship to the pupillary (central) axis. If there is no 'movement' of the opacity, it lies within the pupil (lens). If the opacity 'moves' in the same direction, it is anterior to the lens (cornea). If the opacity 'moves' in the opposite direction, it is posterior to the pupil (posterior lens or vitreous). If the media is clear, it is more likely to be a retinal or optic nerve disorder. If there is a normal red reflex, take a good look at the fundus. Do

2008 Mentor

583. Foreign Body in the Eye

trauma from a scratch, grit or contact lens. Corneal abrasions may also arise if the eyelids do not close properly - eg, where there is neuropathy, proptosis, or ectropion or in unconscious patients. Superficial keratitis may occur in response to UV injury (photokeratitis), or to chemical injury (eg, from tear gas). Corneal FBs usually cause marked irritation, redness and watering, often with pain and a repeated blink reflex. Patients are usually very good at localising the FB [ ] . Some corneal FBs (...) and light perception (if the eye cannot be opened, check light perception through closed lids). Acuities of 6/6 do not necessarily exclude serious problems. Ask about diplopia; check visual fields. Check pupillary reflexes. Test for relative afferent pupillary defect if possible. General inspection Look for signs of infection - purulent discharge, an opaque base of a corneal surface defect, cells or pus in the anterior chamber. Intraocular pressure (IOP) should be assessed if possible, unless open globe

2008 Mentor

584. Floaters Flashes and Halos

. - complex visual hallucinations brought about by bilateral, severe visual loss. Pseudo flashes Although not strictly speaking flashes, the following may be described as such by the patient: Photophobia - usually associated with anterior segment inflammation or retinal hypersensitivity. Glare - a dazzle usually associated with media opacities. Haloes - the ring effect associated with media clouding (eg, the corneal oedema of acute ) and occasionally, media opacities. Floaters Floaters are opacities (...) . Oedema of the corneal epithelium from any cause (eg, overwear). Corneal dystrophies in their later stages. Chronic . Early (glare of headlights making night-time driving impossible). Pigment dispersion syndrome. Vitreous opacities. Drugs (eg, digitalis and chloroquine). When to suspect a retinal detachment [ ] New onset of floaters (mobile dots, lines, or haze). New PINK floater (being almost always associated with a retinal tear and small bleed). New onset of flashes (light often seen as recurrent

2008 Mentor

585. Facial Nerve Palsy (Including Bell's Palsy)

palsy and hypertension). [ ] The following tests are rarely done but, combined with a good understanding of the neuroanatomy, can determine the level of the palsy: Schirmer's tear test (reveals a reduced flow of tears on the side of a palsy affecting the greater palatine nerve). Stapedial reflex (an audiological test, absent if the stapedius muscle is affected). Electrodiagnostic studies (generally a research tool) reveal no changes in involved facial muscles for the first three days but a steady (...) from corneal exposure. This may be successfully achieved by using lubricating drops hourly and eye ointment at night ± an eye patch. Botulinum toxin or surgery (upper lid weighting or tarsorrhaphy) may also be required temporarily. [ ] After the cornea has been protected but recovery is thought to be unlikely, longer-term management of eyelid and facial re-animation may be arranged. Bell's palsy management Steroids : Steroids are effective in the treatment of facial nerve palsy. [ ] Of the 29

2008 Mentor

586. Eye in Systemic Disease

deposits in the retinal vessels remain when blood pressure is reduced; however, retinopathy resolves when blood pressure is treated. Changes develop within 48 hours of blood pressure rising and resolve in 2-10 weeks of it being lowered. Complications of hypertensive retinopathy include optic neuropathy and central vein or artery occlusions. Hyperthyroidism may cause proptosis, which may be the first sign of the condition. This may be unilateral or bilateral. may include corneal ulceration and visual (...) loss. Hyperlipidaemia Corneal arcus may be present at birth, but usually appears in patients aged over 50; it results from cholesterol deposits and can be associated with Acromegaly Optic atrophy is common. There may be nystagmus. Cushing's syndrome Iatrogenic Cushing's syndrome may be associated with steroid-induced cataracts (this is not the case for Cushing's disease) and susceptible individuals may also develop glaucoma. Occasionally, a secreting pituitary tumour can cause bitemporal hemianopia

2008 Mentor

587. Eye Trauma

with 'panda eyes' from a base of skull fracture.) Conjunctiva : look for haemorrhage and lacerations (small lacerations can be subtle - they may show up on staining with fluorescein) - these can indicate an open globe injury. Cornea : lacerations may be small and missed: Perform a Seidel's test first (to assess for leakage from the cornea - see 'Techniques', below) and then assess for corneal abrasion with dilute fluorescein. Anterior chamber : look for hyphaema (the patient needs to be upright to see (...) level). Iris and pupils : check shape, size, reactive and equal. Pupil or iris damage is a serious sign. Fundus : loss of red reflex could be due to opacification from blood in the vitreous or a large retinal detachment. IOP : should also be assessed - if possible - unless you suspect an open globe injury. Perform a functional examination: Movement of the eyes (ask about diplopia before and during examination). Pupil reactions test visual fields . Test for relative afferent pupillary defect

2008 Mentor

588. Examination of the Cranial Nerves

. The pterygoids may jut the jaw forwards. Many neurologists omit the corneal reflex unless a sensory deficit is found, especially in the ophthalmic division, or if there is a lesion of another cranial nerve. Take a clean piece of cotton wool and ask the patient to look away from the side being tested. Gently touch the cornea with the cotton wool and the patient will blink. This requires the sensation of V but also the motor of VII. There may be a positive jaw jerk reflex in spasticity. This is difficult (...) pathway) and the oculomotor nerve (efferent pathway), as the response is dependent upon appreciation of light and the motor response of the muscles of the iris. There is also a consensual response in that the contralateral pupil will also respond but less markedly. Then use the ophthalmoscope to examine the eye. First hold it away from the patient and look through it at the eye. There should be an orange reflex from light reflected from the retina. This means that the lens is clear

2008 Mentor

589. Examination of the Eye

is held about an arm's length away from the patient. Look through the ophthalmoscope and turn the dial until you see the red reflex. This can be attenuated by any opacity between the cornea and the fundus: a corneal opacity is visible externally and a vitreous opacity may be mobile. The red reflex is part of the routine neonatal check. Use a direct ophthalmoscope in a dimly lit room and hold your ophthalmoscope about 2/3 of an arm's length away from the baby. If the baby is screwing their eyes shut (...) passing through the shaft of light) and for flare (slight cloudiness), suggestive of anterior . Pupils Look at their relative size - if you suspect anisocoria (different-sized pupils), stand back from the patient, darken the room and look through the ophthalmoscope. You can elicit the red reflex in both eyes and compare the size of these directly rather than shifting from one to the other close up. Look for change in shape (typically oval in acute angle-closure glaucoma, asymmetry in a penetrating

2008 Mentor

590. Epiphora (Watering Eyes)

- eg, . Tear film deficiency (inappropriate reflex reaction). . . Corneal disease. Inflammatory disease - eg, , . It may occasionally be a presentation in . Punctal malposition (lid laxity - eg, ectropion). Stenosis or obstruction at any point along the nasolacrimal duct: Congenital nasolacrimal duct obstruction - the most common cause of epiphora in childhood Lacrimal sac mass or mucocele Dacryocystitis Lacrimal pump failure - eg, . Nasal obstruction - eg, mass, inflammation or scarring. Previous (...) , or one of our other . In this article In This Article Epiphora In this article The tear film is a complex and important entity that provides corneal lubrication, nourishment and immunological protection among other functions. The air/tear interface is also the most important site of light ray refraction. Tears drain into the upper and lower puncta medially, into their respective canaliculi and then into the common canaliculus. From there, they enter the lacrimal sac (adjacent to the bridge

2008 Mentor

591. Endophthalmitis

Guidelines. You may find one of our more useful. In this article In This Article Endophthalmitis In this article Description Endophthalmitis is severe inflammation of the anterior and/or posterior chambers of the eye. Whilst it may be sterile, usually it is bacterial or fungal, with infection involving the vitreous and/or aqueous humours. Most cases are exogenous and occur after eye surgery (including cataract surgery) or penetrating ocular trauma, or as an extension of corneal infection. An increasing (...) fulminant condition which has a very bleak prognosis. Pathophysiology Normally, the blood-ocular barrier prevents invasion from infective organisms but if this is breached (directly through trauma or indirectly due to a change in its permeability secondary to inflammation), infection can occur. Endophthalmitis can be: Associated with surgery: acute or delayed postoperative. Traumatic: bacterial or fungal endophthalmitis. Endogenous: bacterial or fungal endophthalmitis. Associated with corneal infection

2008 Mentor

592. Cranial Nerve Lesions

. Forms three trunks: ophthalmic, maxillary and mandibular divisions. The latter contains both sensory and motor fibres. There may be considerable individual variation in the exact areas of skin supplied: Ophthalmic division lies with III, IV and VI in the cavernous sinus and supplies the skin over the medial nose, forehead, and eye (including corneal reflex). Maxillary division passes through the inferior part of the cavernous sinus and the foramen rotundum and joins with parasympathetic fibres

2008 Mentor

593. Coma

. Fundoscopy to look for papilloedema. Corneal reflex. Gag reflex. Respiratory pattern. Response to painful stimuli. Plantars. Doll's head manoeuvre. Any evidence of head injury - eg, bruising behind the ear, or panda eyes. There may be abnormal posturing or seizures. Other clues that can be gained from the examination: Clubbing suggests respiratory disease. Tracheal deviation, chest fluid or lung collapse suggest respiratory cause. Enlarged abdominal organs - hepatic disorder, polycystic kidneys (...) (associated with subarachnoid bleeding), or abnormal haematopoiesis. Note position, posture and any spontaneous movements, and examine the ears and pharynx. Examine the skull and spine and test for neck stiffness and Kernig's sign (if there is no cervical spine trauma). Useful focal indicators of pathology in comatose patients Brainstem function Brainstem reflexes identify lesions affecting the reticular activating substance and determine prognosis. Pupillary reactions and corneal reflexes Unilateral

2008 Mentor

594. Coloboma

. Chorioretinal and optic nerve coloboma May be asymptomatic or noticed on routine examination. May present as reduced visual acuity or visual field. May present in adulthood with visual loss due to retinal detachment (see 'Complications', below). The appearance is a white area of the fundus, with defined borders and often with clumps of pigment near the rim. May be noticed by parents or doctors as (white pupil caused by an absent pupillary reflex). Assessment [ ] Paediatric, family and genetic assessment (...) examination - for anterior eye structures (may require general anaesthetic in babies). Further investigations include: CT or MRI scan - for microphthalmia or associated central nervous system (CNS) defects. Evaluation of axial length (by ultrasound) and corneal diameter - these may help to estimate prognosis (see 'Prognosis', below). [ ] Optical coherence tomography - to image optic pits and choroidoretinal colobomata. [ ] Fluorescein angiography. [ ] Differential diagnosis Choroidoretinal lesions can

2008 Mentor

595. Antifungal Medications

and subtropical regions. Fungal infections of the eye may cause orbital cellulitis, dacryocystitis, conjunctivitis, keratitis and endophthalmitis. [ ] Thus, they can work at a superficial level or penetrate deeply into the eye. [ ] Treatment is initiated and monitored by a specialist ophthalmology team. Samples such as corneal scrapes will have been obtained prior to initiation of therapy. Any steroid treatment needs to be discontinued. Antifungal preparations for the eye are not generally available and have (...) . Oral ketoconazole (for any indication) is not recommended, as the risks outweigh the benefits. [ ] Griseofulvin may impair the ability to perform skilled tasks - eg, driving. The toxic effects of alcohol are increased. It is CONTRA-INDICATED in severe liver disease, acute porphyria and systemic lupus erythematosus (SLE). Avoid in pregnancy and hepatic impairment. Miconazole gel is CONTRA-INDICATED in infants with an impaired swallowing reflex, and in the first six months of life for preterm infants

2008 Mentor

596. Antifungal Eye Preparations

frequently seen in tropical and subtropical regions. Fungal infections of the eye may cause orbital cellulitis, dacryocystitis, conjunctivitis, keratitis and endophthalmitis. [ ] Thus, they can work at a superficial level or penetrate deeply into the eye. [ ] Treatment is initiated and monitored by a specialist ophthalmology team. Samples such as corneal scrapes will have been obtained prior to initiation of therapy. Any steroid treatment needs to be discontinued. Antifungal preparations for the eye (...) reflex, and in the first six months of life for preterm infants. Avoid in liver disease, pregnancy, breast-feeding and acute porphyria. Terbinafine should be used with caution in liver or kidney disease, psoriasis (may exacerbate), autoimmune disease, pregnancy or breast-feeding. Liver function should be checked before starting treatment, and monitored every four to six weeks. NB : many nystatin preparations are now withdrawn. This includes vaginal cream, pessaries, pastilles and Tri-Adcortyl Otic®

2008 Mentor

597. Dry Eyes

and salivary glands. Secondary - associated with other autoimmune connective tissue disease (eg, rheumatoid arthritis and systemic lupus erythematosus). 2. Non-Sjögren's syndrome Lacrimal gland insufficiency: Age-related. Congenital. Infiltrative process (eg, lymphoma, sarcoidosis, AIDS, graft-vs-host disease). Lacrimal gland ablation or denervation. Lacrimal gland obstruction: Trachoma. Burns. Erythema multiforme. Reflex hyposecretion (sensory block causing loss of corneal sensation): Diabetes. Contact (...) lens wear. Corneal surgery. Herpes zoster opthalmicus. Herpes simplex keratitis. Reflex hyposecretion (motor block): Cranial nerve VII damage. Anticholinergic medication. Medication causing hyposecretion: Antihistamines. Antidepressants (tricyclic and selective serotonin reuptake inhibitor). Diuretics. Beta-blockers. Antispasmodics. 1. Intrinsic Meibomian gland dysfunction (reduces lipids in tear film): Blepharitis. Systemic dermatoses (eg, rosacea or seborrhoeic dermatitis). Drugs (eg

2008 Mentor

598. Diabetic Retinopathy and Diabetic Eye Problems

afterwards. Before 'homing in' on the fundus, check the red reflex: spots within this suggest a vitreous haemorrhage. Start at the disc and systematically work your way out along each main arterial branch (effectively: up and out, down and out, up and in, down and in). End with the macula ('look directly at the light' - make this bit quick, as it is not very comfortable). When looking at the vessels, note any little red dots (dot haemorrhages or small aneurysms), irregular notching (venous beading (...) an intracranial mass until proven otherwise via imaging. If it is truly a palsy related to diabetic microvasculopathy, it often resolves over a period of months but orthoptic input may be needed. Other eye conditions more commonly found in people with diabetes include dry eyes, corneal abrasions, anterior uveitis, ocular ischaemic syndrome, papillitis and orbital infections. Corneal abnormalities may also be found in these patient groups. Asteroid hyalosis is a condition characterised by little white flecks

2008 Mentor

599. Death (Recognition and Certification)

flow using direct 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 (...) 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

600. Blurred Vision

the retina, namely the cornea, the (crystalline) lens and the vitreous. These are the visual media. Try to decide whether the visual media are clear or not - this will be a good guide as to what the diagnosis might be. If you cannot obtain a red reflex, it is likely that the problem lies within one or more of these structures. This may be an intrinsic problem to the structure (eg, corneal oedema secondary to corneal trauma) or as a result of a more distant problem (eg, clouding of the lens due (...) involves a look at the eye's structure and at its functioning. Assessment of structure Work from front to back, ie start with the lids and examine as far back as the instruments you have will permit you to, looking at the anterior segment, lens, and vitreous through to the fundus. Don't forget to test for corneal sensation (a rolled cotton bud lightly touching the cornea) and then re-examine the cornea using fluorescein. Light from the outside world has to cross a series of transparent media to reach

2008 Mentor

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