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Corneal Reflex

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601. 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

602. 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

603. 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

604. 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

605. 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

606. 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

607. 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

608. 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

609. 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

610. 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

611. 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

612. 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

613. 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

614. 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

615. 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

616. 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

617. 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

618. 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

619. 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

620. 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

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