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Corneal Reflex

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641. Superior tarsectomy augments super-maximum levator resection in correction of severe blepharoptosis with poor levator function. (Abstract)

institution.Chart review of patients who underwent super maximum levator resection with or without superior tarsectomy. Data regarding eyelid position, surgical outcome, and postoperative complications were evaluated.Margin reflex distance-1 (distance [mm] between corneal light reflex and upper eyelid margin), bilateral eyelid symmetry, and postoperative complications.A statistically significant improvement in ptosis correction was demonstrated when integrating the superior tarsectomy with the super maximum (...) levator resection (P = 0.029). In addition, the superior tarsectomy significantly decreased the incidence of undercorrection (margin reflex distance-1 values less than 2.0 mm) compared with the super-maximum levator resection alone (12.5% vs. 70%; P = 0.023). Improved postoperative eyelid symmetry within 1.0 and 1.5 mm was demonstrated in cases treated by the superior tarsectomy. Postoperative complications were similar in both treatments.The super maximum levator resection combined with superior

2006 Ophthalmology

642. A useful augmented lateral tarsal strip tarsorrhaphy for paralytic ectropion. (Abstract)

to evaluate the technique.Prospective noncomparative surgical trial in which preoperative and postoperative symptoms, margin reflex distances, vertical palpebral aperture (PA), lagophthalmos, and corneal findings were recorded. The data were analyzed at 6 months after surgery using the Wilcoxon sign-rank test for nonparametric data.Fourteen consecutive adult patients (15 eyelids) with chronic lagophthalmos and paralytic ectropion.Patients underwent aug-LTS-T. This consisted of a long strip (10-15 mm (...) ) that is attached to the outer temporal orbital rim, at a point higher than a conventional LTS. It included removal of a small part of the upper eyelid anterior lamella laterally to pass the long strip up high enough.Improvement of symptoms, reduction of lower margin reflex distance, lagophthalmos, and improvement of corneal signs.Minimum follow-up was 6 months. There was a significant reduction in PA (P = 0.005) and lagophthalmos (P = 0.0002) with improvement of corneal signs (14 of 15 eyelids = 93%). Surgery

2006 Ophthalmology

643. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Full Text available with Trip Pro

authors identified four class I studies, three class II studies, and five class III studies on clinical findings and circumstances. The indicators of poor outcome after CPR are absent pupillary light response or corneal reflexes, and extensor or no motor response to pain after 3 days of observation (level A), and myoclonus status epilepticus (level B). Prognosis cannot be based on circumstances of CPR (level B) or elevated body temperature (level C). The authors identified one class I, one class II (...) (level B). Ten class IV studies on brain monitoring and neuroimaging did not provide data to support or refute usefulness in prognostication (level U).Pupillary light response, corneal reflexes, motor responses to pain, myoclonus status epilepticus, serum neuron-specific enolase, and somatosensory evoked potential studies can reliably assist in accurately predicting poor outcome in comatose patients after cardiopulmonary resuscitation for cardiac arrest.

2006 Neurology

644. Positive angle kappa: a sign of albinism in patients with congenital nystagmus. (Abstract)

Positive angle kappa: a sign of albinism in patients with congenital nystagmus. To determine whether the association of positive angle kappa and congenital nystagmus is a distinguishing feature of albinism.Observational case series.Prospective examination of the location of the corneal light reflex in patients with albinism and idiopathic congenital nystagmus.A positive angle kappa in at least one eye was noted in 20/21 (95%) patients with albinism versus 4/12 (33%) patients with congenital

2004 American Journal of Ophthalmology

645. Abnormal foveal avascular zone in nanophthalmos. (Abstract)

Abnormal foveal avascular zone in nanophthalmos. To evaluate the foveas of nanophthalmic patients.Retrospective observational case series.Four nanophthalmic patients examined between April 2005 and April 2006 were included. Visual acuity (VA), refractive correction, axial length, corneal diameter, presence or lack of foveal light reflex, as well as fluorescein angiograms (FAs), and optical coherence tomography (OCT) scans of the maculae were evaluated.None of the eight eyes had a foveal light (...) reflex, corresponding to lack of a normal foveal pit on OCT. Fluorescein angiography showed no normal foveal avascular zones; all were either completely absent or small and rudimentary.Nanophthalmic patients rarely have best-corrected visual acuity (BCVA) better than 20/40 at any point in their lives, even with an absence of known complications, such as uveal effusion or glaucoma. In many patients, this visual deficiency may correspond to an absent or rudimentary foveal avascular zone and lack

2007 American Journal of Ophthalmology

646. Predictors of poor neurologic outcome after induced mild hypothermia following cardiac arrest. Full Text available with Trip Pro

after resuscitation from CA and treated with TIMH.None of six patients without pupillary reactivity, six without corneal reflexes on day 3, or eight with myoclonus status epilepticus recovered awareness. Two of 14 patients with motor responses no better than extension at day 3 recovered motor responses only after 6 days post-arrest (one at 5 and one at 6 days post-rewarming) and regained awareness.Loss of motor responses better than extension on day 3 was not prognostically reliable after (...) therapeutic induced mild hypothermia for comatose cardiac arrest survivors. None of the patients who lost pupillary or corneal reflexes on day 3 or developed myoclonus status epilepticus recovered awareness.

2008 Neurology

647. Frontalis sling operation using silicone rod for the correction of ptosis in chronic progressive external ophthalmoplegia. Full Text available with Trip Pro

retrospectively reviewed and the clinical characteristics and postoperative surgical results of these patients were analysed. This study was a retrospective, non-randomised, interventional case series and the main outcome measures were margin reflex distance, eyelid contour and corneal status.Seven patients were recruited (one male and six female). The mean age at the time of operation was 29.6 (range 15-62) years. Two patients had unilateral ptosis and five patients had bilateral ptosis. The mean follow-up (...) period was 22.7 (range 1-61) months. Satisfactory lid height was achieved in all patients. Although corneal erosions were detected in five patients 1 month after surgery, these findings eventually resolved in three patients 2 months later, after the use of artificial tear eyedrops and ointments.The frontalis sling operation using silicone rod can safely and effectively correct ptosis in chronic progressive external ophthalmoplegia patients without serious corneal complications.

2008 British Journal of Ophthalmology

648. Pupillary Abnormalities

in response to light (the direct light reflex) and, to a lesser extent, to near accommodation. The other pupil constricts consensually. Dilation of the pupil results from contraction of the smooth cells of the radial muscle, controlled by the sympathetic nervous system. The sympathetic nervous system acts directly on the muscle's cells peripherally and acts centrally by inhibiting the Edinger-Westphal nucleus. Psychosensory reactions are transmitted via the sympathetic system. Constriction of the pupil (...) in response to light or accommodation occurs when the circular muscle, controlled by the parasympathetic nervous system, contracts. Pathways of the pupillary reflex The pathway for pupillary constriction for each eye has an afferent limb taking sensory information to the midbrain, and two efferent limbs (one to each eye). The afferent limb is made up of the retina, the optic nerve and the pretectal nucleus in the midbrain, all on the same side. The efferent limb for pupillary constriction comes from

2008 Mentor

649. 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

650. 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

651. Lowe's (Oculo-cerebro-renal) Syndrome

and because of the propensity to develop . Glaucoma develops in about half and is difficult to treat. Surgical implantation of artificial valves to control the release of intraocular fluid is often required. Corneal keloids may require surgical removal of the scar tissue, or radiation therapy. Corneal transplantation is difficult because of problems in administering the required intensive postoperative care. Sometimes surgical correction of is required. Other surgery Orchidopexy may be required. Medical (...) predisposes to dehydration and metabolic imbalance, which can be severe. They have a tendency to develop due to hypotonia and poor cough reflex. Other causes of death include infection and , and sudden unexplained death can occur. Death usually occurs in the second or third decade of life. Genetic counselling If the proband represents a new mutation, the risk to subsequent children is low. If the mother is a carrier, there is a 50% chance of any son being affected and any daughter being a carrier. Did you

2008 Mentor

652. Macular Disorders

. Abnormalities of any of the answers suggest macular pathology. Patients can use the grid at home and test themselves (remind them to do one eye at a time) [ ] . Examination of the macula Ophthalmoscopy - the macula is visible as a dark circular patch between the vascular arches, the fovea being about 1 disc diameter lateral to the disc itself. The foveola is usually seen as a bright pinpoint yellow reflex at the centre of the macula. If you ask the patient to look directly at the light, the macula (...) . The optimal management for these conditions is discontinuation of the medication where possible and observation in the ophthalmology outpatient clinic. Many resolve in time. Chloroquine and hydroxychloroquine - these both have the potential for retinotoxicity and may also result in corneal deposits. The retinopathy is related to the total cumulative dose and is more marked with chloroquine. Patients present with decreased vision (which may be severe in end-stage chloroquine maculopathy - less than 6/60

2008 Mentor

653. 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

654. Sudden Death

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 (...) 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

2008 Mentor

655. Squints Full Text available with Trip Pro

, 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

2008 Mentor

656. 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

657. Death (Recognition and Certification)

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 (...) 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

2008 Mentor

658. 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 (...) diminution of vision. Burns affecting the fovea centralis. Worsening macular oedema. Serous and/or choroidal detachment. Ocular pain. Anterior chamber adverse effects - eg, burns affecting the cornea or lens. Complications of intravitreal steroids and triamcinolone [ ] Cataract formation. Raised intraocular pressure. Prognosis Background retinopathy will eventually progress to the more severe forms in the majority of individuals. If left untreated, 50% of those with proliferative DR will lose their sight

2008 Mentor

659. 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

660. Dry Eyes

other . In this article In This Article Dry Eyes In this article Synonyms: dry eye syndrome, dysfunctional tear syndrome, keratoconjunctivitis sicca, xerophthalmia (used for dry eye associated with vitamin A deficiency) Tears are a complex solution of water, proteins, salts, lipids and mucins. These play a hydrating, immunological, nourishing and lubricating role. Some of the components are simply there to allow the tears to remain on the corneal surface effectively and the tear/cornea interface has (...) 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

2008 Mentor

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