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Corneal Reflex

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661. Abdominal Examination

naevi (liver disease). Xanthelasma (symmetrical yellow plaques around the eyelids) may be present in primary biliary cirrhosis or chronic biliary obstruction. Kayser-Fleischer rings (a brown-yellow ring in the outer rim of the cornea) may be present in Wilson's disease. [ ] Leaning over the face to inspect respiration can be used to smell the patient's breath - eg, for alcohol. Hyperventilation may be a sign of acidosis (chronic kidney disease). Examination of the hands Look for: Whether the hands (...) of the fingers for deep palpation, sometimes superimposing the other hand's fingers for an even distribution of pressure. This technique can reach progressively deeper through each relaxation phase of respiration. Develop your own routine, examining each region of the abdomen in turn, starting away from any site of pain. Look for signs of localised guarding (the reflex tensing of the abdominal muscles over the painful area which represents peritonism) and rebound tenderness (initial pressure does not cause

2008 Mentor

662. 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

663. Blepharospasm

. It is thought that there is a defect in this neuronal circuit activity. The precise mechanism is not known but it is likely that there is more than one defective locus resulting in neurotransmission overload and blepharospasm. There are cases of secondary blepharospasm due to identifiable organic disease. Ocular causes include: Eye trauma (mechanical, chemical or thermal) - particularly to the cornea - will cause acute blepharospasm. Blepharitis. Conjunctivitis, iritis, keratitis. Dry eye. Other chronic lid (...) in these patients but has not been widely studied and therefore little is known of this at present. [ ] Untreated, the condition can cause severe psychological distress and is associated with significant psychiatric comorbidity. Investigations Reflex blepharospasm to a secondary cause must be ruled out but, otherwise, isolated blepharospasm does not usually require investigating. Any associated neurological problem should prompt a neurology review. The Blepharospasm Disability Index is a scale used to assess

2008 Mentor

664. 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

665. 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

666. Autonomic Neuropathy

be no sweating or reduced sweating (anhidrosis and hypohidrosis), but excessive sweating (or hyperhidrosis) can occur as a compensatory mechanism. Temperature regulation Hypothermia and hyperpyrexia can result from disruption of the various temperature regulatory mechanisms. Sweating, shivering and vasoactive reflexes can be affected. Face Pallor. Reduced or absent sweating. Vision Blurring of vision. Tunnel vision. Light sensitivity. Difficulty focusing. Reduced lacrimation. Gradual reduction of pupillary (...) size. Cardiovascular Orthostatic hypotension (often associated with or exacerbated by eating, exercise and raised temperature). Other orthostatic symptoms ( for example, nausea, palpitations, light-headedness, tinnitus, shortness of breath). Syncope (may occur with micturition, defecation). Inability to stand without syncope (severe cases). Arrhythmias. Supine hypertension. Loss of diurnal variation in blood pressure (BP). Respiratory In those with diabetes, reduced bronchoconstrictor reflexes have

2008 Mentor

667. 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

668. Coloboma

In This Article Coloboma In this article Coloboma comes from the Greek word koloboma , meaning curtailed. It is used to describe a developmental defect of the eye occurring at embryonic stage. It can involve one or more ocular structures, including the cornea, iris, ciliary body, lens, retina, choroid and optic disc. It most commonly involves the inferonasal quadrant of the eye, and can be unilateral or bilateral, and is often associated with microphthalmia. [ ] Congenital coloboma can occur as an isolated (...) . Zonule and ciliary body coloboma This causes a defect in the zonular fibres around the lens; the ciliary body may also be affected. (The lens tissue itself is not involved.) As a result, the lens may contract segmentally with a notch in the affected region. The condition is therefore sometimes inaccurately termed lens coloboma. Retinochoroidal (choroidal) coloboma Coloboma of the cornea, iris, ciliary body, choroid, retina and/or optic nerve arises from failed or incomplete closure of the embryonic

2008 Mentor

669. 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

670. 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

671. 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

672. 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

673. Heerfordt's Syndrome

glands in isolation occurs frequently in sarcoidosis. Strictly, to fit the criteria of this syndrome, they must all present in combination, along with episodes of fever. Other features of sarcoidosis may co-exist with the syndrome, such as skin lesions and evidence of thoracic involvement. It represents a form of neurosarcoidosis, so there may be other neurological involvement such as meningism, or other cranial nerve lesions leading to ophthalmoplegia, pupillary reflex dysfunction or other (...) motor neurone facial nerve palsy of abrupt onset in young adults is virtually always due to sarcoidosis. There may be accompanying signs of meningism. Eyes Anterior uveitis is painful and presents with: Miosis. Pupillary irregularity. Injected conjunctivae next to the cornea (so-called perilimbal flush). Fundoscopy may show retinal detachment or vasculitis and papilloedema if there is posterior uveitis. Severe cases may show hypopyon - a collection of yellowish inflammatory exudate and cells

2008 Mentor

674. 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

675. 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

676. 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 (...) of the lateral orbital rim while others measure the relative difference between each eye Keratometry - this is the measurement of the corneal curvature, which determines the power of the cornea. Differences in power across the cornea result in astigmatism. Keratometry can be done manually or using automated devices. Keratometry allows visualisation of the pre-corneal tear film and a dynamic view of the surface of the cornea and of the tear film. You can recognise areas of corneal surface irregularity

2008 Mentor

677. 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

678. Endophthalmitis

, particularly in contact lens wear (high-risk factors include extended wear and poor hygiene), where there is pre-existing corneal disease and, occasionally, in other conditions (eg, chronic blepharoconjunctivitis or dacrocystitis, tear film deficiency or topical steroid therapy). If this is severe, there may be progressive ulceration of the cornea which can lead to a bacterial endophthalmitis. Such patients are usually already under the care of an ophthalmic team. Differential diagnosis There are a number (...) 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

2008 Mentor

679. 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

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

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 (...) (taste and salivation) on the medial side of the middle ear, whence it turns sharply (and the chorda tympani leaves), to emerge through the stylomastoid foramen to supply all the muscles of facial expression, including the platysma. Presentation Weakness of the muscles of facial expression and eye closure. The face sags and is drawn across to the opposite side on smiling. Voluntary eye closure may not be possible and can produce damage to the conjunctiva and cornea. In partial paralysis, the lower

2008 Mentor

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