Eye

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For the cause of coma
Eye brow
Loss of outer 1/3 as in myxedema

Eye lid
Puffy eye lid in cases of Myxedema Uraemia in Nephrotic syndrome Graves Disease Long eye lash in TB meningitis

Conjunctiva
Sub-conjunctival hge Intra-cranial hge Conjunctival Kaposi sarcoma: slow growing malignancy occurring in AIDS patients

Sclera
Scleral Icterus Hyperbilirubinemia associated with Jaundice Blue in TB

Pupil Examination
Size and shape
Inequality between pupil diameters in : Unilateral intracranial mass

Anisocoria Mydriasis

Anticholinergic Toxicity Sympathomimetics as Cocaine, Amphetamines Carbon Monoxide Poisoning

Cholinergic Toxicity Opiate overdose Organophosphate Toxicity Horner’s Syndrome Pontine hge or lesion

Miosis

Pupil movements
Oculo-gyric crisis Oculovestibular Testing Cold Calorics Nystagmus both eyes slow toward cold, fast to midline : Not comatose Both eyes tonically deviate toward cold water : Coma with intact brainstem No eye movement : Brainstem injury Movement only of eye on side of stimulus : Internuclear ophthalmoplegia Oculocephalic Reflex Doll’s Eyes If Brainstem intact : Eyes deviate contralaterally as looking away from rotation If Brainstem injury : Eyes follow direction of head rotation

Nystagmus
Spontaneous nystagmus reflects interaction between the oculovestibular system and the cerebral cortex and thus is rare in coma Retractory nystagmus may be seen with midbrain lesions

Funduscopic Exam
Papilledema in cases of
Tumor of the brain, spinal cord, skull Brain abscess Intracranial hemorrhage Hydrocephalus Intracranial infection Head injury

Diabetic retinopathy
Flame shaped hemorrhages Retinal or macular edema In advanced cases, a macular star (ring of exudates from the disc to the macula) and disc edema Sheathing of veins Cotton wool patches Papilloedema Atheromatous emboli in retinal vasculature Arterial plaques Retinal arterial micro aneurysms Intra-retinal lipid exudates : hard exudates

Signs of cardiovascular disease : arteriosclerosis and hypertension

Extra-ocular Movements
Normal movements
Requires intact MLF Intact Brainstem Most comatose patients show roving eye movements Both eyes cross the midline

Limited extraocular muscle movement
Brain abscess & cancer Subdural & Extradural hematoma Diabetes

For the grade of coma
Glasgow Coma Scale
Grade I Does not open eyes Grade II Opens eyes in response to painful stimuli Grade III Opens eyes in response to voice Grade IV Opens eyes spontaneously Grade V N/A Grade VI N/A

by :

www.ayklam.com

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