Eye

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 Anisocoria

Inequality between pupil diameters in : Unilateral intracranial mass

Mydriasis

Anticholinergic Toxicity Sympathomimetics as Cocaine, Amphetamines Carbon Monoxide Poisoning

Miosis

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

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 Signs of cardiovascular disease : arteriosclerosis and hypertension

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

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