Doll's eye sign, absent
Doll's eye sign, absent: Excerpt from Handbook of Signs & Symptoms (Third Edition)
Negative oculocephalic reflex
An indicator of brain stem dysfunction, the absence of the doll's eye sign is detected by rapid, gentle turning of the patient's head from side to side. The eyes remain fixed in midposition, instead of the normal response of moving laterally toward the side opposite the direction the head is turned.Because conjugate eye movement is lost, one eye may move laterally while the other remains fixed or moves in the opposite direction. An abnormal doll's eye sign usually accompanies metabolic coma or increased intracranial pressure (ICP). Associated brain stem dysfunction may be reversible or may progress to deeper coma with absent doll's eye sign.
History and physical examination
After detecting an absent doll's eye sign, perform a neurologic examination. First, evaluate the patient's level of consciousness, using the Glasgow Coma Scale. Note decerebrate or decorticate posture. Examine the pupils for size, equality, and response to light. Check for signs of increased ICP — increased blood pressure, increasing pulse pressure, and bradycardia.
Medical causes
Brain stem infarction
Brain stem infarction causes absent doll's eye sign with coma. It also causes limb paralysis, cranial nerve palsies (facial weakness, diplopia, blindness or visual field deficits, and nystagmus), bilateral cerebellar ataxia, variable sensory loss, a positive Babinski's reflex, decerebrate posture, and muscle flaccidity.
Brain stem tumor
Absent doll's eye sign accompanies coma in a brain stem tumor. This sign may be preceded by hemiparesis, nystagmus, extraocular nerve palsies, facial pain or sensory loss, facial paralysis, a diminished corneal reflex, tinnitus, hearing loss, dysphagia, drooling, vertigo, dizziness, ataxia, and vomiting.
Central midbrain infarction
Accompanying absent doll's eye sign are coma, Weber's syndrome (oculomotor palsy with contralateral hemiplegia), contralateral ataxic tremor, nystagmus, and pupillary abnormalities.
Pontine hemorrhage
Absent doll's eye sign and coma develop within minutes with pontine hemorrhage, a life-threatening disorder. Other ominous signs — such as complete paralysis, decerebrate posture, a positive Babinski's reflex, and small, reactive pupils — may rapidly progress to death.
Posterior fossa hematoma
A subdural hematoma at the posterior fossatypically causes absent doll's eye sign and coma. These signs may be preceded by characteristic signs and symptoms, such as a headache, vomiting, drowsiness, confusion, unequal pupils, dysphagia, cranial nerve palsies, a stiff neck, and cerebellar ataxia.
Other causes
Drugs
Barbiturates may produce severe central nervous system depression, resulting in coma and absent doll's eye sign.
Special considerations
Don't attempt to elicit doll's eye sign in a comatose patient with suspected cervical spine injury; doing so risks spinal cord damage. Instead, evaluate the oculovestibular reflex with the cold caloric test. Normally, instilling cold water in the ear causes the eyes to move slowly toward the irrigated ear. Cold caloric testing may also be done to confirm an absent doll's eye sign.
Continue to monitor vital signs and neurologic status in the patient with an absent doll's eye sign.
Pediatric pointers
Normally, doll's eye sign isn't present for the first 10 days after birth, and it may be irregular until age 2. After that, this sign reliably indicates brain stem function.
An absent doll's eye sign in children may accompany coma associated with a head injury, near-drowning or suffocation, or brain stem astrocytoma.
Pictures
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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