Doll's eye sign, absent [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 side opposite the direction the head is turned. (See Testing for absent doll’s eye sign.)

The absence of doll’s eye sign indicates injury to the midbrain or pons, involving cranial nerves III and VI. It typically accompanies a coma caused by lesions of the cerebellum and brain stem. This sign usually can’t be relied upon in a conscious patient because he can control eye movements voluntarily. Absent doll’s eye sign is necessary for a diagnosis of brain death.

A variant of absent doll’s eye sign that develops gradually is known as abnormal doll’s eye sign. 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 in patients with this 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 (LOC), 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 systolic blood pressure, widening pulse pressure, and bradycardia.

Medical causes

Brain stem infarction

This infarction causes absent doll’s eye sign with a 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 a coma in this type of tumor. This sign may be preceded by hemiparesis, nystagmus, extraocular nerve palsies, facial pain or sensory loss, facial paralysis, diminished corneal reflex, tinnitus, hearing loss, dysphagia, drooling, vertigo, dizziness, ataxia, and vomiting.

Central midbrain infarction

Accompanying absent doll’s eye sign are a coma, Weber’s syndrome (oculomotor palsy with contralateral hemiplegia), contralateral ataxic tremor, nystagmus, and pupillary abnormalities.

Cerebellar lesion

Whether associated with abscess, hemorrhage, or tumor, a cerebellar lesion that progresses to a coma may also cause an absent doll’s eye sign. The coma may be preceded by headache, nystagmus, ocular deviation to the side of the lesion, unequal pupils, dysarthria, dysphagia, ipsilateral facial paresis, and cerebellar ataxia. Characteristic signs of increased ICP may also occur, including decreased LOC, abnormal pupillary responses, increased systolic blood pressure, widening pulse pressure, bradycardia, altered respiratory pattern, papilledema, and vomiting.

Pontine hemorrhage

Absent doll’s eye sign and a coma develop within minutes in this 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 this location typically causes absent doll’s eye sign and a coma. These signs may be preceded by characteristic signs and symptoms, such as headache, vomiting, drowsiness, confusion, unequal pupils, dysphagia, cranial nerve palsies, stiff neck, and cerebellar ataxia.

Other causes

Drugs

Barbiturates may produce severe central nervous system depression, resulting in a coma and absent doll’s eye sign.

Special considerations

Don’t attempt to elicit doll’s eye sign in a comatose patient with a 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 dysfunction. An absent doll’s eye sign in children may accompany a coma associated with head injury, near drowning, suffocation, or brain stem astrocytoma.

Pictures

Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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