Correspondence (letter to the editor): Ocular Signs Should Be Given Attention

In his explanations of the examination and treatment of patients in a coma after acute head injury, Firsching primarily pointed out the prognostic importance of unilateral and bilateral pupillary unresponsiveness (1). In patients in a coma, further ocular signs should be heeded, in addition to the pupillary reflex, such as pendular eye movements, nystagmus, ocular bobbing, skew deviation, or conjugate eye deviation. Furthermore, the tonus of the eyelid muscles should be checked, as should the measurement of the opening in incomplete eyelid closure, corneal reflexes should be tested, Bell‘s phenomenon should be checked for, the positioning of the eyes, and enophthalmos or exophthalmos. Noises above the temple and eye region can be auscultated. Unilateral mydriasis indicates ipsilateral brain injury as a result of epidural or subdural hematoma. Mydrasis in this setting can increase further; in intracranial hematoma, the pupil may adopt an oval shape (“football pupil“) (2).