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Diabetic Exam
 
 
 
 
Diabetic Exam
Poor diabetic control may manifest in many different ways, with macrovascular and microvascular complications. The diabetic examination is useful for diagnosing these complications, particularly when it comes to the vascular and neurologic examination of the lower limb.
 

Pupillary Examination

 
 

Inspection of Pupils

    • Look For

    • The size of the pupils (dilated, normal, constricted) and equality of size bilaterally.
    • Normal Pupillary Size

    • In the dark - 4-8mm
    • Under bright light - 2-4mm
    • Causes of Bilateral Pupillary Dilation

    • Cerebral lesion - herniation, encephalitis, visual cortex infarct, tumour, trauma, MS
    • Drugs - anticholinergics, SSRIs / SNaRIs, stimulants, barbiturates, methanol
    • Brain stem death
    • Causes of Bilateral Pupillary Constriction

    • Drugs - opiates, antipsychotics, acetylcholine, clonidine
    • Intracranial haemorrhage
    • Horner’s syndrome (bilateral) - autonomic failure, amyloidosis, diabetes
    • Causes of Unequal Pupils (Anisocoria)

    • Physiological (20% of the population - compare with an old photo)
    • Migraine
    • Post-ictal
    • Horner’s syndrome (unilateral)
    • Drugs applied to one eye - pilocarpine, tropicamide, cocaine
    • Intraocular conditions - glaucoma, retinal detachment
    • Optic (II) or oculomotor (III) nerve lesion - trauma, compression, optic neuritis, Guillain barré
    • CNS lesion - trauma, tumour, haemorrhage, infarct, MS

Pupillary Light Reflexes

    • How to Elicit

    • Shine a light into each pupil. Watch to see that both the ipsilateral (direct response) and contralateral (consensual response) pupils constrict as a result of the stimulus.
    • Causes of Absent Pupillary Reflexes

    • Intraocular conditions - glaucoma, retinal detachment
    • Optic (II) nerve lesion - trauma, compression, optic neuritis
    • Midbrain lesion - encephalitis, tumour, trauma, haemorrhage, MS, midbrain infarct
    • Oculomotor (III) nerve lesion - trauma, compression, small vessel ischaemia, Guillain barré
    • Medications - sympathomimetic, parasympatholytic (anticholinergics), barbiturates, methanol
    • Interpretation

    • No direct response - absent reflex in the tested eyeIpsilateral oculomotor nerve (III) lesion
    • No consensual response - absent reflex in opposite eyeContralateral oculomotor nerve (III) lesion
    • No afferent response - absent reflex in one eye when testing either eyeIpsilateral optic nerve (II) lesion
    • No response - absent reflex in both eyes when testing either eyeMidbrain lesion, medications

Swinging Light Test

    • How to Perform

    • Shine a light into one eye, swing it into the other eye, and so on back and forth.
    • Interpretation

    • A relative afferent pupillary defect (RAPD) is present if the affected eye dilates, or constricts briefly followed by dilatation.
    • Causes of RAPD

    • Intraocular haemorrhage
    • Retinal detachment
    • Optic or oculomotor nerve lesion
    • Midbrain lesion

Accommodation

    • How to Assess

    • Ask the patient to focus on a distant object, such as the back wall of the room. Place a finger in front of their field of view and ask them to look at it.
    • Causes of Impaired Accommodation

    • Optic (II) nerve lesion - trauma, compression, optic neuritis
    • Thalamic / occipital / midbrain lesion - encephalitis, tumour, trauma, MS, midbrain infarct
    • Oculomotor (III) nerve lesion - trauma, compression, small vessel ischaemia, Guillain barré
Last updated on November 28th, 2019
 
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