Journal ofNeurology, Neurosurgery, and Psychiatry, 1972, 35, 877-880 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.35.6.877 on 1 December 1972. Downloaded from
Corneal reflex in hemisphere disease
R. T. ROSS From the Section ofNeurology, Department of Medicine, University of Manitoba, and the Winnipeg General Hospital, Winnipeg R3E OZ3, Canada
SUMMARY The contralateral corneal reflex may be absent in patients with a deep lesion of the parietal lobe. Frontal and temporal lobe lesions apparently do not interfere with this reflex.
The corneal reflex is part of the neurological paresis was stimulated. The increase, however, examination. In lesions of the fifth and seventh was only a few milliseconds and the number of cranial nerves, as well as intrinsic disease of the cases was thought to be too small for any valid brain-stem, the integrity of the corneal reflex conclusions. may contribute to the diagnosis. In other studies of the blink reflex by Rush- The purpose of this paper is to show the worth (1962), Bender (1968), Bender, Maynard, corneal reflex as a superficial reflex, somewhat and Hastings (1969), Kimura, Powers, and Van
analogous to the abdominal reflexes, which may Allen (1969), and Young and Shahani (1969), guest. Protected by copyright. disappear in disease of the contralateral hemi- there are few, if any, references to hemisphere sphere. Oliver (1952) described three patients, lesions affecting the reflex on the appropriate each of whom had an intracerebral lesion and an side. abnormal corneal reflex. The first had a left The following are brief summaries of 13 intracerebral, frontoparietal haematoma with an patients, all with intracranial lesions and some absent right corneal reflex; the second a left with an absent corneal reflex on the appropriate frontoparietal tumour with an absent right side. corneal reflex, and the third, a right temporo- parietal tumour with an absent left corneal ABSENT CORNEAL REFLEXES reflex. This paper of Oliver's seems to have had very MR. S. E. (Hospital no. 307606) This 24 year old school teacher presented with a one year history of little impact on the literature or standard neuro- left sided Jacksonian sensory fits and difficulty in logical textbooks. fine movements involving the use of his left hand. In De Jong's book, The Neurologic Examina- Examination revealed bilateral papilloedema, an tion (1967), the fact is not mentioned and in absent left corneal reflex, and a gross sensory Brain's Diseases of the Nervous System by Brain disturbance of the left side of his body. There was and Walton (1969), it is also omitted. However, diminished pain sensitivity, astereognosis, inaccurate in the Handbook of Clinical Neurology (1969) the number writing sensibility, and two point discrimina- http://jnnp.bmj.com/ reduced or absent corneal reflex in disease of the tion was at 12 mm on the tip of his left index finger contralateral hemisphere is mentioned briefly. compared with 3 mm on the right. His left arm and Brodal (1969) mentions Oliver's paper in a foot leg were weak, ataxic, and he had a left extensor states that the plantar response. note. Monrad-Krohn (1964) Investigations revealed a large, deep, cystic astro- corneal reflex may be lost in the presence of a cytoma in the parietal region. suprasegmental intracerebral lesion. The blink reflex has been studied by many MRS. E. P. (Hospital no. 307596) She was a 61 year on September 25, 2021 by authors. Magladery and Teasdall (1961) exam- old housewife who had been stricken with a severe ined eight patients suffering from hemisphere occipital and frontal headache and vomiting, and vascular lesions and found a slightly increased within half an hour became unconscious. Examina- latency when the cornea on the side of the hemi- tion revealed a comatose lady with stiff neck, and 877 878 R. T. Ross J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.35.6.877 on 1 December 1972. Downloaded from bilateral extensor plantar responses. About two carotid artery. Nine days after admission she died weeks later she had recovered from the subarachnoid from a pulmonary embolus. There had been no haemorrhage and examination was normal. Carotid change in her neurological findings up to this time. angiography revealed a multilobed aneurysm of the left middle cerebral artery just proximal to the INTACT CORNEAL REFLEXES trifurcation. At surgery the aneurysm ruptured necessitating a clip on the main trunk of the middle MR. E. s. (Hospital no. 256006) This 40 year old cerebral artery. Postoperatively she showed a dense roustabout began to complain of anginal pain in right hemiparesis, almost total sensory neglect, 1968 and in December 1971 was admitted with a aphasia, and an absent right corneal reflex. Post- myocardial infarct. Four days after admission he operative angiography showed the avascular terri- lost his speech and was found to have a paresis of tory of the middle cerebral with little collateral his right face, arm and leg. Visual fields were filling from other vessels. probably normal as was his sensory examination. The absent corneal reflex persisted up to six The paresis was most marked in face and hand. weeks after the operation. During this time her Investigations revealed what was probably an speech began to return and her leg improved to the embolic occlusion of the posterior parietal branch of point of standing and walking with assistance. the left middle cerebral artery. Both corneal reflexes were present, although the response of the right was RM .M. (Hospital no. 307684) This 59 year old slower than the left. (First neurological examination housewife was found unconscious. On examination was about 50 hours after the stroke). Five days after she was comatose, responding only to deep pain, and the cerebral event the corneal responses were normal then only when the painful stimulus was applied to and equal and the dysphasia and hemiparesis were the right side of her body. Over the next 10 to 12 about 75%4 recovered. One wonders if the right
days she gradually wakened and revealed a left corneal reflex might have been absent had he beenguest. Protected by copyright. hemiplegia, absent left corneal reflex, and left examined in the first 24 hours of this illness. extensor plantar response. Carotid angiography revealed an occlusion of the right middle cerebral MR. J. E. (Hospital no. 308312) This 20 year old artery at its origin. A thrombus was seen in the distal cab driver had a six month history of increasing portion of the carotid artery. Anastomotic circula- frontal and occipital headache, intermittent vomit- tion into the infarcted area was negligible. Several ing, and photophobia. Examination revealed bi- weeks after admission when she was fully conscious lateral papilloedema, full visual fields, and weakness and making some recovery in her paretic leg, the and slowness on voluntary movement of the lower corneal reflex on the left remained absent. portion of his left face. His corneal reflexes were present and equal. His left hand and arm were MR. J. M. (Hospital no. 354251) This 81 year old clumsy and incoordinated for fine, rapid, alternating, retired man suddenly developed a paralysis of his movements and the left hand was weak. Two points left face, arm and leg with left homonymous hemi- applied to his right index finger could be distin- anopsia, absent left corneal reflex, and no disturb- guished when separated by 2 to 3 mm while they ance in consciousness. Investigations revealed a merged on the left index finger when separated by 5 thrombosis of his right internal carotid artery 1 cm to 6 mm. Investigations revealed a meningioma, beyond the bifurcation in the neck. No collateral 7 cm in diameter, overlying the convexity of the circulation was seen from the external carotid right hemisphere. About 80% of the tumour was system or the contralateral carotid artery. One anterior to the Rolandic fissure. The anterior month after onset there was no significant change in cerebral vessels were shifted 12 mm to the left of the http://jnnp.bmj.com/ the hemiparesis and the left corneal reflex remained mid line. absent. Postoperatively his face and arm were weaker for about 10 days. Several examinations during this time MRS. M. c. (Hospital no. 354287) This 78 year old showed both corneal reflexes intact. Two points lady was admitted with a hemiparesis of sudden applied to his left index finger merged at 11 to 12 mm onset and no disturbance of consciousness. On separation. examination she revealed paresis of left face, arm and Three patients with unilateral subdural haema- leg, a left homonymous hemianopsia, and an absent tomata were examined. They showed various degrees on September 25, 2021 by left corneal reflex. Investigations showed a throm- of unconsciousness and minimal local signs of intra- bosis of her right internal carotid artery distal to the cranial disease. Their mid-line vascular structures bifurcation in the neck. There was no collateral were shifted between 4 and 12 mm away from the filling from the external carotid or the contralateral midline. One haematoma was frontal, the other two 879 Corneal reflex in hemisphere disease J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.35.6.877 on 1 December 1972. Downloaded from
SUMMARY
Patient + complaints Lesion Location Corneal reflexes
Mr. S. E. Right parietal cystic Rt. = present Left-sided Jacksonian sensory fits glioma Lt. = absent
Mrs. E. P. Surgical clip on left Rt. = absent Postoperative right hemiplegia middle cerebral Lt. = present artery at origin c,1 Mrs. M. M. Occlusion of right Rt. = present Acute left hemiplegia and coma middle cerebral Lt. = absent artery
Mr. J. M. Occlusion of right Rt. = present Acute left hemiplegia internal carotid Lt. = absent artery in neck
Mrs. M. C. Occlusion of right Rt. = present Acute left hemiplegia internal carotid 0 Lt. = absent
artery in neck guest. Protected by copyright.
Mr. E. S. Occlusion of posterior Rt. = slow Myocardial infarction plus right parietal branch of Lt. = present hemiparesis and aphasia left middle cerebral artery
Mr. J. E. Right parietocentral Rt. = present Headaches, vomiting and convexity menin- Lt. = present photophobia gioma
Three patients with headache and Subdural haema- Rt. = present drowsiness. Variable, minimal, tomata Lt. = present localizing signs of intracranial disease
Mrs. E. F. Right fronto- Rt. = present Progressive lethargy, confusion, and temporal glioma Lt. = present left hemiparesis http://jnnp.bmj.com/
Mr. K. F. Left mid-temporal Rt. = present Psychomotor seizures, dysphasia, and astrocytoma Lt. = present right facial weakness 0
Mr. R. R. Right fronto- Rt. = present on September 25, 2021 by Progressive mental slowing, headache, temporal glioma Lt. = present and left-sided weakness
FIGURE The cases are summarized in the Figure. R. T. 880 Ross J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.35.6.877 on 1 December 1972. Downloaded from were centroparietal. None of these patients exhibited parietal lobe seem most likely to result in an slow or absent corneal reflexes at any time in their absent contralateral corneal reflex. hospital stay. Frontal and temporal lobe lesions apparently do not interfere with this reflex. Similarly, MRS. E. F. (Hospital no. 121567) This 81 year old superficial lesions-in this series represented by lady was admitted with a six month history of pro- a convexity meningioma and three subdural gressive lethargy, confusion, and a slowly pro- haematomata-do not interfere with the corneal gressive paresis of her left face, arm, and leg. No reflex. papilloedema was seen, her visual fields were full, All the patients described with absent or and both corneal reflexes were present. Investigations slowed corneal reflexes had other unequivocal showed a large frontotemporal glioma. signs of intrinsic hemisphere disease. No patients have been seen in whom the absent corneal MR. K. F. (Hospital no. 240331) This 62 year old reflex was the first or major physical sign of a school teacher was first seen one year earlier because subcortical, parietal lesion. ofseveral generalized epileptic seizures. All investiga- tions at that time were normal. In October 1971 he REFERENCES was seen again because of confusion, psychomotor Bender, L. F. (1968). Blink reflex test. Electroencephalography seizures, and headaches. Examination showed a and Clinical Neurophysiology, 25, 409. moderate expressive dysphasia, weakness of the Bender, L. F., Maynard, F. M., and Hastings, S. V. (1969). lower portion of his right face, and bilaterally normal The blink reflex as a diagnostic procedure. Archives of corneal reflexes. Physical Medicine, 50, 27-31. Brain, W. R. (1969). Brain's Diseases of the Nervous System, Investigations showed a left mid-temporal astro- 7th edition. Revised by Lord Brain and J. N. Walton. cytoma. Postoperatively the corneal reflexes were Oxford University Press: London. guest. Protected by copyright. both present. Brodal, A. (1969). Neurological Anatomy in Relation to Clinical Medicine, 2nd edition. Oxford University Press: London. MR. R. R. (Hospital no. 307358) This 61 year old De Jong, R. N. (1967). The Neurologic Examination. 3rd edition. Harper: New York. pulp cutter was admitted with a six month history of Kimura, J., Powers, J. M., and Van Allen, M. W. (1969). progressive mental deterioration, headache, and Reflex response of orbicularis oculi muscle to supraorbital weight loss. Examination showed a confused, drowsy nerve stimulation. Archives of Neurology, 21, 193-199. man with paresis of left face, arm, and leg, and Magladery, J. W., and Teasdall, R. D. (1961). Corneal reflexes. An electromyographic study in man. Archives of bilateral papilloedema. Both corneal reflexes were Neurology, 5, 269-274. present. Investigations showed a large, cystic, Monrad-Krohn, G. H. (1964). Clinical Examination of the avascular, right temporal lobe tumour which at Nervous System, p. 207. Lewis: London. surgery was found to be a glioblastoma. Post- Oliver, L. C. (1952). The supranuclear arc of the corneal reflex. Acta Psychiatrica Scandinavica, 27, 329-333. operatively his corneal reflexes were unchanged. Rushworth, G. (1962). Observations on blink reflexes. Journal of Neurology, Neurosurgery, and Psychiatry, 25, 93-108. CONCLUSIONS Vinken, P. J., and Bruyn, G. W. (Eds.) (1969). Handbook of Clinical Neurology, Vol.2, p. 56 and p. 239. North Holland: The absent corneal reflex can be a sign of Amsterdam. Young, R. R., and Shahani, B. (1969). An EMG study of cerebral disease. From the small number of cutaneous blink reflexes. Electroencephalography and patients presented here, deep lesions of the Clinical Neurophysiology, 26, 635. http://jnnp.bmj.com/ on September 25, 2021 by