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ULY CLINIC

20 Julai 2025, 09:18:29

Absent Doll’s Eye Sign

The absent doll’s eye sign also known as Negative Oculocephalic Reflex is characterized by a lack of conjugate lateral eye movement during rapid, passive head rotation in a comatose patient. Normally, the eyes move contralaterally to head movement; in this sign, the eyes remain fixed midline, indicating brainstem dysfunction, specifically involving the midbrain or pons (cranial nerves III and VI). It is a critical clinical indicator in coma evaluation and brain death diagnosis.

Pathophysiology

Loss of the oculocephalic reflex reflects impairment of brainstem pathways mediating conjugate eye movements. The reflex is mediated via the vestibular nuclei and cranial nerves III and VI, integrating inputs from the semicircular canals and ocular muscles.

Clinical Assessment

Perform with the patient supine; gently hold eyelids open.
Rapidly rotate head side to side and observe eye movements.
Normal: Eyes move conjugately opposite to head rotation.
Absent: Eyes remain fixed midline despite head movement.
Avoid testing in patients with suspected cervical spine injury; use caloric vestibular testing instead.

Associated neurologic findings

Coma with absent doll’s eye sign suggests brainstem involvement.
Assess Glasgow Coma Scale score, pupillary size/reactivity, and motor posturing (decorticate/decerebrate).
Monitor for signs of increased intracranial pressure (hypertension, bradycardia, widened pulse pressure).

Differential diagnosis

Etiology	Clinical Features
Brainstem infarction	Coma, cranial nerve III/VI palsies, limb weakness, cerebellar ataxia, positive Babinski, abnormal posturing
Brainstem tumor	Progressive cranial nerve deficits, facial sensory loss, nystagmus, dysphagia, coma with absent reflex
Midbrain infarction	Weber’s syndrome, contralateral hemiplegia, pupillary abnormalities, coma
Pontine hemorrhage	Rapid coma onset, paralysis, small reactive pupils, decerebrate posturing, high mortality
Posterior fossa hematoma	Headache, vomiting, cerebellar signs, cranial nerve palsies, coma
CNS depressant overdose	Barbiturates or sedatives causing coma and absent reflex

Special Testing Considerations

In cervical spine injury, do not perform oculocephalic testing; use cold caloric test for vestibulo-ocular reflex assessment.
Cold water irrigation should induce slow eye deviation toward the irrigated ear in intact brainstem function.

Prognostic Implications

Absent doll’s eye sign confirms brainstem dysfunction and is a key sign in brain death protocols.
May progress from abnormal to absent sign with worsening intracranial pathology.

Pediatric Notes

The reflex is absent or inconsistent in neonates (<10 days) and may be immature until 2 years.
Absence in pediatric coma suggests severe brainstem injury (e.g., trauma, hypoxia, brainstem tumors).

Summary

Absent doll’s eye sign is a vital neurological bedside test indicating brainstem integrity. It assists in localizing lesions, assessing coma severity, and guiding further diagnostic and therapeutic interventions.

References

Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, editors. Harrison’s Principles of Internal Medicine. 21st ed. New York: McGraw-Hill; 2022.
Ropper AH, Samuels MA. Adams and Victor’s Principles of Neurology. 11th ed. New York: McGraw-Hill Education; 2019.
Brazis PW, Masdeu JC, Biller J. Localization in Clinical Neurology. 6th ed. Philadelphia: Wolters Kluwer; 2016.
Greenberg DA, Aminoff MJ, Simon RP. Clinical Neurology. 9th ed. New York: McGraw-Hill; 2019.
Iserson KV. Improvised Medicine: Providing Care in Extreme Environments. 2nd ed. New York: McGraw-Hill Education; 2015.
Aminoff MJ. Neurology and General Medicine. 4th ed. San Diego: Academic Press; 2014.