How to evaluate a doll’s eye reflex

An entire neurological assessment of a comatose patient could be difficult. However, brainstem function and specific cranial nerves (III, IV, VI, VIII) could be assessed by examining the oculocephalic reflex, also generally known as the doll’s eye reflex.

How to Assess a Doll’s Eye Reflex (Bickley et al., 2021)

Before attempting to evaluate the oculocephalic reflex, make sure that the patient has a stable cervical spine, without C-spine precautions or neck trauma. Then, keeping the patient’s upper eyelids open, quickly turn the patient’s head to at least one side after which to the opposite. If a coma patient’s brain stem is unbroken, when the pinnacle is turned in a single direction, the eyes move to the wrong way, like a doll’s eyes. If the eyes still look straight (stay within the midline) without moving in relation to the pinnacle position, this has a negative impact on the doll’s eye movements and will indicate damage to the midbrain or pons. This reflex is suppressed in a conscious adult with normal neurological function, but is energetic in a comatose patient with brainstem function. The test could be performed in each vertical and horizontal directions.

Clinical significance (Dishioni and Tadi, 2022)

The doll eye reflex could be utilized in clinical practice in the next areas:

• Lesions within the vestibular nerve or nuclei have been shown to impair the ipsilateral doll visual reflex.
• Vertigo could be assessed using the visual doll reflex in an office setting.
• Abnormal vertical and horizontal eye movements could also be observed in patients with schizophrenia and bipolar disorder. However, these patients should reveal an intact visual doll reflex.
• The positive doll eye reflex in critically ailing intensive care unit patients may predict altered mental status (i.e., delirium, coma, confusion) after discontinuation of sedatives.
• Newborns don’t suppress the doll eye reflex until 11.5 weeks of age; the reflex could be used as a milestone in neurological development.

Remember…

• Do not perform the doll vision examination on patients with whiplash or neck injury.
• The doll’s positive visual reflex (the eyes move in the wrong way to the pinnacle movement) indicates an intact brain stem.
• A negative visual reflex of the doll (the eyes remain within the midline or move in the identical direction as the pinnacle) indicates serious brainstem dysfunction.
• These results apply only to comatose patients. These reflexes are suppressed in a conscious adult with normal neurological function.

AND

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s guide to physical examination and history taking (thirteenth ed.). Wolters Kluwer Health: Philadelphia.
AND
Division, E., & Tady, P. (2022, May 8). Doll eyes.
https://www.ncbi.nlm.nih.gov/books/NBK551716/

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