Dolls eye movement

The oculocephalic reflex (dolls eye reflex) is an application of the vestibular-ocular-reflex

(VOR) used for neurologic examination of cranial nerves 3,6,and 8, the reflex arch including
brainstem nuclei, and overall gross brainstem function. It is often used to examine patients
in the neurologic critical care setting and may have utility to assess neonates, anesthetized
patients, or dizzy patients. The reflex derives its name from dolls eye appearance that a
patient has if the reflex is positive.
PROCEDURE
The oculocephalic reflex is performed by holding the patients’ eyelids open and moving
their head from side to side. The examination should only be performed on patients with a
stable cervical spine without c-spine precautions. With the patients eyelids open the
examiner observe a positive oculocephalic reflex when the patient moves their eyes
opposite of the rotation of their head, such that their eyes stay looking forward (like a doll’s
eyes). The examiner observes a negative oculocephalic reflex when the patient eyes stay
midline and do not move while the examiner rotates the head. A similar examination is
performable for vertical eye movements. Note that the designation pf “positive”( eyes
moving in the opposite direction of the head movement indicating an intact brainstem
function) or “negative”(eyes moving towards the same direction of the head movement
indicating severe brainstem dysfunction) dolls eyes reflex is an oversimplification and that
some eyes movement with nystagmus can occur in pathologic states. The reflex is
suppressed in a conscious adult with normal neurologic function but is active in a comatose
patients with gross brain stem function, absent if there is damage to the reflex arc.

The reflex arc in the dolls eyes reflex has had extensive research. The vestibulo-ocular-reflex
(VOR) arc consist of a series of brain stem nuclei and the nerves connecting them as well as
the vestibular system and the extra-ocular muscles of the eye. In the most simplified version
of the reflex arc, angular rotation of the head causes endolymph in the horizontal
semicircular canals to rotate opposite to the direction of the head. This causes the ipsilateral
vestibular nerve to activate the ipsilateral vestibular nucleus and the contralateral vestibular
nerve to inhibit the contralateral vestibular nucleus. Both vestibular nuclei then activate or
inhibit both abducens nuclei, which sends signals to the corresponding ipsilateral rectus ana
contralateral oculomotor nucleus through the medial longitudinal fasciculus. The
oculomotor nuclei then activate or inhibit the corresponding ipsilateral meial recti.
Ultimately, the reflex gets elicited if all components of the arc are intact, and a conscious
state does not suppress the reflex.

The examiner should not perform the reflex on those patients with head or neck injuries
that could be further injured by the reflex technique.
CLINICAL SIGNIFICANCE
There are several areas of clinical practice where the dolls eyes reflex has significance:

 Vestibular lesions- Lesion to the vestibular nerve or vestibular nuclei have been
shown to impair the ipsilateral dolls eyes reflex.
 Assessing dizziness- The dolls eye reflex can assess dizziness in the office with rapid
vestibular-ocular reflex testing. Ana abnormal response would show refixation
saccades.
 Psychiatric patients -schizophrenic and bipolar patients can show
abnormal smooth pursuit eye movements (SPEMs), both vertical and horizontal.
However there is evidence that these patients should show an intact dolls eyes
reflex.
  Intensive care unit- The dolls eyes reflex (oculocephalic response) in critically ill
intensive care patients can independently predict altered mental status ( Delirium,
coma, confusion) after cessation of sedation.
 Neonates- Most neonates exhibit an insupressed dolls eye reflex before 11.5 weeks
this can serve as a neonatal milestone in neurologic development
 Anesthesia- There appears to be some utility in assessing the dolls eyes reflex in
ophthalmologic surgery.
 Nursing -Like other reflexes, nursing staff can receive training in evaluating the dolls
eyes reflex in selected patients.
The nurses should know how to elicit the reflex and its prognostic implications. Also it would
be wise to remind the doctor whether a cervical spine injury has been cleared before the
reflect is being elicited in a trauma patients.