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Rajiv Gandhi University of Health Science, Karnataka
Curriculum Development Cell
CONFIRMATION FOR REGISTRATION FOR SUBJECTS FOR DISSERTATION
Registration No.
:
Name of the candidate
: Ms. REMYA HARIDAS
Address
: #160, CHELIKERE,BANASWADI OUTER
ROAD, BEHIND BTS BUS DEPOT,
KALYAN NAGAR, BANGLORE 43
Name of the Institution
: Banglore city college of Nursing
Course of Study and Subject
: MSc Nursing in MSN
Date of submission
:
Title of study
: “A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING
PROGRAMME ON KNOWLEDGE REGARDING THE IMPORTANCE OF PUPILLARY
CHANGES IN NEUROLOGICAL CLIENTS AMONG STAFF NURSES IN SELECTED
HOSPITALS AT BANGALORE”
Brief resume of intended work : Attached
Signature of the Student
:
Guide Name
: Mrs. VIJAYA LAKSHMI
Remarks of the guide
:
Signature of the guide
:
Co-Guide Name
: Mrs. VIJAYA LAKSHMI
Signature of Co-Guide
:
HOD Name
:
Signature of the HOD
:
Principal name
:
Principal mobile No.
:
Principal E-mail ID
:
Principal signature
:
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES.
BANGALORE, KARNATAKA.
“A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED
TEACHING PROGRAMME ON KNOWLEDGE REGARDING THE
IMPORTANCE OF PUPILLARY CHANGES IN NEUROLOGICAL
CLIENTS AMONG STAFF NURSES IN SELECTED HOSPITALS AT
BANGALORE”
SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
Miss. REMYA HARIDAS
BANGALORE CITY COLLEGE OF NURSING
BANGALORE -43, KARNATAKA
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE,
KARNATAKA.
SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1
NAME OF THE CANDIDATE
AND ADDRESS
Miss. Remyaharidas
1st year M.sc Nursing.
Bangalore City College of Nursing
Bangalore-560043
KARNATAKA
2
3
4
5
NAME OF THE INSTITUTION
COURSES OF THE STUDY
AND SUBJECT
Bangalore City College of Nursing
Banglore
M.Sc(N) 1st year
MEDICAL SURGICAL NURSING
DATE OF ADMISSION
TITLE OF THE SUBJECT
A STUDY TO EVALUATE THE EFFECTIVENESS
OF STRUCTURED TEACHING PROGRAMME ON
KNOWLEDGE REGARDING THE IMPORTANCE
OF PUPILLARY CHANGES IN NEUROLOGICAL
CLIENTS AMONG STAFF NURSES IN SELECTED
HOSPITALS AT BANGALORE
6. BRIEF RESUME OF INTENTED WORK
INTRODUCTION:
HEALTH CAN BE DEFINED AS A CONDITION OF BEING SOUND IN BODY, MIND OR
SPIRIT ESPECIALLY FREEDOM FROM PHYSICAL DISEASE OR PAIN.
To be in good health its important that each and every in our body should function
properly. Eyes is an important organ which most of us take it for granted. It’s a highly
specialized sense organ which unlike most organ of body, is available to external examination
.One of its external structure include pupils. The pupil is the space that dilates and constricts in
response to light. Normal pupils are round and constrict symmetrically when a bright light shines
on them. About 20% of population have pupils that are slightly unequal in size that respond
equally to light.[1]
Different neuroanatomical pathways are involved in the control of pupil , the integrity and
the functionality of these neurological pathways can be often be ascertained through the
analysis and interpretation of pupillary behavior .This makes the pupil size and the pupillary light
reflex an important factor to be considered in many clinical conditions. More specifically , the
location of the pupillomotor nuclie and efferent occulomotor nerve is important for assessing the
onset of descending transtentorial herniation and brainstem compression ,its has also been
shown through blood flow imaging the pupillary changes in neurological patients in ICU are
highly correlated with brainstem oxygenated and perfusion or ischemia[2] . High intracranial
pressure in a brain injured patient result more frequently in poor neurological outcomes and
death. High intracranial pressure are associated with pupillary abnormalities of brain injured
patient.
The signs of pupil problems can be noted by change in pupil size, which can occur as a
result of medications drugs and toxins. Some neurological conditions such as stroke, brain
tumor and injury to the brain can also cause change in pupil size on both eyes. The pupillary
mechanism can also be characterized by different neuronal and mechanical nonlinearitis.
Pupillary evaluation in the clinical settings in often performed in very subjective manner
with a pen flash light for reactivity and a pupil gauge for pupil size. Pupil reaction to light should
be brish and after removal of light source the pupil should return to its original size. There
should also be a consensual reaction to the light source that is the opposite pupil also constricts
when the light source is applied to one eye.
In addition to controlling the amount of light that enters the eye, the pupillary
light reflex provides a useful diagnostic tool. It allows for testing the integrity of the
sensory and motor functions of the eye. Under normal conditions, the pupils of both eyes
respond identically to a light stimulus, regardless of which eye is being stimulated. Light entering
one eye produces a constriction of the pupil of that eye, the direct response, as well as a
constriction of the pupil of the unstimulated eye; the consensual response Comparing these two
responses in both eyes is helpful in locating a lesion.
For example, a direct response in the right pupil without a consensual
response in the left pupil suggests a problem with the motor connection to the left pupil (perhaps
as a result of damage to the nerve or Edinger-Westphal nucleus of the brainstem[3]). Lack of
response to light stimulation of the right eye if both eyes respond normally to stimulation of the
left eye indicates damage to the sensory input from the right eye (perhaps to the right retina
or optic nerve.
6.1 NEED FOR STUDY:
Medical caregivers examine pupil size because they can be directly correlated to
health conditions. In this case, it isn’t only the size of the pupils that are noted but their
reactivity and equality too. In normal circumstances, pupils should be neither large nor
small, but average. If extra light is supplied, both pupils should constrict and if surroundings
become darker, both pupils should dilate, equally. What happens in one eye should also
happen in the other, giving a bilateral reaction.
Since nurse is also one of the important personality in the medical field, the nurse
practitioners should have a fair knowledge about pupillary changes among the neurological
clients. The pupillary evaluation in the clinical settings is ofen performed in very subjective
manner with a pen flash light for reactivity and a pupil gauge for pupil size , which can be
used by the nurse practitioner also.
Traumatic brain injuries (TBIs) affect more than 1.4 million Americans annually[4]
Nurses caring for these patients routinely perform serial neurologic assessments, including
pupillary examinations. While nurses are likely familiar with basic components of the
pupillary examination, some confusion about more specific aspects of the examination and
the physiologic basis of the pupillary response may still remain. Therefore, it is important to
identify the key components of a pupillary examination and its associated physiologic
response. So once they know how to perform this pupillary examination, it will be a great
help to the patients.
The pupillary changes can be mostly seen in the cases such as brain injury, stroke
,brain tumer, thired nerve palsy. Horner’s syndrome some of the medications such as
atropine steroids contraceptives etc and early detection of these changes may save the life
of the patients. Appropriate training and ongoing professional development in this field of
study are essential for optimised clinical outcomes. Therefore the identification of pupillary
changes among the critically ill patient may prevent further detoriation of their health
condition. The pupillary light reflex is a reflex that controls the diameter of the pupil, in
response to the intensity (luminance) of light that falls on the retina of the eye, thereby
assisting in adaptation to various levels of darkness and light, in addition
to retinal sensitivity.[5] Greater intensity light causes the pupil to become smaller (allowing
less light in), whereas lower intensity light causes the pupil to become larger (allowing more
light in). Thus, the pupillary light reflex regulates the intensity of light entering the eye.
Twenty-two patients with acute optic neuritis were studied by the techniques of infrared
pupillometry and visual evoked responses (VER) to pattern reversal. A relative afferent pupillary
defect was found in all cases and the magnitude of this defect was found to be related to the
amplitude, but not to the latency, of the VER. During follow-up the afferent defect was found to
remain persistently abnormal while other methods of clinical evaluation could not demonstrate
abnormality reliably. The amplitude of the VER also remained low.[6]
Emergency room physicians routinely assess the pupillary reflex because it is useful for
gauging brain stem function. Normally, pupils react (i.e. constrict) equally. Lack of the pupillary
reflex or an abnormal pupillary reflex can be caused by optic nerve damage, oculomotor nerve
damage, brain stem death and depressant drugs, such as barbiturates. Therefore involvement
of nurses in assessment of pupillary reflexes among the neurological clients is considered as a
vital , to detect the changes in brain stem function..
Early detection of brain death can also be done using the pupillary reflexes to external
stimuli, as such organ transplantation can also be promoted by using this as a tool ,after
confirming the brain death with additional scanning method such as CT Scan ,MRI etc ..
The focus of this study is mainly to evaluate the knowledge among the staff nurses who
come in direct contact with the neurological clients of importance of pupillary reflexes and also
to improve their care by providing knowledge regarding management of pupillary changes in
these patients…
6.2 REVIEW OF LITERATURE:
Review of literature is the key step in the research process. It improves the systematic
identification, location, and summary of the written material that contains information of research
problem.
The overall purpose of the review of literature is to develop a strong knowledge base to
carry out research and other scholarly education.
Pupillographic findings in 39 consecutive cases of harlequin syndrome was done In this,
a consecutive series of 39 patients with harlequin syndrome who were referred to a tertiary
autonomic function laboratory underwent slit-lamp examinations. Results were compared with a
meta-analysis of all previously reported cases of harlequin syndrome. From this the following
conclusions were made .The frequent coexistence of harlequin and Horner syndromes without
other neurologic deficits suggest pathologic changes affecting the superior cervical ganglion.
Because either syndrome may occur alone, damage is apparently selective. Among
the patients with harlequin syndrome who also have tonic pupils and tendon areflexia (HolmesAdie syndrome), we postulate a ganglionopathy affecting not merely the (sympathetic) superior
cervical ganglion, but also the (parasympathetic) ciliary and dorsal root ganglia. Because we
found that more than 10% of patients had an undisclosed mass lesion in the chest or neck or a
generalized
autonomic
neuropathy,
we
recommend
a
targeted
evaluation
in
selected patients with harlequin syndrome.[7]
A study related to Neurological features of congenital fibrosis of the extraocular muscles
type 2 with mutations in PHOX2A was done .Congenital fibrosis of the extraocular muscles type
2 (CFEOM2) is a complex strabismus syndrome that results from mutations in the
homeodomain transcription factor PHOX2A. To define the clinical and neuroimaging features
of patients with this autosomal recessive syndrome, the study included 15 patients with
genetically defined CFEOM2. All patients underwent full neurological, neuro-ophthalmological
and orthoptic assessments.[8]
Twelvepatients had pupillary pharmacological testing and nine had 3.0 tesla MRI of the
brain, brainstem and orbits. They concluded the CFEOM2 phenotype and neuroimaging are
both consistent with the congenital absence of CNs 3 and 4. Additional features included
presence of most central ocular motility reflexes, a central lack of pupillary responsiveness of
uncertain aetiology and modest phenotypic variability that does not correlate with specific
PHOX2A mutations. Clinical presentation, neuroimaging and Phox2a-/- animal models all
support the concept that CFEOM2 is a primary neurogenic abnormality with secondary
myopathic changes.[9]
Prehospital status and treatment among severe traumatic brain injury was conducted. In
this collected data sets from 396 patients with severe TBI (Glasgow Coma Scale score < 9)
included by 5 Austrian hospitals were available. The analysis focused on incidence and/or
degree of severity of typical clinical signs, frequency of use of different management options,
and association with outcomes for both. The following outcome was find out ,the majority
of patients were male (72%), mean age was 49 +/- 21 years, mean injury severity score (ISS)
was 27 +/- 17, mean first GCS score was 5.6 +/- 2.9, and expected hospital survival was 63 +/30%. ICU mortality was 32%, 90-day mortality was 37%, and final outcome was favorable in
35%, unfavorable in 53%, unknown in 12%. They found that age > 60 years, ISS > 50 points,
GCS score < 4, bilateral changes in pupil size and reactivity, respiratory rate < 10/min, systolic
blood pressure (SBP) < 90 mm Hg, and heart rate < 60/min were associated with significantly
higher ICU and 90-day mortality rates, and lower rates of favorable outcome.[10]
A study on False negative apraclonidine test in two patients with Horner syndrome in
this two women aged 34 and 46 years with a cocaine-confirmed oculosympathetic defect
(Horner syndrome) were tested with 1 % topical apraclonidine on separate days. Neither patient
demonstrated a reversal of anisocoria, the current criterion for diagnosing a Horner syndrome
using apraclonidine. Thus, these two patients with an established oculosympathetic defect were
said to have a "negative test" for Horner syndrome. Yet both women showed subtle pupil and/or
lid changes in response to apraclonidine that were consistent with sympathetic denervation
supersensitivity. Reversal of anisocoria following topical apraclonidine does not occur in
all patients with a unilateral oculosympathetic defect and more specific parameters for defining a
positive test result might optimize apraclonidine's utility as a diagnostic test for Horner
syndrome.[11]
Evaluation of visual functions in patients on ethambutol therapy for tuberculosis was
done to study the incidence of clinical and subclinical optic nerve toxicity with ethambutol
therapy in patients with tuberculosis and to evaluate the reversibility of its side effects after
cessation of therapy. This prospective randomized controlled study included 60 newly
diagnosed adult cases of tuberculosis, who were randomly assigned into two groups. The study
group included 30 patients (60 eyes) who received ethambutol as a part of their anti-tubercular
treatment and the control group included 30 patients (60eyes) who did not receive ethambutol.
The patients were examined on monthly basis. The visual parameters studied were best
corrected
visual
acuity, pupillary reactions,
optic
disc changes,
color
vision,
contrast
sensitivity, pupilcycle time, visual field charting and visual evoked potential. Ethambutol was
stopped in those patients in whom toxicity was detected and they were followed more frequently
ethambutol induced ocular toxicity was seen in three patients (10%) in this study. The maximum
visual recovery occurred in first six to eight weeks after stopping ethambutol. The visual
recovery was complete in only one patient, but it was partial in two patients i.e. visual fields,
contrast sensitivity and visual evoked potential remained abnormal.[12]
Pupil response components among patients with Parinaud's syndrome was included In
addition to light flux changes, it is well established that other stimulus attributes such as colour,
spatial structure or movement can also cause a transient constriction of the pupil, even when
the onset of the stimulus causes a net decrease in light flux level on the retina. Although
experimental findings in human subjects with postgeniculate lesions show that the generation of
such responses must involve the processing of stimulus attributes in extrastriate areas of the
cortex, little is known about the site of integration of cortical signals into the pupillomotor
pathway. We have investigated how visual performance and the various components of
the pupil response have been affected in subjects with damage to the dorsal midbrain
(Parinaud's syndrome). The results show that the probable destruction of the olivarypretectal
nucleus and the nucleus of the optic tract has little or no effect on pupil grating or pupil colour
responses.[13]
The objective evaluation of improvement in optic neuropathy following radiation therapy
for thyroid eye disease was to quantify the changes in parameters of optic neuropathy after
orbital irradiation for thyroid eye disease twelve consecutive patients with optic neuropathy from
thyroid eye disease were followed by a single neuro-ophthalmology practice and treated by one
radiation oncologist with radiation therapy from 1991 through 1995. All cases were prospectively
followed for visual acuity, color vision, mean deviation, and/or foveal sensitivity and
afferent pupillary defect. All patients received 2000 cGy in 10 fractions with megavoltage
irradiation to the orbits as a result this study objectively demonstrates improvement in optic
neuropathy from radiation therapy for thyroid eye disease.[14]
Pupillographic
sleepiness
testing
in
hypersomniacs
and
normals
in
this
Seven patients (four with sleep apnea syndrome, three with narcolepsy) and seven agematched
controls
underwent
pupillography
for
11
min
in
complete
darkness.
The changes in pupil size were analyzed mathematically to determine quantitatively the amount
of pupillary instability this study showed that a pupillographic sleepiness test based on the
evaluation of spontaneous pupillary changes in darkness is applicable in hypersomniacs and
may facilitate therapy control, i.e. diagnostic grading by measuring daytime sleepiness
objectively.[15]
Optic neuropathies and
peripheral
oculomotor
disorders in patients with
AIDS
In patients with the acquired immunodeficiency syndrome (AIDS) there is an 8% incidence
of neuro-ophthalmological changes.
ophthalmological changes are:
1)
The
Cranial
commonest
nerve
pareses
2)
of
Optic
these neuroneuropathy
and
3) Pupil disorders. The cranial nerve pareses are usually combined, rather than single, and are
due to intraparenchymatous lesions (toxoplasmosis or lymphoma) or to meningitis (tuberculous
or lymphoma). The optic nerve changes tend to be papillitis due to CMV or optic neuropathy due
to syphilis or to cryptococcal meningitis. Among the pupil changes, Bernard-Horner syndromes
due to sympathetic involvement, Argyll-Robertson pupils due to mesencephalictectal lesions
and mydriasis associated with the common oculo-motor nerve have been described.[16]
Clinical pearls in optometric management of the geriatric patient clinical management
techniques (pearls) are discussed which aid in the diagnosis and treatment of problems specific
to geriatricpatients. Factors noted in patient presentation are stressed and include physical
appearance, ability to move about, and use of other senses. The most commonly occurring eye
anomalies occurring in the geriatric population are discussed including iatrogenic drug side
effects, pupillaryanomalies, extraocular palsies, dry eye, corneal degenerations, refractive
error changes, lenticular changes, glaucoma, age-related maculopathy, vitreoretinal disease,
and ocular manifestations of systemic disease (vascular occlusive disease, diabetes, ischemic
optic neuropathy, other neuro-ophthalmic disease) optometrists as primary health care
providers often provide the only avenue individuals with blinding and sometimes life threatening
conditions have in managing these conditions. Optometrists managing geriatric patients are
required to know what happens to this population from an ocular disease as well as other
function and dysfunction standpoint.[17]
Prognosis in solitary intraventricularhaemorrhage.Clinical and computed tomographic
observations.Isolated intraventricularhaemorrhage (IVH) in the absence of parenchymal
haematoma is unusual. Fifteen patients with solitary IVH among 170 with intracranial
haemorrhage were studied. Clinical details and computed tomographic features were analysed
to evaluate the prognostic significance of various clinical and CT parameters. Outcome is
affected by hypertension, level of consciousness, clinical progression, pupillary changes and
restriction of eye movements. Factors found on CT to have prognostic significance included
degree of ventricular bleed, presence of cisternal bleed, hydrocephalus and cerebral atrophy.[18]
STATEMENT OF THE PROBLEM
“A study to evaluate the effectiveness of structured teaching programme on knowledge
regarding the importance of pupillary changes in neurological clients among staff nurses in
selected hospitals at Bangalore.”
6.3 OBJECTIVES OF THE STUDY:
1. To assess the knowledge level of staff nurses regarding importance of pupillary changes.
2. To evaluate the effectiveness of structured teaching programme on the importance of
pupillary changes in neurological clients among staff nurses.
3. To find out the association between pre and post test knowledge scores regarding
importance of pupillary changes among staff nurses
4. To find out the association of post test level of knowledge with selected demographical
variables.
6.4 OPERATIONAL DEFINITIONS:
KNOWLEDGE
It refers to the correct response from the participants regarding the importance of
pupillary response and is assessed by knowledge questionnaire.
EFFECTIVENESS
It refers to the significant of gaining knowledge as measured by the instrument and
shown by post test knowledge school.
STAFF NURSES
Staff nurses who are working in neurological icu and wards
IMPORTANCE OF PUPILLARY REFLEXES
It refers to the intervention taken to the prior to the onset of pupillary changes for
promoting patient care.
6.5 ASSUMPTIONS
1. Staff nurses have less knowledge regarding importance of pupillary changes
2. Education enhances the staff nurses to identify pupillary changes by themselves.
3. Group teaching will provide opportunity for active learning among participant
6.6 HYPOTHESIS
H1:- There will be significant association between pretest and post test knowledge and selected
demographical variables of staff nurses such as age sex education experience, skill marital
status and source of information.
H2:- The main post test knowledge scores of staff nurses regarding the importance of pupillary
changes will be significantly higher than that of pretest knowledge score.
6.7 VARIABLES UNDER STUDY
6.7.1 DEPENDENT VARIABLES:Knowledge level of staff nurses regarding pupillary changes in neurological clients.
6.7.2 INDEPENDENT VARIABLES:Structured Teaching programme
6.8 MATERIALS AND METHODS :6.8.1 SOURCE OF DATA:
Staff nurses working in selected hospital
6.8.2 METHODS OF DATA COLLECTION:
Prepared questionnaire
6.9 RESEARCH DESIGN:PRE-TEST,POST TEST DESIGN
7. SETTING OF THE STUDY:The study will be conducted among the staff nurse in selected hospitals at banglore
7.1POPULATION:The study includes staff nurse in selected hospitals at banglore.
7.2 SAMPLE SIZE:60 staff nurses.
7.2.1 SAMPLING TECHNIQUE
Simple random sample technique
7.3 SAMPLING CRITERIA
1. INCLUSION CRITERIA
1. The staff nurses who works in selected hospital at banglore
2. The staff nurses who are willing to participate in the study
3. The staff nurses who knows English and kannada
2. EXCLUSION CRITERIA
1. The staff nurses who does not works in selected hospitals at banglore
2. The staff nurses who are not willing to participate in the study
3. The staff nurses who does knows English and kannada
7.4 TOOLS OF DATA COLLECTION
Prepared questionnaires that consists of three parts
Part1: Consists of objective questions related to demographic data
Part2: Consists of questions regarding pupillary changes in nuerological clients.
7.5 METHODS OF DATA COLLECTION:
The prepared questionnaire will be distributed to the subjects or interviewed by the
questionnaire . Prior to the study the purpose of the study will be explained and consent of the
participants will be obtained to involve in the study. Before the original , a pilot study will be conducted
and necessary modifications and further refinements of the tools will be done. Researcher herself will
collect the data.
7.6 DATA ANALYSIS AND INTERPRETATION
Descriptive and inferential statistical techniques such as frequency distribution , central measures (
mean, median, mode) standard deviation. Chi square and corelation co-efficient will be used for data
analysis and presented in the form of tables , graphs and diagrams
7.7 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TOBE
CONDUCTED ON CLIENT/SAMPLE POPULATION /HUMANS OR ANIMALS?
The study will be conducted among the staff nurses in selected hospitals at Bangalore.
7.8 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM INSTITUTES?
Prior permission will be obtained from the concerned authorithies of selected hospitals at
Bangalore to conduct a study and also from research committee of Bangalore City College of Nursing,
Bangalore. The purpose of the study will be explained to the management authority of selected
hospitals at Bangalore.Scientific objectivity of the study will be maintained with honesty and
impartiality.
8. LIST OF REFERENCES:1.Suzanne C. Smeltzer, Brenda G. Bare , Jaince L. Hinkle , Kerry H. Cheever, “Text book of
medical surgical nursing ,12th edition , Lippincott, Williams and Wilkins Page no. 1835-1840.
2. A .K . Khurana , “ Book of ophthalmology”, 4th edition , Oxford Blackwell Publications, page no
167
3.Glen view IL , “Fundamental nuero science for basic and clinical application ,3rd edition,
Churchilll Livingston, Elsevier, Page no. 245-247.
4.Porth, C.M. And atfin, “ Pathology : Concepts of altered health states, Philadelphia Lippincott
William and Wikins,Page no. 1456-1467.
5.Hickey,J.”The clinical practice of neurological and neurosurgical nursing,
6th edition,Philadelphia , Churchill , Page no.134-145
6.Barker,R.A. and Barasi,S,”Neuroscience at a glance, 3rd edition, Oxford Backwell publishing,
Page no.1456,1476.
7. J Neuroophthalmol. ,“Pupillographic findings in 39 consecutive cases of harlequin
syndrome”,2008 Sep;28(3): 171-7.
8. Brain. “Neurological features of congenital fibrosis of the extraocular muscles type 2 with
mutations in PHOX2A”. 2006 Sep;129(Pt 9):2363-74.
9. Lenartova L, Janciak I, Wilbacher I, Rusnak M, Mauritz W; Austrian Severe TBI Study
Investigators,“Severe traumatic brain injury in Austria III: prehospital status and treatment”
10.Bosley TM, Oystreck DT, Robertson RL, al Awad A, Abu-Amero K, Engle EC
Bremner F, Smith S,“Neurological features of congenital fibrosis of the extraocular muscles
type 2 with mutations in PHOX2A”
11. Kawasaki A, Borruat FX,“False negative apraclonidine test in two patients with Horner
syndrome”
12. Goyal JL, De Sarmi, Singh NP, Bhatia A,“Evaluation of visual functions in patients on
ethambutol therapy for tuberculosis: a prospective study”
13. Wilhelm BJ, Wilhelm H, Moro S, Barbur JL,“Pupil response components: studies in patients with
Parinaud's syndrome”
14. Rush S, Winterkorn JM, Zak R,“Objective evaluation of improvement in optic neuropathy following
radiation therapy for thyroid eye disease”
15. Wilhelm H, Lüdtke H, Wilhelm B,“Pupillographic sleepiness testing in hypersomniacs and
normals”
16. Torras-Sanvicens J, Arruga-Ginebreda J,“Optic neuropathies and peripheral oculomotor
disorders in patients with AIDS”
17. Selvin GJ, Townsend JC,“Clinical pearls in optometric management of the geriatric patient”
18. Jayakumar PN, Taly AB, Bhavani UR, Arya BY, Nagaraja D,“Prognosis in solitary
intraventricularhaemorrhage.Clinical and computed tomographic observations”