An indicator of brain stem dysfunction, the absence of the doll's eye sign is detected by rapid, gentle turning of the patient's head from side to side. The eyes remain fixed in midposition, instead of the normal response of moving laterally toward the side opposite the direction the head is turned. (See Testing for absent doll's eye sign.)
The absence of doll's eye sign indicates injury to the midbrain or pons, involving cranial nerves III and VI. It typically accompanies coma caused by lesions of the cerebellum and brain stem. This sign usually can't be relied upon in a conscious patient because he can control eye movements voluntarily. Absent doll's eye sign is necessary for a diagnosis of brain death.
A variant of absent doll's eye sign that develops gradually is known as abnormal doll's eye sign. Because conjugate eye movement is lost, one eye may move laterally while the other remains fixed or moves in the opposite direction. An abnormal doll's eye sign usually accompanies metabolic coma or increased intracranial pressure (ICP). Associated brain stem dysfunction may be reversible or may progress to deeper coma with absent doll's eye sign.
After detecting an absent doll's eye sign, perform a neurologic examination. First, evaluate the patient's level of consciousness, using the Glasgow Coma Scale. Note decerebrate or decorticate posture. Examine the pupils for size, equality, and response to light. Check for signs of increased ICP—increased blood pressure, increasing pulse pressure, and bradycardia.
Brain stem infarction.Brain stem infarction causes absent doll's eye sign with coma. It also causes limb paralysis, cranial nerve palsies (facial weakness, diplopia, blindness or visual field deficits, and nystagmus), bilateral cerebellar ataxia, variable sensory loss, a positive Babinski's reflex, decerebrate posture, and muscle flaccidity.
Brain stem tumor.Absent doll's eye sign accompanies coma with a brain stem tumor. This sign may be preceded by hemiparesis, nystagmus, extraocular nerve palsies, facial pain or sensory loss, facial paralysis, a diminished corneal reflex, tinnitus, hearing loss, dysphagia, drooling, vertigo, dizziness, ataxia, and vomiting.
Central midbrain infarction.With a central midbrain infarction, absent doll's eye sign is associated with coma, Weber's syndrome (oculomotor palsy with contralateral hemiplegia), contralateral ataxic tremor, nystagmus, and pupillary abnormalities.
Pontine hemorrhage.Absent doll's eye sign and coma develop within minutes with pontine hemorrhage, a life-threatening disorder. Other ominous signs—such as complete paralysis, decerebrate posture, a positive Babinski's reflex, and small, reactive pupils—may rapidly progress to death.
Posterior fossa hematoma.A subdural hematoma at the posterior fossa typically causes absent doll's eye sign and coma. These signs may be preceded by characteristic signs and symptoms, such as a headache, vomiting, drowsiness, confusion, unequal pupils, dysphagia, cranial nerve palsies, a stiff neck, and cerebellar ataxia.
Drugs.Barbiturates may produce severe central nervous system depression, resulting in coma and absent doll's eye sign.
▪ Don't attempt to elicit doll's eye sign in a comatose patient with suspected cervical spine injury; doing so risks spinal cord damage.
▪ Monitor vital signs and neurologic status.
▪ Discuss end-of-life issues with the patient's family, if appropriate.
▪ Provide emotional support to the family.
▪ Explain to the patient the underlying cause and its treatment.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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Title: Nursing: Interpreting Signs and Symptoms Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-668-7 
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