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third nerve and re ects the presence of an ipsilateral hemispheral mass A loss of light reaction alone usually precedes enlargement of the pupil As a transitional phenomenon, the pupil may become oval or pear-shaped or appear to be off center (corectopia) due to a differential loss of innervation of a portion of the pupillary sphincter The light-unreactive pupil continues to enlarge to a size of 6 to 9 mm diameter and is soon joined by a slight outward deviation of the eye, as noted below In unusual instances, for unknown reasons, the pupil contralateral to the mass may enlarge rst; this is the case in 10 percent of subdural hematomas but has been far less frequent in our experience with other mass lesions As midbrain displacement continues, both pupils dilate and become unreactive to light probably as a result of compression of the oculomotor nuclei in the rostral midbrain (Ropper, 1990) The last step in the evolution of brainstem compression tends to be a slight reduction in pupillary size, to 5 to 7 mm Normal pupillary size, shape, and light re exes indicate integrity of midbrain structures and a cause of coma other than a mass lesion Pontine tegmental lesions cause extremely miotic pupils ( 1 mm in diameter) with barely perceptible reaction to strong light; this is characteristic of the early phase of pontine hemorrhage The ipsilateral pupillary dilatation from pinching the side of the neck (the ciliospinal re ex, page 242) is also lost in brainstem lesions A Horner syndrome (miosis, ptosis, and reduced facial sweating) may be observed ipsilateral to a lesion of the brainstem or hypothalamus or as a sign of dissection of the internal carotid artery With coma due to drug intoxications and metabolic disorders, pupillary reactions are usually spared, but there are notable exceptions Opiates cause pinpoint pupils with a constriction to light that is so slight that it can be seen only with a magnifying glass Highdose barbiturates may act similarly, but the pupillary diameter tends to be 1 mm or more Poisoning with atropine or with drugs that have atropinic qualities, especially the tricyclic antidepressants, is characterized by wide dilation and xity of pupils; these features are partially reversed by intravenous physostigmine Hippus, or uctuating pupillary size, is said by some observers to be characteristic of the metabolic encephalopathies Movements of Eyes and Eyelids and Corneal Responses These may be altered in a variety of ways In light coma of metabolic origin, the eyes rove conjugately from side to side in random fashion, sometimes resting brie y in an eccentric position These movements disappear as coma deepens, and the eyes then remain motionless in slightly exotropic positions A lateral and slight downward deviation of one eye suggests the presence of a third nerve palsy, and a medial deviation, a sixth nerve palsy There may be a persistent conjugate deviation of the eyes to one side away from the side of the paralysis with a large cerebral lesion (looking toward the lesion) and toward the side of the paralysis with a unilateral pontine lesion (looking away from the lesion) Wrong-way conjugate deviation may sometimes occur with thalamic and upper brainstem lesions (page 226) During a one-sided seizure, the eyes turn or jerk toward the convulsing side (opposite to the irritative focus) The eyes may be turned down and inward (looking at the nose) with hematomas or ischemic lesions of the thalamus and upper midbrain (a variant of Parinaud syndrome; see page 225) Retraction and convergence nystagmus and ocular bobbing, described on page 239, occur with lesions in the tegmentum of the midbrain and pons, respectively Ocular dipping, in which the eyes move down slowly and return rapidly to the meridian, may be observed with coma due to anoxia and drug intoxications; horizontal eye movements are preserved (page.

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volatility changes are less signi cant in trade planning Long-term investors want to avoid high volatility option acquisitions that may decrease in value due to decreasing volatility; in general, volatility will have less effect on the buy and hold investor Daily, weekly, or even annual volatility changes may not necessarily cause a need for adjustment in strategy A retirement portfolio for an investor nearing retirement with an income or growth objective will have signi cantly higher risk from increasing volatility Large swings in price may affect the ability of this type of investor to draw consistently on a portfolio In this situation volatility should be monitored carefully and consideration should be given to moving assets to areas less affected by volatility such as cash equivalent markets With any investment, your rst and foremost duty in risk management is to determine your objectives and risk suitability Let s look at some common investment objectives and how options can t into the portfolio mix A small investor who has an investment objective of retiring at age 65 The goal of the portfolio is time-based and total value based The objective is to have a certain amount of money at a certain point in life so you set up a portfolio for growth for several more years Volatility is going to play less of a role in your risk management decision making than will proper diversi cation and quality products You want to make sure that the stocks, bonds, and funds that you are invested in will rst and foremost survive until your goals are reached You want the investments to grow until they are of value to provide acceptable income The current volatility in the market is likely to be a major consideration only upon entry, exit, or shifting positions unless the objective is short term Time-based or retirement-based investors.