Pupil size chart to scale8/12/2023 ![]() ![]() ![]() (4, 17, 26, 28, 40, 41, 46, 48) A variety of factors affect the reliability of manual assessment and increase inter-examiner disagreement. Manual pupillary assessment is subject to compounded sources of inaccuracies and inconsistencies and can result in as much as 39% inter-examiner variability. These subjective terms are applied without a standardized clinical definition and yield a pronounced level of inter-examiner variability and error. Common terminology employed to describe the pupillary light reflex and pupil size includes “fixed” or “dilated” as well as “brisk”, “sluggish” or “non-reactive” pupils. Traditionally, pupil assessment has been performed in a subjective manner, using a penlight or flashlight to manually evaluate pupil reactivity and a pupil gauge to estimate pupil size. (4, 14, 20, 55, 62) Along with other clinical information such as age, mechanism of injury and Glasgow Coma Score (GCS), the pupillary light reflex is a useful prognostic indicator of survival, functional recovery and long-term outcome. (20)Ībnormalities of pupillary response are associated with neurological deterioration and correlate with poor neurological outcomes. (46, 50, 56) Patients who undergo prompt intervention such as surgery or hyperosmolar therapy after a new finding of pupil abnormality have a better chance of recovery. Depending on pupillary status, neurosurgeons triage patients into either conservative therapy or surgical evacuation of mass lesions. Pupillary information is relied on to guide decisions regarding patient triage and clinical intervention. ![]() Cranial nerve dysfunction may signal increased ICP and/or an increased risk of brain herniation. (4, 26, 34, 41, 46, 47, 50, 55, 63) Pupillary examination involves assessment of the functional status of two cranial nerves (CN) – the optic nerve (CN II) and the oculomotor nerve (CN III). Today, clinicians routinely evaluate pupils as part of the neurological exam and monitoring of all critically ill patients, including those with primary neurological injury as well as those at risk of secondary neurologic insults. (28, 34, 46) For centuries, clinicians have assessed the pupils of patients with impaired consciousness. The clinical neurological exam is an essential component in the assessment and care of patients with a wide variety of illnesses and injuries. Manual pupillary assessment, using a flashlight or penlight, is prone to many sources of inaccuracy and is characterized by subjectivity and low interrater reliability. Pupillary changes correlate with neurological worsening and yet are often undetectable using traditional manual assessment methods. Accurate serial neurological assessment is imperative to 1) rapidly detect changes that may indicate neurologic deterioration, 2) guide patient management, 3) determine the effect of therapeutic interventions and 4) inform prognosis.Īssessment of pupil size and the pupillary light reflex is a critical component of the neurological exam for patients in various settings (26, 50, 55) such as the Emergency Department (ED), Intensive Care Unit (ICU), Operating Room (OR), Post Anesthesia Care Unit (PACU), diagnostic areas such as Interventional Radiology (IR), and Progressive Care Units (PCU). Patients with primary or secondary neurological insult are at risk for development of hydrocephalus, cerebral edema, elevated intracranial pressure (ICP), and brain herniation. As standard of care, all critically ill patients require routine neurologic examination, including pupillary assessment.
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