Moreover, ambient light conditions can affect the validity of the visual assessment of the pupil and increase the inter-observer disagreement.
Icp unequal pupil size manual#
A more precise assessment of the pupil is problematic, since manual pupillary assessment as part of the clinical routine is subject to compounded sources of inaccuracies and inconsistencies, and is characterized by large inter-examiner variability. These subjective terms are often applied without a standard clinical protocol or definition. Patients who undergo prompt intervention (i.e., surgery, hyperventilation, hyperosmolar therapy) after a new pupillary abnormality have improved recovery potential.Ĭommon terminology employed in the clinical literature to describe the pupillary light reflex and pupil size includes “unilateral” or “bilateral nonreactive pupils”, “fixed” or “dilated pupils”, as well as “brisk”, “sluggish”, and “nonreactive” pupils.
It has been shown that neurosurgeons have the tendency to triage patients into either conservative therapy or surgical evacuation of mass lesions, depending on the status of the pupils. In addition to herniation and third nerve compression, it has been shown through blood flow imaging that pupillary changes in the neurological intensive care unit (ICU) are highly correlated with brainstem oxygenation and perfusion/ischemia.įurthermore, other investigators have used pupil size and reactivity as the fundamental parameters of more general outcome predictive models in conjunction with other clinical information such as age, mechanism of injury and Glasgow Coma Scale (GCS), and have correlated such models with the presence and the location of intracranial mass lesions. Depressed light reflex and anisocoria have been associated with such phenomena, and they have been proposed as prognostic indicators of functional recovery after traumatic transtentorial herniation. More specifically, the location of the pupillomotor nuclei in the dorsal midbrain and the efferent oculomotor nerve running from the midbrain to the superior orbital fissure is particularly important for assessing the onset of descending transtentorial herniation and brainstem compression. In the management and prognosis of severe traumatic brain injury (TBI), abnormalities of pupillary response or anisocoria (pupil size asymmetries) are often associated with neurological deteriorations, and they are correlated with poor neurological outcome. This makes the pupil size and the pupillary light reflex an important factor to be considered in many clinical conditions as described, for example, in the work of Loewenfeld. After one hour there was dilation of the constricted pupil and improvement in the ptosis.Different neuroanatomical pathways are involved in the control of the pupil, and the integrity and functionality of these neurological pathways can often be ascertained through the analysis and interpretation of pupillary behavior. One drop of apraclonidine 1% was applied to both eyes.
Icp unequal pupil size full#
Ocular motility was full and funduscopy showed healthy optic discs. Visual acuity was 6/9 in both eyes and intraocular pressures were 12 mm Hg and 14 mm Hg in the right and left, respectively. Both pupils constricted to light and accommodation and there was no relative afferent pupillary defect. On examination she had a partial right upper lid ptosis (fig 1) and her right pupil, which was the abnormal one, was constricted and showed a dilatation lag. She denied any history of trauma, neck pain, weight loss, diplopia, or anhydrosis.
She had visited her primary care doctor because of an upper respiratory tract infection and was unconcerned about her unequal pupil size (anisocoria), stating that she “has had odd pupils and a droopy right lid since being a teenager.” She had no ocular or medical history and was not taking any oral or topical medication.