Pupillary evaluation in comatose patients is often performed in a subjective manner by manually opening the patient eyelids, measuring the size of each pupil with a pupil-gauge ruler, and using a flashlight to illuminate the open eye in a darkened room to assess pupil reactivity. According to standard care protocols, upon detection of such an abnormality, a physician should be notified immediately and often head CT-scan and continuous intracranial pressure monitoring are subsequently used to aid in definitively identifying the cause of the abnormal pupil. When performing a pupillary examination in patients with traumatic brain injury, the medical staff is looking for abnormalities, such as an asymmetric pupil size (anisocoria), irregular pupil shape, or a sluggish or absent pupillary light response. ![]() Additionally, accurate pupillary examination can help detect transtentorial herniation in some head injury patients with low speed trauma who undergo early herniation. Therefore, early and accurate detection of pupillary abnormality can both reduce the time to appropriate interventions, which are frequently life-saving, and avoid frequent computed tomographic scans. The combination of the pupillary examination and Glasgow Coma Scale (GCS) score provides more accurate prognostic information, and patients with a GCS of 3 with reactive pupils have a 33% survival rate, as opposed to patients with a GCS of 3 and fixed dilated pupils who have no reasonable chance of recovery. In a study of functional recovery in patients with traumatic transtentorial herniation, only 3.5% of patients with bilaterally fixed (unresponsive to light) and dilated pupils at admission had a functional recovery. For example, during transtentorial herniation, pupil size and reactivity are the most sensitive and easily identifiable findings. ![]() The prognostic and clinical value of pupillary examinations have been well established for traumatic and non-traumatic injuries and have been featured in benchmark studies as far back as the early 1980s. ![]() Changes in these pupillary parameters can provide important clues to neurologic deterioration, elevated intracranial pressure and herniation. Monitoring pupillary size and light-response is a key component of the neurologic examination in comatose patients with brain injury from multiple etiologies.
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