Pupillary diameter assessment: Need for a graded scale

Assessment of pupillary diameter is useful for lesion location, a necessary step in diagnosing neurologic disorders.1,2 Recognition of pupillary changes can serve as an early warning of acute brain injury, and may, with prompt treatment, prevent further injury. However, not all pupillary changes are relevant, because size changes in various physiologic or pharmacologic conditions.1 A few studies have evaluated the reliability of nurses to assess pupils,3,4 but none evaluated the reliability of physicians. Because, in practice, physicians usually use their own impression to assess pupillary diameter, we questioned if such a practice is justified. In this study, the inter- and intrarater reliability of physicians assessing pupillary diameters using their own judgment or a graded scale was evaluated. Four third- and fourth-year neurology residents consecutively evaluated the pupil size of 100 subjects (60% men; median age, 41.5 years) in randomized order. Subjects gave informed consent. Raters assessed pupil diameter twice with a 20-minute difference between …