1. No category

2014 Neurocritical Care Society Meeting
Poster Presentation
Interrater Reliability
of Pupillary Assessments
Among
Physicians and Nurses
Department of Neurology and Neurotherapeutics and Neurological Surgery
University of Texas Southwestern Medical Center
2014 Neurocritical Care Society Meeting, Seattle, Washington
Interrater
Interrater Re
Re
Interrater Reliability of Pupillary Assessments Among
Physicians
and
Nurses
Interrater Reliability
of Pupillary
Assessments
Sonja E. Stutzman¹,
Interrater
Reliability
of PupillaryAmong
Assessments Among
Physicians
and1Physicians
Sonja E. Stutzman
,Nurses
DaiWai M. Olson
, Ciji Saju3,
and123Nurses
Sonja E. Stutzman¹,
Department
Department of
of Neurology
Neurology and
and Ne
Ne
3
12
Sonja E. Stutzman¹, DaiWai
M. Olson¹²³,
Ciji Saju³,
Margaret
Wilson³,
Aiyagari¹²
Margaret
Wilson
Venkatesh
Aiyagari
Sonja
E. Stutzman¹,
DaiWai
M., Olson¹²³,
CijiVenkatesh
Saju³,
Margaret
Wilson³, Venkatesh Aiyagari¹²
Department of Neurology and Neurotherapeutics¹ and Neurological Surgery², University Hospital³, UT Southwestern Medical Center
Department of Neurology and Neurotherapeutics¹ and Neurological Surgery², University Hospital³, UT Southwestern Medical Center
Department of Neurology and Neurotherapeutics1 and Neurological Surgery2, University Hospital3, UT Southwestern Medical Center
Introduction
Demographics
Introduction
Results
Demographics
Introduction
Introduction
Introduction
Surgical Procedure
tional assessment of pupil size, shape, and reactivity is a
Observational assessment of pupil size, shape, and reactivity is a
(n=57)
ntal aspect of the neurological examination. In neurological
fundamental aspect of the neurological examination.
In neurological 55.1 (sd=15.6)
Mean
Age
54.8 (sd=15.7)
rosurgical patients, examination of the pupils is extremely
Mean Age
and neurosurgical patients, examination of the pupils is extremely
% Male
72 (56.7%)
34 (59.6 %)
n localizing the lesion, characterizing a differential diagnosis,
% Male
helpful in localizing the lesion, characterizing a differential diagnosis,
% Caucasian
103 (81.1%)
47 (82.5%)
owing the course of the disease process. However, interrater
% Caucasian
and following the course of the disease process. However, interrater
y of these findings has not been established.
Primary diagnosis
reliability of these findings has not been established.
Primary diagnosis
All Patients
(n=127)
Not Surgical
Not Surgical
All Patients
Surgical Procedure
(n=70)
(n=57)
(n=70)
(n=127)
55.4 (sd=15.6)
55.1 (sd=15.6)
54.8 (sd=15.7)
55.4 (sd=15.6)
38 (54.3%)
Entire
72 (56.7%)
34 (59.6 %)
38Size
(54.3%)
> 1mm
Cohort
56 (80.0%)
103 (81.1%)
47 (82.5%)
56 (80.0%)
(N=1,166) Equal in size
Left Eye
Kappa
0.54
(.49-.59)
Results
Right Eye
% agree
Kappa
# Vision or ocular history
43 (33.9%)
7 (12.3%)
# Ischemic stroke
40 (31.5%)
20 (35.1%)
# Hem. stroke (SAH/ICH)
23 (18.1%)
18 (31.6%)
# Neoplasm
21 (16.5%)
12 (21.0%)
# Other
9 (7.1%)
5 (8.8%)
# Vision or ocular history
36 (51.4%)
43 (33.9%)
20 (28.6%)
40 (31.5%)
5 (7.1%)
23 (18.1%)
9 (12.9%)
21 (16.5%)
4 (5.7%)
9 (7.1%)
7 (12.3%)
20 (35.1%)
18 (31.6%)
12 (21.0%)
5 (8.8%)
Only
Nurses
(n=952)
36Shape
(51.4%)
20 (28.6%)
5Reactivity
(7.1%)
slow, fixed)
9(brisk,
(12.9%)
4Reactive
(5.7%)
vs not
-
0.68
(.61-.76)
0.48
(.43-.53)
0.69
(.62-.77)
Size > 1mm
0.54
(.49-.60)
Equal in size
-
Shape
Reactivity
(brisk, slow, fixed)
Reactive
0.70
(.62-.78)
0.49
(.43-.55)
0.69
(.61-.78)
vs not
for OS=0.54 (78%), OD=0.54 (79.8%), and OU=0.54 (78.9%).
gical examination. Changes in the pupillary size, shape and/or
neurological examination. Changes in the pupillary
size, shape
and/or for shape for OS=0.68 (94.3%), OD=0.06 (97.6%), and
• Kappa
and agreement
0.49
y can be an early sign of neurological deterioration,
• Kappa and agreement for shape for OS=0.68 (94.3%),Only
OD=0.06Size
(97.6%),
> 1mm and
reactivity can be an early sign of neurological
deterioration,
OU=0.62
(96%).
(.20-.78)
Physician
OU=0.62
(96%).
d intracranial pressure, and worsening midline shift. In
increased intracranial pressure, and worsening
midline
In
• Kappa
andshift.
agreement
for pupil reactivity for OS=0.48 (80%), OD=0.30
(n=33)
Equal OD=0.30
in size
pupillary findings may also be used to monitor response to
•
Kappa
and
agreement
for
pupil
reactivity
for
OS=0.48
(80%),
addition, pupillary findings may also be used to monitor
response
to (79%).
(78%), and
OU=0.40
(78%), and OU=0.40 (79%).
Despite the importance of pupillary assessments, limited
0.64
therapy. Despite the importance of pupillary •assessments,
limited pupils assessed as fixed (non-reactive) by one
Only 49.5% (94/190)
Shape
research has shown that there may be variability in pupillary
•
Only
49.5%
(94/190)
pupils
assessed
as
fixed
(non-reactive)
by
one
(.19-1.0)
previous research has shown that there may be variability
pupillary
assessorinwas
also scored as fixed by the second assessor; [OS = 73/131
assessor was also scored as fixed by the second assessor; [OS
= 73/131
0.73
ments.
Reactivity
(55.7%), and OD = 21/59 (35.6%)].
assessments.
(.45-1.0)
(55.7%), and OD = 21/59 (35.6%)].
(brisk, slow, fixed)
Specific
Specific
Aims
SpecificAims
Aims
This
study
This
study seeks
seeks to:
to:
Methods
mined interrater reliability of bedside pupillary exams as part
reliability of
We examined interrater
reliability
of bedside pupillary exams
1.
Determine
the
1. Determine
theas partinterrater
interrater
of pupillary
pupillary assessments
assessments
ge prospective study. 127 patients with neurological
or
Conclusionreliability
of a large prospective study. 127 patients with neurological or
Conclusion
rgical diagnoses were consented. These patients were
neurosurgical diagnoses were
consented.
These
patients
were
between
two
independent
observers
examining
the
d by staff (RNs and MDs) who were expected to perform
a
These
data
suggest
that
there
is
a
surprisingly
large
degree
of
disagreement
examining
the pupil
pupil at
at the
the
observed by staff (RNs andbetween
MDs) who were expected
to perform
a
These data suggest that there is a surprisingly
large degree of disagreement
two
independent
between
trained
observers when assessingobservers
and scoring pupillary findings.
exam as a normal part of their patient care routine.
Two
between trained observers when assessing and scoring pupillary findings.
pupillary exam as a normal part of their patient
care routine.
Furthermore,
forTwo
96 of 190 (51.5%) assessments, there was no agreement on
dent observers performed a pupillary exam simultaneously
or
same
time.
Furthermore, for 96 of 190 (51.5%) assessments, there was no agreement on
independent observers performed
a pupillary
exam
simultaneously
or
of
pupillary
reactivity.
Interrater
reliability
was
not
significantly
the
absence
same
time.
minutes of each other. Observers were instructed to perform
the absence of pupillary reactivity. Interrater reliability was not significantly
within 5 minutes of each other. Observers were instructed
to perform
different within
vs between observers. Given the importance of pupillary
m as they would under normal conditions using the
different within vs between observers. Given the importance of pupillary
the exam as they would under normal conditions
the with neurological
reactivity using
in patients
injury, these findings may have
reactivity
in patients with
neurological injury, these
findings may have observers
if they
were
nt (penlight or flashlight) that they would use
2.
Determine
ifif they
there
is
a
correlation
between
significant
clinical
Future
research is needed
to standardize
equipment (penlight 2.
or flashlight)
that they would
useif
wereimplications.
Determine
there
is
a greater
greater
correlation
significant
clinical implications.
Future research is between
needed to standardize observers
performing the exam.
pupillary assessments. One mechanism for potential standardization of
typically performing the exam.
pupillary assessments. One mechanism for potential standardization of
pupillary
assessments is through the
use of the Pupillometer.
matched
by
profession
(nursing
versus
medial
background)
assessmentsversus
is through the use
of the Pupillometer.
matched by profession pupillary
(nursing
medial
background)
Methods
One RN
and
One MD
(n=179)
Reactive
vs not
0.79
(.38-1.0)
Size > 1mm
0.51
(.39-.64)
Equal in size
-
(brisk, slow, fixed)
0.61
(.42-.79)
0.38
(.24-.51)
Reactive
vs not
0.67
(.49-.85)
Shape
Reactivity
Right Eye
% agree
Kappa
% agree
Kappa
% agree
Kappa
0.54
0.54
78.9%
79.8% 0.54
78.0%
0.54
Entire
(.50-.58) 78.0%
(.49-.59)
Size > 1mm
(.49-.59)
(.49-.59)
Cohort
0.60
80.8%
(N=1,166)
- (.55-.64)
Equal in size
0.06
0.62
96.0%
94.3%
97.6% 0.68
0.06
(-.07-.19)
(.55-.69) 94.3%
Shape
(-.07-.19)
(.61-.76)
0.30
0.40
80.0%
79.0%
0.30
Reactivity 78.0% 0.48
(.23-.36)
(.36-.44) 80.0%
(.43-.53)
(.23-.36)
(brisk, slow, fixed)
0.64
0.51
Reactive
95.9%
96.7% 0.69
95.0%
0.51
(.58-.71) 95.0%
(.37-.64)
(.37-.64)
(.62-.77)
vs not
0.53
0.52
79.1%
79.7% 0.54
78.6%
0.52
Only
(.49-.57) 78.6%
(.46-.58)
Size > 1mm
(.46-.58)
(.49-.60)
Nurses
0.60
80.8%
(n=952)
- (.54-.65)
Equal in size
.01
0.64
96.3%
94.7%
97.8% 0.70
.01
(.005-.01)
(.56-.72) 94.7%
Shape
(.005-.01)
(.62-.78)
0.33
0.42
80.3%
79.5%
0.33
Reactivity 78.7% 0.49
(.26-.40)
(.38-.47) 80.3%
(.43-.55)
(.26-.40)
(brisk, slow, fixed)
0.67
0.59
Reactive
96.2%
97.1% 0.69
95.2%
0.59
(.59-.74) 95.2%
(.45-.73)
(.45-.73)
(.61-.78)
vs not
0.77
0.63
74.3%
88.6% 0.49
81.4%
0.77
Only
(.55-.98)
(.45-.81) 74.3%
Size > 1mm
(.20-.78)
(.55-.98)
Physician
0.70
87.8%
(n=33)
- (.42-.97)
Equal in size
0.55
95.6%
94.2%
DNC
96.9% 0.64
(.11-.99) 94.2%
DNC
Shape
(.19-1.0)
0.54
85.3%
91.4%
DNC
78.8% 0.73
Reactivity
(.30-.79) 91.4%
DNC
(.45-1.0)
(brisk, slow, fixed)
0.55
Reactive
95.6%
97.1%
DNC
93.9% 0.79
(.09-1.0) 97.1%
DNC
(.38-1.0)
vs not
0.54
0.56
One
RN
77.4%
78.8% 0.51
76.0%
0.56
(.45-.63) 76.0%
(.44-.68)
Size > 1mm
and
(.44-.68)
(.39-.64)
One MD
0.57
79.7%
- (.44-.69)
(n=179) Equal in size
0.55
0.24
94.4%
96.6% 0.61
92.1%
0.24
(.38-.73) 92.1%
(.14-.63)
Shape
(.14-.63)
(.42-.79)
0.07
0.25
74.9%
75.8%
0.07
Reactivity 74.0% 0.38
(-.07-.20)
(.15-.36) 75.8%
(-.07-.20)
(.24-.51)
(brisk, slow, fixed)
-0.02
0.54
-0.02
Reactive
94.4%
93.8%
(-0.0494.9% 0.67
(.36-.72) 93.8%
(-0.040.002) vs not
(.49-.85)
0.002)
Observational
Observational assessment
assessment of
of pupil
pupil size,
size, shape,
shape, and
and reactivity
reactivity is
is a
a
Specific Aims
Specific
Aims
fundamental
aspect
of
the
neurological
examination.
In
neurological
fundamental aspect of the neurological examination. In neurological
dy seeks to:
This study seeks to:
mine the interrater reliability of pupillary and
assessments
neurosurgical
patients,
examination
1. Determine the interrater
reliability
of pupillary assessments
and
patients,
examination of
of the
the pupils
pupils is
is extremely
extremely
een two independent observers examining the pupil at neurosurgical
the
Results
between two independent observers examining the pupil at the
Results
time.
same time.
helpful
in
localizing
the
lesion,
characterizing
a
differential
diagnosis,
helpful
the lesion,
characterizing
a differential diagnosis,
mine if there is a greater correlation between
observers in localizing
2332 (1166observers
paired) observational
assessments
pupils were completed on
2. Determine if there is a greater correlation• between
• 2332 (1166 paired) observational assessments pupils were completed on
hed by profession (nursing versus medial background)
127 consented patients
matched by profession
(nursing
versus medial background)
127 consented
patients
and
following
the
course
of
the
disease
process.
However,
interrater
• Therethe
was composite
agreementof
in all the
three parameters:
size (within
1
and
following
course
disease
process.
interrater
• There was composite agreement in all three parameters: However,
size (within 1
mm), shape, & reactivity for 463 (39.7%) OS; 470 (40.3%) OD; and 328
mm), shape, & reactivity for 463 (39.7%) OS; 470 (40.3%) OD; and 328
Background
OU. findings has not been established.
Background of (28.1%)
reliability
these
(28.1%)
OU.
reliability of• Interrater
these
findings
has
notforbeen
established.
reliability
Kappa values and
% agreement
size (within 1mm)
amination of the pupil is a critical component of the bedside
• Interrater reliability Kappa values and % agreement for size (within 1mm)
Serial examination of the pupil is a critical component
of the bedside
for OS=0.54
(78%), OD=0.54 (79.8%), and OU=0.54 (78.9%).
# Ischemic stroke
# Hem. stroke (SAH/ICH)
# Neoplasm
# Other
Both Eyes
Left Eye
% agree
79.8%
97.6%
Ka
0.
(.50
0.
(.55
0.
(.55
0.
(.36
Mean
Age
Mean
Mean Age
Age
%
Male
%
Male
% Male
%
Caucas
%
% Caucas
Caucas
Primary
dia
Primary
Primary dia
dia
#
Ischemic
# Ischemic
Ischemic
#
#
# Hem.
Hem. str
str
#
Hem.
str
#
# Neoplas
Neoplas
#
Neoplas
#
# Other
Other
#
Other
#
# Vision
Vision or
or
#
Vision
or
78.0%
96.7%
79.7%
-
97.8%
78.7%
97.1%
88.6%
-
96.9%
78.8%
0.
(.58
0.
(.49
0.
(.54
0.
(.56
0.
(.38
0.
(.59
0.
(.45
0.
(.42
0.
(.11
0.
(.30
93.9%
0.
(.09
78.8%
0.
(.45
96.6%
74.0%
0.
(.44
0.
(.38
0.
(.15
•• 2332
2332 ((
127
127 co
co
•• There
There
mm),
mm), s
s
(28.1%
(28.1%
•• Interra
Interra
for
for OS
OS
•• Kappa
Kappa
OU=0.
OU=0.
•• Kappa
Kappa
(78%),
(78%),
•• Only
Only 4
4
asses
asses
(55.7%
(55.7%
94.9%
0.
(.36
The authors of this study would like to thank Weidan Zhao and the many clinicians that contributed to the
The authors of this study would like to thank Weidan Zhao and the many clinicians that
pupillary assessments.
pupi
ding Author: [email protected]
Corresponding Author: [email protected]
Background
Background
Background
Neuroptics Inc. provided Pupillometers and headrests as part of a larger study from which these data are drawn.
Neuroptics Inc. provided Pupillometers and headrests as part of a larger study from which the
Serial
Serial examination
examination of
of the
the pupil
pupil is
is a
a critical
critical component
component of
of the
the bedside
bedside
neurological
examination.
Changes
in
the
pupillary
size,
shape
neurological examination. Changes in the pupillary size, shape and/or
and/or
reactivity
can
be
an
early
sign
of
neurological
deterioration,
reactivity can be an early sign of neurological deterioration,
increased
increased intracranial
intracranial pressure,
pressure, and
and worsening
worsening midline
midline shift.
shift. In
In
addition,
pupillary
findings
may
also
be
used
to
monitor
response
to
addition, pupillary findings may also be used to monitor response to
therapy.
therapy. Despite
Despite the
the importance
importance of
of pupillary
pupillary assessments,
assessments, limited
limited
previous
research
has
shown
that
there
may
be
variability
in
pupillary
previous research has shown that there may be variability in pupillary
assessments.
assessments.
Methods
Methods
Methods
We
We examined
examined interrater
interrater reliability
reliability of
of bedside
bedside pupillary
pupillary exams
exams as
as part
part
of
a
large
prospective
study.
127
patients
with
neurological
of a large prospective study. 127 patients with neurological or
or
neurosurgical
diagnoses
were
consented.
These
patients
were
neurosurgical diagnoses were consented. These patients were
observed
observed by
by staff
staff (RNs
(RNs and
and MDs)
MDs) who
who were
were expected
expected to
to perform
perform a
a
pupillary
exam
as
a
normal
part
of
their
patient
care
routine.
Two
pupillary exam as a normal part of their patient care routine. Two
independent
independent observers
observers performed
performed a
a pupillary
pupillary exam
exam simultaneously
simultaneously or
or
within
5
minutes
of
each
other.
Observers
were
instructed
to
perform
within 5 minutes of each other. Observers were instructed to perform
the
the exam
exam as
as they
they would
would under
under normal
normal conditions
conditions using
using the
the
equipment
(penlight
or
flashlight)
that
they
would
use
if
they
were
equipment (penlight or flashlight) that they would use if they were
typically
typically performing
performing the
the exam.
exam.
Corresponding Author: [email protected]
Corresponding
Author: [email protected]
Corresponding
Corresponding Author:
Author: [email protected]
[email protected]
These
These
betwee
betwee
Further
Further
the
the abs
abs
differen
differen
reactiv
reactiv
signific
signific
pupilla
pupilla
pupilla
pupilla
1
nterrater
ReliabilityofofPupillary
PupillaryAssessments
AssessmentsAmo
Amo
terrater Reliability
InterraterPhysicians
Reliability
of Pupillary
Assessments
Physicians
and
NursesAmong
and
Nurses
Physicians and Nurses
Interrater Reliability
of Pupillary
Assessments
Among
Interrater
Reliability
of
Pupillary
Assessments
Among Venkatesh Aiya
Sonja
Stutzman¹,
DaiWai
Olson¹²³,
Ciji
Saju³,
Margaret
Wilson³,
onja
Olson¹²³,
Ciji
Saju³,
Margaret
Wilson³,
Venkatesh
Aiyag
SonjaE.E.
E.Stutzman¹,
Stutzman¹,DaiWai
DaiWaiM.M.
M.
Olson¹²³,
Ciji
Saju³,
Margaret
Wilson³,
Venkatesh
Aiya
Physicians
and
Nurses
Sonja E. Stutzman Physicians
, DaiWai M. Olson
, Ciji Saju ,
and Nurses
1
123
3
3
12
Sonja E. Stutzman¹, DaiWai
M. Olson¹²³,
Ciji Saju³,
Margaret
Wilson³,
Aiyagari¹²
Margaret
Wilson
Venkatesh
Aiyagari
Sonja
E. Stutzman¹,
DaiWai
M., Olson¹²³,
CijiVenkatesh
Saju³,
Margaret
Wilson³, Venkatesh Aiyagari¹²
ment
Neurology
and
Neurotherapeutics¹
and
Neurological
Surgery²,
University
Hospital³,
Southwestern
M
nt of of
Neurology
and
Neurotherapeutics¹
and
Neurological
University
Hospital³,
UTUT
Southwestern
Med
Department
of Neurology and Neurotherapeutics¹
and
Neurological
Surgery², UniversitySurgery²,
Hospital³,
UT Southwestern
Medical Center
ment
of
Neurology
and
Neurotherapeutics¹
and
Neurological
Surgery²,
University
Hospital³,
Department of Neurology
and
Neurotherapeutics¹ and Neurological
Surgery², University
Hospital³, UT Southwestern
Medical Center UT Southwestern M
Department of Neurology and Neurotherapeutics1 and Neurological Surgery2, University Hospital3, UT Southwestern Medical Center
Introduction
Demographics
Introduction
Results
Demographics
Demographics
Demographics
Demographics
Demographics
Surgical Procedure
tional assessment of pupil size, shape, and reactivity is a
Observational assessment of pupil size, shape, and reactivity is a
(n=57)
ntal aspect of the neurological examination. In neurological
fundamental aspect of the neurological examination.
In neurological 55.1 (sd=15.6)
Mean
Age
54.8 (sd=15.7)
rosurgical patients, examination of the pupils is extremely
Mean Age
and neurosurgical patients, examination of the pupils is extremely
% Male
72 (56.7%)
34 (59.6 %)
n localizing the lesion, characterizing a differential diagnosis,
% Male
helpful in localizing the lesion, characterizing a differential diagnosis,
% Caucasian
103 (81.1%)
47 (82.5%)
owing the course of the disease process. However, interrater
% Caucasian
and following the course of the disease process. However, interrater
y of these findings has not been established.
Primary diagnosis
reliability of these findings has not been established.
Primary diagnosis
All Patients
(n=127)
Not Surgical
Not Surgical
All Patients
Surgical Procedure
(n=70)
(n=57)
(n=70)
(n=127)
55.4 (sd=15.6)
55.1 (sd=15.6)
54.8 (sd=15.7)
55.4 (sd=15.6)
38 (54.3%)
Entire
72 (56.7%)
34 (59.6 %)
38Size
(54.3%)
> 1mm
Cohort
56 (80.0%)
103 (81.1%)
47 (82.5%)
56 (80.0%)
(N=1,166) Equal in size
Results
Left Eye
Kappa
0.54
(.49-.59)
-
Right Eye
% agree
Kappa
Both Eyes
Left Eye
Right Eye
% agree
Kappa
% agree
Kappa
% agree
Kappa
0.54
0.54
78.9%
79.8% 0.54
78.0%
0.54
Entire
(.50-.58) 78.0%
(.49-.59)
Size > 1mm
(.49-.59)
(.49-.59)
Cohort
0.60
80.8%
(N=1,166)
- (.55-.64)
Equal in size
0.06
0.62
96.0%
94.3%
97.6% 0.68
0.06
(-.07-.19)
(.55-.69) 94.3%
Shape
(-.07-.19)
(.61-.76)
0.30
0.40
80.0%
79.0%
0.30
Reactivity 78.0% 0.48
(.23-.36)
(.36-.44) 80.0%
(.43-.53)
(.23-.36)
(brisk, slow, fixed)
0.64
0.51
Reactive
95.9%
96.7% 0.69
95.0%
0.51
(.58-.71) 95.0%
(.37-.64)
(.37-.64)
(.62-.77)
vs not
0.53
0.52
79.1%
79.7% 0.54
78.6%
0.52
Only
(.49-.57) 78.6%
(.46-.58)
Size > 1mm
(.46-.58)
(.49-.60)
Nurses
0.60
80.8%
(n=952)
- (.54-.65)
Equal in size
.01
0.64
96.3%
94.7%
97.8% 0.70
.01
(.005-.01)
(.56-.72) 94.7%
Shape
(.005-.01)
(.62-.78)
0.33
0.42
80.3%
79.5%
0.33
Reactivity 78.7% 0.49
(.26-.40)
(.38-.47) 80.3%
(.43-.55)
(.26-.40)
(brisk, slow, fixed)
0.67
0.59
Reactive
96.2%
97.1% 0.69
95.2%
0.59
(.59-.74) 95.2%
(.45-.73)
(.45-.73)
(.61-.78)
vs not
0.77
0.63
74.3%
88.6% 0.49
81.4%
0.77
Only
(.55-.98)
(.45-.81) 74.3%
Size > 1mm
(.20-.78)
(.55-.98)
Physician
0.70
87.8%
(n=33)
- (.42-.97)
Equal in size
0.55
95.6%
94.2%
DNC
96.9% 0.64
(.11-.99) 94.2%
DNC
Shape
(.19-1.0)
0.54
85.3%
91.4%
DNC
78.8% 0.73
Reactivity
(.30-.79) 91.4%
DNC
(.45-1.0)
(brisk, slow, fixed)
0.55
Reactive
95.6%
97.1%
DNC
93.9% 0.79
(.09-1.0) 97.1%
DNC
(.38-1.0)
vs not
0.54
0.56
One
RN
77.4%
78.8% 0.51
76.0%
0.56
(.45-.63) 76.0%
(.44-.68)
Size > 1mm
and
(.44-.68)
(.39-.64)
One MD
0.57
79.7%
- (.44-.69)
(n=179) Equal in size
0.55
0.24
94.4%
96.6% 0.61
92.1%
0.24
(.38-.73) 92.1%
(.14-.63)
Shape
(.14-.63)
(.42-.79)
0.07
0.25
74.9%
75.8%
0.07
Reactivity 74.0% 0.38
(-.07-.20)
(.15-.36) 75.8%
(-.07-.20)
(.24-.51)
(brisk, slow, fixed)
-0.02
0.54
-0.02
Reactive
94.4%
93.8%
(-0.0494.9% 0.67
(.36-.72) 93.8%
(-0.040.002) vs not
(.49-.85)
0.002)
Surgical
Patients
Surgical
Procedure
NotNot
Surgical
AllAll
Patients
Surgical
Procedure
All
Patients
Surgical
Procedure
Not
Surgical
s is
a a
is
a Specific Aims
Specific Aims
(n=57)
(n=70)
(n=127)
(n=57)
(n=70)
(n=127)
(n=127)
(n=57)
(n=70)
gical
dy
seeks
to:
cal
This study seeks to:
gical
mine the interrater reliability of pupillary assessments
1. Determine Mean
the interrater
reliability of pupillary assessments55.1 (sd=15.6)
Age
54.8
(sd=15.7)
55.4
(sd=15.6)
Mean
Age
55.1 (sd=15.6)
54.8
(sd=15.7)
55.4
(sd=15.6)
een
two independent observers examining
the
pupil
at the
mely
Mean
Age
54.8
(sd=15.7)
55.4
(sd=15.6)
ely
Results
between two
independent
observers examining the pupil at the55.1 (sd=15.6)
mely
Results
time.
same time.
%
Male
72
(56.7%)
34
(59.6
38
(54.3%)
mine if there is a greater correlation
between
observers
2332 (1166observers
paired)72
observational
assessments pupils were34
completed
on %)%)
osis,
% Male
(56.7%)
(59.6
(54.3%)
2. Determine
if there
is a greater correlation• between
• 2332 (1166 paired) observational
assessments
pupils were completed on38 38
%
Male
72
(56.7%)
34
(59.6
%)
(54.3%)
sis,
osis,
hed
by profession (nursing versus medial background)
127 consented patients
matched by profession (nursing versus medial background)
127 consented patients
•
There
was
composite
agreement
in
all
three
parameters:
size
(within
1
% Caucasian
Caucasian
103
(81.1%)
47
(82.5%)
(80.0%)
• There was composite agreement
in all
three parameters: size (within 1 56 56
rater
103103
(81.1%)
47
(82.5%)
(80.0%)
ter
mm), shape, & reactivity
for 463
(39.7%) OS; 470 (40.3%) OD;
and47
328 (82.5%)
%
(81.1%)
56
(80.0%)
rater Background % Caucasian
mm), shape, & reactivity for 463
(39.7%) OS; 470 (40.3%) OD; and 328
(28.1%) OU.
Background
# Ischemic stroke
# Hem. stroke (SAH/ICH)
# Neoplasm
# Other
# Vision or ocular history
43 (33.9%)
7 (12.3%)
# Ischemic stroke
40 (31.5%)
20 (35.1%)
# Hem. stroke (SAH/ICH)
23 (18.1%)
18 (31.6%)
# Neoplasm
21 (16.5%)
12 (21.0%)
# Other
9 (7.1%)
5 (8.8%)
# Vision or ocular history
36 (51.4%)
43 (33.9%)
20 (28.6%)
40 (31.5%)
5 (7.1%)
23 (18.1%)
9 (12.9%)
21 (16.5%)
4 (5.7%)
9 (7.1%)
7 (12.3%)
20 (35.1%)
18 (31.6%)
12 (21.0%)
5 (8.8%)
Only
Nurses
(n=952)
36Shape
(51.4%)
20 (28.6%)
5Reactivity
(7.1%)
slow, fixed)
9(brisk,
(12.9%)
4Reactive
(5.7%)
vs not
0.68
(.61-.76)
0.48
(.43-.53)
0.69
(.62-.77)
Size > 1mm
0.54
(.49-.60)
Equal in size
-
Shape
Reactivity
0.70
(.62-.78)
0.49
(.43-.55)
(brisk, slow, fixed)
(28.1%) OU.
• Interrater reliability Kappa values and % agreement for size (within 1mm)
Reactive
0.69
amination of the pupil is a critical component of the bedside
• Interrater reliability Kappa values and % agreement for size (within
1mm)
Serial examination of the pupil is a critical component
of the bedside
for OS=0.54
(78%), OD=0.54 (79.8%), and OU=0.54 (78.9%).
(.61-.78)
vs
not
for
OS=0.54
(78%),
OD=0.54
(79.8%),
and
OU=0.54
(78.9%).
gical examination. Changes in the pupillary size, shape and/or
neurological examination. Changes in the pupillary
size, shape
and/or for shape for OS=0.68 (94.3%), OD=0.06 (97.6%), and
• Kappa
and agreement
0.49
Only
y can be an early sign of neurological deterioration,
•
Kappa
and
agreement
for
shape
for
OS=0.68
(94.3%),
OD=0.06
(97.6%),
and
Size
>
1mm
reactivity can be an early sign of neurological
deterioration,
OU=0.62
(96%).
(.20-.78)
Physician
OU=0.62 (96%).
d intracranial pressure, and worsening midline shift. In
increased intracranial pressure, and worsening
midline
In
• Kappa
andshift.
agreement
for pupil reactivity for OS=0.48 (80%), OD=0.30
(n=33)
Equal OD=0.30
in size
pupillary findings may also be used to monitor response to
•
Kappa
and
agreement
for
pupil
reactivity
for
OS=0.48
(80%),
addition, pupillary findings may also be used to monitor
response
to (79%).
(78%), and
OU=0.40
(78%), and OU=0.40 (79%).
Despite the importance of pupillary assessments, limited
0.64
therapy. Despite the importance of pupillary •assessments,
limited pupils assessed as fixed (non-reactive) by one
Only 49.5% (94/190)
Shape
research has shown that there may be variability in pupillary
•
Only
49.5%
(94/190)
pupils
assessed
as
fixed
(non-reactive)
by
one
(.19-1.0)
previous research has shown that there may be variability
pupillary
assessorinwas
also scored as fixed by the second assessor; [OS = 73/131
assessor was also scored as fixed by the second assessor; [OS
= 73/131
0.73
ments.
Reactivity
(55.7%), and OD = 21/59 (35.6%)].
assessments.
(.45-1.0)
(55.7%), and OD = 21/59 (35.6%)].
(brisk, slow, fixed)
Primary
diagnosis
Primary
diagnosis
Primary
diagnosis
#
Ischemic
stroke
43
(33.9%)
# Ischemic
stroke
43 43
(33.9%)
# Ischemic
stroke
(33.9%)
#
Hem.
stroke
(SAH/ICH)
40
(31.5%)
# Hem.
stroke
(SAH/ICH)
40 40
(31.5%)
# Hem.
stroke
(SAH/ICH)
(31.5%)
#
Neoplasm
23
(18.1%)
# Neoplasm
23 23
(18.1%)
# Neoplasm
(18.1%)
#
Other
21
(16.5%)
# Other
21 21
(16.5%)
# Other Methods
(16.5%)
Methods
# Vision
Vision
orpartocular
ocular
history
9 (7.1%)
(7.1%)
# pupillary
Vision
or asocular
history
9 (7.1%)
mined interrater reliability of bedside
exams
or
history
9
We examined #
interrater reliability
of bedside pupillary
exams as part
7 (12.3%)
(12.3%)
7 (12.3%)
7
20
(35.1%)
20 20
(35.1%)
(35.1%)
18
(31.6%)
18 18
(31.6%)
(31.6%)
12
(21.0%)
12 12
(21.0%)
(21.0%)
5
(8.8%)
5 (8.8%)
5 (8.8%)
One RN
and
One MD
(n=179)
ge prospective study. 127 patients with neurological or
Conclusion
ments
of a large prospective study. 127 patients with neurological or
nts
Conclusion
ments
rgical diagnoses were consented. These patients were
neurosurgical diagnoses were consented. These patients were
d by staff (RNs and MDs) who were expected to perform a
These data
suggestathat there is a surprisingly large degree of disagreement
observed by staff (RNs and MDs) who were expected
to perform
These data suggest that there is a surprisingly large degree of disagreement
tthe
the
between trained observers when assessing and scoring pupillary findings.
exam
as a normal part of their patient care routine. Two
the
between trained
observers when assessing and scoring pupillary findings.
pupillary exam as a normal part of their patient
care routine.
Results
Furthermore,
forTwo
96 of 190 (51.5%) assessments,
there was no agreement on
dent observers performed a pupillary exam simultaneously or
Results
Results
Results
0.51
(.39-.64)
Equal in size
-
0.61
(.42-.79)
Furthermore, for 96 of 190 (51.5%) assessments, there was noReactivity
agreement on 0.38
independent observers performed a pupillary exam
simultaneously
or
of
pupillary
reactivity.
Interrater
reliability
was
not
significantly
the
absence
Observers were instructed to perform
the absence of pupillary reactivity. Interrater reliability was not
(.24-.51)
(brisk,significantly
slow, fixed)
within 5 minutes of each other. Observers were instructed
to perform
different within
vs between observers. Given the importance of pupillary
Shape
79.8%
97.6%
78.0%
96.7%
Ka
0.
(.50
0.
(.55
0.
(.55
0.
(.36
0.
(.58
0.
(.49
0.
(.54
0.
(.56
0.
(.38
Entire
Entire
Entire
Coho
Cohort
Coho
(N=1,
(N=1,16
(N=1,
36
(51.4%)
36 36
(51.4%)
(51.4%)
20
(28.6%)
20 20
(28.6%)
(28.6%)
5
(7.1%)
5 (7.1%)
5 (7.1%)
9
(12.9%)
9 (12.9%)
Reactive
9 (12.9%)
vs not
4 (5.7%)
(5.7%)
4 (5.7%)
4
Size > 1mm
0.79
(.38-1.0)
% agree
79.7%
-
97.8%
78.7%
97.1%
88.6%
96.9%
78.8%
0.
(.59
0.
(.45
0.
(.42
0.
(.11
0.
(.30
93.9%
0.
(.09
78.8%
0.
(.45
-
0.
(.44
0.
(.38
0.
(.15
Only
Only
Only
Nurse
Nurses
Nurse
(n=95
(n=952)
(n=95
96.6%
minutes of each other.
74.0%
m as they would under normal conditions using the
different within vs between observers. Given the importance of pupillary
the exam as they would under normal conditions
the with neurological
reactivity using
in patients
injury, these findings may have
Reactive
reactivity in patients with neurological injury, these findings
may have 0.67
nt (penlight or flashlight) that they would use if they were
0.
significant
clinical
equipment (penlight or flashlight) that they would
use if they
wereimplications. Future research is needed to standardize
(.49-.85)
94.9%
vs not
significant clinical implications. Future research is needed to standardize
(.36
performing the exam.
pupillary assessments. One mechanism for potential standardization of
typically performing the exam.
pupillary assessments. One mechanism for potential standardization of
pupillary assessments is through the use of the Pupillometer.
The authors of this study would like to thank Weidan Zhao and the many clinicians that contributed to the
pupillary assessments is through the use of the Pupillometer.
The authors of this study would like to thank Weidan Zhao and the many clinicians that
rvers
ers
rvers
2332
(1166
paired)
observational
assessments
pupils
were
completed
• ••2332
(1166
paired)
observational
assessments
pupils
were
completed
onon
2332
(1166
paired)
observational
assessments
pupils
were
completed
on
127
consented
patients
127
consented
patients
127
consented
patients
There
was
composite
agreement
three
parameters:
size
(within
• ••There
was
composite
agreement
in in
allall
three
parameters:
size
(within
1 1
There
was
composite
agreement
in
all
three
parameters:
size
(within
1
mm),
shape,
&
reactivity
for
463
(39.7%)
OS;
470
(40.3%)
OD;
and
328
mm),
shape,
&
reactivity
for
463
(39.7%)
OS;
470
(40.3%)
OD;
and
328
mm), shape, & reactivity for 463 (39.7%) OS; 470 (40.3%) OD; and 328
(28.1%)
OU.
(28.1%)
OU.
(28.1%)
OU.
Interrater
Kappa
values
and
agreement
size
(within
1mm)
• ••Interrater
reliability
Kappa
values
and
%%
agreement
forfor
size
(within
1mm)
Interrater reliability
reliability
Kappa
values
and
%
agreement
for
size
(within
1mm)
OS=0.54
(78%),
OD=0.54
(79.8%),
and
OU=0.54
(78.9%).
forfor
OS=0.54
(78%),
OD=0.54
(79.8%),
and
OU=0.54
(78.9%).
for OS=0.54 (78%), OD=0.54 (79.8%), and OU=0.54 (78.9%).
Kappa
and
agreement
shape
OS=0.68
(94.3%),
OD=0.06
(97.6%),
and
• ••Kappa
and
agreement
forfor
shape
forfor
OS=0.68
(94.3%),
OD=0.06
(97.6%),
and
Kappa
and
agreement
for
shape
for
OS=0.68
(94.3%),
OD=0.06
(97.6%),
and
OU=0.62
(96%).
OU=0.62
(96%).
OU=0.62 (96%).
Kappa
and
agreement
pupil
reactivity
OS=0.48
(80%),
OD=0.30
• ••Kappa
Kappaand
andagreement
agreementforfor
forpupil
pupilreactivity
reactivityforfor
forOS=0.48
OS=0.48(80%),
(80%),OD=0.30
OD=0.30
(78%),
and
OU=0.40
(79%).
(78%),
and
OU=0.40
(79%).
(78%), and OU=0.40 (79%).
Only
49.5%
(94/190)
pupils
assessed
fixed
(non-reactive)
one
• ••Only
49.5%
(94/190)
pupils
assessed
asas
fixed
(non-reactive)
byby
one
Only
49.5%
(94/190)
pupils
assessed
as
fixed
(non-reactive)
by
one
assessor
was
also
scored
as
fixed
by
the
second
assessor;
[OS
=
assessor
was
also
scored
as
fixed
by
the
second
assessor;
[OS
=
assessor was also scored as fixed by the second assessor; [OS 73/131
= 73/131
73/131
(55.7%),
and
OD
=
21/59
(35.6%)].
(55.7%),
and
ODOD
= 21/59
(35.6%)].
(55.7%),
and
= 21/59
(35.6%)].
ding Author: [email protected]
Corresponding Author: [email protected]
dside
de
dside
nd/or
/or
nd/or
ation,
on,
ation,
t.
t.In In
In
se
to to
se
to
mited
ed
mited
illary
ary
illary
part
art
part
al
or
al or
or
were
ere
were
mrm
a a
rm
a
Two
wo
Two
sly
oror
sly
or
form
rm
form
hethe
the
were
ere
were
pupillary assessments.
pupi
Neuroptics Inc. provided Pupillometers and headrests as part of a larger study from which these data are drawn.
Neuroptics Inc. provided Pupillometers and headrests as part of a larger study from which the
Only
Only
Only
Phys
Physicia
Phys
(n=33
(n=33)
(n=33
One
One
RNR
One
R
and
and
and
One
One
MDM
One
M
(n=1
(n=179)
(n=1
Conclusion
Conclusion
Conclusion
Conclusion
These
data
suggest
that
there
a
large
degree
disagreement
These
data
suggest
that
there
is is
a surprisingly
large
degree
of of
disagreement
These
data
suggest
that
there
is
a surprisingly
surprisingly
large
degree
of
disagreement
between
trained
observers
when
assessing
and
scoring
pupillary
findings.
between
trained
observers
when
assessing
and
scoring
pupillary
findings.
between
trained
observers
when
assessing
and
scoring
pupillary
findings.
Furthermore,
for
96
of
190
(51.5%)
assessments,
there
was
no
agreement
Furthermore,
forfor
9696
of of
190
(51.5%)
assessments,
there
was
nono
agreement
onon
Furthermore,
190
(51.5%)
assessments,
there
was
agreement
on
the
absence
of
pupillary
reactivity.
Interrater
reliability
was
not
significantly
thethe
absence
of of
pupillary
reactivity.
Interrater
reliability
was
not
significantly
absence
pupillary
reactivity.
Interrater
reliability
was
not
significantly
differentwithin
withinvsvs
vsbetween
betweenobservers.
observers.Given
Giventhethe
theimportance
importanceof of
ofpupillary
pupillary
different
different
within
between
observers.
Given
importance
pupillary
reactivity
in
patients
with
neurological
injury,
these
findings
may
have
reactivity
in
patients
with
neurological
injury,
these
findings
may
reactivity in patients with neurological injury, these findings mayhave
have
significant
clinical
implications.
Future
research
is
needed
to
standardize
significant
clinical
implications.
Future
research
is
needed
to
standardize
significant clinical implications. Future research is needed to standardize
pupillaryassessments.
assessments.One
Onemechanism
mechanismforfor
forpotential
potentialstandardization
standardizationof of
of
pupillary
pupillary
assessments.
One
mechanism
potential
standardization
pupillary
assessments
is
through
the
use
of
the
Pupillometer.
pupillary
assessments
is is
through
thethe
use
of of
thethe
Pupillometer.
pupillary
assessments
through
use
Pupillometer.
2
TheTh
a
Th
ments Among
Interrater Reliability of Pupillary Assessments Among
Physicians
and
Nurses
Interrater Reliability
of Pupillary
Assessments
Interrater
Reliability
of PupillaryAmong
Assessments Among
, Venkatesh Aiyagari¹²
Physicians
and1Physicians
Sonja E. Stutzman
,Nurses
DaiWai M. Olson
, Ciji Saju3,
and123Nurses
3
12
Sonja E. Stutzman¹, DaiWai
M. Olson¹²³,
Ciji Saju³,
Margaret
Wilson³,
Aiyagari¹²
Margaret
Wilson
Venkatesh
Aiyagari
Sonja
E. Stutzman¹,
DaiWai
M., Olson¹²³,
CijiVenkatesh
Saju³,
Margaret
Wilson³, Venkatesh Aiyagari¹²
l³, UT Southwestern Medical
Center
Department of Neurology
and Neurotherapeutics¹ and Neurological Surgery², University Hospital³, UT Southwestern Medical Center
Department of Neurology and Neurotherapeutics¹ and Neurological Surgery², University Hospital³, UT Southwestern Medical Center
Department of Neurology and Neurotherapeutics1 and Neurological Surgery2, University Hospital3, UT Southwestern Medical Center
Introduction
Demographics
Introduction
l
Specific Aims
Specific Aims
# Ischemic stroke
# Hem. stroke (SAH/ICH)
# Neoplasm
# Other
Results
Demographics
Surgical Procedure
tional assessment of pupil size, shape, and reactivity is a
Observational assessment of pupil size, shape, and reactivity is a
(n=57)
ntal aspect of the neurological examination. In neurological
fundamental aspect of the neurological examination.
In neurological 55.1 (sd=15.6)
Mean
Age
54.8 (sd=15.7)
rosurgical patients, examination of the pupils is extremely
Mean Age
and neurosurgical patients, examination of the pupils is extremely
% Male
72 (56.7%)
34 (59.6 %)
n localizing the lesion, characterizing a differential diagnosis,
% Male
helpful in localizing the lesion, characterizing a differential diagnosis,
% Caucasian
103 (81.1%)
47 (82.5%)
owing the course of the disease process. However, interrater
% Caucasian
and following the course of the disease process. However, interrater
y of these findings has not been established.
Primary diagnosis
reliability of these findings has not been established.
Primary diagnosis
All Patients
(n=127)
Not Surgical
Not Surgical
All Patients
Surgical Procedure
(n=70)
(n=57)
(n=70)
(n=127)
55.4 (sd=15.6)
55.1 (sd=15.6)
54.8 (sd=15.7)
55.4 (sd=15.6)
38 (54.3%)
Entire
72 (56.7%)
34 (59.6 %)
38Size
(54.3%)
> 1mm
Cohort
56 (80.0%)
103 (81.1%)
47 (82.5%)
56 (80.0%)
(N=1,166) Equal in size
Results
Results
43 (33.9%)
7 (12.3%)
# Ischemic stroke
40 (31.5%)
20 (35.1%)
# Hem. stroke (SAH/ICH)
23 (18.1%)
18 (31.6%)
# Neoplasm
21 (16.5%)
12 (21.0%)
# Other
9 (7.1%)
5 (8.8%)
# Vision or ocular history
Left Eye
36 (51.4%)
43 (33.9%)
20 (28.6%)
40 (31.5%)
5 (7.1%)
23 (18.1%)
9 (12.9%)
21 (16.5%)
7 (12.3%)
20 (35.1%)
18 (31.6%)
12 (21.0%)
Right Eye
36Shape
(51.4%)
20 (28.6%)
5Reactivity
(7.1%)
slow, fixed)
9(brisk,
(12.9%)
4Reactive
(5.7%)
vs not
Left Eye
Kappa
0.54
(.49-.59)
0.68
(.61-.76)
0.48
(.43-.53)
Kappa
Entire
Size > 1mm
Cohort
(N=1,166) Equal in size
Shape
Methods
Reactivity
Methods
(brisk, slow, fixed)
% agree
Kappa
0.54
(.49-.59)
78.0%
0.54
(.49-.59)
79.8%
-
-
-
-
0.68
(.61-.76)
0.48
(.43-.53)
94.3%
80.0%
0.06
(-.07-.19)
0.30
(.23-.36)
% agree
97.6%
78.0%
Reactive
vs not
% agree
Kappa
Both Eyes
Left Eye
Right Eye
% agree
Kappa
% agree
Kappa
% agree
Kappa
0.54
0.54
78.9%
79.8% 0.54
78.0%
0.54
Entire
(.50-.58) 78.0%
(.49-.59)
Size > 1mm
(.49-.59)
(.49-.59)
Cohort
0.60
80.8%
(N=1,166)
- (.55-.64)
Equal in size
0.06
0.62
96.0%
94.3%
97.6% 0.68
0.06
(-.07-.19)
(.55-.69) 94.3%
Shape
(-.07-.19)
(.61-.76)
0.30
0.40
80.0%
79.0%
0.30
Reactivity 78.0% 0.48
(.23-.36)
(.36-.44) 80.0%
(.43-.53)
(.23-.36)
(brisk, slow, fixed)
0.64
0.51
Reactive
95.9%
96.7% 0.69
95.0%
0.51
(.58-.71) 95.0%
(.37-.64)
(.37-.64)
(.62-.77)
vs not
0.53
0.52
79.1%
79.7% 0.54
78.6%
0.52
Only
(.49-.57) 78.6%
(.46-.58)
Size > 1mm
(.46-.58)
(.49-.60)
Nurses
0.60
80.8%
(n=952)
- (.54-.65)
Equal in size
.01
0.64
96.3%
94.7%
97.8% 0.70
.01
(.005-.01)
(.56-.72) 94.7%
Shape
(.005-.01)
(.62-.78)
0.33
0.42
80.3%
79.5%
0.33
Reactivity 78.7% 0.49
(.26-.40)
(.38-.47) 80.3%
(.43-.55)
(.26-.40)
(brisk, slow, fixed)
0.67
0.59
Reactive
96.2%
97.1% 0.69
95.2%
0.59
(.59-.74) 95.2%
(.45-.73)
(.45-.73)
(.61-.78)
vs not
0.77
0.63
74.3%
88.6% 0.49
81.4%
0.77
Only
(.55-.98)
(.45-.81) 74.3%
Size > 1mm
(.20-.78)
(.55-.98)
Physician
0.70
87.8%
(n=33)
- (.42-.97)
Equal in size
0.55
95.6%
94.2%
DNC
96.9% 0.64
(.11-.99) 94.2%
DNC
Shape
(.19-1.0)
0.54
85.3%
91.4%
DNC
78.8% 0.73
Reactivity
(.30-.79) 91.4%
DNC
(.45-1.0)
(brisk, slow, fixed)
0.55
Reactive
95.6%
97.1%
DNC
93.9% 0.79
(.09-1.0) 97.1%
DNC
(.38-1.0)
vs not
0.54
0.56
One
RN
77.4%
78.8% 0.51
76.0%
0.56
(.45-.63) 76.0%
(.44-.68)
Size > 1mm
and
(.44-.68)
(.39-.64)
One MD
0.57
79.7%
- (.44-.69)
(n=179) Equal in size
0.55
0.24
94.4%
96.6% 0.61
92.1%
0.24
(.38-.73) 92.1%
(.14-.63)
Shape
(.14-.63)
(.42-.79)
0.07
0.25
74.9%
75.8%
0.07
Reactivity 74.0% 0.38
(-.07-.20)
(.15-.36) 75.8%
(-.07-.20)
(.24-.51)
(brisk, slow, fixed)
-0.02
0.54
-0.02
Reactive
94.4%
93.8%
(-0.0494.9% 0.67
(.36-.72) 93.8%
(-0.040.002) vs not
(.49-.85)
0.002)
Both Eyes
dy seeks to:
This study seeks to:
# Vision or ocular history
4 (5.7%)
0.69
9 (7.1%)
5 (8.8%)
mine the interrater reliability of pupillary assessments
(.62-.77)
1. Determine the interrater reliability of pupillary assessments
een two independent observers examining the pupil at the
0.54
Only
Results
between two independent observers examining the pupil at the
Size > 1mm
Results
time.
(.49-.60)
Nurses
same time.
mine if there is a greater correlation between observers
•
2332
(1166
paired)
observational
assessments
pupils
were
completed
on
(n=952)
Equal in size
2. Determine if there is a greater correlation between observers
• 2332 (1166 paired) observational assessments pupils were completed
on
hed by profession (nursing versus medial background)
127 consented patients
matched by profession (nursing versus medial background)
127 consented patients
0.70
• There was composite agreement in all three parameters: size (within 1
Shape
(.62-.78)
• There was composite agreement in all three parameters: size (within 1
mm), shape, & reactivity for 463 (39.7%) OS; 470 (40.3%) OD; and 328
0.49
mm), shape, & reactivity for 463 (39.7%) OS; 470 (40.3%) OD; and
328
Reactivity
Background
(28.1%) OU.
Background
(.43-.55)
(brisk, slow, fixed)
(28.1%) OU.
• Interrater reliability Kappa values and % agreement for size (within 1mm)
Reactive
0.69
amination of the pupil is a critical component of the bedside
•
Interrater
reliability
Kappa
values
and
%
agreement
for
size
(within
1mm)
Serial examination of the pupil is a critical component
of the bedside
for OS=0.54
(78%), OD=0.54 (79.8%), and OU=0.54 (78.9%).
(.61-.78)
vs not
for OS=0.54 (78%), OD=0.54 (79.8%), and OU=0.54 (78.9%).
gical examination. Changes in the pupillary size, shape and/or
neurological examination. Changes in the pupillary
size, shape
and/or for shape for OS=0.68 (94.3%), OD=0.06 (97.6%), and
• Kappa
and agreement
0.49
Only
y can be an early sign of neurological deterioration,
•
Kappa
and
agreement
for
shape
for
OS=0.68
(94.3%),
OD=0.06
(97.6%),
and
Size
>
1mm
reactivity can be an early sign of neurological
deterioration,
OU=0.62
(96%).
(.20-.78)
Physician
OU=0.62 (96%).
d intracranial pressure, and worsening midline shift. In
increased intracranial pressure, and worsening
midline
In
• Kappa
andshift.
agreement
for pupil reactivity for OS=0.48 (80%), OD=0.30
(n=33)
Equal OD=0.30
in size
pupillary findings may also be used to monitor response to
•
Kappa
and
agreement
for
pupil
reactivity
for
OS=0.48
(80%),
addition, pupillary findings may also be used to monitor
response
to (79%).
(78%), and
OU=0.40
(78%), and OU=0.40 (79%).
Despite the importance of pupillary assessments, limited
0.64
therapy. Despite the importance of pupillary •assessments,
limited pupils assessed as fixed (non-reactive) by one
Only 49.5% (94/190)
Shape
research has shown that there may be variability in pupillary
•
Only
49.5%
(94/190)
pupils
assessed
as
fixed
(non-reactive)
by
one
(.19-1.0)
previous research has shown that there may be variability
pupillary
assessorinwas
also scored as fixed by the second assessor; [OS = 73/131
assessor was also scored as fixed by the second assessor; [OS
= 73/131
0.73
ments.
Reactivity
(55.7%), and OD = 21/59 (35.6%)].
assessments.
(.45-1.0)
(55.7%), and OD = 21/59 (35.6%)].
(brisk, slow, fixed)
6)
Results
Right Eye
Kappa
0.54
(.50-.58)
0.60
(.55-.64)
0.62
(.55-.69)
0.40
0.79
(.36-.44)
(.38-1.0)
% agree
78.9%
80.8%
96.0%
79.0%
% agree
79.8%
97.6%
78.0%
96.7%
79.7%
97.8%
78.7%
97.1%
88.6%
96.9%
78.8%
93.9%
Ka
0.
(.50
0.
(.55
0.
(.55
0.
(.36
0.
(.58
0.
(.49
0.
(.54
0.
(.56
0.
(.38
0.
(.59
0.
(.45
0.
(.42
0.
(.11
0.
(.30
0.
(.09
One RN
0.51
mined interrater reliability of bedside pupillary exams as part
0.
Size > 1mm
We examined interrater reliability of bedside pupillary exams as part
and
(.39-.64)
78.8%
ge prospective study. 127 patients with neurological or
(.45
Conclusion
of a large prospective study. 127 patients with neurological or
One MD
Conclusion
rgical diagnoses were consented. These patients were
neurosurgical diagnoses were consented. These patients were
0.
(n=179) Equal in size
d by staff (RNs and MDs) who were expected to perform a
These data
suggestathat there is a surprisingly large degree of disagreement
(.44
observed by staff (RNs and MDs) who were expected
to perform
These data suggest that there is a surprisingly large degree of disagreement 0.61
between trained observers when assessing and scoring pupillary findings.
exam as a normal part of their patient care routine. Two
0.
Shape findings.
between trained observers when assessing and scoring pupillary
pupillary exam as a normal part of their patient
care routine.
(.42-.79)
96.6%
Furthermore,
forTwo
96 of 190 (51.5%) assessments, there was no agreement on
dent observers performed a pupillary exam simultaneously or
(.38
Furthermore, for 96 of 190 (51.5%) assessments, there was noReactivity
agreement on 0.38
independent observers performed a pupillary exam
simultaneously
or
of
pupillary
reactivity.
Interrater
reliability
was
not
significantly
the
absence
0.
minutes of each other. Observers were instructed to perform
significantly
the absence of pupillary reactivity. Interrater reliability was not
(.24-.51)
74.0%
(brisk,
slow,
fixed)
within 5 minutes of each other. Observers were instructed
to
perform
different within vs between observers. Given the importance of pupillary
(.15
m as they would under normal conditions using the
different within vs between observers. Given the importance of pupillary
the exam as they would under normal conditions
the with neurological
reactivity using
in patients
injury, these findings may have
Reactive
reactivity in patients with neurological injury, these findings
may have 0.67
nt (penlight or flashlight) that they would use if they were
0.
significant
clinical
equipment (penlight or flashlight) that they would
use if they
wereimplications. Future research is needed to standardize
(.49-.85)
94.9%
vs not
significant clinical implications. Future research is needed to standardize
(.36
performing the exam.
pupillary assessments. One mechanism for potential standardization of
typically performing the exam.
pupillary assessments. One mechanism for potential standardization of
pupillary assessments is through the use of the Pupillometer.
The authors of this study would like to thank Weidan Zhao and the many clinicians that contributed to the
pupillary assessments is through the use of the Pupillometer.
The authors of this study would like to thank Weidan Zhao and the many clinicians that
d on
Only
Nurses
(n=952)
Reactive
vs not
0.54
(.49-.60)
78.6%
Equal in size
-
-
Shape
Reactivity
(brisk, slow, fixed)
mm)
), and
D=0.30
Reactive
vs not
Only
Size > 1mm
Physician
(n=33)
Equal in size
eement
ndings.
ment on
ficantly
upillary
y have
dardize
ation of
0.69
(.61-.78)
94.7%
80.3%
95.2%
96.7%
0.64
(.58-.71)
95.9%
0.67
(.59-.74)
96.2%
0.53
79.1%
(.49-.57)
0.60
80.8%
(.54-.65)
pupillary assessments.
pupi
Neuroptics Inc. provided Pupillometers and headrests as part of a larger study from which these data are drawn.
0.64Neuroptics Inc. provided Pupillometers and headrests as part of a larger study from which the
.01
96.3%
97.8%
(.56-.72)
(.005-.01)
0.33
0.42
78.7%
79.5%
(.26-.40)
(.38-.47)
0.52
(.46-.58)
79.7%
0.59
(.45-.73)
97.1%
74.3%
0.77
(.55-.98)
88.6%
-
-
-
-
94.2%
DNC
96.9%
91.4%
DNC
78.8%
0.79
(.38-1.0)
97.1%
DNC
93.9%
0.55
(.09-1.0)
95.6%
Size > 1mm
0.51
(.39-.64)
76.0%
0.56
(.44-.68)
78.8%
0.54
(.45-.63)
77.4%
Equal in size
-
-
-
-
Reactivity
(brisk, slow, fixed)
One RN
and
One MD
(n=179)
0.70
(.62-.78)
0.49
(.43-.55)
0.51
(.37-.64)
0.49
(.20-.78)
Shape
131
95.0%
Size > 1mm
ding Author: [email protected]
Corresponding Author: [email protected]
1
0.69
(.62-.77)
Reactive
vs not
0.64
(.19-1.0)
0.73
(.45-1.0)
(brisk, slow, fixed)
0.61
(.42-.79)
0.38
(.24-.51)
Reactive
vs not
0.67
(.49-.85)
Shape
Reactivity
92.1%
75.8%
93.8%
0.24
(.14-.63)
0.07
(-.07-.20)
-0.02
(-0.040.002)
96.6%
74.0%
94.9%
0.63
(.45-.81)
0.70
(.42-.97)
0.55
(.11-.99)
0.54
(.30-.79)
0.57
(.44-.69)
0.55
(.38-.73)
0.25
(.15-.36)
0.54
(.36-.72)
81.4%
87.8%
95.6%
85.3%
79.7%
94.4%
74.9%
94.4%
The authors of this study would like to thank Weidan Zhao and the many clinicians that contributed to the pupillary assessments.
The authors
of thisInc.
study
would
like to thank
many
clinicians
that
contributed
to the
NeurOptics,
provide
Pupillometers
and Weidan
headrestsZhao
as partand
of athe
larger
study
from which
these
data were drawn.
pupillary assessments.
3