# Pupil Examination

## Overview

This module describes how to examine a patient’s pupils.

## Indications

1. Patients complaining of loss of vision

2. Condition with risk of loss of vision

3. Suspected head injury

## Contraindications

1. None

## Patient information & consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“I need to test your pupils. They look like the dark centre of your eyes, but actually let light in which reacts with nerves to form your vision. Examining your pupils also gives me information about the pathways connecting your brain and your eyes.”

### What can my patient expect?

“I will look at your pupils while you focus far away, and shine a torchlight into each of them a few times to see how they react to light.”

### What is my patient’s role?

“Try to stay relaxed and try to keep focusing in the distance.”

## Preparation

###

### Documentation

1. Patient notes

### Equipment

1. Alcohol-based hand rub

2. Penlight torch

## Site & Positioning

The patient should be sitting upright in ambient light conditions.

## Procedure

Follow medical asepsis without gloves.

1. Perform hand hygiene.

2. General observation: In a normally lit room, ask the patient to fixate at a target across the room to reduce accommodation (miosis). Diffusely illuminate both pupils from below with a penlight. Note the size (normal is 2 mm in bright conditions and 6 mm in dark conditions) and shape (pupil sizes should be equal).

3. Light reflex test: normally both pupils will constrict if you shine the light into one eye. Bring a penlight in from the temporal side and shine it into one eye.

   The pupil should constrict
   The pupil should constrict

   If a pupil does not constrict, its pupillary reflex is not intact.

   . Repeat with the other eye.

4. Consensual light reflex: Shine a light into one eye while observing the other for

   pupil constriction
   pupil constriction

   If the other pupil does not constrict, the consensual light reflex is not intact.

   . Repeat with the other eye.

5. Swinging light reflex: Swing the penlight from one eye to the other a few times while the patient focuses in the distance.

   Both pupils should constrict
   Both pupils should constrict

   An abnormal response is if the pupils dilate when the light is shone into the affected eye. This eye has a relative afferent pupillary defect (RAPD).

   .

6. Near reflex test: Ask the patient to look at a near target such as your finger at 20-30 cm from the patient's nose. Pupils constrict (miosis), accommodate and converge.

7. Record the results in patient notes.

## Troubleshooting

My patient has an abnormal test result.

These patients should be referred to an ophthalmologist.

## Risks

1. None

## References

1. Pons J. How To Examine The Eye. In: Mash B, Blitz-Lindeque J, eds. South African Family Practice Manual. 2nd ed. Pretoria: Van Schaik Publishers; 2010: 134-137.

2. Wilson FM. Practical Ophthalmology a manual for beginning Residents. 2005: 129-132. ISBN 1-56055-034-1