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Speaker: ‘Please stop using PERRLA’ when examining patients for neuro-ophthalmic conditions

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KOLOA, Hawaii – When examining a neuro-ophthalmic patient, physicians must check the pupil in the light and the dark, a presenter said here.

“If you’re using the abbreviation PERRLA – pupil, equal, round, reactive to light and accommodation – please stop,” Andrew G. Lee, MD, Professor of Ophthalmology in Neurology and Neurological Surgery, Weill Cornell Medical College, said during a mini-symposium on neuro-ophthalmology at the Hawaiian Eye meeting. “Because the pupil can be equal, round and reactive to both light and accommodation and have a whopping relative afferent pupil defect (RAPD).”

PERRLA checks only one of the three things physicians are supposed to check, according to Lee.

Andrew G. Lee

“You’re supposed to check the pupil in the light, in the dark and swing the flashlight. You know this from residency. PERRLA only tests the parasympathetic function to light and accommodation. It does not tell you anything about anisocoria in the dark, and that’s the key and differentiating feature of the Horner syndrome,” he told attendees.

So physicians have two options. They can either abandon the abbreviation or modify it.

“What extra stuff should you write? PERRLDA – pupil, equal, round, reactive in the light and the dark and accommodation,” Lee said.

“Plus RAPD. So it should be PERRLDARAPD,” he quipped.

Relying only on the technician to check pupil is another easy exam mistake to make, Lee said. If the chief complaint from a patient is ptosis, unexplained vision loss or diplopia, the physician must see that patient him or herself.

Other easy exam errors to make when examining a neuro-ophthalmic patient include not taking blurred disc margins seriously, misusing the term “papilledema,” writing “dysconjugate gaze” or “EOMI” [extraocular movements intact] as the only motility evaluation and using optic atrophy as a diagnosis, he said.

“Optic atrophy is a sign, not a diagnosis,” Lee said. –by Daniel Morgan

Disclosure: Lee has no relevant financial relationships to disclose.