Abnormal pupil shape/response

[MelissaLPN, ASN, LPN, RN]

I work in a LTC facility and have noticed on several residents during my initial assessment and neuro check that one of the pupils is either irregular in shape and or abnormal pupil response. According to the H&P this is a new onset, I put them on the MD list after calling the MD and being told to do so. The next time I work I see that the MD has found no problems and documents everything as normal ( including perrla) as well as the nurse continuing to document perrla. Low and behold the resident still has an oblong pupil or fixed?

I have even had my findings double checked by an RN and she agreed with my assessment but the MD doesn't? I spoke with one of the nurses and she said " Oh that's how so and so always is, so i put perrla because its nothing out of the ordinary."

Is this normal for the elderly? I have done dozens of google searches and only found congenital or trauma related problems correlating with abnormal pupil shape or response.

I try very hard to do thorough assessments and I confused as to why I am the only one finding these anomalies? I can understand other nurses maybe not bothering to check but the MD? I feel like a fool for even mentioning it but I know I am not wrong, so why the brush off? I am not above error but when three nurses agree, why not the MD? anyone else experience this? Any advice would be welcome.

[xtxrn, ASN, RN]

Cataract surgery can leave irregular pupils- I definitely wouldn't chart PERRLA- I'd note the irregularity every time I had to chart pupil assessments. :)

[systoly]

I see a lot of asymetrical pupils in home care and unfortunately a lot of documentation noting Perl. I think that's nuts. If this condition is congenital/chronic, then why not document as such. As long as an unusual finding is documented as something else, time and resources will be misallocated.

[CT Pixie, BSN, RN]

Agree with xtxrn, I work LTC and a lot of my cataract patients have one or both pupils that aren't "normal". I never chart PERRLA, I always describe the pupil if I need to do a pupil assessment.

[Esme12, ASN, BSN, RN]

anisocoria, or a difference in the diameter of the pupils in dim illumination, may be physiologic if the difference is less than 1 mm and both pupils react briskly and equally to light. otherwise it may be pathologic.

there are four possible causes:

• parasympathetic innervation failure causes a relatively dilated pupil that reacts sluggishly to direct light.
  the major concern, as with ptosis, is a third cranial nerve palsy, especially one caused by an aneurysm. however, anisocoria is never caused by a third nerve palsy unless there are other signs of a third cranial nerve palsy—ptosis, reduced ocular movements, or ocular misalignment.
  a common cause of isolated anisocoria is a viral infection of the ciliary ganglion (adie's syndrome), an orbital structure that receives the parasympathetic component of the third cranial nerve.
  
• horner's syndrome causes anisocoria in which the affected pupil is smaller, but both pupils react briskly to light. ptosis is usually present but is always mild (2 mm or less).
  for more information on horner's syndrome see ptosis in this section.
  
• chemical blockade. if parasympatholytic (atropine-like) chemicals come in contact with the conjunctiva by accidental (or deliberate!) instillation, they will deactivate the iris sphincter muscle and cause (often very wide) pupil dilation.
  this occurs most commonly among hospital personnel and those exposed to atropine-containing plants.
  
• iris sphincter damage. inflammation and trauma to the iris sphincter are other causes of anisocoria. the pupil is usually irregular in shape and magnified examination shows evidence of muscle damage.
  

http://www.kellogg.umich.edu/theeyeshaveit/symptoms/anisocoria.html

iris sphicnter muscles, sphincter pupillae and dilator pupillae.... muscles that contracts/dilates the iris, narrowing/enlarging the diameter of the pupil of the eye. it is composed of circular fibers arranged in a narrow band, about 1 mm wide, surrounding the margin of the pupil toward the posterior surface of the iris. the circular fibers near the free margin of the iris are closely packed. those that are near the periphery of the band are more separated and form incomplete circles. the fibers of the sphincter pupillae blend with the fibers of the dilatator pupillae near the margin of the pupil and are innervated by a motor root of the ciliary ganglion from the oculomotor nerve. both of which can deteriorate with age causing irregular appearing pupils and impercieveable reaction to light.

i hope this helps......

[bestallaround, ADN, CNA, LPN, RN]

You might also want to see what meds they are on. Alot of eye drops will have that effect.

[CT Pixie, BSN, RN]

You might also want to see what meds they are on. Alot of eye drops will have that effect.

Totally agree, and I totally forgot that some eye gtts do this..thanks for that reminder :)

[systoly]

anisocoria, or a difference in the diameter of the pupils in dim illumination, may be physiologic if the difference is less than 1 mm and both pupils react briskly and equally to light. otherwise it may be pathologic.

there are four possible causes:

• parasympathetic innervation failure causes a relatively dilated pupil that reacts sluggishly to direct light.
  the major concern, as with ptosis, is a third cranial nerve palsy, especially one caused by an aneurysm. however, anisocoria is never caused by a third nerve palsy unless there are other signs of a third cranial nerve palsy--ptosis, reduced ocular movements, or ocular misalignment.
  a common cause of isolated anisocoria is a viral infection of the ciliary ganglion (adie's syndrome), an orbital structure that receives the parasympathetic component of the third cranial nerve.
  
• horner's syndrome causes anisocoria in which the affected pupil is smaller, but both pupils react briskly to light. ptosis is usually present but is always mild (2 mm or less).
  for more information on horner's syndrome see ptosis in this section.
  
• chemical blockade. if parasympatholytic (atropine-like) chemicals come in contact with the conjunctiva by accidental (or deliberate!) instillation, they will deactivate the iris sphincter muscle and cause (often very wide) pupil dilation.
  this occurs most commonly among hospital personnel and those exposed to atropine-containing plants.
  
• iris sphincter damage. inflammation and trauma to the iris sphincter are other causes of anisocoria. the pupil is usually irregular in shape and magnified examination shows evidence of muscle damage.
  

http://www.kellogg.umich.edu/theeyeshaveit/symptoms/anisocoria.html

iris sphicnter muscles, sphincter pupillae and dilator pupillae.... muscles that contracts/dilates the iris, narrowing/enlarging the diameter of the pupil of the eye. it is composed of circular fibers arranged in a narrow band, about 1 mm wide, surrounding the margin of the pupil toward the posterior surface of the iris. the circular fibers near the free margin of the iris are closely packed. those that are near the periphery of the band are more separated and form incomplete circles. the fibers of the sphincter pupillae blend with the fibers of the dilatator pupillae near the margin of the pupil and are innervated by a motor root of the ciliary ganglion from the oculomotor nerve. both of which can deteriorate with age causing irregular appearing pupils and impercieveable reaction to light.

i hope this helps......

thank you for that.

[Esme12, ASN, BSN, RN]

Thank you for that.

Your Welcome.....:)

[caliotter3]

I would also note the irregularity each time that you chart. I have encountered a similar situation with a home health client. The boss even stated to me that the other nurses don't chart what I do, the insinuation being (as I see it), is that if they don't chart it, it does not exist. The clinical nursing supervisor told me to continue to chart what I assess, in spite of the other nurses charting the opposite. It is a pain, particularly when notification having been made to the doctor elicits nothing.

[Anna Flaxis, BSN, RN]

I had this exact situation in the ED. Patient comes in from a facility for a change in LOC. Neuro assessment reveals pupil size unequal. I cannot find any info on this in the paperwork sent from the facility, nor in the the computerized medical record, so I have no way of knowing if this is new and related to the change in LOC, or if this is old and has nothing to do with it. Family members don't know, can't get anyone on the phone from the facility who knows, and none of the H&Ps in the computer system make any mention.

It turned out to be an old finding, but I wasted a lot of precious time trying to find out.

You are right to document WHAT YOU OBSERVE, and everyone else should do this as well.

[MelissaLPN, ASN, LPN, RN]

I swear you are probably talking about my resident! I sent her to the ER for the above complaint, gave report to er charge nurse stating that there was a neuro change, after a fall. I send paper work stating she had a change in neuro/pupil response, she comes back.... dx of pneumonia! No one freaking addressed the neuro deficit!! I felt like an absolute idiot.