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A New View of Pupillary Examination: Providing Accurate, Objective, Reliable Results Using Automated Pupillometry

Information gained from pupillary assessment is used in decision-making regarding patient triage, diagnosis, treatment, and prognosis. For more than 100 years, clinicians have evaluated pupil size and reactivity to light in patients with brain injury or impaired consciousness to monitor neurological status and trends.¹ Images of a physician or nurse shining a penlight into the eyes of a patient to assess pupil reactivity are universal.

NeurOptics^® NPi^® Pupillometers provide accurate, reliable and objective pupil size and reactivity data, independent of the examiner, to support neurological examination in adult and pediatric patients with brain injury across a broad spectrum of diagnoses. Patients with primary neurological diagnoses such as traumatic brain injury (TBI), stroke, or seizure, along with patients suffering neurological consequences after cardiac arrest, ECMO and other medical conditions can benefit from automated pupillometry.

The Challenges

• Early detection of neurological injury is critical for effective and timely diagnosis and treatment.²
• Traditionally, pupil reactivity is manually measured by penlight or flashlight, and pupil size is visually estimated using a pupil gauge.
• These manual methods are subjective, inaccurate, and prone to variability and error.^2-9
• A variety of factors can affect the validity of manual pupil assessment and increase inter-examiner disagreement, including poor lighting conditions, the examiner’s visual acuity, and the strength, distance, and orientation of the light stimulus with respect to the patient’s eye.^5,8
• Studies show inter-examiner disagreement in the manual evaluation of pupillary reaction to be as high as 39 percent.^4,7,8,10
• With manual assessment, errors during documentation, recording, and reporting of pupillary data can occur.

An Automated Approach to Pupillary Evaluation

• Automated assessment of the pupillary light reflex provides an objective way of measuring pupillary reactivity across a broad spectrum of neurological disease.
• Automated pupillometry overcomes the limitations of manual assessment and offers quantitative infrared technology to objectively and accurately measure and trend pupil size and reactivity.
• Removing variability and subjectivity, NeurOptics NPi Pupillometers express pupil reactivity numerically as the Neurological Pupil index™ (NPi®) on a scale of 0 to 4.9. This numeric value allows a more rigorous and objective interpretation of the pupillary light reflex by comparing the patient’s measurement to scaled normative data.
• By automatically deriving whether the patient’s pupillary reactivity, measured by NPi, falls within the normal range (“brisk”) or outside of the normal range (“sluggish,” “atypical,” or “non-reactive”), the NPi Pupillometers provide a reliable and effective way to quantitatively classify and trend the pupillary light reflex for the first time ever.^3,4,10,11
• The most effective way to use the Pupillometer is to establish the earliest possible baseline measurement when the patient is admitted into the critical care unit or emergency department, and then trend for changes over time via standard assessment protocols.
• Numerous studies and medical associations have validated the importance of pupillometry and NPi in the clinical setting.
• Automated assessment of pupillary reactivity, measured by the NPi, provides a standard, reproducible measurement of pupil size and reactivity to help support the prognosis of poor neurological outcome in patients who remain comatose hours after cardiac arrest.^12-14
• It has been shown that quantitative NPi can predict a poor outcome in patients with cardiac arrest from day 1 after VA-ECMO insertion, with no false positives. Combining NPi and 12-h PREDICT-VA ECMO score increased the sensitivity of outcome prediction, while maintaining 100% specificity.¹⁵
• Researchers also concluded that the use of NPi provides important supplementary diagnostic, therapeutic, and prognostic information to guide the management of nonconvulsive status epilepticus and severe TBI patients.^16,17
• A case study series published in the Journal of Neuroscience of Nursing revealed that automated infrared pupillometry is an accurate tool that provides reliable data in patients with a poor baseline neurological examination after stroke.¹⁸
• A study in World Neurosurgery showed that automated pupillometry can improve triage and expedite treatment for patients with traumatic brain injuries.¹⁹

The New NPi^®-300 Automated Pupillometer

• The NeurOptics NPi^®-300 Pupillometer is the newest model of handheld optical scanner measuring pupil size and reactivity in patients requiring neurological pupil examinations.
• The NPi-300’s Wireless Charging technology offers improved reliability for the clinician.
• The NPi-300 Incorporated Barcode Scanner eliminates the need for external barcode scanners and allows clinicians to scan a new 1D or 2D patient ID accurately, instantaneously, and easily.
• The NPi-300 features an ergonomic handle design—the texturized plastic and improved grip help prevent dropping and discoloration.
• The updated Graphical User Interface (GUI) features modern icon-based navigation, NPi and Size trends graphed over 12-hour time windows, and an easy-to-read LCD touchscreen that enhances the visibility of the results screen.
• The NPi-300 is designed to upload into any hospital electronic medical record (EMR) system using the SmartGuard^® Reader, which eliminates the possibility of data entry error and saves valuable nursing time.

Company Background

Headquartered in Irvine, Calif., NeurOptics^® is the leader in the science of pupillometry. Driven by a passion to help clinicians improve patient outcomes, NeurOptics develops and markets innovative technology for use in critical care medicine, neurology, neurosurgery, emergency medicine, and research. NeurOptics NPi^® Pupillometers have been included in more than 130 clinical studies, adopted in over 700 hospitals in the United States, and are represented in more than 40 countries worldwide.

Conclusion

The clinical neurological exam is a cornerstone of providing care to patients with a wide variety of neurological injuries,^2,3 and pupillary examination is a key component of this neurological assessment. Unlike manual pupillary evaluations using a penlight, NeurOptics NPi Pupillometers offer accurate and objective pupil data, resulting in a significant quality improvement for this important component of the neurological examination.

References

1. Loewenfeld I. The Pupil: Anatomy, Physiology, and Clinical Application. Ames: Iowa State University Press; 1993.
2. Kerr R, Bacon A, Baker L, et al. Underestimation of pupil size by critical care and neurosurgical nurses. American J of Critical Care. 2016;25(3):213-219.
3. Olson D, Fishel M. The use of automated pupillometry in critical care. Critical Care Nursing Clinics North America. 2015;28(2016):101-107.
4. Meeker M, Du R, Bacchetti P, et al. Pupil examination: validity and clinical utility of an automated pupillometer. J Neurosci Nurs. 2005;37:34–40. 6.
5. Wilson S, Amling J, Floyd S, McNair N. Determining interrater reliability of nurses’ assessments of pupillary size and reaction. J Neurosci Nurs. 1988;20:189–192.
6. Litvan I, Saposnik G, Mauriño J, et al. Pupillary diameter assessment: need for a graded scale. Neurology. 2000;54:530–531. 25.
7. Olson D, Stutzman S, Saju C, Wilson M, Zhao W, Aiyagari V. Interrater reliability of pupillary assessments. Neurocrit Care. 2015. 26.
8. Stutzman S, Olson D, Saju C, Wilson M, Aiyagari V. Interrater reliability of pupillary assessments among physicians and nurses. UT Southwestern Medical Center; 2014. 27.
9. Worthley L. The pupillary light reflex in the critically ill patient. Crit Care and Resuscitation. 2000;2(7).
10. Du R, Meeker M, Bacchetti P, Larson M, Holland M, Manley G. Evaluation of the portable infrared pupillometer. Neurosurg. 2005;57:198–203.
11. Chen J, Gombart Z, Rogers S, Gardiner S, Cecil S, Bullock R. Pupillary reactivity as an early indicator of increased intracranial pressure: the introduction of the neurological pupil index. Surg Neurol Int. 2011;2:82.
12. Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 142(16_suppl_2). doi:10.1161/cir.0000000000000916
13. Oddo M, Sandroni C, Citerio G, et al. Quantitative versus standard pupillary light reflex for early prognostication in comatose cardiac arrest patients: an international prospective multicenter double-blinded study. Intensive Care Med. 2018;44:2102¬–2111. https://doi.org/10.1007/s00134-018-5448-6
14. Riker RR, Sawyer ME, Fischman VG, et al. Neurological Pupil index and pupillary light reflex by pupillometry predict outcome early after cardiac arrest. Neurocrit Care. 2020;32:152–161. https://doi.org/10.1007/s12028-019-00717-4
15. Miroz JP, Ben-Hamouda N, Bernini A, et al. Neurological Pupil index for early prognostication after venoarterial extracorporeal membrane oxygenation. Chest J. 2020;157(5):1167–74. https://doi.org/10.1016/j.chest.2019.11.037
16. Jahns FP, Miroz JP, Messerer M, et al. Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury. Crit Care. 2019;23:155. https://doi.org/10.1186/s13054-019-2436-3
17. Godau J, Bierwirth C, Rösche J, Bösel J. Quantitative infrared pupillometry in nonconsulsive status epilepticus. Neurocrit Care. 2020. https://doi.org/10.1007/s12028-020-01149-1
18. Cortes MX, Siaron KB, Nadim HT, Ahmed KM, Romito JW. Neurological Pupil Index as an indicator of irreversible cerebral edema: a case series. J Neurosci Nurs. 2021 Mar 29. PMID: 33782353.
19. El Ahmadieh TY, Bedros N, Stutzman SE, et al. Automated pupillometry as a triage and assessment tool in patients with traumatic brain injury. World Neurosurg. 2020. https://doi.org/10.1016/j.wneu.2020.09.152

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