Clinical Grading of Relative Afferent Pupillary Defects

Abstract

OBJECTIVES: To assess the validity and reproducibility of quantitating relative afferent pupillary defects with the swinging flashlight test, using a 3-second pause technique, and to compare this grading system with that using neutral density filters. DESIGN: We prospectively studied patients with relative afferent pupillary defects by using the swinging flashlight test with a standardized illumination time of 3 seconds (pause time) for each eye. Each relative afferent pupillary defect was graded as follows: grade I, a weak initial constriction and greater redilatation; grade II, initial stall and greater redilatation; grade III, immediate pupillary dilatation; grade IV, immediate pupillary dilatation following prolonged illumination of the good eye for 6 seconds; grade V, immediate pupillary dilatation with no secondary constriction. The grades on the individual resident evaluations were compared with those on the group evaluations, and the grading system was compared with the neutral density filter grading system. SETTING: Neuro-ophthalmology service of an urban teaching hospital. STUDY PARTICIPANTS: A total of 119 patients. RESULTS: There was a good correlation in all grades between individual resident and group evaluations, with an overall 78% agreement. The five grades had corresponding values in neutral density filter log units: grade I, 0.4; grade II, 0.7; grade III, 1.1; grade IV, 2.0; and grade V, infinity. CONCLUSIONS: The 3-second pause technique for the swinging flashlight test is a reliable method for the detection and quantitation of relative afferent pupillary defects. The grading system can be compared with the neutral density filter grading system, and each grade has a corresponding value in log units.