Archives of Academic Emergency Medicine. 2019; 7 (1): e62

LE T T E R TO ED I TO R

The Value of Ultrasonography in determining Pupillary
Light Reflex in Patients with Traumatic Ocular Injuries; a
Letter to Editor
Hamid Mirjalili1, Ali Raee Ezzabadi1∗, Yeganeh Yazdiyousefi1, Mohammad Ali Jafari Nadoshan1

1. Emergency Department, Shahid Sadoughi University of Medical Science, Yazd, Iran.

Received: July 2019; Accepted: August 2019; Published online: 10 November 2019

Cite this article as: Mirjalili H, Raee Ezzabadi A, Yazdiyousefi Y, Jafari Nadoshan M A. The Value of Ultrasonography in determining Pupillary

Light Reflex in Patients with Traumatic Ocular Injuries; a Letter to Editor. Arch Acad Emerg Med. 2019; 7(1): e62.

Pupillary light reflex (PLR) measurement is one of the fre-

quent physical examinations used by emergency physicians

for assessment of brain stem function and monitoring of in-

tracranial pressure (1, 2). PLR could be abnormal due to var-

ious causes such as optic nerve damage, oculomotor nerve

damage, brain stem lesion, and using central nervous system

depressant drugs, such as barbiturates.

Direct PLR measurement is not always possible in patients

with ocular trauma suffering from hematoma, hyphema, and

etc. One helpful tool for measuring PLR in this situation

is ultrasonography (3, 4). Using a coronal ultrasonographic

view of the iris upon contralateral stimulation with a pen-

light, Ashot et al. emphasized that ultrasonography could

be considered as a practical, fast and recordable method for

evaluating PLR (5).

Using consecutive sampling, the authors of this letter exam-

ined all head trauma patients suffering from unilateral ocular

trauma, who visited the emergency departments of Shahid

Sadooghi and Shahid Rahnemoun hospitals, Yazd, Iran, from

2017 to 2018 (ethics code: IR.SSU.MEDICINE.REC.1396.265).

Patients with bilateral ocular trauma, penetrating trauma,

history of any chronic disease (glaucoma, cataract, retina,

etc.), or previous eye surgeries were excluded.

Using EZONO 3000 ultrasound system and a linear probe

with a 10 MHz frequency in coronal sections, PLR was mea-

sured in both intact and injured eyes. The probe is fanned

until the iris and pupil are visualized and a bright light is

flashed (distance 1 cm).

The pupil sizes for both intact and injured eyes were mea-

sured and registered through physical examination and ul-

∗Corresponding Author: Ali Raee Ezzabadi; Emergency Department, Shahid
Sadoughi Hospital, Shahid Ghandy Blvd., Ebne Sina Ave., Yazd, Iran. Tel:
00989131589448, Email: Ali.raee@gmail.com

trasonography before and after flashing light to the eye, sep-

arately (PLR in injured eye was measured using indirect light

and light was flashed into the intact eye). Then, the initial

pupil size and PLR were compared between physical and ul-

trasonography examinations (The study was performed on

both conscious and unconscious patients). Finally, 74 cases

with the mean age of 20.30 ± 44.9 years were studied (87.8%
male). In physical examination, patients’ pupillary response

was unclear in 17 cases, light response occurred in 55 cases,

and two patients didn’t exhibit pupillary response. However,

examining the patients’ pupils through ultrasonography, the

PLR in one case was unclear and 62 individuals exhibited

pupillary response, while 11 did not.

There was a significant difference between physical exami-

nation and ultrasonography findings regarding the pupil size

of injured eyes (2.82 ± 1.63 vs 3.58 ± 0.95, respectively; p =
0.001), while this was not observed in healthy eyes (3.55 ±
0.54 vs 3.50 ± 0.45, respectively; p = 0.065). It seems that, the
use of ultrasound could be helpful in decreasing the number

of unclear PLR through accurate detection and measurement

of pupil size in injured eyes. Emergency physicians can con-

sider ultrasonography as an accessible tool, complementary

to physical examination for more accurate decision making

in treatment of trauma patients.

1. Appendix

1.1. Acknowledgements

This article is derived from the thesis of Dr. Hamid Mirjalili

to achieve his specialist degree in emergency medicine.

1.2. Author’s contribution

All authors met the four criteria for authorship contribution

based on recommendations of the International Committee

of Medical Journal Editors.

This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).
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H. Mirjalili et al. 2

Authors ORCIDs
Ali Raee Ezzabadi: 0000-0002-1545-1790

Hamid Mirjalili: 0000-0002-1268-0395

Yeganeh Yazdiyousefi: 0000-0002-2893-349X

Mohammad Ali Jafari Nadoshan: 0000-0002-3171-6453

1.3. Conflict of interest

None.

1.4. Funding and support

None.

References

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in idiopathic intracranial hypertension. Investigative oph-

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2. Szabadi E. Functional Organization of the Sympathetic

Pathways Controlling the Pupil: Light-Inhibited and

Light-Stimulated Pathways. Frontiers in Neurology.

2018;9(1069).

3. Blaivas M, Theodoro D, Sierzenski PR. A study of bed-

side ocular ultrasonography in the emergency depart-

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4. Blaivas M. Bedside emergency department ultrasonogra-

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5. Sargsyan AE, Hamilton DR, Melton SL, Amponsah D, Mar-

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This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).
Downloaded from: http://journals.sbmu.ac.ir/aaem


	Appendix
	References