A Novel Method for Measuring the Pupil Diameter and Pupillary Light Reflex of Healthy Volunteers and Patients With Intracranial Lesions Using a Newly Developed Pupilometer

Abstract

Background: Physicians currently measure the pupil diameter and the pupillary light reflex with visual observations using a ruler and a traditional penlight, leading to possibly inaccurate and subjective assessments. Although a mobile pupillometer has been developed and is available in clinical settings, this device can only assess one pupil at a time. Hence, an indirect pupillary light reflex, including those under irradiation to the opposite side of pupil, cannot be evaluated. Consequently, we have developed a new automatic mobile pupilometer, the Hitomiru^®, with Hitomiru Co., Ltd. (Tokyo, Japan). This device is a two-glass type pupilometer with a video recording system. The pupil diameter and light reflex of both pupils can be measured simultaneously; therefore, both indirect and direct light reflexes can be assessed. Purpose: To evaluate the clinical ability of the Hitomiru^® pupilometer to assess the pupil diameter and the pupillary light reflex of healthy volunteers and patients with intracranial lesions in an intensive care unit (ICU). Methods: Twenty-five healthy volunteers and five ICU patients with intracranial lesions on only the left side were assessed using the Hitomiru^® pupilometer. The protocol was as follows: infrared light was applied to both pupils, followed by visible light to the right pupil, infrared light to both pupils, visible light to the left pupil, and then infrared light to both pupils. All the intervals were 2 s, and the dynamics of pupil diameters on both sides were continuously recorded. Results: The healthy adults had approximately 0.5 mm anisocoria, miosis was harder, and mydriasis was less with increased age. There were several differences in miosis rates, miosis times, and mydriasis rates between the healthy adults and the patients with intracranial lesions with both direct irradiation and indirect irradiation. Conclusions: The initial trial estimated and digitally recorded direct and indirect light reflexes, including rapidity of miosis after direct and indirect lights on, and mydriasis after direct and indirect lights off. The Hitomiru^® pupilometer was a useful device to digitally record and investigate the relationship between pupil reflexes and intracranial diseases.

Keywords: digital record; direct and indirect irradiation; intracranial lesions; miosis; mobile type pupilometer; mydriasis; pupil diameter; pupil light reflexes.

Figure 1

The Hitomiru^® pupillometer. (A) The shape of the Hitomiru^® device is like a glass with light sources and a video camera which allows automatically captures the image of pupils. The captured data is sent to the computer, which is connected to the pupillometer, then the diameters are recorded and analyzed with included proprietary software. (B) The Hitomiru^® pupillometer used on a volunteer. (C) Measurement screen of the device. In the upper image, the right and left pupil is captured with a blue and red circle, respectively. In the lower image, the blue and red line shows a right and left pupil diameter, respectively. The yellow zone in the upper and lower section of the graph shows the right and left eye irradiation, respectively. When the irradiation induces miosis, the lines go downward. Conversely, when the cessation of irradiation induces a mydriasis, the lines go upward.

Figure 2

Spontaneous pupil diameters without irradiation in healthy volunteers. Data are presented as the mean ± SD. Closed circles show data distribution. ^*P < 0.05. N = 25/group.

Figure 3

Miosis rates (A,B), miosis times (C,D), and mydriasis rates (E,F) in healthy volunteers. There were no significant differences in miosis rate (A,B), miosis time (C,D), and mydriasis rate (E,F) in both right and left pupils between direct and indirect irradiation. For all panels, Data are presented as the mean ± SD. Closed circles show data distribution. NS, not significant. N = 25/group.

Figure 4

The relationship between spontaneous pupil diameters and age in healthy volunteers. The pupil diameters were significantly smaller with increased age in both the right and left eyes. r, correlation coefficients. ^***P < 0.001. N = 25/group.

Figure 5

Relationship between age and miosis rate (A,B), miosis time (C,D), and mydriasis rate (E,F) in healthy volunteers. r, correlation coefficients. ^**P < 0.01, ^*P < 0.05. N = 25/group.

Figure 6

Comparison of spontaneous pupil diameters (A), miosis rate (B,C), miosis time (D,E), and mydriasis rate (F,G) between the volunteers and patients. Column scatter plots representing the data distribution (open and closed circles), median (horizontal bar), and interquartile range (vertical bar). NS, not significant. ^**P < 0.01, ^*P < 0.05. N = 5 in each group.