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Peer-reviewedCC BY-NC-NDBMC anesthesiology

Comparison of bedside clinical pupillary assessment with automated pupillometry in sedated ICU patients.

  • Alice Arndt1
  • Pierre-Antoine Seube-Remy1
  • Thierry Floch1
  • Carl Arndt2
  • Lukshe Kanagaratnam3,4
  • Vincent Legros5,6,7
7 affiliations
  1. 1Service d'anesthésie-réanimation et médecine péri-opératoire, Hôpital Maison Blanche, CHU de Reims, Reims, F-51000, France.
  2. 2Service d'Ophtalmologie, CHU de Reims, Reims, F-51000, France.
  3. 3Département de recherche et de santé publique, CHU de Reims, Reims, F-51000, France.
  4. 4Université de Reims Champagne-Ardenne, VieFra, Reims, F-51100, France.
  5. 5Service d'anesthésie-réanimation et médecine péri-opératoire, Hôpital Maison Blanche, CHU de Reims, Reims, F-51000, France. [email protected].
  6. 6Université de Reims Champagne-Ardenne, VieFra, Reims, F-51100, France. [email protected].
  7. 7Critical Care and Perioperative Medicine, Hôpital Maison Blanche, CHU de Reims, 45 Rue Cognacq Jay, Reims, 51092, France. [email protected].
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Abstract

Background

Pupillary assessment is central in neurocritical care and although inherently subjective, bedside penlight examination remains standard practice. While automated pupillometry provides objective, standardized measurements, the reliability of manual assessment across professional categories remains poorly characterized.Methods

Prospective observational study in a surgical and trauma intensive care unit (Reims, Feb-Dec 2025). Thirty sedated or comatose adults underwent repeated pupillary assessments by nurses, residents, and senior physicians, which were compared with automated pupillometry as the reference standard, yielding 1,692 paired bilateral measurements from 30 patients. Primary outcome was agreement for anisocoria detection (≥ 1 mm) and secondary outcomes were pupil size and reactivity, measured using Brennan-Prediger adjusted kappa and McNemar test.Results

Agreement for anisocoria was substantial: nurses κ = 0.64 (95% CI 0.57-0.72), residents κ = 0.74 (0.68-0.81), physicians κ = 0.71 (0.64-0.78 ,p < 0.0001). False-positive rates were high (82-86%), while true anisocoria was detected in 55-73% of cases. For pupil size, agreement was substantial: nurses κ = 0.65 (0.60-0.70), residents κ = 0.64 (0.59-0.65), physicians κ = 0.66 (0.60-0.71), but mydriasis was largely missed (6-11% detection; p < 0.0001). Reactivity showed the weakest agreement: nurses κ = 0.40 (0.34-0.47), residents κ = 0.32 (0.26-0.39), physicians κ = 0.41 (0.34-0.47), with systemic underestimation in nurses (p ≤ 0.0001) and a bidirectional error pattern for residents (p = 0.81).Conclusion

In sedated ICU patients, bedside pupillary assessment showed substantial but systematically biased agreement with automated pupillometry, particularly for anisocoria, mydriasis, and pupillary reactivity. These findings highlight the limitations of subjective bedside assessment and support automated pupillometry as an objective complement to routine clinical examination.Trial registration

NCT06733207, registered 10 December 2024 - Retrospectively registered, https://clinicaltrials.gov/study/NCT06733207.

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Cite

BibTeXRIS
BibTeX
@article{arndt2026comparison,
  title = {{Comparison of bedside clinical pupillary assessment with automated pupillometry in sedated ICU patients.}},
  author = {Alice Arndt and Pierre-Antoine Seube-Remy and Thierry Floch and Carl Arndt and Lukshe Kanagaratnam and Vincent Legros},
  journal = {BMC anesthesiology},
  year = {2026},
  month = jul,
  doi = {10.1186/s12871-026-04124-z},
  url = {https://europepmc.org/article/MED/42968011},
  note = {CC BY-NC-ND},
}
RIS
TY  - JOUR
TI  - Comparison of bedside clinical pupillary assessment with automated pupillometry in sedated ICU patients.
AU  - Alice Arndt
AU  - Pierre-Antoine Seube-Remy
AU  - Thierry Floch
AU  - Carl Arndt
AU  - Lukshe Kanagaratnam
AU  - Vincent Legros
PY  - 2026
DA  - 2026/07/28
JO  - BMC anesthesiology
DO  - 10.1186/s12871-026-04124-z
UR  - https://europepmc.org/article/MED/42968011
AB  - Background  Pupillary assessment is central in neurocritical care and although inherently subjective, bedside penlight examination remains standard practice. While automated pupillometry provides objective, standardized measurements, the reliability of manual assessment across professional categories remains poorly characterized.Methods  Prospective observational study in a surgical and trauma intensive care unit (Reims, Feb-Dec 2025). Thirty sedated or comatose adults underwent repeated pupillary assessments by nurses, residents, and senior physicians, which were compared with automated pupillometry as the reference standard, yielding 1,692 paired bilateral measurements from 30 patients. Primary outcome was agreement for anisocoria detection (≥ 1 mm) and secondary outcomes were pupil size and reactivity, measured using Brennan-Prediger adjusted kappa and McNemar test.Results  Agreement for anisocoria was substantial: nurses κ = 0.64 (95% CI 0.57-0.72), residents κ = 0.74 (0.68-0.81), physicians κ = 0.71 (0.64-0.78 ,p < 0.0001). False-positive rates were high (82-86%), while true anisocoria was detected in 55-73% of cases. For pupil size, agreement was substantial: nurses κ = 0.65 (0.60-0.70), residents κ = 0.64 (0.59-0.65), physicians κ = 0.66 (0.60-0.71), but mydriasis was largely missed (6-11% detection; p < 0.0001). Reactivity showed the weakest agreement: nurses κ = 0.40 (0.34-0.47), residents κ = 0.32 (0.26-0.39), physicians κ = 0.41 (0.34-0.47), with systemic underestimation in nurses (p ≤ 0.0001) and a bidirectional error pattern for residents (p = 0.81).Conclusion  In sedated ICU patients, bedside pupillary assessment showed substantial but systematically biased agreement with automated pupillometry, particularly for anisocoria, mydriasis, and pupillary reactivity. These findings highlight the limitations of subjective bedside assessment and support automated pupillometry as an objective complement to routine clinical examination.Trial registration  NCT06733207, registered 10 December 2024 - Retrospectively registered, https://clinicaltrials.gov/study/NCT06733207.
SN  - 1471-2253
ER  -