RAPD for the rest of us

[Adcadet]

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What do you guys think about just listing "PERRLA" and "EOMI" in general medicine H&Ps (like I regularly see done) vs. skipping the "A" in PERRLA (from what I have hear and can figure it adds nothing and just annoys the patient) and testing for a RAPD? Is checking for an APD that important to comment on for most patients? I've heard ophthalmologists mention how important it is but I have yet to see +/-APD commented on even in neurology notes in stroke patients. And do you ophtho folks really want to see a mention of a confrontational field test on all patients as well?

Just trying to sort out what I want to include in my standard bag o' tricks for admissions.

 

[Pastrami King]

As with most tests in medicine, the utility of any physical exam maneuver is totally dependent on the pretest probability of the disease. But given that physical diagnosis is free (although time-consuming), people are willing to overlook that sometimes.

I think that we get picky about the A in PERRLA b/c people write it without actually testing for accommodation.

I imagine that most people in medicine wouldn't test for accommodation unless they were dealing with a specific subset of neurologic or neurosurgical disorders, diseases like syphilis, or pupillary abnormalities/anisocoria.

Maybe the others on this board can comment on testing for an APD. Most of the penlights that med students and non-ophtho residents carry around do a pretty bad job of helping you pick up a subtle APD. That's why we tend to use a muscle light/direct ophthalmoscope.

What do you guys think about just listing "PERRLA" and "EOMI" in general medicine H&Ps (like I regularly see done) vs. skipping the "A" in PERRLA (from what I have hear and can figure it adds nothing and just annoys the patient) and testing for a RAPD? Is checking for an APD that important to comment on for most patients? I've heard ophthalmologists mention how important it is but I have yet to see +/-APD commented on even in neurology notes in stroke patients. And do you ophtho folks really want to see a mention of a confrontational field test on all patients as well?

Just trying to sort out what I want to include in my standard bag o' tricks for admissions.

 

[shredhog65]

If you really can check for an RAPD it would be great. In my experience, however, most non-ophthalmologist/ OD/ ophth-techs don't really know how to check for one. Even some ophthalmologists miss tr RAPD's.

 

[Adcadet]

If you really can check for an RAPD it would be great. In my experience, however, most non-ophthalmologist/ OD/ ophth-techs don't really know how to check for one. Even some ophthalmologists miss tr RAPD's.

From what I've seen, I agree with the light business, which is why I use a pretty powerful pen light (expensive, but it was a gift) and dim the room. On my ophtho rotation I got decent at picking up ones my chief resident called slight, so I hope I can pick up on moderate to severe ones these days with my pen light.

 

[Caffeinated]

On more than one occasion, I have seen several ophthalmologists/optometrists hovering over a patient trying to pick up slight APDs. To the unskilled observer (someone who is isn't scrutinizing pupillary light reflexes on a regular basis), a slight APD is nearly impossible to catch. More pronounced APDs will most likely have symptomatic vision loss, which will prompt an ophtho consult from the admitting team. So I would say that testing for an APD on a general medicine admission (e.g., pneumonia, CHF exacerbation) is not necessary. But that's just the opinion of this medical student/former optometrist. That being said, when I do an admission H&P, I always check for an APD. I find it hard to check direct and consensual reflexes without going straight into a swinging flashlight test.

 

[Adcadet]

That being said, when I do an admission H&P, I always check for an APD. I find it hard to check direct and consensual reflexes without going straight into a swinging flashlight test.

As the son of an optometrist and one who spent hours learning to pick up subtle APDs I feel the need to check. At this point I'm weighting the ridicule of my classmates and residents against my compusion. My compulsions tend to win, as evidenced by the tuning fork in my pocket.

 

[Retinamark]

If light reflexes are abnormal, you need to check the accommodative response to be able to detect Light-Near Dissociation. This is an important thing to detect, because it can be totally asymptomatic & has potentially life threatening causes, eg Pineal or dorsal midbrain tumors.

If the light reflexes are intact and normal, there is no real need to check for the accommodative response. There is no disorder that I can think of that causes loss of the near pupil response and spares the pupillary light reflexes.

Having said that, for people who are learning, it is worth checking, so you can get an idea of what is normal. Our prof gave us very wise advice, when he said with many sublte signs in medicine, you need to see one hundred normals, to be able to confidently pick up subtle abnormals