Conduct the PERRLA Eye Exam to check on your patient’s pupils and see if their current state is well or if they point to a possible eye condition.

By Matt Olivares on Jul 15, 2024.


Fact Checked by Nate Lacson.

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What is the PERRLA Eye Exam?

The is a procedure that healthcare professionals often conduct during eye examinations and comprehensive examinations, such as the Nurse Neurological Assessment and the HEENT Assessment. This particular eye examination is a pupillary response test, which means that this exam will be used to gauge the pupils. The exam will assess two things in particular: 1) the appearance of the pupils and 2) if they’re functioning normally.

If you have ever had your eyes checked or if you go through your annual physical examinations, then there’s a good chance that you have gone through PERRLA Eye Exams before. But what does PERRLA stand for? PERRLA means: Pupils. Equal. Round. Reactive to Light. Accommodation. Let’s break this down one by one:

  1. P = Pupil
  • Pupils are the dark circles located in the centers of the irises. These dark circles sometimes shrink. Sometimes they become wide. The function of a pupil is to regulate how much light enters your eye. Whenever it performs its function, their size changes.
  1. E = Equal
  • What is meant by equal is that the pupils should be the same size. If their sizes are not the same, that might be indicative of something, which we’ll get to later.
  1. R = Round
  • Pupils are circles, so they should be round. Should, because it’s possible for pupils to not be fully round. If pupils are not round, then this might also be indicative of something.
  1. R and L = Reactive to Light
  • Pupils, as we mentioned earlier, will change sizes to control how much light enters the eyes. When light is shined on the eyes, the pupils should shrink. If they don’t, then that is also indicative of a potential problem.
  1. A = Accommodation.
  • The pupils also adjust their size depending on if you’re focusing on looking at an object close to you or something that’s a little far. If you’re looking at something close, your pupils should become smaller.

How to conduct the PERRLA Eye Exam

Before conducting this exam, you must prepare a chair, a penlight, and a dimly lit room. Once you have all these, you’re prepared to conduct the PERRLA Eye Exam. Here’s what you need to do:

  • The first thing you have to do is check if the patient’s pupils are equal in terms of size. If there is a difference of over 1 millimeter, that might indicate a problem concerning the brain, cranial nerve, or blood vessels.
  • Second, you must check if the pupils are round or if they have unusual shapes or borders. If they are not round, that could also indicate the possibility of the same problems mentioned above.
  • Third, grab your penlight and perform the swinging light test component of the examination. Dim the lights of the room, then shoot light into one of their eyes using the penlight for three seconds. Do the same for the other eye. Whether you’re shining the light into the left or right eye, both pupils should become smaller at the same time. After turning off the light, their pupils should dilate at the same time. When the pupils dilate, they become larger.
  • Last, you’re going to check if your pupils are able to adjust their size when they focus. Grab an object and move it until it’s close to their noise. Make sure that they’re looking at the object. The pupils should get smaller and smaller the closer the object gets.

That’s it! All you need to do after is to jot down your findings. Based on what you have observed, are the patient’s pupils all good? Or did you notice anything that could point to the likes of Anisocoria, Horner’s Syndrome, RAPD (Relative Afferent Pupillary Defect), or some other condition? If there are any signs that point to potential problems, please conduct more tests, especially ones that can confirm these problems.

When is it best to conduct the PERRLA Eye Exam?

If you have a patient who presents themselves for an appointment to have their eyes checked, that’s one of the best times to conduct the PERRLA Eye Exam. However, before you conduct that, you need to explain what the PERRLA Eye Exam is to the patient. Protocol dictates that you need to let your patient decide if they want to take the examination or not because it is within their rights to take or refuse a test.

Also, we mentioned earlier that the PERRLA Eye Exam is normally included in certain comprehensive examinations. An example of a comprehensive examination that includes the PERRLA Eye Exam would be the HEENT Assessment. One of Es stands for Eyes and the PERRLA Eye Exam is part of that component of the assessment. Another would be the Nurse Neurological Assessment, which is what nurses conduct on patients who need to be examined for neurological conditions.

We actually recommend that you include this as part of comprehensive examinations. The reason for this is that the PERRLA Eye Exam is not a diagnostic test. It merely identifies signs pointing to certain problems. That’s not us saying it’s unreliable. It is because the following tests that need to be conducted will depend on your observations.

What are the benefits of the PERRLA Eye Exam?

It’s a simple and inexpensive eye exam to conduct.

The PERRLA Eye Exam is great because it requires no special equipment. You just need a chair for your patient to sit on, a penlight to check the pupils, and a dimly lit room. Not only is it inexpensive, but it’s also easy to do. The instructions are straightforward, and you can accomplish this exam within five minutes. Depending on how quickly you’re able to conduct the exam and gather the necessary information, the five minutes can even include writing down your observations.

It can help professionals determine what tests to conduct next.

As we mentioned earlier, the PERRLA Eye Exam isn’t a diagnostic test and should not be the sole assessment you conduct to deduce problems. But this doesn’t mean you should dismiss the validity of this exam because depending on what you find during this exam, the PERRLA Eye Exam can set the course for what tests to conduct.

For example, if your pupils don’t react to light the way they should, that could indicate potential problems like an infection in the optic nerve or even glaucoma. Another example would be pupils having unusual shapes or not equal in size. If that’s the case for your patient, the unusual shapes or the lack of equality in size could point to problems like migraines or stroke.

It can be used to monitor patients down the line.

The PERRLA Eye Exam is not a one-time, big-time thing. Since it’s often included in comprehensive examinations, some of which are conducted whenever there’s a change in nurse or doctor shift, the exam can be used as a monitoring assessment.

Let’s stipulate that you have a patient who was confirmed to have a certain eye condition, and the eye condition is still in its early stages. The PERRLA Eye Exam can be used again to check any pupil changes over time and determine if the condition is getting worse or better based on comparing results with previous PERRLA Eye Exams.

How long does it take to accomplish the PERRLA Eye Exam?
How long does it take to accomplish the PERRLA Eye Exam?

Commonly asked questions

How long does it take to accomplish the PERRLA Eye Exam?

You can finish this test in five minutes.

Is the PERRLA Eye Exam invasive?

The PERRLA Eye Exam is a non-invasive exam. The healthcare professional handling you will simply need to assess your pupils, which they can do using their eyes and a penlight.

What are the limitations of the PERRLA Eye Exam?

It is limited to identifying signs of potential problems. It doesn’t diagnose anything.

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