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How to test for a relative afferent pupillary defect (RAPD)

Article  in  Community eye health / International Centre for Eye Health · January 2012
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 RELATIVE AFFERENT PUPILLARY DEFECT

How to test for a relative afferent

pupillary defect (RAPD)
David C Broadway cranial nerve (the oculomotor nerve), first eye for at least 3 seconds. This
Consultant ophthalmic surgeon, causing both pupils to constrict, even allows the pupil size to stabilise. Note
Department of Ophthalmology, Norfolk
even though only one eye is being whether the pupil of the eye being
& Norwich University Hospital, and illuminated reacts briskly and constricts
Honorary Reader, University of East stimulated by the light.
fully to the light. Also note what happens
Anglia, Norwich, UK. A positive RAPD means there are differ- to the pupil of the other eye: does it also
ences between the two eyes in the constrict briskly?
The ‘swinging light test’ is used to detect
afferent pathway due to retinal or optic • Move the light quickly to shine in the
a relative afferent pupil defect (RAPD): a
nerve disease. If the light used is suffi- other eye. Again, hold the light steady
means of detecting differences between
ciently bright, even a dense cataract or for 3 seconds. Note whether the pupil
the two eyes in how they respond to a
corneal scar will not give a RAPD as long being illuminated stays the same size,
light shone in one eye at a time. The test
as the retina and optic nerve are healthy. or whether it gets bigger. Note also what
can be very useful for detecting unilateral
Indeed, the test can be used to assess happens to the other eye.
or asymmetrical disease of the retina or
the health of the retina and optic nerve • As there is a lot to look at, repeat the
optic nerve (but only optic nerve disease
behind a dense cataract, for example. test, observing what happens to the
that occurs in front of the optic chiasm).
In glaucoma, if other tests of visual pupils of both eyes when one and then
The physiological basis of the RAPD
function (e.g. visual fields) are not the other eye is illuminated.
test is that, in healthy eyes, the reaction
possible, detecting a RAPD can be very
of the pupils in the right and left eyes are When the test is performed on someone
useful as it indicates that there is more
linked. In other words, a bright light shone with unilateral or asymmetrical retinal or
optic nerve damage in one eye than in
into one eye leads to an equal optic nerve disease, a RAPD should be
the other, even if the visual acuity in
constriction of both pupils. When the light present (Figure 3). The following happens:
both eyes is equal.
source is taken away, the pupils of both
eyes enlarge equally. This is called the NOTE: If the glaucomatous damage is • When the light is shone into the eye with
consensual light reflex. equal in the two eyes, there will be no the retinal or optic nerve disease, the
To understand how the pupils react to RAPD, however severe the damage is. pupils of both eyes will constrict, but not
light, it is important to understand the fully. This is because of a problem with
light reflex pathway (Figure 1). This The swinging light test the afferent pathway.
pathway has two parts. In a normal swinging light test (i.e. there • When the light is shone into the other,
is no RAPD) the pupils of both eyes normal (less abnormal) eye, both pupils
1 The afferent part of the pathway (red) constrict equally regardless of which eye will constrict further. This is because the
refers to the nerve impulse/message is stimulated by the light (Figure 2). afferent pathway of this eye is intact, or
sent from the pupil to the brain along the In an abnormal swinging-light test (i.e. less damaged than that of the other eye.
optic nerve when a light is shone in that there is a RAPD) there is less pupil • When the light is shone back into the
eye. constriction in the eye with the retinal or abnormal eye, both pupils will get larger,
2 The efferent part of the pathway (blue) optic nerve disease (Figure 3). even the pupil in the normal eye.
is the impulse/message that is sent • It doesn’t matter whether you start with
from the mid-brain back to both pupils Steps the eye you think has the greater
via the ciliary ganglion and the third • Use a bright torch which can be focussed problem or the healthier eye: as long as
to give a narrow, even beam of light. the light is switched from one eye to the
Figure 1. The light reflex pathway
Perform the test in a semi-darkened other and back again the signs should
showing the afferent path (red) and the
room. If the room is too dark it will be become apparent.
efferect path (blue)
difficult to observe the pupil responses,
Sometimes the RAPD is obvious, as the
John Yaw-Jong Tsai, Touro University

particularly in heavily pigmented eyes.

pupil in the (most) affected eye very
• Ask the patient to look at a distant
object, and to keep looking at it. Use a obviously gets larger when that eye is
Snellen chart, or a picture. This is to illuminated. But the signs can be more
Third prevent the near-pupil response (a subtle (see Table 1).
cranial constriction in pupil size when moving
nerve focus from a distant to a near object).
Specific situations
Hippus
While performing the test, take care not
Normal pupils, particularly those of young
to get in the way of the fixation target.
people, sometimes show slight fluctu-
• Move the whole torch deliberately from
side to side so that the beam of light is ation in size (of less than 1 mm) even
Optic directed directly into each eye. Do not when the light shining into the eye is
Ciliary nerve constant. This is called hippus and it can
swing the beam from side to side
ganglion make eliciting a RAPD more difficult.
around a central axis (e.g. by holding it
in front of the person’s nose) as this can Non-reactive pupils
also stimulate the near response. A RAPD can still be detected even if one
• Keep the light source at the same pupil cannot change size (i.e. it is fixed),
distance from each eye to ensure that because of trauma, posterior synechiae
Light source the light stimulus is equally bright in both. or because dilating or constricting eye
Light source • Keep the beam of light steadily on the drops have been used (Figure 4). Having

58 Community Eye Health Journal | VolUME 25 ISSUES 79 & 80 | 2012

CEHJ79_FINAL4_OA.indd 58 01/02/2013 11:48

 established that the pupil of one eye Table 1. The grading of a RAPD in the swinging light test
does not change size, regardless of
which eye has the light shone into it, amaurotic This is seen when one eye has no perception of light. The pupil of this
concentrate on the eye where the pupil is eye only constricts when light is shone into the other eye. When the
reactive. Note what happens to the light is shone back into the eye with no perception of light the pupil
reacting pupil when the light is shone rapidly enlarges against the light.
into each eye in turn. Figure 4 shows
3–4+ The pupil enlarges as soon as the light is swung from the normal eye
what happens when the eye with the
into the abnormal eye.
afferent pathway defect is also the eye
with the fixed pupil. If the (more) normal 1–2+ The pupil enlarges, but only after a short delay, after the light is swung
eye is the one with the fixed pupil then, from the normal eye into the abnormal eye.
as the light moves from this eye to the
other eye, the reacting pupil will dilate. Subtle/ Sometimes the pupils of both eyes can enlarge in the short time
trace interval between shining the light in the normal eye and the abnormal
asymmetric refractive errors and/or
eye. If this happens, the pupil of the abnormal eye may constrict a
amblyopia
little bit before enlarging.
These occur when the vision is poor but
the eye itself is normal, and are not
associated with a RAPD. causes of RaPds A RAPD is an extremely important local-
Common causes of unilateral optic nerve ising clinical sign that can be detected by
maculopathy a simple, quick, non-invasive clinical test,
Unless very severe, this not usually disorders that can be associated with a
provided that the test is performed
associated with a RAPD and in eyes RAPD include ischaemic optic
carefully and correctly.
where the macular damage is sufficient neuropathy, optic neuritis, optic nerve
references
to result in an RAPD, the grade is rarely compression (orbital tumours or 1 Gunn RM. Functional or hysterical amblyopia.
more than 1–2+ (Table 1). Extensive dysthyroid eye disease), trauma, and Ophthalmol Reviews 1902;21:271–280.
2 Levatin P. Pupillary escape in disease of the retina and
retinal damage, major retinal vascular asymmetric glaucoma. Less common suh optic nerve. Arch Ophthalmol 1959;62:768–779.
causes include infective, infiltrative, carci- 3 Bell RA, Waggoner PM, Boyd WM, et al. Clinical grading
occlusion, or retinal detachment, by of relative afferent pupillary defects. Arch Ophthalmol.
contrast, can lead to a high-grade RAPD. nomatous, or radiation optic neuropathy. 1993;111:938–942.

Figure 2. Swinging-light test – normal Figure 3. Swinging-light test – left RAPD Figure 4. Swinging-light test: left RAPD +
(no RAPD) Illumination of the (more) normal right eye non-reactive left pupil
Illumination of either eye induces normal causes both pupils to constrict. When the Illumination of the relatively normal right eye
and equal pupil responses in both eyes light is moved to the (more) abnormal left causes only right pupil constriction. When
(consensual responses). eye (e.g. with optic neuropathy), both the light is moved to the abnormal left eye
pupils dilate (constrict less), the left pupil (e.g. fixed pupil and optic neuropathy), the
dilating despite the light being shone right pupil dilates (constricts less). Returning
directly at it. Returning the light to the the light to the right eye results in constriction
Light source (relatively) normal right eye results in of the right pupil again. In this situation it is
constriction of both pupils again. only necessary to observe the eye with the
reactive pupil in order to identify an RAPD.
RIGHT EYE LEFT EYE RIGHT EYE LEFT EYE RIGHT EYE LEFT EYE
Eye with optic Eye with optic neuropathy
neuropathy (for example) and
(for example) non-reactive pupil

© The author/s and Community Eye Health Journal 2012. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License.

CEHJ79_FINAL4_OA.indd 59 01/02/2013 11:48

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