I’ve been doing this job for almost 30 years, and let me tell you, never in my professional career have I ever met a pupil that wasn’t equal round and reactive to light. I’m not one to brag, but I can diagnose a stroke, appendicitis, and kidney stones in a matter of seconds. I can even hear a I/VI heart murmur from across the room, so believe me when I say with 100% certainty that every eyeball that has come through my ED since 1985 has been a capital P-E-R-R-L-A.
Just last week, there was a high speed motor vehicle accident victim that came rolling into the trauma bay. It was a bad one. Every bone in his face was broken. His lower jaw was left somewhere out on I-35. He probably had a nose at one point, but I sure as hell couldn’t find it. Looked like he didn’t even have a face, but his eyes were perfectly PERRLA. No question about it. Even though his eyelids were swollen shut, any emergency physician worth a damn would tell you, those pupils were equal, they were round, and they were as reactive to light as I’ve ever seen.
When I think people (especially jerkoff ophthalmologists) won’t believe my eye exam when they read my note, I’ll add the “A” to PERRL to show how serious I am. Most emergency docs don’t have enough confidence in their exam skills to add the “A,” but I have the experience and know-how to go all the way. When you look at my note and see “Pupils Equal Round and Reactive to Light, Awesome!!” you can be sure that those pupils were stone cold normal.
A few years back I got called up by an ophthalmologist who said I wrote down PERRLA on a patient with a prosthetic eye. I said to him, “You’re damn right I did! Have you seen what they’re doing with fake eyes these days? That prosthetic eye was just as PERRLA as a real eye.” I suggested that he keep up with the literature right before he hung up on me.
These young ER docs, they finish residency thinking they got it all figured out. They are always saying, “these pupils are unequal, or those pupils aren’t round.” Well then what are they, square?! Wait until you’ve been doing this for 30 years and have examined thousands of PERRLA eyes before you start saying there are non-PERRLA eyes out there.
No ER doc knows their way around a pupil exam better than me. People can claim all they want that they’ve seen a non-PERRLA eye in my ED. Well, I’ll believe it when I see it, but I won’t, because they don’t exist.