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

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