A 30 s test for quantitative assessment of a relative afferent pupillary defect (RAPD): the infrared pupillary asymmetry (IPA)



Detection of a relative afferent pupillary defect (RAPD) by the swinging-light test can be challenging in clinical practice (dark eyes, anisocoria, dark environment). We developed a new method of RAPD quantification based on the recording of the infrared pupillary asymmetry (IPA) with a standard optical coherence tomography (OCT) device.


The diagnostic value of the IPA for detection of the RAPD was determined by receiver-operating characteristic (ROC) curves and area under the curve (AUC).


Twenty-nine subjects were included in this study (17 controls and 12 unilateral optic neuropathies). The IPA was significantly greater in unilateral optic neuropathies (0.39) compared to controls (0.18, p = 0.001). The diagnostic value was good with a ROC–AUC of 0.843. Importantly, the IPA correlated significantly with the inter-eye percentage difference of the macular ganglion cell-inner plexiform layer (mGCIPL) thickness (R = 0.53, p = 0.01). Assessment of the IPA took less than 30 s.


The present data show that the IPA is a practical and rapid test that can be applied in a clinical setting. The IPA may be a valuable functional outcome measure for clinical trials, complementing structural retinal OCT data in a biological meaningful way. The IPA should be further investigated for suitability for optic neuritis treatment trials.

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Nathalie Stéphanie Meneguette was sponsored by a Du Pré Grant from the MS International Federation.

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Correspondence to Axel Petzold.

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Conflicts of interest

Axel Petzod is supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health. He is member of the steering committee for the OCTiMS study (Novartis) and performed OCT QC for the PASSOS study (Novartis) and received consulting fees. J. Emanuel Ramos de Carvalho and Nathalie Stéphanie Meneguette declare that they have no conflict of interest.

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Meneguette, N.S., de Carvalho, J.E.R. & Petzold, A. A 30 s test for quantitative assessment of a relative afferent pupillary defect (RAPD): the infrared pupillary asymmetry (IPA). J Neurol 266, 969–974 (2019). https://doi.org/10.1007/s00415-019-09223-1

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  • Optical coherence tomography
  • Infrared pupillary asymmetry
  • IPA
  • Relative afferent pupillary defect
  • RAPD