# Accommodation or Acuity (PERLA)



## JJR512 (Dec 6, 2010)

My EMT instructor recently said that he hates to see the letter 'A' used when describing pupils (i.e., "PERL*A*), because it stands for "acuity" which isn't checked in the field. But, according to him, lots of providers just write "PERLA" without really knowing what it means because that's what they've seen other providers do. All they really know is that it's what to write when the pupils are fine.

I've done some research on my own and discovered that the 'A' may stand for "accommodation", though. Accommodation is the eye's ability to change its focus. Specifically, changing its optical power to focus on something nearer or farther.

So I wonder do those of who write "PERLA" actually check something for the 'A', and if so, what does it mean for you—acuity or accommodation? And how do you actually check whatever you're checking?


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## Veneficus (Dec 6, 2010)

JJR512 said:


> My EMT instructor recently said that he hates to see the letter 'A' used when describing pupils (i.e., "PERL*A*), because it stands for "acuity" which isn't checked in the field. But, according to him, lots of providers just write "PERLA" without really knowing what it means because that's what they've seen other providers do. All they really know is that it's what to write when the pupils are fine.
> 
> I've done some research on my own and discovered that the 'A' may stand for "accommodation", though. Accommodation is the eye's ability to change its focus. Specifically, changing its optical power to focus on something nearer or farther.
> 
> So I wonder do those of who write "PERLA" actually check something for the 'A', and if so, what does it mean for you—acuity or accommodation? And how do you actually check whatever you're checking?



Accomodation. 

I do not break out an eye chart put the patient a distance away and ask them to read the lines.


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## JJR512 (Dec 6, 2010)

Veneficus said:


> Accomodation.


...


JJR512 said:


> And how do you actually check whatever you're checking?


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## 8jimi8 (Dec 6, 2010)

Have them focus on your finger at a distance and then move it closer to their face.  Very easy to incorporate while you are checking oculomotor function. Is it spoonfeeding time?


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## Akulahawk (Dec 6, 2010)

PERLA. As others have stated, the "A" is "Accommodation". Find out what it is, and why you might want to check for it while doing oculomotor function. There really _is_ a reason why...


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## Sam Adams (Dec 6, 2010)

JJR512 said:


> My EMT instructor recently said that he hates to see the letter 'A' used when describing pupils (i.e., "PERL*A*), because it stands for "acuity" which isn't checked in the field.



Could be worse ... I was taught: P-upils E-qual A-nd R-eactive to L-ight.

Have since learned accomodation. 

Use your finger. Normal pupil function produces visible changes if you have them look at you finger/ pen both near and far.


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## Sassafras (Dec 6, 2010)

Sam Adams said:


> Could be worse ... I was taught: P-upils E-qual A-nd R-eactive to L-ight.
> 
> Have since learned accomodation.
> 
> Use your finger. Normal pupil function produces visible changes if you have them look at you finger/ pen both near and far.



This is what I learned.  I have never heard of accomodation until now.  What changes am I looking for that indicate normal vs. abnormal?


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## Akulahawk (Dec 6, 2010)

Sassafras said:


> This is what I learned.  I have never heard of accomodation until now.  What changes am I looking for that indicate normal vs. abnormal?


Inability to accommodate... normally, you can.


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## MrBrown (Dec 6, 2010)

Veneficus said:


> I do not break out an eye chart put the patient a distance away and ask them to read the lines.



Good thing mate, testing Brown's visual acuity may result in a negative number (or a very large one!)


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## JJR512 (Dec 6, 2010)

8jimi8 said:


> Have them focus on your finger at a distance and then move it closer to their face.  Very easy to incorporate while you are checking oculomotor function. Is it spoonfeeding time?



When you start with your finger at a distance, then move it closer, what you can observe with the eyes is called _convergence_. Keep moving your finger in, right to the top of the bridge of the nose, and you'll have a cross-eyed patient. Seeing whether the eyes can change their convergence does _not_ tell you if the patient is actually _accommodating_ the change in distance. Accommodation is achieved by altering the shape of the lens, which is a muscular action. The lens is behind the iris, so you can see part of it through the pupil. What I am endeavoring to determine is whether it's actually possible to see, with my own bare eyes, that the lens is indeed changing shape, because other than the iris opening or closing, I've never noticed anything else going on in the pupil.

So go ahead, Mr. Smartypants, start the spoonfeeding.


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## Aidey (Dec 6, 2010)

You don't need to see it, all you need to do is ask the patient if your finger/penlight is still in focus.


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## MS Medic (Dec 6, 2010)

Best bit of advice I was ever given was that PEARL does not tell anyone taking report anything useful. Learn your S scale, do a 11 point cranial nerve exam (skipping the olfactory nerve) then chart: PUPILS S3/REACTIVE, - NEURO DEFICITS NOTED (or what ever the findings are).


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## JJR512 (Dec 6, 2010)

Aidey said:


> You don't need to see it, all you need to do is ask the patient if your finger/penlight is still in focus.


Thanks. About how far do you stop? I know the minimum accommodating distance increases with age in most people.



MS Medic said:


> Best bit of advice I was ever given was that PEARL does not tell anyone taking report anything useful. Learn your S scale, do a 11 point cranial nerve exam (skipping the olfactory nerve) then chart: PUPILS S3/REACTIVE, - NEURO DEFICITS NOTED (or what ever the findings are).


I have no idea what the "S scale" is; never heard of it.


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## MS Medic (Dec 6, 2010)

JJR512 said:


> I have no idea what the "S scale" is; never heard of it.



It is a scale that determines exact pupil size in cm. It can be found in the ALS pocket flip manual and on many disposable pen lights you can get from sites like GAULS. Much more accurate than PEARL, since you can give exact size even if pupils are uneven.


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## Veneficus (Dec 6, 2010)

JJR512 said:


> What I am endeavoring to determine is whether it's actually possible to see, with my own bare eyes, that the lens is indeed changing shape, because other than the iris opening or closing, I've never noticed anything else going on in the pupil.




I really can't figure out how you would actually see the lens change shape, even with an opthalmoscope you would be looking through it. (it is afterall transparent)

While testing for convergence, you can ask the pt if they still see it and if it is clear or hazy and at what distance.

Of course being wary for Argyll Robertson Pupil.


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## JJR512 (Dec 6, 2010)

MS Medic said:


> It is a scale that determines exact pupil size in cm. It can be found in the ALS pocket flip manual and on many disposable pen lights you can get from sites like GAULS. Much more accurate than PEARL, since you can give exact size even if pupils are uneven.



Ah, OK. I've only ever seen that referred to as the pupil scale or chart. What does "S scale" mean, what does the 'S' stand for?

(By the way, I think the site you meant was Galls.)


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## JJR512 (Dec 6, 2010)

Veneficus said:


> I really can't figure out how you would actually see the lens change shape, even with an opthalmoscope you would be looking through it. (it is afterall transparent)



Exactly. I didn't think it could be seen directly at all, especially in the field.


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## MS Medic (Dec 6, 2010)

JJR512 said:


> Ah, OK. I've only ever seen that referred to as the pupil scale or chart. What does "S scale" mean, what does the 'S' stand for?
> 
> (By the way, I think the site you meant was Galls.)



Don't know what the "S" stands for. TBH I have never really thought to ask that before.:blush:
And yes I did mean galls. Sorry for the typo. :blush:again


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## JJR512 (Dec 6, 2010)

MS Medic said:


> Don't know what the "S" stands for. TBH I have never really thought to ask that before.:blush:



It's either something really scientific and technical...Or it could be something really simple, like "Size. :lol:


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## JPINFV (Dec 6, 2010)

Akulahawk said:


> Inability to accommodate... normally, you can.



Alternatively, and like prostitutes, they accommodate, but don't react. Prostitutes also have syphilis.


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## JPINFV (Dec 6, 2010)

Veneficus said:


> Of course being wary for Argyll Robertson Pupil.



That's definitely a major part of testing accomodation. Does the pupils constrict as the eyes accommodate?


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## JJR512 (Dec 6, 2010)

JPINFV said:


> Alternatively, and like prostitutes, they accommodate, but don't react. Prostitutes also have syphilis.



"Prostitute's pupils" is what the condition Veneficus mentioned earlier, Argyll Robertson pupil, used to be known as, for exactly that reason.


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## JPINFV (Dec 6, 2010)

JJR512 said:


> "Prostitute's pupils" is what the condition Veneficus mentioned earlier, Argyll Robertson pupil, used to be known as, for exactly that reason.



Argyll Robertson pupils are pupils that do not constrict to light, but do constrict during accommodation. It's a sign of neurosyphilis.


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## JJR512 (Dec 6, 2010)

JPINFV said:


> Argyll Robertson pupils are pupils that do not constrict to light, but do constrict during accommodation. It's a sign of neurosyphilis.



Right. They do not react to light but they do accommodate. Thus the basis for my previous statement.


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## JPINFV (Dec 6, 2010)

Ah, I misinterpreted your post... sorry about that.


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## 8jimi8 (Dec 6, 2010)

I didn't tell you to look for convergence.  If you knew the answer, why were you posting the question?  Or did you just learn it after demanding that we spoonfeed you?  

Sorry.  Maybe I misinterpreted your elipses... Maybe i should have read that as "I've already been searching and can't find a test for accomodation"


I have noticed that many paramedics document ( and even in reporting software ) "perla"

What I learned in nursing school was perrlaa and what I learned in my basic class was "perla."


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## Bosco836 (Dec 7, 2010)

JJR512 said:


> So I wonder do those of who write "PERLA" actually check something for the 'A', and if so, what does it mean for you—acuity or accommodation?



I've always been taught that the A in PERLA = accommodation.


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## SerumK (Dec 7, 2010)

PERRLA = Pupils Equal, Round, Reactive to Light and Accommodation

I learned that in nursing school. In my EMT class, they just taught us PERRL.


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## ffemt8978 (Dec 8, 2010)

Off topic posts removed, thread closed.


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