Relative afferent pupillary defect in patients

with asymmetric cataracts

Jeong-Min Hwang, MD, Cheol Kim, MD, Ji-Young Kim, MD

Purpose: To prospectively investigate the incidence, associated factors, and

prognostic significance of relative afferent pupillary defects (RAPDs) in eyes with
less severe cataract than in contralateral eyes.
Setting: Department of Ophthalmology, Seoul Municipal Boramae Hospital, Col-
lege of Medicine, Seoul National University, Seoul, Korea.
Methods: Forty patients with asymmetric cataract and a differences of 3 or more
lines of Snellen visual acuity between eyes had detailed ophthalmic examinations
including visual acuity, slitlamp evaluation, a swinging flashlight test before and
after cataract surgery, and color vision assessment.
Results: Twenty-three of 40 patients (58%) had an RAPD (mean extent 0.39 log
unit ⫾ 0.17 [SD]) in the eye with less severe cataract. The RAPD resolved or
switched to the other eye after cataract extraction. All 5 patients with a unilateral
totally opaque lens had a contralateral RAPD, confirming the relationship between
totally opaque cataracts and RAPDs. The difference in visual acuity between the
2 eyes did not differ between patients with RAPD and those without RAPD. There
was no association between the presence of RAPD and postoperative visual
acuity.
Conclusions: More than half the patients with asymmetric cataract had an RAPD
that resolved in the eye with less severe cataract after cataract extraction. All pa-
tients with a unilateral totally opaque lens had an RAPD. The presence of a preop-
erative RAPD was not related to postoperative visual acuity.
J Cataract Refract Surg 2004; 30:132–136  2004 ASCRS and ESCRS

T he swinging flashlight test is an objective method to

diagnose a lesion of the anterior visual pathways.1 A
relative afferent pupillary defect (RAPD) usually occurs
in an eye with a unilateral or asymmetric optic nerve
Accepted for publication October 8, 2003.
From the Department of Ophthalmology, Seoul Municipal Boramae
Hospital, College of Medicine, Seoul National University, Seoul, Korea.
None of the authors has a financial or proprietary interest in any
material or method mentioned.
Hokyung Lee, MD, Seok Joon Park, MD, and Hyeong Gon Yu, MD,
provided advice and assistance. The Editorial Services, Seoul National
University College of Medicine, Seoul, Korea, assisted with the prepara-
tion of the paper.
Reprint requests to Jeong-Min Hwang, MD, Department of Ophthal-
mology, Seoul Municipal Boramae Hospital, College of Medicine, Seoul
National University, 395, Sindaebang-2-dong, Dongjak-ku, Seoul
156-707, Korea. E-mail: hjm@snu.ac.kr.
 2004 ASCRS and ESCRS
Published by Elsevier Inc.
or extensive retinal disease.1 In general, the eye with
poorer visual acuity has the RAPD. However, in eyes
with an ocular media abnormality such as corneal opac-
ity, hyphema, anterior segment membrane, cataract, or
vitreous opacity, an RAPD is reported to occur in the
eye with better visual acuity; that is, the contralateral
eye of the eye with an ocular media abnormality.2–4
Relative afferent pupillary defects are reported to resolve
in all patients after cataract extraction.2,3 All previous
studies report patients with very asymmetric cataracts.2,3
There has been no report in the literature of whether
RAPDs also occur in eyes with less severe cataract.
Moreover, little information has been published on the
frequency of RAPD in the better eye, the extent to
which interocular difference in visual acuity and degree
of cataract cause RAPD, and the visual prognosis in
the presence of preoperative RAPD in the contralateral
0886-3350/03/$–see front matter
doi:10.1016/j.jcrs.2003.11.022
 RELATIVE AFFERENT PUPILLARY DEFECT IN ASYMMETRIC CATARACT

eye. For instance, it has not been confirmed whether

concern about visual prognosis is warranted in the ab-
sence of RAPD in the contralateral eye of an eye with
dense cataract.
This prospective study was performed to expand
our understanding of this condition with regard to these
issues. It evaluated the degree of cataract and the pres-
ence of RAPD in eyes with different degrees of asymmet-
ric cataract before and after cataract extraction.

Patients and Methods

A prospective study of patients who visited our clinic
for cataract surgery from July 1999 to December 2000 was
conducted. All patients provided informed consent. Forty
patients with asymmetric cataract and a difference of 3 or
more lines of Snellen visual acuity (more than 0.35 logMAR)
between eyes were included. Excluded were patients with a
history of cerebrovascular accident, cerebral palsy, mental
retardation, cataract or retina surgery, ocular trauma, amblyo-
pia, strabismus, nystagmus, media opacity other than cataract,
glaucoma, or anisometropia of more than 2.0 diopters spheri-
cal equivalent and those with perioperative complications.
Patients in the very early stage of diabetic retinopathy were
not excluded.
The mean age of the 20 men and 20 women was 62.1
years ⫾ 13.1 (SD) (range 31 to 82 years). Twenty-three
patients (57.5%) had an RAPD (RAPD group), and 17
patients (42.5%) had no RAPD (NRAPD group). Cataracts
were categorized according to their location and degree of
opacity. Medical histories and a review of systems were
obtained.
All 40 patients had a detailed ophthalmic examination
including visual acuity; intraocular pressure; slitlamp, fundus,
and eye motility evaluations; manifest or cycloplegic refrac-
tion; color vision assessment; and fundoscopy before and
after cataract extraction. Pupil examinations, including the
swinging flashlight test, were performed by 1 surgeon
(J.-M.H.) who was masked to the visual acuity and degree
of cataract.
The amount of RAPD was measured using neutral den-
sity filters (Optec International Ltd.). Pupil examinations
were performed using an indirect ophthalmoscope light under
dim background illumination with the patient fixating at
distance. An indirect ophthalmoscope light was alternated
from 1 eye to the other every 2 to 4 seconds. The same time
was spent examining each eye. The log unit of neutral density
filters was increased from zero by 0.3 log unit until there
was no different pupil response.
Patients then had phacoemulsification with implantation
of a posterior chamber intraocular lens in the worse eye (ie,
the eye with more severe cataract) by 1 surgeon (J.-Y.K.).
Figure 1. (Hwang) LogMAR differences in the RAPD group. The
difference between the 2 eyes was more than 1.50 logMAR or less
than 0.50 logMAR in 17 of 23 patients (76%).
One to 5 months after cataract extraction, an ophthalmologic
examination was performed as preoperatively.
Results
The mean extent of RAPD measured with a neutral
density filter was 0.39 ⫾ 0.17 log unit (range 0.30 to
0.90 log unit) in the RAPD group and 0 log unit in
the NRAPD group. In the RAPD group, RAPD was not
found in any patient postoperatively except 1 patient with
bilateral cortical cataract in whom the RAPD switched
to the other eye.
The mean difference in visual acuity between the
2 eyes of each patient was 1.12 ⫾ 0.78 logMAR in the
RAPD group and 0.95 ⫾ 0.42 logMAR in the NRAPD
group (P ⫽ .384, t test for equality of means). An
RAPD was present in 8 of 10 patients (80%) with an
interocular difference in visual acuity of more than 1.50
logMAR, in 6 of 18 patients (33%) with an interocular
difference between 0.50 logMAR and 1.50 logMAR,
and in 9 of 12 patients (75%) with an interocular
difference less than 0.50 logMAR.
Six of 23 patients (26%) in the RAPD group (Figure
1) and 12 of 17 patients (71%) in the NRAPD group
(Figure 2) had an interocular difference in visual acuity
between 0.50 logMAR and 1.50 logMAR. Five of 10
patients with an interocular difference in visual acuity
of more than 1.50 logMAR had a totally opaque lens
and a contralateral RAPD. There was no statistically

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 RELATIVE AFFERENT PUPILLARY DEFECT IN ASYMMETRIC CATARACT
Figure 2. (Hwang) LogMAR differences in the NRAPD group. The
difference between 2 eyes was between 0.50 logMAR and 1.50
logMAR in 12 of 17 patients (71%).
significant difference between the degree of cataract (ie,
nucleosclerosis, cortical opacity, posterior subcapsular
opacity) and the presence of RAPD between the RAPD
and NRAPD groups.
Visual acuity improved postoperatively by a mean
of 1.12 ⫾ 0.69 logMAR in the RAPD group and 0.88 ⫾
0.39 logMAR in the NRAPD group (P ⫽ .184, t test
for equality of means). The final mean postoperative
visual acuity was 0.14 ⫾ 0.17 logMAR in the RAPD
group and 0.19 ⫾ 0.19 logMAR in the NRAPD group
(P ⫽ .304, t test for equality of means).
Discussion
If a patient has an RAPD in the same eye as a
unilateral cataract, there is a high likelihood that there
is a major defect of the anterior visual pathway in that
eye.2–4 Studies have found that all patients with mature
or nuclear cataracts had a measurable RAPD in the
other eye.2–4 In every case in these studies except 1 patient
with bilateral cortical cataract, in whom the RAPD
switched to the other eye, the RAPD resolved after
cataract extraction.2,3 However, the importance of the
postoperative prognosis in patients who do not have an
RAPD in the contralateral eye of an eye with a totally
opaque lens has not been confirmed. Neither has the
frequency of RAPD in eyes with asymmetric cataracts.
Furthermore, the difference in visual prognosis between
eyes with RAPD and contralateral eyes without RAPD
134 J CATARACT REFRACT SURG—VOL 30, JANUARY 2004
has not been evaluated. This study was performed to
investigate these issues.
In our study, an RAPD occurred in 58% of the
better eyes of patients with asymmetric cataract. The
RAPD resolved or switched to the other eye after cata-
ract extraction, as in a report by Lam and Thompson.2
There was no difference in the final postoperative visual
acuity between the RAPD and NRAPD groups. These
results suggest that an RAPD is not universally observed
in better eyes of patients with asymmetric cataract and
implies that RAPDs are not a prognostic factor in cata-
ract surgery. However, all 5 patients with a unilateral
totally opaque lens had a contralateral RAPD, confirm-
ing the relationship between totally opaque cataracts
and RAPDs. Because all patients with a unilateral totally
opaque lens developed a postoperative RAPD in the
better eye, it is not clear whether concern about the
visual prognosis is warranted in the absence of an RAPD
in the contralateral eye in patients with a unilateral
totally opaque lens.
Our study demonstrated that an RAPD is not lim-
ited to patients with a large interocular difference in
visual acuity between eyes; 60% of patients with an
interocular difference less than 0.74 logMAR also had
an RAPD. Most patients in the RAPD group had a
large or small interocular logMAR difference between
eyes, whereas the difference in the NRAPD group was
intermediate. We assumed these results might be caused
by the type of cataract; thus, we tried to classify the
type of lens opacity in patients with an RAPD and
a small interocular logMAR difference between eyes.
However, the pattern of lens opacities was so diverse
that the meaning of these findings could not be interpre-
ted. We could not compare our results with those in
previous studies because little information has been
published concerning the parameters we studied.
In our study, the mean extent of RAPD measured
with a neutral density filter was 0.39 ⫾ 0.17 log unit,
similar to the mean of 0.44 log unit (range 0.25 to
0.57 log unit) reported by Lam and Thompson.2 These
values are much smaller than those in cases of optic
nerve disease or profound retinal lesion. No patient with
a preoperative RAPD had an RAPD postoperatively,
confirming that a contralateral cataract is the sole cause
of RAPD.
It remains to be elucidated why a cataract causes
an RAPD in the better eye in patients with asymmetric
 RELATIVE AFFERENT PUPILLARY DEFECT IN ASYMMETRIC CATARACT

Table 1. Patients’ profile before cataract surgery.

BCVA
LogMAR Amount of RAPD
Patient Better Eye Worse Eye Difference (Log Unit) Group

1 20/25 20/50 0.30 0.3 RAPD

2 20/25 20/50 0.30 0.3 RAPD
3 20/20 20/40 0.30 0.3 RAPD
4 20/40 20/100 0.40 0.3 RAPD
5 20/40 20/100 0.40 0.3 RAPD
6 20/20 20/50 0.40 0.3 RAPD
7 20/25 20/70 0.44 0.6 RAPD
8 20/25 20/70 0.44 0.9 RAPD
9 20/25 20/70 0.44 0.3 RAPD
10 20/100 20/400 0.60 0.6 RAPD
11 20/25 20/200 0.90 NR RAPD
12 20/50 20/400 0.90 0.3 RAPD
13 20/25 20/200 0.90 0.3 RAPID
14 20/25 20/300 1.06 NR RAPD
15 20/25 20/400 1.20 0.3 RAPD
16 20/20 20/800 1.60 0.3 RAPD
17 20/30 CF 2–4 ft 1.83 0.3 RAPD
18 20/25 CF ⱕ1 ft 2.10 0.6 RAPD
19 20/30 HM 2.13 0.3 RAPD
20 20/25 HM 2.20 0.3 RAPD
21 20/20 HM 2.30 0.3 RAPD
22 20/20 HM 2.30 0.6 RAPD
23 20/20 HM 2.30 0.3 RAPD
24 20/20 20/40 0.30 0 NRAPD
25 20/50 20/100 0.40 0 NRAPD
26 20/25 20/70 0.44 0 NRAPD
27 20/20 20/100 0.70 0 NRAPD
28 20/20 20/100 0.70 0 NRAPD
29 20/20 20/100 0.70 0 NRAPD
30 20/30 20/200 0.85 0 NRAPD
31 20/30 20/200 0.85 0 NRAPD
32 20/25 20/200 0.90 0 NRAPD
33 20/50 20/400 0.90 0 NRAPD
34 20/40 20/400 1.00 0 NRAPD
35 20/20 20/200 1.00 0 NRAPD
36 20/50 20/800 1.20 0 NRAPD
37 20/20 20/400 1.30 0 NRAPD
38 20/30 20/800 1.45 0 NRAPD
39 20/20 20/800 1.60 0 NRAPD
40 20/25 CF 2–4 ft 1.90 0 NRAPD
BCVA ⫽ best corrected visual acuity; CF ⫽ counting fingers; HM ⫽ hand motions; NR ⫽ not recorded; NRAPD ⫽ no relative afferent pupil
defect; RAPD ⫽ relative afferent pupil defect

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 RELATIVE AFFERENT PUPILLARY DEFECT IN ASYMMETRIC CATARACT
cataract. Lam and Thompson2 speculate that cataracts
might induce RAPDs in opposite eyes by increasing
the intraocular scattering of light. They also considered
the state of dark adaptation behind a cataract. A dense
cataract must shade the retina because some light is
reflected back through the pupil by the opaque lens and
some is absorbed by the brunescence of the lens. Burian
and Burns5 suggest that a dense cataractous lens modifies
the retinal illumination, enhancing or reducing it. Cox6
postulates that the cataract converts the focal-light stim-
ulus to a full-field stimulus, giving a more effective
pupillomotor stimulus. Sadun and coauthors7 theorize
that there is central or retinal modulation of nerve
signals that enhances the afferent pupillary input. Fur-
ther study of the mechanism of RAPDs is required.
136 J CATARACT REFRACT SURG—VOL 30, JANUARY 2004
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3. Hwang JM, Chang JH. A relative afferent pupillary de-
fect in the contralateral eye of a unilateral cataract.
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4. Bullock JD. Relative afferent pupillary defect in the “bet-
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Thompson. Ophthalmology 1990; 97:337–338
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