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Author Notes:

Alexander Papangelou, Email: apapang@emory.edu

Alex Papangelou, Milad Sharifpour and Paul Garcia contributed to study conception and design. Material preparation, data collection and analysis were performed by Tuam Cassim, Haresh Patel and David Boorman. The first draft of the manuscript was written by Alex Papangelou. All authors contributed to editing and approved the final manuscript.

The authors would like to thank Katherine Egan, Renee Atkins and the rest of the research staff in the Department of Anesthesiology at Emory University Hospital. We would also like to acknowledge Paige Santee and Grace Edgarton who collected data in the preoperative clinic as a component of a university research course credit. All of these individuals were instrumental in the data collection process. We would like to thank Neurotrack Technologies, Inc for donating non-surgical VPC data and testing keys, as well as Neuroptics Corp for the loaning of their pupillometers.

Alex Papangelou serves as a consultant to Vistendo, Inc on grants awarded by the Defense Health Agency (DHA).

Alex Papangelou serves as a consultant to Vistendo, Inc on grants awarded by the Defense Health Agency (DHA). The authors otherwise have no relevant financial or non-financial interests to disclose.


Research Funding:

Support was provided solely from institutional and/or departmental sources (Team Based Science Grant). A portion of Dr. Paul Garcia’s research effort is supported by a grant from the James S. McDonnell Foundation (jsmf.org) Grant Number. 220020484. Emory university department of anesthesiology team based science (TBS) grant, James S. McDonnell foundation, 220020484


  • Science & Technology
  • Life Sciences & Biomedicine
  • Anesthesiology
  • Visual paired comparison task
  • Pupillometer
  • Maximum constriction velocity
  • Maximum pupil size
  • Cognitive impairment
  • Preoperative

Associations of an eye-tracking task and pupillary metrics with age and ASA physical status score in a preoperative cohort


Journal Title:



Volume 37, Number 3


, Pages 795-803

Type of Work:

Article | Final Publisher PDF


Advanced age, American Society of Anesthesiologists physical status (ASA) classification and the presence of cognitive impairment are associated with an elevated risk of postoperative morbidity and mortality. The visual paired comparison (VPC) task, which relies on recognition of novel images, examines declarative memory. VPC scores have demonstrated the ability to detect mild cognitive impairment and track progression of neurodegenerative disease. Quantitative pupillometry may have similar value. We evaluate for associations between these variables of interest and the feasibility of performing these tests in the preoperative clinic. Prospective data from 199 patients seen in the preoperative clinic at a tertiary academic center were analyzed. A 5 min VPC task (Neurotrack Technologies, Inc, Redwood City, CA) was administered during their scheduled preoperative clinic visit. Pupillary light reflexes were measured at the same visit (PLR-3000™, Neuroptics Corp, Irvine, California).Thirty-four percent of patients were categorized as ASA 2 and 58% as ASA 3. Median age was 57 (IQR: 44–69). Associations were demonstrated between age and ASA physical status (Mann–Whitney U Test, p < 0.0001), maximum pupil size (Spearman Rank Correlation, r = − 0.40, p < 0.0001), and maximum constriction velocity (Spearman Rank Correlation, r = − 0.39, p < 0.0001). Our data also revealed an association between VPC score and age (Spearman Rank Correlation, p = 0.0016, r = − 0.21) but not ASA score (Kruskal–Wallis Test, p = 0.14). When compared to a nonsurgical cohort with no history of memory impairment, our population scored worse on the VPC task (Mann–Whitney U Test, p = 0.0002). A preoperative 5 min VPC task and pupillometry are feasible tests in the preoperative setting and may provide a valuable window into an individual’s cognition prior to elective surgery.
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