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Eye Tracking as a Biomarker for Concussion in Children

Bin Zahid, Abdullah MD*,†,‡; Hubbard, Molly E. MD*,†; Lockyer, Julia MS§; Podolak, Olivia MD§; Dammavalam, Vikalpa M. BS*,†,‡; Grady, Matthew MD§,¶; Nance, Michael MD§; Scheiman, Mitchell OD, PhD; Samadani, Uzma MD, PhD*,†,‡; Master, Christina L. MD§,¶

doi: 10.1097/JSM.0000000000000639
Original Research: PDF Only

Objective: Concussion is the most common type of brain injury in both pediatric and adult populations and can potentially result in persistent postconcussion symptoms. Objective assessment of physiologic “mild” traumatic brain injury in concussion patients remains challenging. This study evaluates an automated eye-tracking algorithm as a biomarker for concussion as defined by its symptoms and the clinical signs of convergence insufficiency and accommodation dysfunction in a pediatric population.

Design: Cross-sectional case–control study.

Setting: Primary care.

Patients: Concussed children (N = 56; mean age = 13 years), evaluated at a mean of 22-week post-injury, compared with 83 uninjured controls.

Independent Variables: Metrics comparing velocity and conjugacy of eye movements over time were obtained and were compared with the correlation between Acute Concussion Evaluation (ACE) scores, convergence, and accommodation dysfunction.

Main Outcome Measures: Subjects' eye movements recorded with an automated eye tracker while they watched a 220-second cartoon film clip played continuously while moving within an aperture.

Results: Twelve eye-tracking metrics were significantly different between concussed and nonconcussed children. A model to classify concussion as diagnosed by its symptoms assessed using the ACE achieved an area under the curve (AUC) = 0.854 (71.9% sensitivity, 84.4% specificity, a cross-validated AUC = 0.789). An eye-tracking model built to identify near point of convergence (NPC) disability achieved 95.8% specificity and 57.1% sensitivity for an AUC = 0.810. Reduced binocular amplitude of accommodation had a Spearman correlation of 0.752(P value <0.001) with NPC.

Conclusion: Eye tracking correlated with concussion symptoms and detected convergence and accommodative abnormalities associated with concussion in the pediatric population. It demonstrates utility as a rapid, objective, noninvasive aid in the diagnosis of concussion.

*Department of Surgery, Hennepin County Medical Center, Minneapolis, Minnesota;

Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota;

Surgical Services, Minneapolis VA Health Care System, Minneapolis, Minnesota;

§Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;

Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and

Pennsylvania College of Optometry at Salus University, Pennsylvania.

Corresponding Author: Uzma Samadani, MD, PhD, 701 Park Ave S PL. 610, Minneapolis, MN 55415 (

Supported by departmental funding to the principal investigators (U.S. and C.L.M.) at their respective institutions.

Portions of this work were presented in abstract form at a Sports Medicine meeting in June 2016.

A.B. Zahid and U. Samadani have submitted intellectual property related to the technology used in this article. These patents are owned by New York University (NYU), the Department of Veteran Affairs (VA), and Hennepin County Medical Center (HCMC) and licensed to Oculogica Inc, a company in which U. Samadani, NYU, the VA, and HCMC all have an equity interest. U. Samadani also has grant funding from and has served as an advisor for Abbott Diagnostic Laboratories. U. Samadani and M.E. Hubbard also have grant funding from Integra Inc. The remaining authors report no conflicts of interest.

Received September 27, 2017

Accepted May 30, 2018

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