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History and Future Directions of Vision Testing in Head Trauma

Akhand, Omar, BS; Rizzo, John-Ross, MD, MSCI; Rucker, Janet C., MD; Hasanaj, Lisena, MPA; Galetta, Steven L., MD; Balcer, Laura J., MD, MSCE

Section Editor(s): Costello, Fiona MD, FRCP(C); Prasad, Sashank MD

Journal of Neuro-Ophthalmology: March 2019 - Volume 39 - Issue 1 - p 68–81
doi: 10.1097/WNO.0000000000000726
State-of-the-Art Review

Background: Concussion leads to neurophysiologic changes that may result in visual symptoms and changes in ocular motor function. Vision-based testing is used increasingly to improve detection and assess head injury. This review will focus on the historical aspects and emerging data for vision tests, emphasizing rapid automatized naming (RAN) tasks and objective recording techniques, including video-oculography (VOG), as applied to the evaluation of mild traumatic brain injury.

Methods: Searches on PubMed were performed using combinations of the following key words: “concussion,” “mild traumatic brain injury,” “rapid automatized naming,” “King-Devick,” “mobile universal lexicon evaluation system,” “video-oculography,” and “eye-tracking.” Additional information was referenced from web sites of vendors of commercial eye-tracking systems and services.

Results: Tests of rapid number, picture, or symbol naming, termed RAN tasks, have been used in neuropsychological studies since the early 20th century. The visual system contains widely distributed networks that are readily assessed by a variety of functionally distinct RAN tasks. The King-Devick test, a rapid number naming assessment, and several picture-naming tests, such as the Mobile Universal Lexicon Evaluation System (MULES) and the modified Snodgrass and Vanderwart image set, show capacity to identify athletes with concussion. VOG has gained widespread use in eye- and gaze-tracking studies of head trauma from which objective data have shown increased saccadic latencies, saccadic dysmetria, errors in predictive target tracking, and changes in vergence in concussed subjects. Performance impairments on RAN tasks and on tasks recorded with VOG are likely related to ocular motor dysfunction and to changes in cognition, specifically to attention, memory, and executive functioning. As research studies on ocular motor function after concussion have expanded, so too have commercialized eye-tracking systems and assessments. However, these commercial services are still investigational and all vision-based markers of concussion require further validation.

Conclusions: RAN tasks and VOG assessments provide objective measures of ocular motor function. Changes in ocular motor performance after concussion reflect generalized neurophysiologic changes affecting a variety of cognitive processes. Although these tests are increasingly used in head injury assessments, further study is needed to validate them as adjunctive diagnostic aids and assessments of recovery.

Departments of Neurology (OA, JRR, LH, SLG, LJB), Population Health (LJB), Ophthalmology (SLG, LJB), and Physical Medicine and Rehabilitation (JRR), New York University School of Medicine, New York, New York.

Address correspondence to Laura J. Balcer, MD, MSCE, Department of Neurology, New York University School of Medicine, 240 East 38th Street, 20th Floor, New York, NY 10016; E-mail:

L. J. Balcer has received investigator-initiated research grant funding from Biogen. The remaining authors report no conflicts of interest.

© 2019 by North American Neuro-Ophthalmology Society