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Beyond qualitative appraisal, however, there are many more parameters of eye movements, such as their velocity, accuracy, and error rate, which can be easily measured with the right machines and may provide valuable diagnostic and prognostic information that is not currently considered by physicians during clinical workup. An acute care physician may look at opening or closing of the eyes in response to stimuli, pupil response to light, blink reflex, or the direction of spontaneous movement as part of clinical workup depending on the level of consciousness of the patient. Traditionally, eye assessment in DOC has been limited to simple assessment of eye response. There are estimates of up to 40% misdiagnosis rate between VS and MCS ( 8). A clinically standardized tool in the form of an eye movement measurement device, easily accessible and interpretable by all staff involved in the DOC patientвЂ™s care would help to supplement patient care. However, it is difficult to make accurate decisions, partly due to the limited responsiveness and arousal of the patients, and partly due to the specialized training necessary to conduct a thorough neurological exam, and interpret neuroimaging and electrophysiology. The diagnosis from this assessment then dictates the clinical treatment plan and patient prognosis. Research has shown that neurophysiological monitoring may also be useful ( 7). The clinical gold standard for diagnosis of DOC is bedside behavioral assessment, in-hospital observation, and specialized robust scales such as the Coma Recovery Scale-Revised (CRS-R) ( 5), and neurocognitive assessment in advanced stages of recovery ( 6). Quantifying this neurological damage may be useful and requires more than the simple qualitative appraisals of eye, sensory, and motor function. If this is a reliable and accurate model, damage which significantly reduces consciousness will likely affect the brain areas necessary for successful eye movement. Categorization of DOC has been repeatedly invaluable from a clinical perspective to make practical decisions about life support, palliative care, and/or treatment plan, but theory suggests that self-referential states such as consciousness are produced by coordinated diffuse network activations integrating multiple sets of different nuclei in the brain ( 4). Each category of DOC is associated with its own clinical course and prognosis. Locked-in syndrome, minimally conscious state (MCS), vegetative state (VS), and coma are four major classifications ( 3). From both perspectives, it is important to have effective tools to make the best clinical decisions.Дisorders of consciousness are divided into several domains. Furthermore, caregivers for DOC patients experience a higher level of anxiety, depression, and maladaptive psychological states compared with control participants and with themselves at the beginning of their caregiving period ( 1, 2). There are little means by which a clinician can assess and prognose clinical course in severe cases of disorders of consciousness (DOC), limiting effective care of patients. We see the emergence of long-term eye-tracking studies with seamless integration of technology in the future to improve the performance of clinical assessment in DOC. We posit that eye tracking can improve clinical diagnostic precision for DOC, a key component of assessment that often dictates the course of clinical care in DOC patients. The close relationship between eye movement generation and organic dysfunction in the brain allows these tools to be applied to the assessment of severe DOC as a unique supplementary toolset. New tools have become available at cliniciansвЂ™ disposal to assess eye movements with high spatial and temporal fidelity.

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We will focus on the effectiveness of each technique in the diagnostic classification of these patients and the gradual trend in research from manual to computerized tracking methods. We review the literature to appraise the evidence supporting or disputing the use of eye movement measurement in disorders of consciousness (DOC) with low levels of arousal or awareness, such as minimally conscious state (MCS), vegetative state (VS), and coma for diagnostic and prognostic purposes.

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