Beyond seizures: eye tracking evidence of cognitive dysfunction in epilepsy - A systematic review

Cognitive dysfunction is a common and disabling feature of epilepsy, affecting attention, memory, executive function, and socioemotional processing. Conventional neuropsychological assessments may lack sensitivity to subtle deficits and are influenced by educational and linguistic factors. Eye tracking provides high-temporal-resolution quantification of oculomotor behavior linked to distributed cognitive networks; however, its relationship to traditional neuropsychological performance in epilepsy has not been systematically synthesized.

This systematic review followed PRISMA 2020 guidelines (PROSPERO CRD42026180147). MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library were searched from inception through June 2025. Studies enrolling adults with epilepsy and reporting eye tracking outcomes related to cognitive function were included. Cognitive domains comprised attention, memory, executive/inhibitory control, and socioemotional processing. Methodological quality was appraised using the Joanna Briggs Institute checklist. Due to heterogeneity in paradigms, devices, and outcome metrics, findings were synthesized narratively.

Ten studies met inclusion criteria, encompassing temporal lobe, frontal, generalized, and drug-resistant epilepsies. Across domains, individuals with epilepsy demonstrated prolonged fixation duration, altered saccadic dynamics, reduced novelty preference, impaired inhibitory control, and atypical emotion-related gaze patterns compared with controls. Eye tracking metrics showed partial convergence with traditional neuropsychological measures but frequently detected abnormalities despite preserved conventional test performance, suggesting complementary sensitivity to implicit or early-stage cognitive dysfunction.

Eye tracking reveals reproducible oculomotor signatures of cognitive network dysfunction in epilepsy. Standardized paradigms and longitudinal designs are essential to determine the mechanistic specificity and predictive value of these measures relative to traditional neuropsychological assessment in epilepsy care.