Clinically accessible eye-tracking in thyroid-associated ophthalmopathy: exploratory classification modeling and gaze...

Thyroid-associated ophthalmopathy (TAO) is an autoimmune orbital disease that may cause ocular motility abnormalities, altered periocular appearance, and psychosocial burden. However, clinically practical tools for early recognition and objective functional assessment remain limited. This study aimed to evaluate whether clinically accessible eye-tracking could support auxiliary classification of thyroid-associated ophthalmopathy and characterize visual attention patterns toward disease-related periocular images.

In this cross-sectional study, 229 adults from a tertiary ophthalmology center were enrolled, including 181 patients with TAO and 48 healthy controls. Eye movements were recorded using a clinically accessible eye-tracking system during fixation, smooth pursuit with nine-grid spatial analysis, and image-viewing tasks. Random forest models were developed using nine-grid smooth-pursuit gaze-distribution features. A primary model included eye-tracking features plus age and sex, while a secondary model assessed eye-tracking features after demographic adjustment. Group differences in gaze metrics and region-of-interest allocation were analyzed using regression-based methods.

Fixation stability did not differ significantly between groups, but patients with TAO showed increased gaze dispersion. In smooth pursuit, the primary model achieved an AUC of 0.903, and the secondary model achieved an AUC of 0.778. In image-viewing tasks, gaze allocation differed between groups: compared with controls, patients with TAO paid less attention to more obvious pathological periocular features in earlier-stage images and more attention to near-recovery appearances in later-stage images. Distinct viewing patterns were also observed across preoperative and postoperative images from different surgical categories.

Clinically accessible eye-tracking may provide behavioral markers for auxiliary TAO classification and reveal altered visual attention to TAO-related periocular appearance. Further validation in larger, independent cohorts is needed.

ClinicalTrials.gov, NCT07381413. Prospectively registered.