The Craig Hospital Eye Evaluation Rating Scale (CHEERS)

Background Oculomotor deficits in smooth pursuit, saccades, vestibular–ocular reflex (VOR), vergence, and fixation are common problems seen after moderate to severe traumatic brain injury (TBI). No scale currently exists to rate all of these together. The Craig Hospital Eye Evaluation Rating Scale (CHEERS) was designed to systematically quantify frequency and severity of eye movement deficits in TBI. Objective To assess the intra‐ and interrater reliability of a new rating scale for detecting the presence and degree of 5 oculomotor abnormalities after TBI. Design A reliability study. Setting This was an institution‐based study at Craig Rehabilitation Hospital. Participants English‐speaking patients between ages 18 and 65 years with a primary diagnosis of moderate to severe mechanical TBI and who were not blind in either eye were eligible. Methods Between October 2013 and March 2014, a total of 11 TBI patients and 9 non‐TBI controls were enrolled in the study. The median age was 30 years (range, 18‐74 years) for subjects and 52 years (range, 28‐63 years) for controls. All patients were male, and 8 of 9 controls were female. Eye movements (fixation, smooth pursuit, saccade, convergence, and vestibular–ocular reflex) were recorded for each on digital video. They were rated on 2 separate occasions by each of the 2 raters. Main Outcome Measurements Inter‐ and intrarater reliability tests. Results Median elapsed time between the first and second ratings was 7 days (range, 5‐44 days). Intrarater agreement was very strong (Spearman ρ ≥ 0.900) for pursuit, saccades, and VOR for both raters, and strong (Spearman ρ ≥ 0.710) for vergence and fixation. The interrater agreement for detecting presence of any oculomotor abnormality was substantial (unweighted κ = 0.63). The interrater concordance on the full range of scale scoring was strongest on the VOR test (weighted κ = 0.98), was substantial for vergence, pursuit, saccades, and total score (weighted κ > 0.60), and was moderate for fixation. For TBI patients, every eye movement rated was found to be more abnormal than compared to those in the controls. Conclusions CHEERS is a reliable scale for assessing and quantifying oculomotor deficits commonly observed in moderate to severe TBI. Further studies to validate the scale's utility in outcome prediction, and its applicability to broader brain injury populations, are warranted. Level of Evidence IV