Diagnostic accuracy of objective measures for ocular malingering: A systematic review

Abstract

PURPOSE: To evaluate the diagnostic accuracy of objective tests including Visual Evoked Potentials (VEP), pupillometry, and eye-tracking technologies in detecting ocular malingering among individuals suspected of fabricating visual impairments for secondary gain. METHODS: Following PRISMA guidelines, PubMed, Web of Science, Scopus, EMBASE, and Cochrane Library were searched until June 2025. Studies evaluating objective diagnostic methods for detecting ocular malingering that reported diagnostic accuracy metrics were included. Two reviewers performed data extraction and quality assessment using QUADAS-2. RESULTS: Ten studies from 1993 to 2017 with 20 to 222 subjects were included. Approximately half of the studies employed experimentally simulated malingering paradigms, while the remainder involved clinically suspected cases. VEP was the most frequently evaluated modality and showed high sensitivity across studies, although specificity varied. Pattern-reversal VEPs showed effectiveness in adults and military conscripts, while step VEPs demonstrated 100% specificity in paediatric cases. Pupillometry and specialised colour vision tests achieved 80-94% sensitivity and specificity rates. Most studies showed low bias risk in index test and reference standard domains. These findings suggest potential utility of objective tools as adjuncts in clinical and medico-legal settings. CONCLUSION: Objective diagnostic measures demonstrate promising utility as adjunctive tools for detecting ocular malingering and may support clinical decision making by providing reproducible assessments that bypass voluntary patient control. However, heterogeneity in study designs limits generalisability. Future research should standardise protocols and validate findings across diverse populations.