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INO and cognitive decline are common in people with multiple sclerosis (PwMS). We assessed the impact of INO on visual versus non-visual cognitive tests in PwMS.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      PwMS (\n                      <jats:italic>n<\/jats:italic>\n                      =197) completed auditory and visual neuropsychological tests, and demographically corrected\n                      <jats:italic>Z<\/jats:italic>\n                      -scores were obtained. INO was quantified using the DEMoNS infrared oculography protocol, applying the versional dysconjugacy index (VDI) of area under the saccadic trajectory (AUC) and peak velocity amplitude ratio (pV\/Am). A subset (\n                      <jats:italic>n<\/jats:italic>\n                      =102) was reassessed after 6 years. Regression models were adjusted for disease duration, disability, cortical grey matter, and thalamic volume.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      The presence of (mild) INO alone (\n                      <jats:italic>n<\/jats:italic>\n                      =66, 34%) was not associated with visual cognitive test performance after adjusting for disease characteristics. However, more severe right-sided INO on leftward gaze was associated with poorer performance on the Symbol Digit Modalities Test (SDMT) and Concept Shifting Test (CST): 0.1 increase in leftward VDI-pV\/Am corresponded to SDMT and CST\n                      <jats:italic>Z<\/jats:italic>\n                      -score reductions of \u22120.08 (95% CI \u22120.13 to \u22120.03) and \u22120.14 (95% CI \u22120.22 to \u22120.07), respectively. This effect was not observed for the Paced Auditory Serial Addition Test (PASAT). Longitudinally, new right-sided INO (\n                      <jats:italic>n<\/jats:italic>\n                      =2) corresponded with CST performance decline (\n                      <jats:italic>Z<\/jats:italic>\n                      -score \u22123.96, 95% CI \u22125.88 to \u22122.05), but not after adjustment for disease characteristics.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Severe right-sided INO impairs performance on cognitive tests requiring rapid eye movements (e.g. SDMT, CST), independent of cognitive ability. These tests should be interpreted with caution in people with severe INO.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00415-026-13905-y","type":"journal-article","created":{"date-parts":[[2026,6,2]],"date-time":"2026-06-02T14:33:03Z","timestamp":1780410783000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["What if it is the eyes? The effect of eye movement disorders on cognitive testing in MS"],"prefix":"10.1007","volume":"273","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0453-6449","authenticated-orcid":false,"given":"S. N.","family":"Hof","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"E.","family":"Keytsman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"T. A. 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Hof: nothing to disclose. E. Keytsman: nothing to disclose. T.A. Fuchs received research support from the European Committee for Treatment and Research in Multiple Sclerosis, serves on the editorial board of Frontiers in Neurology, and received consulting fees for Click Therapeutics and Registry Multiple Sclerosis (ReMuS). M.H.J. Wessels: nothing to disclose. D. de Jong nothing to disclose. E.M.M. Strijbis: serves on the editorial board of Neurology and reports speaker fees from Merck and Novartis. M. Schoonheim: serves on the editorial board of Neurology, Multiple Sclerosis Journal and Frontiers in Neurology, receives research support from the Dutch MS Research Foundation, Eurostars-EUREKA, ARSEP, Amsterdam Neuroscience, MAGNIMS and has served as a consultant for or received research support from Atara Biotherapeutics, Biogen, Celgene\/Bristol Meyers Squibb, EIP, Sanofi, MedDay and Merck. L.J. van Rijn: nothing to disclose. A. Petzold: reports Royalties\/licenses for a chapter on INO from Up-to-Date. B.M.J. Uitdehaag: reports consultancy fees from Immunic Therapeutics. J. van Schependom: nothing to disclose. B.W. van Oosten: nothing to disclose.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflicts of interest"}},{"value":"The study was approved by the Medical Ethical Committee on Human Research of the Amsterdam UMC (study number 2015.227), in accordance with the tenets of the Declaration of Helsinki.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical approval"}},{"value":"Informed consent was obtained from all individual participants included in the study.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent to participate"}}],"article-number":"355"}}