Adapting the way an eye examination is delivered for neurodivergent patients can help optometrists preserve the reliability of their clinical findings while maintaining established standards of care, said Sophia Capo, OD, FAAO, in her “Accessible by Design: Eye Examination Methodology for Neurodivergent Populations” presentation at the American Academy of Optometry annual meeting. Neurodivergence encompasses naturally occurring variations in neurocognitive functioning and can include overlapping neurodevelopmental conditions, such as autism, ADHD, and intellectual disability, as well as acquired neurodivergence, such as that associated with traumatic brain injury, Dr. Capo explained. An estimated 15% to 20% of the general population may be considered neurodivergent when overlapping neurodevelopmental conditions are considered. Individual prevalence estimates include autism in 1 in 31 8-year-old children in the United States, ADHD in approximately 8% of children and adolescents globally, and intellectual disability in approximately 1% of the population.¹

Dr. Capo explained evidence of increased rates of strabismus, convergence insufficiency, accommodative dysfunction, and reduced stereopsis among neurodivergent populations. For comparison, she said, a 2023 systematic review and meta-analysis found a pooled prevalence of convergence insufficiency of approximately 7.98% in the general population. Meta-analytic evidence also indicates that patients with autism spectrum disorder (ASD) have approximately 4.72 times greater odds of strabismus compared with those without ASD.

These visual differences are accompanied by potential barriers to obtaining reliable clinical measurements, such as sensory sensitivities, communication differences, and executive function demands, that can present barriers to health care encounters for neurodivergent individuals. Dr. Capo outlined a framework of principles to address these challenges:

• Flexibility over rigidity

• Function over form

• Behavior as clinical data

Her goal, she told Optometric Management, is to “empower my optometry colleagues to provide gold standard eye care to individuals of all abilities.”

Flexibility Over Rigidity: Creating an Accessible Examination

Sensory processing differences, communication and motor-planning considerations, anxiety, and previous negative medical experiences can all affect an examination, Dr. Capo said. Environmental and procedural modifications can include reducing noise and overcrowding, minimizing sensory triggers, and adjusting the clinician's communication modality. Reducing a patient’s stress in environments with sensory triggers can improve cooperation and, in turn, measurement reliability, Dr. Capo said.

Function Over Form: Adapting Acuity, Refraction, and Binocular Testing

Visual acuity assessment can be adapted through symbol-based, matching, or preferential-looking methods when conventional letter charts are not feasible, Dr. Capo described. Objective measurements, such as cycloplegic assessment for accurate refractive measurement, particularly when accommodation could mask hyperopia, is supported by pediatric evaluation guidance, she said. This modality may become especially important when limited cooperation reduces opportunities for repeated testing.

Binocular vision and oculomotor assessments may also require modification. Simplified, single-task testing and single-step instructions can reduce the cognitive load that is associated with executive function and processing speed differences.

Dr. Capo cautioned against overinterpreting facility-based and speed-based measures, however. Variability in attention and processing speed can influence a patient’s performance on timed tests and potentially cause results to be misinterpreted as visual deficits when the patient may not have them. Therefore, she suggested, clinicians should document when a particular function cannot be assessed.

Behavior as Clinical Data: Putting Results Into Context

Clinicians can also consider behavioral responses in lieu of relying on subjective reports of a neurodivergent patient’s vision, Dr. Capo continued. Studies of accommodation in patients with ASD have used dynamic retinoscopy and accounted for residual refractive error. Their findings support an approach that combines measurement with observation of visual function, she said.

Management considerations may extend to spectacle prescribing, environmental and visual supports, vision therapy, and interdisciplinary collaboration to further address patient needs. Environmental modifications that reduce sensory overload may also have applications beyond the examination room, including classroom and home environments. In addition to documentation of testing adaptations, communication with patients and caregivers should incorporate clear language and focus on the patient’s strengths.

Conclusion

Adaptations to examinations are not a departure from rigorous optometric testing but are a means of maintaining diagnostic validity when sensory, communication, or executive-function barriers interfere with conventional methods, Dr. Capo said. Remember that maintaining a gold standard in testing does not mean that the same testing approach can or should be used for every patient, and regulating the patient’s stress should also precede refraction when necessary. Optometry is an important point of access for detecting visual differences and providing functional support for neurodivergent patients, Dr. Capo concluded.

Reference

1. Bölte S, Neufeld J, Marschik, PB, Williams ZJ, Gallagher L, Lai M-C. Sex and gender in neurodevelopmental conditions. Nat Rev Neurol. 2023;19(3):136–159. doi:10.1038/s41582-023-00774-6