Being able to serve the population of patients on the autism spectrum is incredibly invaluable. It empowers eyecare professionals, expands your patient base, and shows another aspect of your character to your community. Effectively performing comprehensive eye exams for these patients is our responsibility as optometrists and may require additional care, attention, and approaches. Continue reading for an overview of clinical optometry and autism.
Brief on autism
Autism spectrum disorder (ASD) is a condition involving developmental impairments in behavior, language, and social skills. Approximately 1-2% of the population is affected with a prevalence of 1 in 88 children, and typically symptoms start appearing by age 2.1-2
An array of symptoms affecting communication and behavioral characteristics lead to a diagnosis of ASD, often under the direction of a team of healthcare providers, educators, and professionals.
Considerations with patients on the autism spectrum
Certain developmental challenges and implications are critical factors in ocular and vision assessments.
Important characteristics to take into consideration while performing an eye exam are behavioral variations that may include:
- Gaze aversion
- Abnormal social interaction
- Desire to be left alone
- Repetitive behaviors
- Highly fixated interests
- Resistance to changing routine
Each individual on the spectrum has varying symptoms and faces different challenges. As healthcare physicians we can understand, discover, and respect any boundaries that make patients uncomfortable.
Learning these boundaries will allow us to earn our autistic patients’ trust and solidify the foundational rapport needed for effective evaluations and test results.
Optometric exam guidelines
Although there is a lack of standardization in diagnostic tools to assess visual impairment in the autistic population, here we share in-depth optometric exam guidelines.3
Best attention is required for obtaining accurate findings, for which shaping technique can be used by performing successive reinforcement. This helps the patient become comfortable with a new behavior or procedure. For certain tests, you may utilize distraction techniques to achieve results from more strenuous tests.
To avoid distress, having concrete, concise instructions is beneficial. Even non-verbal support and gestures are effective. Give a thumbs up, nod, and smile!
Download the Autism Spectrum Disorder Optometric Exam Cheat Sheet
Step-wise comprehensive eye exam
When I shadowed a private practice in Atlanta, I came across an incredible idea for providers who see pediatrics as well as special needs populations. They had what I would call a “welcome package” with photos and videos that act as a walkthrough of the practice. These pre-appointment resources will allow your patients to confide in you and feel comfortable in the office space that may be daunting otherwise.
Make the check-in process as seamless as possible. If an online system is not in place for paperwork to be completed, have options in the waiting room that will assist patients with ASD to relax, play, or read with ease. Another consideration is to take a detailed case history in a telehealth appointment prior to the examination, as this can be extensive. Limiting waiting room time can maximize how effectively you can retain attention for important components of the eye exam.
Preliminary testing
Many of the preliminary tests are critical to perform in patients with ASD. If frustration runs high, obtain results from necessary tests first. Matching visual acuities with Lea symbols may be an option and isolating single letters or symbols may avoid confusion.
Consider palpation for IOP that is difficult to achieve with other tests. Hirshberg testings for ocular posture and tracing for color vision tests can be helpful. Most importantly, use interesting targets for testing. Toys or objects that are colorful, move, and have flashing lights work well, along with animated cartoons or videos.
Vision exam
For non-verbal patients or poor responders, retinoscopy is key to sustaining refractive results. For patients who may not be able to stay stationary long, loose lenses may be an option. Get creative for patients who have difficulty concentrating: change the target or put on a video target. If the parent or guardian is available, have them assist to make the patient feel more secure.
Accommodative and binocular deficiencies, along with visual processing delays and oculomotor dysfunctions are more common within this population. Be sure to test these areas or refer for this additional testing when indicated.
Ocular exam
For the ocular health assessment, you may note that intimidating equipment can distress patients. Show the patient how they work on their guardian for reassurance. If bright lights seem provoking, shine a BIO or DO light on the patient’s hand.
Occasionally, it is necessary to split up the full eye exam into parts to avoid overwhelming the child. The subsequent advantage is that this opens a window for building trust and a healthy rapport between you, your staff, the patient and the family.
Tips to consider for patients on the autism spectrum
Patient care is affected by possible social or communication impairments. Some ASD patients may have a behavioral trait of defensiveness to tasks and testing; in this scenario selecting testing options that limit tactile patient interaction may be beneficial. For example, check vergence measures with a prism bar or tropias with Hirshberg.
Equipping your optometry practice for ASD patients
Beyond the exam room, compiling a resource that conveys the office space and staff will lessen tension for a patient with ASD. Whether sent as an email or listed on your practice website, be sure to share this with a patient who may require additional attention.
Among certain specialty equipment, such as a spot screener, that one may need for pediatric eye exams are the simple ways to accommodate patients on the autism spectrum disorder.
Have access to entertaining targets, games, and toys. Videos are great tools for consistent targets that may be needed for refraction measures. Games and matching are significant for monitoring underlying deficits in visual spatial development. And, of course, prizes and stickers are perfect ways to reward patients.
Exam set-up
Educating your staff on best practices and considerations when providing care to ASD patients is imperative. They hold an impactful role in shaping patient confidence.
Firstly, when confirming the appointment, it is worthwhile to ask about any challenges or concerns that the guardian may want to share beforehand. If there is any hesitance, disclose the option of breaking up the exam into multiple appointments if needed.
Once the staff member has a better gauge of where the patient may be on the spectrum or what challenges he or she has, discuss the possibility of extending the exam time slot if focused care may be required.
Empowering your staff
Along with having patience, creativity is key! Share the techniques you’ll be applying in the exam lane, outlined in Figure 1, below.
For the patient chart, be sure to stress the importance of a detailed patient history. For ASD patients, the medical history includes any known milestone delays that affect cognitive and social development. For management purposes, knowing the patient’s healthcare team is advantageous to keep on file as well.
During preliminary testing, if visual acuity becomes touch, determine if it is central, steady, and maintained (CSM). When testing anxiety is noted, try having patients count down with you, ask what cool things they see in the room, or use non-verbal feedback. Lastly, it is okay to skip difficult tests and return to them later.
Autism spectrum disorder and vision findings
Patients with ASD have an increased prevalence of vision impairments such as strabismus, oculomotor deficits, and poor contrast sensitivity.
Certain sensory processing deficits can cause global processing challenges such as slower analysis of motion, poor facial recognition, and delayed speech.4 During our optometric exam, we must take special care in discerning underlying visual perception dysfunctions, whether visual discrimination, figure-foreground, or visual spatial discernment.
ASD and ocular treatments
Patients on the autism spectrum disorder may require specific treatments or therapies based on diagnoses made. In eye care, therapeutic drops may be indicated for ocular use. Discuss tips that help the patient and guardian best prepare to instill them at home.
Based on the functioning of the patient, glasses specifically designed without nose pads may be suggested to withstand wear and tear for the safety of the patient. Other visual correction measures such as contacts may require additional attention or repeat in-office training to build confidence.
Furthermore, vision therapy could be planned for visual processing deficiencies, binocular vision discrepancies, or accommodative dysfunction. Long term goals may be projected to build more effective visual perceptual skills, prioritize eliminating amblyogenic factors, or concentrate on accommodative difficulties.
Certainly, measurable tasks that incorporate a mixture of activities is key for ASD patients. Use motor tasks and engaging games in addition to standardized therapy activities; a balance will keep patients engaged, excited, and challenged.
Takeaways and tips
In conclusion, it is critical to take a step back and consider the environment for patients on the autism spectrum disorder. Additionally, it is important to understand ASD as a diagnosis, the potential associated visual findings and the critical role you will play in the lifelong management of these patients’ health.
Providing an excellent patient experience at your office is important for both patients and their guardians. In fact, something as simple as not wearing a white coat could make a big impact in allowing ASD patients to feel more at ease.
Overall, having ASD patients feel safe and comfortable is of utmost importance, and in turn, it will lead to the best testing outcomes for your clinical exam!
For more tips, don't forget to download the Autism Spectrum Disorder Optometric Exam Cheat Sheet!
References
- Little, J. (2018). Vision in children with autism spectrum disorder: A critical review. Clinical and Experimental Optometry, 101(4), 504-513. doi:10.1111/cxo.12651
- Team THE. Doctors who specialize in autism. Healthline. https://www.healthline.com/health/autism-doctors. Published January 6, 2022. Accessed July 10, 2022.
- Wrzesińska, M., Kapias, J., Nowakowska-Domagała, K., & Kocur, J. (2017). Visual impairment and traits of autism in children. Psychiatria Polska, 51(2), 349-358. doi:10.12740/pp/onlinefirst/61352
- Pellicano E, Gibson LY. Investigating the functional integrity of the dorsal visual pathway in autism and dyslexia. Neuropsychologia 2008; 46: 2593–2596.
