Published in Primary Care

ADHD in the Optometry Lane: Ocular Manifestations, Common Misdiagnosis, and Exam Guidelines

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4 min read

Learn key factors to keep in mind when caring for the eyecare needs of patients with attention deficit hyperactivity disorder, including taking case history, adjusting exam flow, and educating staff.

ADHD in the Optometry Lane: Ocular Manifestations, Common Misdiagnosis, and Exam Guidelines
According to disability rights activist, Robert Hensel, "There is no greater disability in society than the inability to see a person as more." Although the average optometrist likely sees more patients without Attention Deficit Hyperactivity Disorder (ADHD) than not, it is pivotal that these patients get the best care possible. By making some slight alterations to the common exam flow and keeping in mind a few key metrics, both your patient and you will leave the office that day with a complete and rewarding feeling.

What is ADHD?

Although I understand it is important to fully define what ADHD is, that will require much more than this article allows for so I will focus mostly on the process of going through an eye exam for patients with this condition.
But, to briefly summarize, ADHD is defined as a common mental health disorder that includes a combination of persistent problems, such as difficulty paying attention, hyperactivity, and impulsive behavior.2 It most frequently affects males at an estimated ratio of 4:1.1 Treatment usually consists of a behavioral therapy component coupled with pharmaceuticals, ranging from stimulants (such as amphetamine) to antidepressants (such as bupropion). When left untreated— or with inadequate treatment—ADHD can lead to educational challenges, difficulty with interpersonal relationships, job instability, and consequently low self-esteem.2

Tips for a successful exam

Within the optometry exam, there are certain behaviors exhibited by patients with ADHD that can be helpful to notice, however, they can also make the findings confusing for the clinician. It is important to note that many ocular findings can overlap with other systemic deficits the patient may exhibit (i.e., just because a patient has these symptoms does not necessarily mean they are due to their visual system). It is also important to remember that because most ADHD medications stimulate the sympathetic nervous system, the overactivation of this system can cause certain ocular side effects.

Common ocular findings in patients with ADHD

  • Convergence insufficiency (most common)
  • Saccadic dysfunction
  • Visual perception deficits
  • Refractive error (although literature consistency varies)

Ocular side effects of ADHD medications

  • Decreased accommodative amplitudes
  • Dilated pupils
  • Nystagmus
  • Blur

Case history considerations with ADHD

When it comes to the case history, some patients with ADHD can have trouble verbalizing (or sometimes even noticing) their symptoms, so it becomes crucial that the right questions are asked. For example, they may not know if they have blurry vision because they have never seen clearly before, so asking if they have blur could give us little information about their vision.
Below are common case history questions that can help give you valuable information about the patient’s visual system.

High value questions to ask in patient/parent with ADHD

  • Do they run into things or appear excessively clumsy?
  • Do they often lose their place when they read?
  • Do they rub their eyes often?
  • Do they “tic” with strong blinks or eye rolling?
  • Do they have a hard time concentrating on a task when extraneous stimuli are present?
As I mentioned before, many of these symptoms can overlap with other systemic deficits associated with ADHD; however, our job is to maximize their vision potential. This becomes especially important as ADHD can be commonly misdiagnosed when in reality, the patient is suffering from a vision problem. Difficulty focusing, re-reading lines, and poor comprehension can all be a result of a vision problem, making it all the important to rule these out before giving a diagnosis of ADHD.

Tips for creating a comfortable environment for the ADHD patient

When it comes to tips and tricks to make the exam easier and more reliable, most of the same tests can be performed. The key here is to make the correct accommodations to the environment, and this starts before the patient even steps foot in the office with educating staff and enhancing the environment.

Prepare the patient and inform staff

When the family or patient calls to make their appointment, ask if they are able to bring any toys or items that give the patient a sense of comfort (i.e., a blanket, favorite toy car, etc.) Highlight this patient on the schedule and remind your staff of this patient’s appointment. Patients with ADHD can be remarkably aware of their surroundings so ensuring they are comfortable with the initial encounter at the front desk is important.

Carry out the exam from start to finish

When it comes to pre-testing, I recommend doing the entire exam yourself (as the doctor) instead of having a technician perform them. Creating a rapport and showing that this is a safe environment can be built by keeping the same person doing the entire exam.

Create a visually soothing environment

For the exam room itself: keep the lights dim and be very “smooth” with all of your tests. Lots of overhead brightness and erratic movements can be signs to the patient that this may not be a safe environment.

Prioritize gentle communication

Talk softly and give calming sound effects (i.e., a“whoosh” when shining a transilluminator in their eye).

Involve parents while treating pediatric patients

If the patient is young enough, it can help to have the child sit in their parent’s lap or hold their hand for the duration of the exam.

Adhere to appropriate treatment plans

And finally, when it comes to prognosis/treatment, follow every process you would for a neurotypical individual. Correct the refractive error, prescribe medications when needed, and recommend vision therapy when appropriate. When it comes to the refraction, it can be helpful to make large jumps between options to ease any anxiety associated with small changes For binocular testing, a CISS survey along with a quick NPC and cover test can help narrow in on vision therapy candidates for CI patients.

In closing

It is important to note that although this patient may not leave your office with a crisp 20/20 or a renewed sense of top-notch visual perception skills, maximizing every area of their vision to the degree that their potential allows is critical.
  1. Sex and age differences in Attention-Deficit/Hyperactivity Disorder symptoms and diagnoses: Implications for DSM-V and ICD-11. NIH.
  2. What is ADHD? American Psychiatric Association.
Steven Hoffman, OD
About Steven Hoffman, OD

Dr. Steven Hoffman is board-certified Optometrist currently practicing in Los Angeles, CA. Dr. Hoffman attended the Southern California College of Optometry before continuing on to complete his Pediatric Optometry and Vision Rehabilitation Residency at the same institution. In his free time, Dr. Hoffman aims to spread awareness about eye health and recommended eyecare products through his YouTube channel and Instagram (@steven.hoffman___). He is passionate about serving the underprivileged and low-income communities where comprehensive eyecare is needed.

Steven Hoffman, OD
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