Seeing the Whole Picture: Accessible Eye Care for Neurodivergent Patients

Neurodivergence – including autism spectrum disorder, attention-deficit/hyperactivity disorder, and Tourette syndrome – is increasingly recognised, affecting around 20% of the population to various extents.¹ Autism alone is now estimated to affect around one in 40 Australians, a figure that has risen over the years as diagnostic criteria have evolved and clinicians have become better at recognising autism in women and girls, who were long overlooked by diagnostic tools developed around male presentations. 

Having readily available modifications, which do not alter the validity of testing, makes eye examinations more accessible for this population. It also makes results more clinically meaningful, because confounding factors – anxiety, sensory overload, miscommunication – have been removed from the equation. 

Barriers exist across the entire patient journey – booking, arriving, waiting, the examination itself, choosing frames, understanding information, and managing costs – and most of them are modifiable. 

A Double Disadvantage 

According to researchers from Autism Spectrum Australia (Aspect), autistic people tend to experience more vision problems than the general population, yet often struggle harder to have their needs met, because the services they need to access are themselves inaccessible. It is, as Aspect’s autism-friendly lead Dr Tom Tutton explained at Optometry Australia’s recent Optometry Clinical Conference, “a sort of double disadvantage” – and something as small as having to make a phone call to book an appointment can be enough to delay someone from seeking the help they need. 

That point was borne out in two recent studies led by Aspect researcher Dr Chris Edwards, in collaboration with optometrists, ophthalmologists, and other researchers. The first, a survey of autistic adults and parents of autistic children and adults across Australia and New Zealand, found sensory sensitivity and anxiety or stress sat at the top of the barrier list for both groups.² Autistic adults also cited the pressure of making quick decisions – such as choosing frames – and the financial cost of glasses or specialist follow-up. Parents pointed to difficulty helping their child understand instructions, fear or distress around eye drops, and simply communicating with staff. 

Open-text responses added further insights. Participants described three broad themes: the interpersonal side of care – whether staff explained what was happening, whether the patient felt rushed, whether the clinician seemed to understand autism; the sensory and environmental load of the appointment itself, from bright lights and noise to crowded waiting rooms and unfamiliar proximity to a stranger in a small, dark room; and the financial barrier that follows the test – even an accessible eye examination is of limited use if a patient cannot afford the glasses, lenses or specialist care it leads to. 

A second study, surveying almost 200 eye care professionals (mostly optometrists, with an average of 19 years’ experience), found clinicians scored highly on general autism knowledge but that this knowledge did not reliably translate into confidence supporting autistic patients in the consulting room.³ The strongest predictor of that confidence – or self-efficacy – was simply how often a clinician worked with patients with autism, suggesting most practitioners are left to learn largely through on-the-job trial and error. 

Clinicians reported their own barriers too: difficulty adapting instructions or supporting non-verbal patients, limited time within a standard appointment structure to explain the assessments properly or offer breaks, and uncertainty interpreting behaviour that may look like ‘challenging behaviour’ but is, in fact, distress, overwhelm or sensory overload. The strategies clinicians already found most useful were consistent with what patients said they wanted: clear, calm, jargon-free explanations; an adapted sensory environment; and actively seeking a patient’s consent before touching them or proceeding with a test. 

Together, the two studies suggest the same conclusion: accessibility is not only about equipment or specialist knowledge. Barriers exist across the entire patient journey – booking, arriving, waiting, the examination itself, choosing frames, understanding information, and managing costs – and most of them are modifiable. 

Before the Patient Arrives 

Accessibility starts well before a patient reaches the consulting room. For many autistic people, uncertainty about where they are going, who they will meet, what will happen, and what it might feel like can be a significant barrier to attending healthcare. Providing information and choices before the appointment can reduce some of that uncertainty and give patients time to prepare in the way that works for them. 

This does not need to involve an elaborate accessibility program. A few practical changes to booking and pre-appointment communication can make a substantial difference. 

Signal that accommodations are welcome. Patients should not have to guess whether it is acceptable to ask for something different. A statement on the website or booking form such as “Please tell us if there is anything we can do to make your eye examination more comfortable or accessible” gives explicit permission to ask. Practices may also choose to display recognised hidden-disability signage or explain that staff have undertaken autism or neurodiversity training. 

Offer more than one way to book. Telephone calls can be a significant barrier for some autistic people. Where possible, offer online booking alongside telephone booking, and consider email or text-based communication for appointment queries. 

Send a digital reminder. A text or email reminder can support planning and reduce the executive-function demand of keeping track of an appointment. Where possible, include practical information such as the appointment time, location, parking or public transport information and what the patient should bring. 

Ask about accommodations before the appointment. Include a simple question on the booking or intake form such as: “Is there anything we can do to make your visit easier?” You might prompt for sensory needs, communication preferences, difficulty with touch or bright lights, preferred ways of receiving instructions, or anything that is likely to cause distress. Avoid assuming that every autistic patient will want the same adjustments. 

Give patients a way to tell you what helps. Some people will have very specific preferences: they may need extra processing time, prefer written rather than verbal information, find unexpected touch difficult, need to know before lights are dimmed or brightened, or want a support person to answer some questions. Recording this information means the patient does not have to explain it repeatedly to different staff. 

Offer a short pre-visit when it would help. Sometimes called a ‘meet and see’, this can be particularly useful for children or patients who find unfamiliar environments difficult. They can enter the practice without the expectation of completing an examination, see the waiting and consulting rooms, meet a staff member and, if appropriate, look at or handle some of the equipment. Even allowing additional familiarisation time immediately before an appointment may help. 

Offer quieter appointment times where possible. Some patients will find being in the practice considerably easier to manage when there are fewer people, less conversation, and less general activity. Staff can identify typically quieter sessions and offer these as an option. 

Make the unfamiliar more familiar before the patient arrives. Have photographs of the practice available on your website, or create a short ‘What to expect at your appointment’ practice guide that can be viewed online or sent when an appointment is booked. It does not need to be complicated. Include photographs of: 

• The outside of the building and entrance,
• Reception and the waiting area,
• The consulting room,
• The optometrist and other staff the patient may meet, 
• Commonly used equipment, and
• Any particularly unfamiliar parts of the examination. 

Accompany the photographs with a simple step-by-step explanation: arrive at reception → wait → meet the optometrist → go into the consulting room → have your eyes checked → choose glasses if needed → go home. 

For children, consider providing a social story or picture book before the appointment. A resource such as my Going to the optometrist book [written by the author, pictured above] can introduce the visit in child-friendly language and pictures. It can show the child what the waiting room might look like, who they may see, and some of the things that may happen during the eye examination. Families can read it several times beforehand rather than introducing all of this information for the first time on the day. 

Be specific about anything unusual. If the appointment may involve dilating drops, retinal photography, an eye-pressure measurement or another procedure that could involve an unfamiliar sensation, tell the patient beforehand where practical. Explain what will happen, approximately how long it takes and what they may see, hear or feel. Knowing what is coming can be much easier than coping with a surprise. 

The aim is not to eliminate every unknown or create a completely predictable appointment. Eye examinations sometimes change depending on what is found. Instead, give the patient as much useful information as you reasonably can, minimise avoidable surprises, and make it clear that they can tell you what they need. 

For someone who has previously found healthcare overwhelming, simply being able to see the room, recognise the person they are going to meet, and understand the basic sequence of the appointment can make walking through the door considerably easier. 

Create a Comfortable Environment 

This population generally prefers a reduced sensory environment. Set patients up for success by taking the following steps: 

• Lower room lights and check they don’t flicker. 
• Minimise background noise by switching off instrumentation you aren’t using and turning down or off any background music. 
• Reduce visual clutter by turning off screens until you need them. 
• Use a quieter side room, where available, for parts of the process that don’t require your main equipment – such as frame styling. 
• Minimise waiting time wherever possible. If a wait is unavoidable, be clear about how long it will be, and consider having something on hand to fill the time, such as a colouring book or fidget toy, since it is often not the wait itself but its unpredictability that causes distress.
• Explicitly give patients permission to use their own coping strategies – noise-cancelling headphones, fidget tools, or stepping out for a moment – rather than waiting for them to ask. 
• Limit the number of different staff a patient has to interact with during a visit, so they aren’t repeatedly navigating new introductions and small talk. 
• Warn the patient when their sensory environment is about to change. “I’llturn on the lights now… I’m going to shine this light in your eyes. It’s bright, but I’ll be quick” gives advance notice when a sensation is going to be strong. Give them a moment to process the information before moving on, especially for an unusual experience, such as doubling for phoria with a prism. 

Communicate Well 

Communication differences can be minimal or vast, and around half of autistic people find speech difficult in at least some situations, so it pays to build flexibility into how you communicate from the outset. 

• Introduce yourself clearly and calmly, and explain what you’re about to do before you do it. Showing, e.g., “come and have a look at this”, or demonstrating on yourself first is often more effective than describing. 
• Take a moment to build rapport. Autistic patients, particularly children, often wear an interest openly on a t-shirt or bag; noticing and asking about it can make the rest of the appointment considerably easier. 
• Avoid medical jargon. 
• Favour closed questions with a yes/no or clearly defined answer over open or ambiguous ones. When comparing lenses, patients can find “which is clearer, one or two?” genuinely distressing if the two options look almost identical; the uncertainty about whether they might choose ‘wrong’ can trigger real anxiety. Reassure patients explicitly that there is no wrong answer, and thatit’s fine to say the two look the same. 
• Ask for consent before touching a patient, and narratewhat’s about to happen and how it will feel: “I’m going to need to get quite close; is that okay? Now I’m going to do this; it’s a puff of air, it might feel a bit strange. Let me know when you’re ready.” Small as it sounds, this hands back a measure of control in a situation where patients otherwise have very little. 
• Let patients know upfront that they’re allowed to ask for a break at any point if things become too much, rather than waiting for them to work up the courage to ask. 
• Offer a genuine choice between two fixed options to help a hesitant patient get started: “would you like to sit in the big chair, or sit with mum?” 

Modify Tests  

Visual acuity. Visual acuity can be easily measured by matching letters or shapes. Establish rapport by testing both eyes open briefly, then encourage the child to have each eye occluded. Offer a choice of a parent’s hand, sticky patch or pirate patch. Those with sensory issues will appreciate the choice. Remember to record if you are using a single letter vs a crowded optotype.  

Refraction. Use your retinoscope and confirm with a trial frame in free space. With practice, this is usually faster than using a phoropter, and your equipment is less at risk of fingerprints. 

Phorias. These are easily measured with a red plate. If you are using a phoria card, ask the patient to touch the card once you’ve taken the prism away. If they touch the number line, they’ve generally understood the task; if they touch the arrow, try again. They can also touch the distance phoria card if they can reach it easily. Try saying “go across and show me where the arrow pointed”. 

Accommodation. Near retinoscopy is the fastest measure of the degree and posture of the accommodative system. Use an interesting target under your retinoscope to hold fixation and engagement. 

Fusional reserves. In free space with a prism bar, most patients will be able to tell you when the shape you’re holding turns into two shapes. 

Motilities and near point of convergence. Stickers are the best tool for younger children. Have the child choose one and ask them to follow it with their eyes “so they can take it home”. For anyone too old for stickers, targets that you would ordinarily use for accommodation work well. 

Stereoacuity. Many patients prefer a larger personal space and so prefer to hold red/green or polarised glasses themselves rather than have them fitted. They will generally accept putting on glasses that are handed to them. Use the Randot butterfly test, as patients will often reach for the butterfly the moment they see it. 

Creating accessible eye examinations doesn’t require many adjustments, but it can make a significant difference to the ease of the appointment, for patient and practitioner alike.

Adults Too 

While this battery of testing is most commonly used with children, it is equally useful with adults.^4,5 There is significant literature around reduced accommodative function in this population, so a supportive near lens is often useful, and can prove more subjectively valuable than objective testing alone would suggest. 

Creating accessible eye examinations doesn’t require many adjustments, but it can make a significant difference to the ease of the appointment, for patient and practitioner alike. The evidence from both patients and practitioners points the same way: accessibility is shaped by the whole experience – how a patient books and prepares, how they’re welcomed, how the environment feels, how clearly things are explained, and whether they can afford to act on the outcome. Simplifying instructions, reducing the sensory load and adjusting communication to match the patient are practical, low-cost ways to allow a meaningful examination to take place, and to get the best possible results. 

Aspect has produced a free, practice-ready resource summarising its top recommendations, available at aspect.org.au,6 with a more detailed version published in Optometry Australia’s Clinical and Experimental Optometry.⁷  

Naima Bammann B Optom AAVC (The Eye Fairy) is a behavioural optometrist with Eyes & Vision in Adelaide. 

 References

1. Diversity Council Australia. Neurodiversity at work. Available at dca.org.au/research/neurodiversity-data-at-work [accessed Aug 2026].
2. Edwards C, Love AM, Gibbs V, et al. Understanding eye care access for autistic adults and families: A convergent mixed-methods study. Autism. 2026 Jan;30(1):122-133.doi: 10.1177/13623613251371509. 
3. Edwards C, LoveAMA,  ParmarK, et al. Autism in eye care: A mixed-methods study of professional knowledge, confidence and clinical experience. Ophthalmic Physiol Opt. 2025; 45: 2116–2128. doi: 10.1111/opo.70029. 
4. López-Hernández AE, Miquel-López C, García-Medina JJ, García-Ayuso D. Attention-deficit/hyperactivity disorder (ADHD) is associated with near heterophoria and accommodative dysfunction. Vision Res. 2025Dec;237:108699.doi: 10.1016/j.visres.2025.108699. 
5. Redondo B, Vera J, Jiménez R, et al. Attention-deficit/hyperactivity disorder childrenexhibitan impaired accommodative response. Graefes Arch Clin Exp Ophthalmol. 2018 May;256(5):1023-1030. doi: 10.1007/s00417-018-3948-2. 
6. Autism Spectrum Australia (Aspect). Autism-friendly eye care: practitionerwebinarand research briefing, 2026. Available at autismspectrum.org.au. 
7. Edwards C, Love AMA, Cai RY, Constable PA, Love DC, Parmar K, Gowen E, Doherty M, Gibbs V. Improving eye care access for autistic people: applying the autistic SPACE framework. Clin ExpOptom. 2026 Jul;109(5):1089-1092.doi: 10.1080/08164622.2025.2606937.