The College of Optometrists

Examining patients with autism

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Sub-sections

Key points

  • If possible, offer the patient the opportunity to attend the practice before their appointment, to help them get used to the surroundings
  • Try and offer the patient an appointment at a quiet time of day when they are least likely to be kept waiting
  • Explain what you are going to do in advance using clear language and give direct instructions as to what you would like the patient to do
  • Allow extra time for the visit.
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This Guidance does not change what you must do under the law. 

What autism is and how it affects patients

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Autism is a lifelong developmental disorder that affects how a person communicates with, and relates, to other people, and how they experience the world around them.52 It affects people in different ways, so you should adapt your routine according to the patient’s needs. It has been suggested that approximately 45% of people with autism also have learning disabilities,53 so for these people you should refer to the section on Examining patients with learning disabilities.

Ocular conditions of patients with autism

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In contrast to many other developmental conditions, people with autism should be expected to have good visual acuity.  If you find reduced visual acuity54 you should investigate it further. Children and young people with autism are more likely to have refractive errors with an astigmatic component,55 strabismus and poor accommodative function.56 You should therefore explore accommodative function when providing eyecare.

Principles of examining patients with autism

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You should ask the patient, or their carer if appropriate, whether  they would like to visit the practice before their appointment, to help them become used to the surroundings and the equipment. If this is not possible, you could provide photographs of the instruments you will use, or allow time at the beginning of the examination for the patient to familiarise themselves with the practice and the room setup. You could also provide a list of the questions you are likely to ask, such as history and symptoms. There is a checklist available to help you see how autism-friendly your practice environment is (refer to COVID-19 guidance).57 
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If relevant, try to speak to the patient’s carer before the appointment to find out what the patient may like or dislike or respond well to.58 
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Reduce the number of staff involved in the patient’s journey. This is because it takes time for a person with autism to become comfortable with a new person.
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Knowing when something will happen is important to a person with autism so, If possible, try and offer the patient an appointment at a quiet time of day and when they are least likely to be kept waiting, for example the first appointment of the day or immediately after lunch. . Tell the patient if you are running late, and be realistic about when they are likely to be seen, so that they can wait outside or come back later.
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Ask direct questions rather than waiting for the patient to volunteer information. Explain why each test is being conducted and what is going to happen before each test, using clear language.  Give direct instructions, such as ‘please put your chin on the chin rest’ rather than asking ‘can you put your chin on the chin rest?’. 
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Allow extra time, and allow the pace of the examination to be partially dictated by the patient.

Adapting your routine

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Some people with autism may not like you within their personal space, so be prepared to adapt your routine accordingly (refer to COVID-19 guidance).
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Some people with autism are very sensitive to light, so tell the patient when you need to shine a light into their eye and make sure they are comfortable with that. Be aware that pen lights may trigger seizures in some people.59
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If you use a trial frame, keep it on for as short a time as possible, as some people with autism find this difficult to cope with.
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Some people with autism may tend to repeat the last thing you say, so adapt your routine to repeat tests in a different order, such as saying ‘clearer second or first’. You may have to ask more than once.
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If a person with autism engages in behaviour to help them deal with stress, such as rocking or flicking their fingers, do not try to stop this behaviour unless it is essential. Regularly reassure the patient.

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