I have been thinking a lot about autism spectrum disorder (ASD) after meeting a lovely 4 year old on the spectrum.  As mentioned previously, I’m working one day a week in practice, surrounded by a fantastic team, and they tend to save the best patients for me.

A couple of weeks ago, I saw a young boy, H, who came in with his mum, dad and brother for his first eye test.  His mum was concerned because H said he wasn’t seeing well in the distance and there was also a family history of strabismus.  When H was booked in, a note was made in the diary that he had ASD and sensory issues.  The appointment was in the middle of the afternoon, at that time when, if one or two people show up late, my clinic starts running behind.

I looked at the diary and spoke to the optical consultants about my plan for the day.  Basically, I wanted H seen as soon as he came in, I didn’t want to keep him or his family waiting in a busy, bright area, especially since I had no idea the nature or strength of his sensory issues.

As the day progressed, everything seemed to be running smoothly.  The patient immediately before H turned up quite early and everything was going well.  I’d said to the OCs that they could try and do a photo for H if he was willing but, otherwise, no pre-screening was necessary.

H quite liked getting the fundus photo taken and wasn’t put off at all by the flashes of light.  In general, he seemed a little nervous and a bit shy, like most children arriving for their first eye examination.  He was doing the “hiding behind mum” thing that young children tend to do when they are unsure of a situation.

We went into the test room and he got up on the chair.  I moved the chair up a bit until he could see the mirror and, again, he seemed fine, if a little apprehensive.  His mum was sitting under the mirror, on hand in case he needed her.

Everything started quite well.  We chatted about his t-shirt (which had Spiderman on it, his favourite superhero) and talked about his vision.  History and symptoms was going fine but H was so shy that day, he was looking down and talking into his chest.  I couldn’t make out what he was saying so I asked him if he could speak up, as I couldn’t hear him over the noise of the air conditioning in the room.  That was a big mistake.

I had drawn H’s attention to the air con.  Suddenly, he was very aware of it. “I don’t want it!” he threw his hands up to his face and his mum rushed forward.  He just wanted to be out of the room at that point.  We all went out to the waiting area which was quiet, except for my previous patient looking at glasses.

H sat down with his parents and brother.  It took a few minutes for him to recover from that bit of sensory overload but he seemed quite happy to be outside the test room, surrounded by his family.  H refused to go back in so I just picked up my pen torch, occluder, ret and budgie stick and knelt down on the floor of the waiting room and did as much of the eye test as H felt comfortable with.

His eyes were straight, motility was full and smooth (and a bit giggly) and ret showed what might be a small plus Rx.  Of course, I wasn’t able to get vision and he refused to let me have a look at his eyes with the ophthalmoscope.  His fundus photo looked the picture of health but I still needed to check the peripheral retina.

After a chat, we decided to book H in for another appointment in two weeks’ time.  We went for an early morning appointment, the first one of the day, and a note was made in the diary to switch the air con off before his arrival (this had to be done upstairs, in a part of the store I have no access to).  His brother J, also 4, was booked in for a check as well.

So I had two weeks to come up with an idea of how to make the eye test a nicer experience for H.  I ended up buying Spiderman stickers and taking my noise cancelling headphones into work.  Turns out that the noise of the fan wasn’t the issue, it was the thought of it being on that he disliked.

Anyway, I came in early that day to make sure everything was set up and the air con was off.  It was, of course, one of the hottest days of the year so that air con was on the second H had left the store.  But I’m getting ahead of myself.

H was a lot more relaxed when I saw him.  He was still using his mum as a human shield but he was peeking around her more often – I took that as a good sign.  We went into the test room, I asked if he wanted to sit on his mum’s knee (I sensed that he didn’t like the electric motor moving the chair up at his last visit) and he was quite happy with that.  I asked if I should close the door and he said “no” so I left it open.   We used Snellen pictures to get vision and I tried ret again.  H didn’t want the lights off or dimmed so I wasn’t able to do Mohindra ret as planned.  His vision was very good though and his stereo acuity was fine.  A small plus prescription in a 4 year old (similar in both eyes) isn’t worth prescribing and I didn’t want to cyclo him unless there was a compelling need.

The Spiderman stickers went down a treat and during his brother’s eye test, I put a little Spiderman on my nose as a near fixation target (when he wasn’t looking).

“Your nose!” J said.

“Is there something on my nose?” I asked, looking puzzled.


“What is it?” I tried to look at my nose (esophoria for the win).


“Oh, he’s tickling my nose, what’s he doing?”

“He’s jumping!”

“Where’s he jumping to?”

… and this went on for as long I needed for the cover test.

At the end, I discussed my findings with H and J’s parents and they were all just about to leave when their mum said to H, “That was okay, wasn’t it?”

H turned to me, looking as serious as a 4 year old can, and said, “Yes, but Michelle is very silly.”

I’ll take that as a compliment.