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Eyes and Vision in ADHD

Eyes and Vision in ADHD

Author: Ulrich Brennecke
Review: AnnChristin Roeber, Dr. (May 2026)

Note on evidence classification: To date, there has not been a single randomized controlled trial in this area addressing the question of whether ADHD and visual impairments are related. The studies marked with (E 1a) are meta-analyses and systematic reviews of observational studies, not of RCTs. While they represent the highest level of evidence available here, they do not achieve the same level of certainty as a meta-analysis of RCTs.

People with ADHD are more likely to have eye and vision abnormalities than people without ADHD. This article summarizes what research has found on this topic, how reliable these findings are, and what they mean in everyday life.

(E 2b): ADHD is associated with changes in the dopamine system. Dopamine is a neurotransmitter that acts in the brain. However, it also acts in the retina of the eye. There, among other things, it controls how the eye reacts to light, how it adjusts to the transition between day and night, and how it develops during childhood. This is the main reason why a link between ADHD and vision is plausible in the first place.

(E 1a): The following are commonly found in ADHD:

  • Difficulty organizing and interpreting what one sees, such as recognizing objects or orienting oneself in space
  • Difficulty bringing both eyes together when looking at nearby objects (convergence insufficiency). This makes reading for long periods of time tiring
  • impaired spatial vision (depth perception)
  • Strabismus and latent strabismus (the eyes deviate only when control is lost)
  • Astigmatism and farsightedness
  • Eye movements that are slightly slower, less precise, and more erratic
  • slower or less precise focusing at close range (accommodation)
  • a pupil that reacts differently
  • minor differences in the optic disc and retinal vessels that can only be seen with special equipment

(E 1a): The largest analysis to date of 35 studies involving over three million participants found that ADHD is associated with visual function problems, but not with structural changes in the eye. The thickness of the retinal nerve fiber layer is normal. There is no overall difference in prescription strength. It remains unclear whether nearsightedness is more common in individuals with ADHD. Although a German dataset initially found an association, it was no longer detectable after accounting for other confounding factors.

(ADxS assessment): Most well-substantiated findings indicate a risk that is approximately 20% to 90% higher. This is significant, but it does not mean that the majority of people with ADHD have an eye problem. Very high percentages in this text (such as +950%) almost always come from small, individual studies with few participants and are therefore unreliable.

It remains unclear what is the cause and what are the consequences

(ADxS assessment): There are three possible explanations for the causes, and they are not mutually exclusive:

  • Vision problems can exacerbate ADHD symptoms. People who have blurred vision while reading or have to suppress double vision can quickly appear unfocused
  • ADHD exacerbates eye problems, for example through the dopamine system or due to a lack of time spent in daylight
  • Both have a common cause in early brain development

(E 3): There is also an assessment issue: Many vision tests require persistent attention and patience. A child with ADHD may perform worse on such tests without having any actual vision problems.

(E 2a): In one study, visual acuity and visual field improved with stimulant medication; another study found no improvement. With ADHD medication, the risk of nearsightedness was lower and the pupil was slightly larger. An examination conducted six months after starting methylphenidate revealed minor changes in the cornea. The authors therefore recommend regular eye exams for patients on long-term medication.

(ADxS assessment):

  • It’s a good idea to have an eye exam or an orthoptic evaluation, especially if reading is tiring, letters appear blurry or jump around, your eyes get tired quickly when doing close-up work, or you experience headaches

  • The ophthalmologist should be aware that the patient has ADHD.

  • Binocular vision should also be tested (convergence, stereopsis, latent strabismus). A standard eye exam at an optometrist’s office does not cover these aspects.

  • If a problem is found, treatment is advisable and can make reading easier. However, it is not a substitute for ADHD treatment. ADHD is not an eye condition.

  • Conversely, a normal eye examination does not rule out ADHD

  • (E 2b): ADHD is characterized by an impaired dopamine system with reduced extracellular dopamine. Dopamine is also involved in the visual system. (E 2b)1(E 2b)2(E 2b)3(E 2b)4(E 2b)5
  • (E 1a): In a study of 42 children with ADHD and 50 controls, 83% of the ADHD group without medication achieved a visual acuity of over 0.8, compared with 98% of the controls (p = 0.032).(E 3)6 The most comprehensive meta-analysis to date (k = 35 studies, N = 3,250,905) found a 94% increased risk of unspecified visual problems in ADHD (OR = 1.94) and concluded that ADHD is associated with a range of functional visual problems, but not with structural changes in the eye. (E 1a)7
  • (E 3): Young adults with ADHD (n = 30 vs. 30 controls) reported significantly more everyday problems in four of eight domains of a visual function questionnaire: visual search, visual processing speed, peripheral vision, and depth perception. In contrast, no difference was found in self-reports of color perception. In the objective color test (Farnsworth-Munsell 100 Hue), the ADHD group made more errors only in the blue spectrum. The overall test across all spectra was not significant. (E 3)8 A selective blue deficit has also been reported in children with ADHD. (E 3)9
  • (E 2a): ADHD medication improved visual field abnormalities and visual acuity in children with ADHD. (E 2a)10 Another study found no significant improvements.(E 3)6 In a small study, surgical treatment of strabismus improved ADHD symptoms, as reported by parents, in 7 out of 8 people with ADHD. (E 4)11
  • A small study was able to distinguish people with ADHD from people without the condition quite well using eye-tracking. (E 3)12

(ADxS assessment): It is possible that eye problems may contribute to or exacerbate ADHD symptoms, just as ADHD may contribute to or exacerbate eye problems.

1. Visual-perceptual problems in ADHD (+950%)

Implications for People with ADHD
Visual-perceptual problems mean that the eyes see normally, but the brain has difficulty processing what is seen. People with ADHD have a harder time recognizing objects or faces, lose their sense of direction in rooms, have trouble judging movement, or cannot take in multiple things at once in a cluttered scene (such as finding a face in a crowd). This occurs significantly more often in ADHD. It has nothing to do with intelligence or visual acuity. It can occur even with perfect visual acuity and is not a sign of clumsiness, but rather a definable pattern of perception.

A study found visual-perceptual problems in 21% of children with ADHD, compared with only 2% of children without the condition. (E 3)6

  • The finding is based on 9 out of 42 children with ADHD compared to 1 out of 50 children in the control group (p < 0.007). It was assessed through a structured medical history interview with the child and parents using 12 questions covering five areas (recognition, orientation, depth perception, motion perception, and simultaneous perception), rather than through a performance test. The most commonly affected areas were simultaneous perception, orientation, and motion perception (n = 5 each), followed by depth perception and recognition (n = 4 each). (E 3)6
  • (ADxS assessment): The percentage in the headline is unreliable because it is based on only one control case: A single additional case in the control group would halve the ratio.

2. Convergence Insufficiency and ADHD (+200% to +400%)

Implications for People with ADHD

When looking at something close up, both eyes must turn slightly inward to produce a single, sharp image. If this doesn’t work well enough, it’s called convergence insufficiency. In such cases, you can usually still see clearly, but only because the eye muscles are constantly working to compensate. This takes effort.

Typical signs: After 10 to 20 minutes of reading, the text becomes blurry, the lines jump around, the eyes burn, a headache develops in the forehead area, you lose your place, or you’d rather not read at all. Some people unconsciously close one eye while reading or hold the book very close or very far away.

In everyday life, this is easily confused with concentration problems, and the two reinforce each other.

Convergence insufficiency can be measured orthoptically and, in many cases, treated with exercises or prism glasses. If reading is noticeably difficult for someone, it’s worth having their binocular vision examined specifically. A standard eye exam does not check for this.

Eye convergence movements are oppositely directed (disjunctive) eye movements. Convergence refers to the inward movement of the eyes when focusing on nearby objects. Convergence insufficiency is a binocular dysfunction, not a purely ocular motor disorder.

A meta-analysis of 35 studies involving N = 3,250,905 participants found that ADHD was associated with a fivefold increased risk of a reduced near-convergence point (OR = 5.02). (E 1a)7

Studies have found that convergence insufficiency is four times as common in children with ADHD (24% vs. 6%) (E 3)6 and three times as common as in children without ADHD (E 4)13.
In one study, however, the difference arose almost entirely from the performance-related subscale (loss of concentration, slow reading, forgetting what was read; 2.8 vs. 2.2, p < 0.0001), while the eye-related subscale showed no difference (double vision, eye pain, headache); 1.9 vs. 1.8, p = 0.31). Part of the seemingly higher CI distress in ADHD may therefore be due to ADHD itself, as measured by an eye-related questionnaire. (E 2b)14

Another study found significant abnormalities in the modulation of the eye convergence response in people with ADHD during attention tasks. The diagnostic accuracy of the test was 79 percent. (E 3)15

(ADxS Assessment): The frequency with which convergence insufficiency is found in ADHD depends heavily on which diagnostic criteria are applied.

  • (E 3): Significant differences were found for positive and negative fusion convergence (PFV and NFV).
  • The PFV break/recovery values for the ADHD group and the control group were 18.9/16.2∆ and 26.9/22.1∆, respectively.
  • The NFV break/recovery values for the ADHD group and the control group were 15.7/13∆ and 19.3/15.9∆, respectively.
  • When using the three indicators of a recessed near convergence point (NPC), reduced PFV, and exophoria that is 4∆ greater at near than at distance, the prevalence of convergence insufficiency was the same in the ADHD and control groups (p = 0.34). When only two signs for the diagnosis of convergence insufficiency were considered (recessed NPC and reduced PFV), the prevalence of convergence insufficiency was significantly higher in the ADHD group (p < 0.01). (E 3)16

3. Stereopsis (stereoscopic vision, depth perception) in ADHD (+333%)

Implications for People with ADHD

Spatial vision occurs because both eyes provide slightly different images, and the brain uses this information to calculate depth. If this ability is impaired, people estimate distances less accurately. In everyday life, this is evident when pouring a drink, reaching for objects, playing ball sports, climbing stairs, or parking a car.

That doesn’t mean we’re blind to depth. The brain also uses other cues, such as size, occlusion, and shadows. It just requires more effort and is more prone to errors.

A test for spatial vision requires persistence and careful observation. Some of the poorer results seen in ADHD may be due to attention issues rather than problems with the eyes. This should be addressed during the examination.

Stereoacuity refers to the smallest transverse disparity that can still be perceived as a difference in depth when viewed binocularly. It is expressed in arcseconds.

(E 3): Several studies report impaired stereopsis in children with ADHD. (E 3)17 Stereopsis (depth perception) was impaired in 26% of children with ADHD, compared with 6% of those without the condition.(E 3)6 It is possible that this high percentage was due to a lack of attention.(E 3)6

4. Strabismus / Heterophoria (crossed eyes / latent strabismus) in ADHD (+93% to +300%)

Implications for People with ADHD

In strabismus, one eye visibly deviates from the line of sight. In latent strabismus (heterophoria), the deviation is hidden: The brain normally keeps the eyes aligned, but control is lost when the person is tired, stressed, or engaged in prolonged close-up work. Latent strabismus is significantly more common than visible strabismus and is often overlooked because there are no outward signs.

(E 1a): The association with ADHD is bidirectional: Strabismus is more common in children with ADHD, and ADHD is more common in children with strabismus. The increased risk observed in large, well-controlled studies is moderate (approximately 14% to 100%)—not dramatic.

(ADxS Assessment): If a child is diagnosed with strabismus, it is important to carefully assess whether there are also attention problems. Conversely, in cases of ADHD, it is worth investigating whether there is latent strabismus. Both conditions can be treated, often with glasses, prisms, or orthoptic training, and less commonly with surgery.

A study found that among children with ADHD

  • higher incidence of strabismus (crossed eyes) (17% to 24% compared to 6% in those not affected) (E 3)6
  • higher incidence of heterophoria (latent strabismus) (27% compared with 10% in unaffected individuals) (E 3)6

(E 2b): A population-based case-control analysis of South Korean claims data (n = 327,076 cases of strabismus, matched 1:1) found a 14% increased risk of ADHD associated with strabismus (adjusted OR 1.14, 95% CI 1.10 to 1.17).(E 3)18 Another cohort study found a doubled risk of ADHD in cases of convergent strabismus (inward turning of the eyes, esotropia) and a 44% increased risk of ADHD in cases of divergent strabismus (outward turning of the eyes, exotropia: one or both eyes deviate outward away from the nose). (E 2b)19

A predisposition to strabismus is thought to causally increase the risk of ADHD. (E 2b)20

  • Scientific: Effect sizes from meta-analyses, registry data, and KiGGS
  • Strabismus was associated with a 92% increased risk of mental disorders. Exotropia was associated with a risk of mental disorders ranging from +44% to +170% (meta-analysis, N = 683,942). (E 1a)21
  • A meta-analysis of 35 studies with N = 3,250,905 participants found a 93% increased risk of strabismus (OR = 1.93) and a 79% increased risk of hyperopia (OR = 1.79) in individuals with ADHD.(E 1a)22
  • An analysis of the KiGGS study (N = 13,488) found strabismus in 8.2% of children with ADHD, compared with 4.2% of people with ADHD (OR 2.04). (E 3)23
  • ADHD and hyperopia, myopia, astigmatism, and strabismus were mutually predictive. (E 2b)24

5. Astigmatism in ADHD (+79% to +300%)

Implications for People with ADHD

Astigmatism (corneal curvature, colloquially known as “astigmatic vision”) means that the cornea is not uniformly curved. As a result, points appear as short lines at any distance. The image is not simply blurry, but slightly distorted.

Minor changes are barely noticeable in everyday life because the brain compensates. However, this takes effort and manifests as eye strain, headaches, and squinting.

(E 1a): Astigmatism is more common in ADHD and is one of the conditions that is easiest to correct: A pair of properly fitted glasses is usually sufficient.

Correcting astigmatism is one of the most worthwhile reasons to have an eye exam. It is important to perform the measurement using eye drops to dilate the pupils (cycloplegia), because otherwise, especially in children, certain values may be overlooked.

A study found astigmatism in 24% of children with ADHD, compared with only 6% of children without ADHD. (E 3)6

A meta-analysis of 35 studies involving 3,250,905 participants found a 79% increased risk of astigmatism in individuals with ADHD (OR 1.79). (E 1a)7

An analysis of the KiGGS study (N = 13,488) found astigmatism in 10.9% of children with ADHD, compared with 6.2% of people with ADHD (calculated OR 1.75, reported OR 1.84).(E 3)23

ADHD was associated with hyperopia, myopia, astigmatism, and strabismus. (E 2b)24

6. Eye Movements and ADHD

Implications for People with ADHD

The eyes almost never stay still. They jump from point to point several times per second (saccades) and pause briefly in between. When reading, this is what guides the eyes along the line.
(E 1a): In ADHD, these eye movements are, on average, somewhat slower, less precise, and, above all, more irregular. The ability to keep the gaze fixed on a single point is also more difficult.

(ADxS assessment): This explains some well-known everyday experiences: getting lost while reading, reading lines twice or skipping them, or constantly having to search for the right spot while copying.
This is not a weakness of the eye muscles. The same areas of the brain that control attention and impulse control also control eye movements. So, in essence, the eyes reveal what is already the core issue in ADHD—only in a way that can be measured very precisely.
For this reason, researchers are investigating whether eye movements can serve as an objective diagnostic tool. So far, this remains a matter of research and is not yet a recognized diagnostic method.
Even simple things can be helpful in practice: a line guide or using your finger to follow the lines, larger font, and shorter reading passages with breaks.

An experimental study (n = 16) reports significant abnormalities in eye movements in ADHD, as determined by electrooculography (EOG). (E 3)25

A large study found a correlation between premature anticipatory eye movements and inattention, but not between directional errors and ADHD symptoms. (E 2b)26

6.1. Saccades

Various studies using the gap/overlap test found slower and more variable saccadic reaction times in children with ADHD. One study was able to eliminate this biomarker by using warning signals during the test. (E 2b)27

A meta-analysis found evidence that children with ADHD: (E 1a)28

  • made more directional errors on an antisaccade task
  • were slower and performed worse on oculomotor tasks
  • performed eye movements with less precision

(E 2b): Saccadic eye movements (saccades) are strongly influenced by factors such as attention and inhibition. (E 2b)29(E 2b)30
(ADxS assessment): Since attention and inhibition are impaired in ADHD, it seems plausible that saccadic eye movements would show abnormalities in individuals with ADHD.

Voluntary eye movements are controlled by the dlPFC: Voluntary control of eye movements is closely linked to the direction of attention. The dlPFC also houses working memory, which is typically impaired in ADHD.
People with ADHD showed increased saccade latency and intensity, as well as shorter fixation times, during eye-tracking tasks. (E 3)31

The abnormalities in saccadic eye movements associated with ADHD can reportedly be improved through computer-based training. (E 2a)32

  • In the antisaccade task, prolonged latencies were found in ADHD and, to an even greater extent, in schizophrenia; they were also observed in bipolar disorder, and with smaller and less robust effect sizes in obsessive-compulsive disorder. Deficits in inhibitory control appear to be present in the antisaccade task across all mental disorders, particularly as reflected in error rates. (E 1a)33
  • Faster visual orientation due to shorter saccadic reaction times (SRT) was observed in baseline trials compared to overlap trials, for faces compared to non-face stimuli, and (more pronounced in children without ADHD and/or autism) for multimodal stimuli compared to unimodal stimuli. A linear negative correlation was found between presaccadic pupil size and SRTs in children with ASD without ADHD, as well as a quadratic correlation in children with ADHD without ASD, in whom SRTs were slower when the intra-individual presaccadic pupil size was smallest or largest. (E 3)34
  • Individuals with borderline personality disorder and comorbid ADHD exhibited impaired response preparation, which led to reduced visual fixation on task cues and greater variability in saccadic responses (i.e., saccadic reaction time and peak velocity). Saccadic deficits in borderline personality disorder, as well as in ADHD with comorbid borderline personality disorder, do not appear to stem from an inability to perform antisaccades, but rather from insufficient preparation for the upcoming task. This could result from abnormal signal transmission in cortical regions such as the frontal eye fields, the posterior parietal cortex, and the ACC. (E 3)35

6.2. Pupil velocity

A study found significantly higher pupil velocity values in children with ADHD, which correlated positively with the RNFL measurements of their right eyes. (E 3)36

6.3. Pupil diameter, pupil restlessness

Implications for People with ADHD

The pupil doesn’t just change in response to light. It also dilates when you’re concentrating, paying attention, or when something surprising happens. It thus serves as a window into the brain’s state of alertness and arousal, which is regulated, among other things, by the neurotransmitter norepinephrine.
(E 3): In ADHD, the pupil’s response is, on average, more subdued. It dilates less during demanding tasks and fluctuates less at rest.

(ADxS assessment): This is consistent with the idea that the activation system in ADHD is calibrated differently—that is, it is not consistently underactive, but is not optimally adapted to the task at hand.
Pupil size has no practical implications in everyday life. You don’t notice it, and there is no test at the ophthalmologist’s office that could be used to diagnose ADHD based on it. It is, however, an interesting approach for research into objective measurement methods.
(E 3): There is one practical side effect: ADHD medications cause the pupils to dilate slightly. This can increase sensitivity to glare, for example, when driving at dusk. Sunglasses can help.

(E 3): In adults with ADHD, it was found that

  • reduced pupillary oscillation performance during passive conditions with minimal distraction, as well as during rest conditions without distraction. This is a sign of generally reduced catecholaminergic activity, which is independent of the visual task or ongoing cognitive effort. (E 3)37
  • reduced pupil dilation during a task requiring sustained visual attention (E 3)38

(ADxS assessment): The authors’ very restrictive approach to data disclosure could be an indication of potential diagnostic utility.
ADHD medication significantly increased pupil diameter (3.91 mm vs. 3.58 mm, p = 0.017). (E 3)39

Measurements of pupil diameter reveal abnormalities in the noradrenergic system in ADHD.

For more information, see Tonic and Phasic Norepinephrine in ADHD in the article “Norepinephrine.”

  • Pupillary restlessness shows a high degree of correlation between the two eyes. This suggests a control center within the Edinger-Westphal complex in the midbrain that acts on both irises simultaneously.(E 3)37 The Edinger-Westphal complex is the most important parasympathetic preganglionic motor hub for the pupillary constrictor muscle and is connected via various pathways to the catecholaminergic network, including the locus coeruleus. The noradrenergic activity of the locus coeruleus significantly influences pupil diameter.
  • The locus coeruleus is the brain’s primary source of norepinephrine and strongly influences neuronal dopamine function and dopaminergic receptors. (E 3)37 To date, no direct neurological projections between the locus coeruleus and the Edinger-Westphal complex are known. There may be an indirect connection via intermediate circuits. In addition, the Edinger-Westphal complex is modulated by the neocortex and hypothalamus. Attention influences the baseline tone of the pupillary dilator muscle via the pupillary sympathetic system. This could amplify the biomechanical push-pull mechanism of the sphincter-ciliary muscle system and increase the sensitivity and amplitude of pupillary oscillations. (E 3)37
  • (E 2b): Tonus and phasic norepinephrine firing can be detected based on pupil diameter. The basal pupil diameter corresponds to tonic noradrenergic firing, and a change in pupil diameter corresponds to phasic noradrenergic activity. A phasic pupil dilation correlated with correct responses, while a tonic pupil dilation correlated with periods of low reward value. (E 2b)40(E 3)41 An increase in baseline pupil diameter correlated with a decrease in task utility and a disengagement from the task (exploration), while a decrease in baseline diameter accompanied by an increase in task-induced dilation correlated with engagement in the task (exploitation). (E 2b)42
  • Pupil dilation is a physiological indicator of increased arousal and noradrenergic activity in the locus coeruleus.(E 2b)27 Resting pupil diameter also reflects connectivity between frontoparietal, striatal, and thalamic brain regions. (E 2b)43
  • Pupil dilation amplitudes in response to relatively unexpected spatial target stimuli showed: (E 3)44* Shorter pupil dilation latencies in ADHD compared to ASD, ASD + ADHD, and controls.* In ASS and ASS + ADHD, orientation reactions were slower than in controls, and pupil dilation amplitudes were higher compared to ADHD and controls.

6.4. Eye stability

Implications for People with ADHD

(E 3): When someone focuses on a single point, their gaze is never completely still. In people with ADHD, the gaze wanders more than in those without the condition. This happens even when there is nothing around that could be distracting. The restlessness, therefore, does not come from the outside, but from within.

(ADxS assessment): This explains why a low-stimulus workspace helps, but doesn’t solve everything. A tidy desk eliminates external distractions, but the inner restlessness remains.

A measurement of fixation stability based on the area of the bivariate contour ellipse (BCEA)—a continuous index of gaze dispersion during the task—revealed a significantly higher BCEA value in children with ADHD, reflecting their increased gaze instability. The impairment in gaze fixation persisted even in the absence of visual distractions, suggesting an intrinsic attention deficit in ADHD. (E 3)45

7. Visual Field Defects

Implications for People with ADHD

(E 3): This refers to how often a person moves their head or shifts their gaze in a given situation—that is, changes the portion of the world they are currently seeing. A study using virtual reality showed that the less accurately children performed a task, the more frequently they shifted their field of view. These shifts in gaze were not related to the severity of ADHD symptoms, but rather to their current performance.

(ADxS assessment): This suggests that the gaze is more indicative of momentary overwhelm than of a fixed trait. No concrete conclusions can yet be drawn from this for everyday life. This is a single research finding.

Another study found that, in children, visual field shifts moderated the relationship between hyperactivity/impulsivity on the one hand and problems with attention focus and information processing on the other. As performance accuracy decreased, visual field shifts increased, although this correlation did not reflect the severity of the symptoms. (E 3)46

8. Paper Thickness in ADHD

Implications for People with ADHD

The macula is the area of the retina responsible for the sharpest vision. Its thickness can be measured with a painless scan.

(E 4): A very small study found a discrepancy here in relation to ADHD and suggested that this might reflect differences in the brain. Since the retina and the brain are developmentally linked, this is not an outlandish idea.

(ADxS assessment): This is explicitly a hypothesis based on a pilot study. Larger studies have not yet confirmed structural retinal changes in ADHD. For clinical practice, this finding is currently insignificant.

A small study hypothesizes that increased macular thickness in children with ADHD may reflect the increased ratio of the thickness of the right frontal lobe to that of the parietal cortex in ADHD. (E 4)47

9. Accommodation in ADHD

Implications for People with ADHD

Accommodation is the eye’s ability to focus at different distances, similar to a camera’s autofocus. When looking back from the window to the book, the eye has to adjust.
(E 1a): With ADHD, this autofocus tends to focus slightly less accurately on average and lags slightly when looking at nearby objects.

(ADxS assessment): The effect is small and most people are unaware of it. However, it can contribute to close-up work feeling more tiring and to attention waning more quickly while reading.
(E 3): The findings are inconsistent. One study found no difference compared to the control group. No effect of ADHD medication on visual acuity was observed.

(ADxS Assessment): If close-up work is difficult for someone, it is worth having their accommodation and convergence tested. The two are closely related and are examined together.

Accommodation refers to the eye’s ability to focus on and bring objects at different distances into sharp focus. Children with ADHD showed a reduced accommodative response that was not influenced by the accommodative stimulus. There was no significant effect of ADHD medication on accommodation accuracy. (E 3)48

Another study found no differences between children and adolescents with ADHD and the control group in terms of visual acuity, refraction, or accommodative ability. (E 3)16

  • A meta-analysis of 35 studies involving 3,250,905 participants found an increased risk of greater delay in ADHD (Hedge’s g = 0.63 [CI: 0.30 to 0.96]) and variability (Hedge’s g = 0.40 [CI: 0.17 to 0.64]) in the accommodative response in ADHD. (E 1a)7
  • Compared to the control group, people with ADHD showed: (E 3)49
    • a significantly higher accommodation lag (+0.30 ± 0.17 D vs. +0.18 ± 0.23 D)
    • a higher amplitude of accommodation (13.15 ± 1.73 vs. 12.07 ± 1.60)
    • a higher prevalence of near heterophoria
    • There were no differences between people with ADHD who were taking medication and those who were not
    • Men showed higher near heterophoria than women
    • Men showed significantly more phoria at close range

10. Morphological Changes in the Optic Nerves in ADHD

Implications for People with ADHD

(E 3): An image of the fundus allows for the measurement of the optic disc and the retinal vessels. In children with ADHD, these structures were, on average, slightly smaller, and the retinal vessels were slightly less tortuous.
(ADxS assessment): These are minor differences in group averages, not a medical condition. No one’s vision is impaired as a result, and no harm comes from it.

(E 3): The authors interpret the finding as evidence of an early developmental peculiarity of nerve and vascular tissue.
(ADxS assessment): Because the eye develops from the brain during the embryonic period, the retina can reveal early signs that are not apparent in the brain itself. This finding is therefore relevant to our understanding of ADHD, but not to eye health.

One study found that children with ADHD were more likely to have smaller optic nerves, smaller neuroretinal rim areas, or reduced tortuosity of the retinal arteries. (E 3)6

Compared to a healthy control group, children with ADHD showed significantly smaller papillary areas, neuroretinal margins, and excavations, as well as reduced tortuosity of the retinal arteries and veins. The authors interpret this as evidence of an early developmental disorder of neural and vascular structures in the CNS. At least one fundus abnormality was found in 7 of 9 children with visuocognitive problems. (E 3)6

11. DRD4-7R and Vision in ADHD

Implications for People with ADHD

(E 2b): DRD4 is a gene encoding a dopamine receptor subtype. A specific variant of this gene (7R) is one of the best-documented genetic risk factors for ADHD. It is also active in the retina.

(ADxS assessment): This is the most direct evidence to date that ADHD and vision problems may indeed share a common biological root and are not merely coincidentally associated. The same gene is active in both conditions.
So far, the consequences have not led to any practical applications. There is no useful genetic test for this, because the variant is also found in many people without ADHD and does not provide any insight into individual cases.

The DRD4 7R variant is one of the strongest single-gene risk factors for ADHD. For more information, see ⇒ Candidate Genes for ADHD In the chapter ⇒ Etiology.

  • (E 2b): The D4 dopamine receptor (gene: DRD4) is expressed in the retina, where it modulates signal processing in photoreceptors, in part via the second messenger cAMP.(E 2b)50 Drd4 transcription follows a distinct circadian pattern. (E 2b)5
  • DRD4-7R correlates with a reduced ability to decrease levels of the light-sensitive second messenger cyclic adenosine monophosphate (cAMP) in response to light. (E 2b)51
  • In addition, there were indications of a possible correlation between DRD4-7R and increased daytime sleepiness (E 3)52, which could be a consequence of the interplay between dopamine and melatonin.

12. Refractive Errors (Vision Problems) and ADHD

Implications for People with ADHD

Refractive errors are the classic vision conditions: nearsightedness, farsightedness, and astigmatism.

(E 1a): The overall picture is mixed. Individual studies found a very high prevalence of vision problems among children with ADHD, but a large meta-analysis of 35 studies found no overall difference in prescription strength. The situation is clearer for specific types of vision problems: farsightedness and astigmatism are more common in ADHD, while the prevalence of nearsightedness is uncertain.
(ADxS Assessment): An undiagnosed vision problem makes close-up work tiring and can make children appear unfocused. This is true regardless of whether it is more common in children with ADHD. Because children barely notice a gradual deterioration themselves and do not complain about it, regular checkups are advisable (using eye drops to dilate the pupils, since farsightedness in particular is otherwise often overlooked).

A study found refractive errors in 83% of the children with ADHD who were examined. (E 4)53A meta-analysis of 35 studies involving 3,250,905 participants found no increased prevalence of refractive errors in ADHD (Hedge’s g = 0.08 [CI: -0.26 to 0.42]). (E 1a)7
A study found no differences between children and adolescents with ADHD and a control group in terms of visual acuity, refraction, or accommodation ability. (E 3)16

Within the ADHD group, the prevalence of ametropia (refractive error) under cycloplegia was significantly higher among people with ADHD who did not take medication than among people with ADHD who did take medication (69.6% vs. 37.5%, χ² = 7.32, p = 0.026). This is a subgroup analysis of a cross-sectional study (N = 100). A causal effect of medication cannot be inferred from these findings. (E 3)39

  • (E 4): A dysfunction of retinal dopamine could affect the neurodevelopmental growth of the eye, leading to refractive errors. This could help explain the prevalence of refractive errors in ADHD. (E 4)53(E 4)54
  • (ADxS assessment): There is growing evidence that the global increase in myopia is dopaminergic and linked to a lack of exposure to natural daylight.
  • From 1981 (1982) to 2002/2003, outdoor activities were cut in half, from 1 hour and 40 minutes per week to 50 minutes per week. Sports participation decreased from 4:04 to 2:59 hours per week (E 3)55

12.1. Farsightedness (hyperopia, hypermetropia) (+67%)

Implications for People with ADHD

Farsightedness doesn’t mean that you can see particularly well at a distance. It means that the eye has to constantly readjust its focus, especially when looking at close objects. Children can do this effortlessly for a long time, which is why a standard eye exam often doesn’t reveal the condition.
(ADxS assessment): Although visual acuity is normal in this case, the child constantly has to strain. This manifests as a reluctance to read, rapid fatigue while doing homework, headaches in the afternoon, or as a concentration problem that isn’t really one.

(E 1a): Farsightedness is one of the findings that are most reliably associated with ADHD.
(ADxS assessment): Farsightedness can be effectively corrected with glasses. It is crucial that the measurement be taken with the pupil dilated, because otherwise it cannot be detected.

An analysis of the KiGGS study (N = 13,488) found that 13.0% of children with ADHD had farsightedness, compared with 8.2% of people with ADHD (OR 1.67). (E 3)23

ADHD was associated with hyperopia, myopia, astigmatism, and strabismus. (E 2b)24

12.2. Nearsightedness (myopia) (+29%)

Implications for People with ADHD

(E 1a): Whether nearsightedness is more common in ADHD is the most unclear question in this chapter. Some large datasets find a slight association, while other analyses no longer find one once other influencing factors are taken into account.
(E 2b): It is noteworthy that the risk of nearsightedness was significantly lower among people taking ADHD medication than among people with ADHD who were not treated. The presumed reason is that dopamine in the retina slows the longitudinal growth of the eye.
(ADxS Assessment): This is an incidental finding based on billing data and is not a reason to take or avoid taking medication for eye-related issues.

(E 2b): What is well established and relevant to everyone: Daylight protects against nearsightedness. Children who spend time outdoors every day are less likely to become nearsighted.
(ADxS assessment): Regardless of ADHD, this is one of the few truly well-supported recommendations for eye health, and it is easy to implement.

(E 1a): The evidence regarding myopia is inconsistent.

  • A Taiwanese registry cohort (data from 2009 to 2020) found a 22% increased risk of myopia among people with ADHD who have not been treated compared with people without ADHD (aHR 1.22, 95% CI 1.21 to 1.24). (E 2b)56
  • In the KiGGS analysis (N = 13,488), myopia was initially more common among children with ADHD (16.2% vs. 13.1%, OR 1.29). However, after adjusting for other ADHD risk factors, this association was no longer significant, unlike for hyperopia, astigmatism, and strabismus. (E 3)57
  • A meta-analysis of 35 studies found no overall difference in refractive errors (Hedge’s g = 0.08 [CI -0.26 to 0.42]). (E 1a)7

Compared with people with ADHD who are untreated, the risk of myopia was reduced by 39% among those taking ADHD medication (aHR 0.61, 95% CI 0.59 to 0.62). The risk was reduced more significantly with two active ingredients (aHR 0.28) than with one (aHR 0.50). (E 2b)56

ADHD was associated with hyperopia, myopia, astigmatism, and strabismus. (E 2b)24

(E 2b): A lack of bright daylight (outdoors) increases the risk of nearsightedness (myopia). The increase in nearsightedness due to a lack of daylight is mediated by dopamine. (E 4)58(E 2b)59 The release of dopamine in the retina inhibits the progression of nearsightedness. (E 2b)56

13. Visuomotor function correlates with inhibition and cognitive flexibility

Implications for People with ADHD

Visual-motor skills refer to the interaction between vision and movement—for example, eye-hand coordination when writing, catching, or cutting.

(E 3): Children who have difficulty making smooth, eye-guided movements also tend to have a harder time blocking out distractions. And those who have trouble switching between tasks physically also have trouble doing so mentally.
(ADxS assessment): This explains why motor clumsiness and concentration problems often occur together in ADHD. These are not two separate issues, but two sides of the same regulatory capacity.
If a child seems clumsy and has poor handwriting, this is not a sign of laziness, nor should it be viewed in isolation from ADHD. Occupational therapy can be a helpful approach in such cases.

Visuomotor function is the coordination of visual perception and the musculoskeletal system and includes, among other things, eye-hand coordination.

  • Scientific: Correlation patterns between visuomotor and cognitive measures
  • A study reports: (E 3)60
  • Visuomotor fluency correlated significantly with cognitive inhibition. The ability to perform visually guided, continuous movements fluently correlates with the ability to inhibit the effects of distracting information.
  • Visuomotor flexibility correlated significantly with cognitive flexibility. The ability to spontaneously use visual information to flexibly modify motor responses correlates with the ability to cognitively shift from one mindset to another.

14. Retinal detachment, retinal tears

Implications for People with ADHD

(E 2b): ADHD is slightly more common among people with retinal detachment or retinal tears. The increase is small, at 19 percent.

(ADxS assessment): Retinal detachments are rare, and a slight increase in risk for a rare event still represents a very small risk. A correlation can also be explained by other factors, such as nearsightedness or a higher rate of head injuries.
Important: Sudden flashes of light, a swarm of new black spots, or a shadow moving across your field of vision from one side are warning signs of a retinal detachment, which must be examined by an ophthalmologist or at an emergency eye clinic on the same day.

(E 4): There is also debate over whether retinal disorders could contribute to the shifts in the day-night rhythm that are common in ADHD. This is a hypothesis, not a proven fact.

Retinal detachments and tears were associated with a 19% increased risk of ADHD. (E 2b)61

The discussion focuses on whether retinal disorders could cause the shifts in circadian rhythm commonly seen in ADHD and whether these could be a major cause of ADHD. (E 4)62

15. Retina for ADHD Diagnosis

Implications for People with ADHD

(E 3): Researchers are investigating whether ADHD can be detected from a photograph of the back of the eye. A computer program trained on a large number of such images was able to distinguish between children with and without ADHD with remarkable accuracy.

(ADxS assessment): This sounds like a simple, objective test, but unfortunately it is not yet practical to use. It remains to be seen whether it will work just as well with a completely different group of children in a typical clinical setting (where there are many more disorders than just ADHD). Without machine learning, the ability to distinguish between cases is significantly weaker.

ADHD continues to be diagnosed through medical history, questionnaires, and clinical interviews. Skepticism is warranted regarding paid eye scans marketed as ADHD tests.

(E 3): Using machine learning, ADHD could be distinguished very effectively from images of the retina. AUROC values ranging from 0.955 to 0.969 were achieved.(E 3)63 Machine learning based on electroretinogram curves was used to investigate the distinction between individuals with ASD and controls. The classification performance was low, with a balanced accuracy of 0.66.(E 3)64

Comparative data without machine learning and RNFL meta-analysis

  • A study that did not use machine learning found an AUC of 0.6 to 0.7 for detecting ADHD based on a diluted Retina test. (E 3)65
  • In contrast, a meta-analysis of 35 studies involving 3,250,905 participants found no change in the thickness of the retinal nerve fiber layer in ADHD (Hedge’s g = -0.19 [CI: -0.41 to 0.02]).(E 1a)7

16. Conjunctivitis

Implications for People with ADHD

(E 1a): Conjunctivitis (red, itchy, watery eyes) occurs somewhat more frequently in individuals with ADHD. The association is weak and is no longer statistically significant in the studies with the best methodological design.

(ADxS assessment): The obvious explanations are simple: more frequent eye-rubbing, more allergies, and less consistent hygiene.

(E 1a): ADHD is associated with an increased risk of conjunctivitis:

  • 1.69-fold increased risk (statistically significant) across all studies (systematic review, k = 3 meta-analyses, N = 41,908, n = 9,564) (E 1a)66
  • 1.41-fold risk (not statistically significant) when limited to gold-standard studies (systematic review, k = 2 meta-analyses, N = 4,193, n = 1,065) (E 1a)66

17. Stimulants and Eye Parameters

Implications for People with ADHD

(E 2a): After six months of methylphenidate treatment, an examination revealed minor changes in the cornea (the clear front part of the eye) as well as slightly elevated intraocular pressure. However, the pressure remained within the normal range.
(ADxS assessment): What this means in the long term remains to be seen. These are measurement values, not a disease. No person with ADHD has had their vision worsened as a result. There is no reason to discontinue an effective treatment.

(E 2a): However, this is a good reason to have an eye exam before starting treatment and then at longer intervals during long-term treatment. The authors of the study explicitly recommend this.
(ADxS assessment): If you’re going for a checkup anyway, mention the medication. A more common and harmless side effect of stimulants is dilated pupils. This can increase sensitivity to glare.

The authors recommend regular eye exams for patients taking stimulants long-term. (E 2a)67

  • Scientific: Specular microscopy and topographical measurements after 6 months of MPH
  • A prospective observational study involving 100 untreated children with ADHD and 100 age- and sex-matched healthy controls found the following in children with ADHD after 6 months of MPH treatment, as determined by specular microscopy and corneal topography: (E 2a)67
  • Endothelial cell density was significantly reduced, with a significant but weak correlation with inattention
  • significantly increased average cell area
  • Standard deviation of cell area significantly increased
  • The coefficient of variation for cell area has increased significantly
  • Hexagonality index changed
  • Central corneal thickness is significantly increased, with a significant but weak correlation with inattention
  • Intraocular pressure is significantly elevated but within normal physiological limits

18. Unchanged eye parameters

Implications for People with ADHD

(E 3): Just as important as the noticeable characteristics are the aspects of ADHD that are not noticeable. The length of the eyeball, the shape of the cornea, and the anterior chamber of the eye do not differ from those of people without ADHD.
(ADxS assessment): ADHD is associated with specific characteristics of visual function, not with an abnormally structured eye.

(E 2b): An interesting finding from a genetic analysis is that a predisposition to ADHD appears to be associated with a slightly lower risk of glaucoma, but with a slightly higher risk of corneal inflammation and corneal ulcers.
(ADxS assessment): The latter is associated with more frequent eye rubbing and less careful handling of contact lenses. People who wear contact lenses should pay attention to hygiene and wearing time.

  • Axle length unchanged (E 3)39
  • Corneal topography parameters unchanged (E 3)39
  • Anterior chamber characteristics unchanged (E 3)39
  • ADHD is thought to causally increase the risk of corneal ulcers and corneal inflammation. (E 2b)
  • ADHD is thought to causally reduce the risk of glaucoma. (E 2b)20

  1. Pozdeyev, Tosini, Li, Ali, Rozov, Lee, Iuvone (2008): Dopamine modulates diurnal and circadian rhythms of protein phosphorylation in photoreceptor cells of mouse retina. Eur J Neurosci. 2008 May;27(10):2691-700. doi: 10.1111/j.1460-9568.2008.06224.x. PMID: 18547251; PMCID: PMC2440701. ↥

  2. Klitten, Rath, Coon, Kim, Klein, Møller (2008): Localization and regulation of dopamine receptor D4 expression in the adult and developing rat retina. Exp Eye Res. 2008 Nov;87(5):471-7. doi: 10.1016/j.exer.2008.08.004. PMID: 18778704; PMCID: PMC2597030. ↥

  3. Pflug, Nelson, Huber, Reitsamer (2008): Modulation of horizontal cell function by dopaminergic ligands in mammalian retina. Vision Res. 2008 Jun;48(12):1383-90. doi: 10.1016/j.visres.2008.03.004. PMID: 18440579; PMCID: PMC5244834. ↥

  4. Ruan, Allen, Yamazaki, McMahon (2008): An autonomous circadian clock in the inner mouse retina regulated by dopamine and GABA. PLoS Biol. 2008 Oct 14;6(10):e249. doi: 10.1371/journal.pbio.0060249. PMID: 18959477; PMCID: PMC2567003. ↥

  5. Kim, Bailey, Weller, Sugden, Rath, Møller, Klein (2010): Thyroid hormone and adrenergic signaling interact to control pineal expression of the dopamine receptor D4 gene (Drd4). Mol Cell Endocrinol. 2010 Jan 15;314(1):128-35. doi: 10.1016/j.mce.2009.05.013. PMID: 19482058; PMCID: PMC2783391. ↥ ↥

  6. Grönlund, Aring, Landgren, Hellström (2006): Visual function and ocular features in children and adolescents with attention deficit hyperactivity disorder, with and without treatment with stimulants. Eye (Lond). 2007 Apr;21(4):494-502. doi: 10.1038/sj.eye.6702240. PMID: 16518370. N = 92, n =42 ↥ ↥ ↥ ↥ ↥ ↥ ↥ ↥ ↥ ↥ ↥ ↥

  7. Bellato, Perna, Ganapathy, Solmi, Zampieri, Cortese, Faraone (2022): Association between ADHD and vision problems. A systematic review and meta-analysis. Mol Psychiatry. 2022 Aug 5. doi: 10.1038/s41380-022-01699-0. PMID: 35931758. METASTUDIE ↥ ↥ ↥ ↥ ↥ ↥ ↥

  8. Kim, Chen, Tannock (2014): Visual function and color vision in adults with Attention-Deficit/Hyperactivity Disorder. J Optom. 2014 Jan-Mar;7(1):22-36. doi: 10.1016/j.optom.2013.07.001. PMID: 24646898; PMCID: PMC3938738. ↥

  9. Banaschewski, Ruppert, Tannock, Albrecht, Becker, Uebel, Sergeant, Rothenberger (2006): Colour perception in ADHD. J Child Psychol Psychiatry. 2006 Jun;47(6):568-72. doi: 10.1111/j.1469-7610.2005.01540.x. PMID: 16712633. ↥

  10. Martin, Aring, Landgren, Hellström, Grönlund (2008): Visual fields in children with attention-deficit / hyperactivity disorder before and after treatment with stimulants. Acta Ophthalmol. 2008 May;86(3):259-64. doi: 10.1111/j.1755-3768.2008.01189.x. PMID: 18494726. N = 42, n = 18 ↥

  11. Chung, Chang, Rhiu, Lew, Lee (2012): Parent-reported symptoms of attention deficit hyperactivity disorder in children with intermittent exotropia before and after strabismus surgery. Yonsei Med J. 2012 Jul 1;53(4):806-11. doi: 10.3349/ymj.2012.53.4.806. PMID: 22665350; PMCID: PMC3381481. N = 51, n = 8 ↥

  12. Merzon L, Pettersson K, Aronen ET, Huhdanpää H, Seesjärvi E, Henriksson L, MacInnes WJ, Mannerkoski M, Macaluso E, Salmi J (2022): Eye movement behavior in a real-world virtual reality task reveals ADHD in children. Sci Rep. 2022 Nov 24;12(1):20308. doi: 10.1038/s41598-022-24552-4. PMID: 36434040; PMCID: PMC9700686. N = 73 ↥

  13. Granet, Gomi, Ventura, Miller-Scholte (2005): The relationship between convergence insufficiency and ADHD. Strabismus. 2005 Dec;13(4):163-8. doi: 10.1080/09273970500455436. PMID: 16361187. ↥

  14. Barnhardt, Cotter, Mitchell, Scheiman, Kulp (2012): CITT Study Group. Symptoms in children with convergence insufficiency: before and after treatment. Optom Vis Sci. 2012 Oct;89(10):1512-20. doi: 10.1097/OPX.0b013e318269c8f9. PMID: 22922781; PMCID: PMC3461822. ↥

  15. Jiménez, Avella-Garcia, Kustow, Cubbin, Corrales, Richarte, Esposito, Morata, Perera, Varela, Cañete, Faraone, Supèr, Ramos-Quiroga (2020): Eye Vergence Responses During an Attention Task in Adults With ADHD and Clinical Controls. J Atten Disord. 2020 Jan 20;1087054719897806. doi: 10.1177/1087054719897806. PMID: 31959011. n = 144 ↥

  16. Clavé L, Torrents A (2025): Convergence insufficiency prevalence in attention deficit and hyperactivity disorder children depends on the diagnosis criteria. Ophthalmic Physiol Opt. 2025 Jan;45(1):23-30. doi: 10.1111/opo.13411. PMID: 39462237; PMCID: PMC11629851. N = 60 ↥ ↥ ↥

  17. Karaca, Demirkılınç Biler, Palamar, Özbaran, Üretmen (2020). Stereoacuity, Fusional Vergence Amplitudes, and Refractive Errors Prior to Treatment in Patients with Attention-Deficit Hyperactivity Disorder. Turk J Ophthalmol. 2020 Mar 5;50(1):15-19. doi: 10.4274/tjo.galenos.2019.17802. PMID: 32166943; PMCID: PMC7086097. N = 71 ↥

  18. Choi, Park, Yang, Kim, Roh, Oh (2021): Association of mental disorders and strabismus among South Korean children and adolescents: a nationwide population-based study. Graefes Arch Clin Exp Ophthalmol. 2021 Oct 26. doi: 10.1007/s00417-021-05325-7. PMID: 34698906. ↥

  19. Tsai, Su, Liu, Tsai, Tsai (2021): High Risk for Attention-Deficit Hyperactive Disorder in Children with Strabismus: A Nationwide Cohort Study from the National Health Insurance Research Database. Life (Basel). 2021 Oct 26;11(11):1139. doi: 10.3390/life11111139. PMID: 34833015; PMCID: PMC8622056. N = 10.245, n = 2.049 Strabismus ↥

  20. Chen XN, Zhang Y, Kam KW, Au SCL, Zhang XJ, Ng MPH, Yip WW, Ip P, Wong ICK, Young AL, Pang CP, Tham CC, Chen LJ, Yam JC (2025): Genetic association of attention-deficit/hyperactivity disorder with thirteen ocular disorders. J Affect Disord. 2025 Sep 15;385:119422. doi: 10.1016/j.jad.2025.119422. PMID: 40381862. ↥ ↥

  21. Krungkraipetch L, Krungkraipetch N, Threetong T (2025): A Meta-Analysis of Association Between Strabismus in Children/Adolescents and Risk of Mental Health Disorders. Clin Ophthalmol. 2025 Jul 16;19:2333-2342. doi: 10.2147/OPTH.S530788. PMID: 40689234; PMCID: PMC12276737. METASTUDY ↥

  22. Bellato, Perna, Ganapathy, Solmi, Zampieri, Cortese, Faraone (2023): Association between ADHD and vision problems. A systematic review and meta-analysis. Mol Psychiatry. 2023 Jan;28(1):410–422. doi: 10.1038/s41380-022-01699-0. PMID: 35931758. METASTUDY ↥

  23. Reimelt C, Wolff N, Hölling H, Mogwitz S, Ehrlich S, Roessner V (2021): The Underestimated Role of Refractive Error (Hyperopia, Myopia, and Astigmatism) and Strabismus in Children With ADHD. J Atten Disord. 2021 Jan;25(2):235-244. doi: 10.1177/1087054718808599. PMID: 30371126. ↥ ↥ ↥

  24. Chou WP, Chen YL, Hsiao RC, Lai YH, Yen CF (2023): Bidirectional Associations Between Hyperopia, Myopia, Astigmatism, and Strabismus and Attention-Deficit/Hyperactivity Disorder in Children: A National Population-Based Cohort Study. Braz J Psychiatry. 2023 Sep 17. doi: 10.47626/1516-4446-2023-3156. Epub ahead of print. PMID: 37718319. n = 1.884.701 ↥ ↥ ↥ ↥

  25. Latifoğlu, Esas, Demirci (2019): Diagnosis of attention-deficit hyperactivity disorder using EOG signals: a new approach. Biomed Tech (Berl). 2019 Sep 18. pii: /j/bmte.ahead-of-print/bmt-2019-0027/bmt-2019-0027.xml. doi: 10.1515/bmt-2019-0027. ↥

  26. Siqueiros Sanchez, Falck-Ytter, Kennedy, Bölte, Lichtenstein, D’Onofrio, Pettersson (2020): Volitional eye movement control and ADHD traits: a twin study. J Child Psychol Psychiatry. 2020 Feb 5:10.1111/jcpp.13210. doi: 10.1111/jcpp.13210. PMID: 32020616. n = 640 Zwillinge ↥

  27. Kleberg, Frick, Brocki (2020): Can auditory warning signals normalize eye movements in children with ADHD? Eur Child Adolesc Psychiatry. 2020 Feb 1:10.1007/s00787-020-01484-w. doi: 10.1007/s00787-020-01484-w. PMID: 32008169. n = 71 ↥ ↥

  28. Sherigar SS, Gamsa AH, Srinivasan K (2022): Oculomotor deficits in attention deficit hyperactivity disorder: a systematic review and meta-analysis. Eye (Lond). 2022 Oct 24. doi: 10.1038/s41433-022-02284-z. PMID: 36280758. ↥

  29. Massen C (2004): Parallel programming of exogenous and endogenous components in the antisaccade task. Q J Exp Psychol A. 2004 Apr;57(3):475-98. doi: 10.1080/02724980343000341. PMID: 15204137. ↥

  30. Motomura Y, Hayashi S, Kurose R, Yoshida H, Okada T, Higuchi S (2023): Effects of others’ gaze and facial expression on an observer’s microsaccades and their association with ADHD tendencies. J Physiol Anthropol. 2023 Sep 7;42(1):19. doi: 10.1186/s40101-023-00335-2. PMID: 37679805; PMCID: PMC10486107. ↥

  31. Yoo JH, Kang C, Lim JS, Wang B, Choi CH, Hwang H, Han DH, Kim H, Cheon H, Kim JW (2024): Development of an innovative approach using portable eye tracking to assist ADHD screening: a machine learning study. Front Psychiatry. 2024 Feb 15;15:1337595. doi: 10.3389/fpsyt.2024.1337595. PMID: 38426003; PMCID: PMC10902460. ↥

  32. Lee, Yeung, Sze, Chan (2020): Computerized Eye-Tracking Training Improves the Saccadic Eye Movements of Children with Attention-Deficit/Hyperactivity Disorder. Brain Sci. 2020 Dec 21;10(12):1016. doi: 10.3390/brainsci10121016. PMID: 33371236; PMCID: PMC7766133. ↥

  33. Breuer F, Meyhöfer I, Lencer R, Sprenger A, Roesmann K, Schag K, Dannlowski U, Leehr EJ (2024): Aberrant inhibitory control as a transdiagnostic dimension of mental disorders - A meta-analysis of the antisaccade task in different psychiatric populations. Neurosci Biobehav Rev. 2024 Oct;165:105840. doi: 10.1016/j.neubiorev.2024.105840. PMID: 39103067. METASTUDY ↥

  34. Bellato A, Arora I, Kochhar P, Ropar D, Hollis C, Groom MJ (2023): Relationship between autonomic arousal and attention orienting in children and adolescents with ADHD, autism and co-occurring ADHD and autism. Cortex. 2023 Jun 28;166:306-321. doi: 10.1016/j.cortex.2023.06.002. PMID: 37459680. ↥

  35. Calancie OG, Parr AC, Brien DC, Coe BC, Booij L, Khalid-Khan S, Munoz DP (2024): Impairment of Visual Fixation and Preparatory Saccade Control in Borderline Personality Disorder With and Without Comorbid Attention-Deficit/Hyperactivity Disorder. Biol Psychiatry Cogn Neurosci Neuroimaging. 2024 Nov;9(11):1178-1187. doi: 10.1016/j.bpsc.2024.07.003. PMID: 39032694. ↥

  36. Aslan, Uzun, Fındık, Kaçar, Okutucu, Hocaoğlu (2020): Pupillometry measurement and its relationship to retinal structural changes in children with attention deficit hyperactivity disorder. Graefes Arch Clin Exp Ophthalmol. 2020 Jun;258(6):1309-1317. doi: 10.1007/s00417-020-04658-z. PMID: 32236704. n = 75 ↥

  37. Privitera CM, Noah S, Carney T, Klein SA, Lenartowicz A, Hinshaw SP, McCracken JT, Nigg JT, Karalunas SL, Reid RC, Oliva M, Betts SS, Simpson GV (2025): Pupillary unrest is attenuated in attention deficit hyperactivity disorder (ADHD). Neurosci Lett. 2025 Mar 10;851:138148. doi: 10.1016/j.neulet.2025.138148. PMID: 39914659; PMCID: PMC11981475. ↥ ↥ ↥ ↥

  38. Privitera CM, Noah S, Carney T, Klein SA, Lenartowicz A, Hinshaw SP, McCracken JT, Nigg JT, Karalunas SL, Reid RC, Oliva MT, Betts SS, Simpson GV (2024): Pupillary dilations in a Target/Distractor visual task paradigm and attention deficit hyperactivity disorder (ADHD). Neurosci Lett. 2024 Jan 1;818:137556. doi: 10.1016/j.neulet.2023.137556. PMID: 37951300; PMCID: PMC11787866. ↥

  39. López-Hernández AE, Miquel-López C, García-Medina JJ, García-Ayuso D (2024): Impact of stimulant treatment on refractive errors and pupil diameter in attention deficit hyperactivity disorder. Acta Ophthalmol. 2024 Aug;102(5):e842-e850. doi: 10.1111/aos.16657. PMID: 38337176. n = 100 ↥ ↥ ↥ ↥ ↥

  40. Beatty J (1982): Phasic not tonic pupillary responses vary with auditory vigilance performance. Psychophysiology. 1982 Mar;19(2):167-72. doi: 10.1111/j.1469-8986.1982.tb02540.x. PMID: 7071295. n = 11 ↥

  41. Bast N, Boxhoorn S, Supér H, Helfer B, Polzer L, Klein C, Cholemkery H, Freitag CM (2023): Atypical Arousal Regulation in Children With Autism but Not With Attention-Deficit/Hyperactivity Disorder as Indicated by Pupillometric Measures of Locus Coeruleus Activity. Biol Psychiatry Cogn Neurosci Neuroimaging. 2023 Jan;8(1):11-20. doi: 10.1016/j.bpsc.2021.04.010. PMID: 33930603. ↥

  42. Gilzenrat MS, Nieuwenhuis S, Jepma M, Cohen JD (2010): Pupil diameter tracks changes in control state predicted by the adaptive gain theory of locus coeruleus function. Cogn Affect Behav Neurosci. 2010 May;10(2):252-69. doi: 10.3758/CABN.10.2.252. PMID: 20498349; PMCID: PMC3403821. ↥

  43. Shine JM, Bissett PG, Bell PT, Koyejo O, Balsters JH, Gorgolewski KJ, Moodie CA, Poldrack RA (2016): The Dynamics of Functional Brain Networks: Integrated Network States during Cognitive Task Performance. Neuron. 2016 Oct 19;92(2):544-554. doi: 10.1016/j.neuron.2016.09.018. PMID: 27693256; PMCID: PMC5073034. ↥

  44. Boxhoorn S, Bast N, Supèr H, Polzer L, Cholemkery H, Freitag CM (2020): Pupil dilation during visuospatial orienting differentiates between autism spectrum disorder and attention-deficit/hyperactivity disorder. J Child Psychol Psychiatry. 2020 May;61(5):614-624. doi: 10.1111/jcpp.13179. PMID: 31853987. ↥

  45. Moiroud L, Moscoso A, Acquaviva E, Michel A, Delorme R, Bucci MP (2025): Gaze Dispersion During a Sustained-Fixation Task as a Proxy of Visual Attention in Children with ADHD. Vision (Basel). 2025 Sep 1;9(3):76. doi: 10.3390/vision9030076. PMID: 40981319; PMCID: PMC12452707. N = 44, n = 22 ↥

  46. Mangalmurti, Kistler, Quarrie, Sharp, Persky, Shaw (2020): Using virtual reality to define the mechanisms linking symptoms with cognitive deficits in attention deficit hyperactivity disorder. Sci Rep. 2020 Jan 17;10(1):529. doi: 10.1038/s41598-019-56936-4. PMID: 31953449; PMCID: PMC6969149. N = 85 ↥

  47. Bae, Kim, Han, Han (2019): Pilot Study: An Ocular Biomarker for Diagnosis of Attention Deficit Hyperactivity Disorder. Psychiatry Investig. 2019 May;16(5):370-378. doi: 10.30773/pi.2019.02.26.1. n = 25 ↥

  48. Redondo, Molina, Vera, Muñoz-Hoyos, Barrett, Jiménez (2020): Accommodative response in children with attention deficit hyperactivity disorder (ADHD): the influence of accommodation stimulus and medication. Graefes Arch Clin Exp Ophthalmol. 2020 Jun;258(6):1299-1307. doi: 10.1007/s00417-020-04645-4. PMID: 32172295. ↥

  49. López-Hernández AE, Miquel-López C, García-Medina JJ, García-Ayuso D (2025): Attention-Deficit/Hyperactivity Disorder (ADHD) is associated with near heterophoria and accommodative dysfunction. Vision Res. 2025 Dec;237:108699. doi: 10.1016/j.visres.2025.108699. PMID: 40975966. N = 80, n = 40 ↥

  50. Klitten LL, Rath MF, Coon SL, Kim JS, Klein DC, Møller M (2008): Localization and regulation of dopamine receptor D4 expression in the adult and developing rat retina. Exp Eye Res. 2008 Nov;87(5):471-7. doi: 10.1016/j.exer.2008.08.004. PMID: 18778704; PMCID: PMC2597030. ↥

  51. Asghari, Sanyal, Buchwaldt, Paterson, Jovanovic, Van Tol (1995): Modulation of intracellular cyclic AMP levels by different human dopamine D4 receptor variants. J Neurochem. 1995 Sep;65(3):1157-65. doi: 10.1046/j.1471-4159.1995.65031157.x. PMID: 7643093. ↥

  52. Jawinski, Tegelkamp, Sander, Häntzsch, Huang, Mauche, Scholz, Spada, Ulke, Burkhardt, Reif, Hegerl, Hensch (2016): Time to wake up: No impact of COMT Val158Met gene variation on circadian preferences, arousal regulation and sleep. Chronobiol Int. 2016;33(7):893-905. doi: 10.1080/07420528.2016.1178275. PMID: 27148829. ↥

  53. Mezer, Wygnanski-Jaffe (2012): Do children and adolescents with attention deficit hyperactivity disorder have ocular abnormalities? Eur J Ophthalmol. 2012 Nov-Dec;22(6):931-5. doi: 10.5301/ejo.5000145. PMID: 22505050. ↥ ↥

  54. Stone, Pardue, Iuvone, Khurana (2013): Pharmacology of myopia and potential role for intrinsic retinal circadian rhythms. Exp Eye Res. 2013 Sep;114:35-47. doi: 10.1016/j.exer.2013.01.001. PMID: 23313151; PMCID: PMC3636148. ↥

  55. Juster FT, Stafford F, Ono H (2004): Changing Times of American Youth: 1981-2003. Ann Arbor, MI: Institute for Social Research, University of Michigan, 2004. ↥

  56. Huang YT, Lu JY, Tien PT, Cheng YD, Lin HJ, Hsieh YW, Tsai FJ, Wan L, Lin HJ (2025): Dopaminergic medications as a preventive for myopia: insights derived from pediatric patients diagnosed with attention deficit hyperactivity disorder. Postgrad Med J. 2025 Apr 15:qgaf051. doi: 10.1093/postmj/qgaf051. PMID: 40231424. ↥ ↥ ↥

  57. Reimelt C, Wolff N, Hölling H, Mogwitz S, Ehrlich S, Roessner V (2021): The Underestimated Role of Refractive Error (Hyperopia, Myopia, and Astigmatism) and Strabismus in Children With ADHD. J Atten Disord. 2021 Jan;25(2):235-244. doi: 10.1177/1087054718808599. PMID: 30371126. n = 13.488 ↥

  58. Zhou X, Pardue MT, Iuvone PM, Qu J (2017): Dopamine signaling and myopia development: What are the key challenges. Prog Retin Eye Res. 2017 Nov;61:60-71. doi: 10.1016/j.preteyeres.2017.06.003. PMID: 28602573; PMCID: PMC5653403. ↥

  59. McCarthy CS, Megaw P, Devadas M, Morgan IG (2007): Dopaminergic agents affect the ability of brief periods of normal vision to prevent form-deprivation myopia. Exp Eye Res. 2007 Jan;84(1):100-7. doi: 10.1016/j.exer.2006.09.018. PMID: 17094962. ↥

  60. Ferguson C, Hobson C, Hedge C, Waters C, Anning K, van Goozen S (2023): Disentangling the relationships between motor control and cognitive control in young children with symptoms of ADHD. Child Neuropsychol. 2023 Mar 22:1-26. doi: 10.1080/09297049.2023.2190965. PMID: 36946244. n = 255 ↥

  61. Zhang Z, Bao S, Yan D, Zhai M, Qu J, Zhou M (2024): Causal Relationships Between Retinal Diseases and Psychiatric Disorders Have Implications for Precision Psychiatry. Mol Neurobiol. 2024 Sep 6. doi: 10.1007/s12035-024-04456-2. PMID: 39240279. ↥

  62. Bijlenga, Vollebregt, Kooij, Arns (2019): The role of the circadian system in the etiology and pathophysiology of ADHD: time to redefine ADHD? Atten Defic Hyperact Disord. 2019 Mar;11(1):5-19. doi: 10.1007/s12402-018-0271-z. ↥

  63. Choi H, Hong J, Kang HG, Park MH, Ha S, Lee J, Yoon S, Kim D, Park YR, Cheon KA (2025): Retinal fundus imaging as biomarker for ADHD using machine learning for screening and visual attention stratification. NPJ Digit Med. 2025 Mar 17;8(1):164. doi: 10.1038/s41746-025-01547-9. PMID: 40097590; PMCID: PMC11914053. ↥

  64. Chistiakov S, Dolganov A, Constable PA, Zhdanov A, Kulyabin M, Thompson DA, Lee IO, Albasu F, Borisov V, Ronkin M (2025): Time Series Classification of Autism Spectrum Disorder Using the Light-Adapted Electroretinogram. Bioengineering (Basel). 2025 Sep 2;12(9):951. doi: 10.3390/bioengineering12090951. PMID: 41007197; PMCID: PMC12467820. ↥

  65. Miquel-Lopez C, Garcia-Medina JJ, Lopez-Hernandez AE, Garcia-Ayuso D, De-Paco-Matallana M, Hernandez-Olivares J, Pinazo-Duran MD, Del-Rio-Vellosillo M (2025): Retinal Thinning in Attention Deficit Hyperactivity Disorder (ADHD): Structural Changes Detected by Spectral-Domain OCT. J Clin Med. 2025 Aug 13;14(16):5723. doi: 10.3390/jcm14165723. PMID: 40869549; PMCID: PMC12387911. ↥

  66. Arrondo G, Solmi M, Dragioti E, Eudave L, Ruiz-Goikoetxea M, Ciaurriz-Larraz AM, Magallon S, Carvalho AF, Cipriani A, Fusar-Poli P, Larsson H, Correll CU, Cortese S (2022): Associations between mental and physical conditions in children and adolescents: An umbrella review. Neurosci Biobehav Rev. 2022 Jun;137:104662. doi: 10.1016/j.neubiorev.2022.104662. PMID: 35427644. UMBRELLA REVIEW ↥ ↥

  67. Sumer F, Yazici M (2025): Alterations in Corneal Morphology and Thickness Associated with Methylphenidate Treatment in Children with Attention-Deficit/Hyperactivity Disorder. Diagnostics (Basel). 2025 Sep 18;15(18):2368. doi: 10.3390/diagnostics15182368. PMID: 41008740; PMCID: PMC12468723. ↥ ↥