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Eyes and Vision in ADHD

Eyes and Vision in ADHD

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

A number of studies have identified various visual problems in children with ADHD. These include visuoperceptual problems, convergence insufficiency, impaired stereopsis, a higher prevalence of refractive errors, an increased risk of strabismus (crossed eyes) and astigmatism, as well as abnormalities in eye movements and accommodation. In addition, ADHD is associated with neurophysiological changes in the optic nerves, genetic links to the DRD4 dopamine receptor gene, and altered pupillary dynamics. Visuomotor function—that is, the coordination of visual perception and the motor system—correlates with cognitive abilities such as inhibition and cognitive flexibility.

ADHD is characterized by an impaired dopamine system with reduced extracellular dopamine.
Dopamine also plays a role in the visual system.12345

In a study of 42 children with ADHD and 50 controls, 83% of the ADHD group achieved a visual acuity of over 0.8 without medication, compared with 98% of the controls (p = 0.032).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.7
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 the self-report on 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.8A selective blue deficit has also been reported in children with ADHD.9

ADHD medication improved visual field abnormalities and visual acuity in children with ADHD.10 Another study found no significant improvements.6 In a small study, surgical treatment of strabismus improved ADHD symptoms, as reported by parents, in 7 out of 8 people with ADHD.11
A small study was able to distinguish people with ADHD from those without the condition quite well using eye-tracking.12
It is therefore 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%)

A study found visual-perceptual problems in 21% of children with ADHD, compared with only 2% of children without ADHD.6

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

Eye convergence movements are oppositely directed (disjunctive) eye movements. Convergence refers to the inward-directed convergence that occurs when looking at 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).7

A study found that 24% of children with ADHD had convergence insufficiency, compared with only 6% of children without ADHD.6
Several other studies found that ADHD was three times as common in children with convergence insufficiency as in those without the condition.1314
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%.15

Significant differences were found between 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 group and the control group (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).16

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

Stereoacuity is a person’s ability to perceive objects at different distances as separate entities. Stereoacuity thus refers to the smallest transverse disparity that can still be perceived binocularly as a difference in depth; it is expressed in arcseconds.

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

4. Strabismus / Heterophoria (Strabismus / Latent Strabismus) in ADHD (+93% to +300%)

A study found that among children with ADHD

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

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 1.10–1.17).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).19
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).20

A meta-analysis of 35 studies involving N = 3,250,905 participants found that ADHD was associated with a 93% increased risk of strabismus (OR = 1.93) and a 79% increased risk of hyperopia (OR = 1.79).21

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).22
ADHD and hyperopia, myopia, astigmatism, and strabismus were mutually predictive.23
A predisposition to strabismus is believed to causally increase the risk of ADHD.24

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

A study found astigmatism in 24% of children with ADHD, compared with only 6% of children without ADHD.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).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).22
ADHD and hyperopia, myopia, astigmatism, and strabismus were mutually predictive.23

6. Eye Movements and ADHD

An experimental study (n = 16) reports significant differences in eye movements in individuals with ADHD, as determined by electrooculography (EOG).25
A large study found a correlation between premature anticipatory eye movements and inattention, but not between directional errors and ADHD symptoms.26

6.1. Saccades

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

A meta-analysis found evidence that children with ADHD:28

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

Saccadic eye movements (eye jumps) are strongly influenced by factors such as attention and inhibition.2930 Since attention and inhibition are impaired in ADHD, it seems plausible that saccadic eye movements would show abnormalities in 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 exhibited increased saccade latency and intensity, as well as shorter fixation times, during eye-tracking tasks.31
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 during the antisaccade task appear to be present across all mental disorders, particularly as reflected in error rates.32

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 intra-individual presaccadic pupil size was smallest or largest.33

It is believed that computer-based training can help correct the abnormalities in saccadic eye movements associated with ADHD.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.35

6.2. Pupil velocity

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

6.3. Pupil diameter, pupil movement

Among adults with ADHD, it was found that

  • Reduced pupillary oscillation performance during passive viewing 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.37
  • reduced pupil dilation during a task requiring sustained visual attention38

The authors’ highly restrictive approach to data disclosure could be an indication of potential diagnostic utility.

Pupillary activity shows a high degree of correlation between the two eyes. This suggests a control center at the level of the Edinger-Westphal complex in the midbrain that acts on both irises simultaneously.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.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.37

Tonic and phasic norepinephrine firing can be detected based on pupil diameter.
The basal pupil diameter corresponds to tonic norepinephrine 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.3940 An increase in baseline pupil diameter correlated with a decrease in task utility and disengagement from the task (exploration), a decrease in baseline diameter accompanied by an increase in task-induced dilation correlated with engagement in the task (exploitation).41
Pupillary dilation is a physiological indicator of increased arousal and noradrenergic activity in the locus coeruleus.27
Pupil diameter at rest also reflects the connectivity between the frontoparietal, striatal, and thalamic regions of the brain.42

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.”

Pupil dilation amplitudes in response to relatively unexpected spatial target stimuli showed:43

  • in cases of ADHD
    • Shorter pupillary dilation latencies compared to the ASS, ASS + ADHD, and control groups.
  • for ASD and ASD + ADHD
    • slower orientation responses than the control group
    • higher pupil dilation amplitudes compared to ADHD patients and controls

ADHD medication significantly increased pupil diameter (3.91 mm vs. 3.58 mm, p = 0.017).44

6.4. Eye stability

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.45

7. Visual Field Defects

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.46

8. Paper Thickness in ADHD

A small study hypothesizes that increased macular thickness in children with AD(H)D could account for the increased ratio of the thickness of the right frontal lobe to that of the parietal cortex observed in ADHD.47

9. Accommodation in ADHD

Children with ADHD showed a reduced accommodation response that was not influenced by the accommodation stimulus. There was no significant effect of ADHD medication on accommodation accuracy.48 Accommodation refers to the eye’s ability to focus on objects at different distances.
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, 0.96]) and variability (Hedge’s g = 0.40 [CI: 0.17, 0.64]) in the accommodative response.7

A study found no evidence of any issues related to visual acuity, refraction, or accommodative ability in children and adolescents with ADHD.16

Compared to the control group, people with ADHD showed:49

  • a significantly higher accommodation delay (+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 take medication and those who do not take medication
  • Men exhibited a higher degree of near heterophoria than women
  • Men showed significantly more phoria at close range

10. Morphological Changes in the Optic Nerves in ADHD

A study found that children with ADHD were more likely to have smaller optic nerves, smaller neuroretinal margins, or reduced tortuosity of the retinal arteries.6Compared to a healthy control group, children with ADHD exhibited significantly smaller optic disc 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 out of 9 children with visuocognitive problems.

11. DRD4-7R and Vision in ADHD

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.50 Drd4 transcription follows a distinct circadian pattern.5

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 ⇒ Pathogenesis.
DRD4-7R correlates with a reduced ability to deplete the light-sensitive second messenger cyclic adenosine monophosphate (cAMP) in response to light.51
In addition, there were indications of a possible correlation between DRD4-7R and increased daytime sleepiness52, which could be a consequence of the seesaw effect between dopamine and melatonin.

12. Refractive Errors (Vision Problems) and ADHD

A study found refractive errors in 83% of the children with ADHD who were examined.53 A 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, 0.42]).7

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.5354

There is growing evidence that the global rise in myopia is dopaminergic in nature and is linked to a lack of daylight.
Between 1981 and 2002, outdoor activities fell by half, from 1 hour and 40 minutes per week to 50 minutes per week.55

Within the ADHD group, the prevalence of ametropia (refractive error) under cycloplegia was significantly higher among people with ADHD who were not taking medication than among those on 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 results.44

A study found no evidence of any issues related to visual acuity, refraction, or accommodative ability in children and adolescents with ADHD.16

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

An analysis of the KiGGS study (N = 13,488) found that 13.0% of children with ADHD had hyperopia, compared with 8.2% of people with ADHD (OR 1.67).22
ADHD and hyperopia, myopia, astigmatism, and strabismus were mutually predictive.23

12.2. Nearsightedness (myopia) (+29%)

The evidence regarding nearsightedness is inconsistent.

  • A Taiwanese registry cohort (data from 2009–2020) found a 22% increased risk of myopia among people with untreated ADHD compared with people without ADHD (aHR 1.22; 95% CI 1.21–1.24).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 the associations with hyperopia, astigmatism, and strabismus.57
  • A meta-analysis of 35 studies found no overall difference in refractive errors (Hedge’s g = 0.08 [CI −0.26; 0.42]).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 0.59–0.62); the reduction was greater when taking two active ingredients (aHR 0.28) than when taking one (aHR 0.50).56
ADHD and hyperopia, myopia, astigmatism, and strabismus were mutually predictive of one another.23
A lack of bright daylight (outdoors) increases the risk of nearsightedness (myopia). The increase in nearsightedness caused by a lack of daylight is mediated by dopamine.5859 The release of dopamine in the retina inhibits the progression of nearsightedness56

13. Visuomotor function correlates with inhibition and cognitive flexibility

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

A study reports: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

Retinal detachments and tears were associated with a 19% increased risk of ADHD.61

The discussion focuses on whether retinal disorders could cause the shifts in circadian rhythms that are common in ADHD and whether these could be a major cause of ADHD.62

15. Retina for ADHD Diagnosis

Using machine learning, the system was able to distinguish ADHD very accurately based on images of the retina, achieving AUROC values ranging from 0.955 to 0.969.63The same technique is also suitable for diagnosing ASD.64
A study that did not use machine learning found an AUC of 0.6 to 0.7 for ADHD based on retinal thinning.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, 0.02])7

16. Conjunctivitis

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)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)66

17. Stimulants and Eye Parameters

A study using specular microscopy and corneal topography found the following in children with ADHD after 6 months of MPH treatment:67

  • Endothelial cell density significantly reduced
    • a significant but weak correlation with inattention
  • Average cell area significantly increased
  • Standard deviation of cell area significantly increased
  • Coefficient of variation of cell area significantly increased
  • Hexagonality index
  • Central corneal thickness significantly increased
    • a significant but weak correlation with inattention
  • Intraocular pressure significantly elevated within normal physiological limits

The authors recommend regular eye exams for those taking stimulants over the long term.

18. Unchanged eye parameters

  • Axle length unchanged44
  • Corneal topography parameters remain unchanged44
    • ADHD is believed to causally increase the risk of corneal ulcers and corneal inflammation24
  • Properties of the anterior chamber remain unchanged44
  • ADHD is thought to causally reduce the risk of glaucoma24

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