The Influence of Refractive Errors on Facial Expression Processing in Children With Autism Spectrum Disorder: An Eye‐Tracking Study

Facial expression processing is important for social understanding; among children with autism spectrum disorder (ASD), refractive errors may reduce visual input, further hindering their ability to recognize and interpret faces. This study aimed to investigate the gaze patterns of children with ASD when viewing facial emotion expression pictures under refractive errors and compare these patterns with those of typically developing (TD) children. A total of 76 participants diagnosed with ASD and 73 TD children matched by age were included. All children underwent a comprehensive ophthalmic examination and successfully completed the eye-tracking tasks. Astigmatism accounted for > 90% of refractive errors, though all types were included to reflect real-world visual challenges. The results showed that children with refractive errors showed slower responses to the visual stimuli than children with typical refractive status. Children with ASD and refractive errors exhibited slower responses to the mouth area compared to the nose and eyes and experienced difficulty in rapidly distinguishing between the nose and eyes. Additionally, they were unable to differentiate visual patterns between the nose and mouth regions during fixation tasks. In contrast, children with ASD with typical refractive status showed visual sensitivity and tendencies for areas of interest (AOIs) comparable to those of TD children, with response times fastest for the nose, followed by the eyes, and slowest for the mouth. In conclusion, refractive errors, particularly astigmatism, may substantially contribute to difficulties in accurately responding to facial social cues and directing visual attention to socially relevant areas in children with ASD.