Vision, Attention and Reading

This is Laurie Cestnick, Ph.D., a clinical neuropsychologist who practices in Massachusetts.  She has impressive credentials, having taught at Harvard and MIT, and being on the staff of the Hallowell Center in Sudbury, Mass.    Dr. Cestnick has published some interesting research relating to visual processes and dyslexia, and in particular is very interested in visual attention.  Her work is a nice example of the potential synergy between clinical neuropsychologists and developmental/rehabilitative optometrists.  You may recall that a couple of months ago I did a six part series on our patient, Ruth, who is experiencing alexia sine agraphia.  As Ruth recovered in therapy and in time, she progressed from alexia to dyslexia, and she exhibits features of hemispatial neglect layered on top of her right homonymous field loss.  The last part of the series discussed optometric approaches to visual attention and temporal order challenges in patients with acquired dyslexia that can also be seen in children with developmental dyslexia.  For that reason I found this YouTube video presentation by Dr. Cestnick of particular interest.

At the end of Dr. Cestnick’s video, at the 1:09:10 mark, a woman asks her if she has any advice for optometrists or ophthalmologists evaluating a child for these types of problems.  Dr. Cestnick notes that you want to rule out a vision problem.  Reading issues aren’t always brain based.  She mentions that a “stereoptic vision problem can look like neglect”.  She goes on to explain a stereoptic vision problem, which sounds like she’s describing either a shifting due to unstable phoria (she describes a phi phenomenon), or a type of midline shift one might notice in suppression.  Dr. Cestnick opines that “when you send these kids to get their vision tested, they come back saying they have ocular motor dysfunction – which basically means they think their muscles are weak, which they can never test for, which is the same as saying they have a brain based problem.  You can’t tell sometimes if it’s eye based or brain based, you can only tell if it’s something strong like stereoptic.”

Dr. Cestnick is on the right track, noting that patients with these issues need help not only in improving spatial awareness in the field in which they have inattention, and that neglect can occur in the right field which is more disruptive when reading English (witness our patient, Ruth) – but that timing or speed is a crucial factor.  Many individuals with neglect will do well if they have time to scan, but will get tripped up otherwise.  There is much in her presentation that is insightful, and her approach would be that much more powerful if combined with knowledge of what developmental/rehabilitative assessment and therapy has to offer.


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