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Visual perceptual

Dysfunctions and

Made by :Gundeep
MOT Neurology
What is visual perception ?
The ability to use vision to adapt to the
environment which requires the integration
of vision within the CNS to turn the raw data
supplied by the retina into cognitive
concepts of the perception of space and
objects that can be manipulated and used
for decision making .
The process by which this occurs is known
as visual perception .
How it works ?
It occurs through visual processes

Visual input from environment to eye

Pathway from retina to geniculate nucleus to primary

visual cortex

Input travel from primary visual cortex to

preforntal lobe for complete visual processing
Visual processing within the CNS


The visual cortexis the part of the cerebral cortex responsible for
processing visual information, and is located in the occipital lobe.
The term visual cortex refers to the primary visual cortex (also
known as striate cortex or V1) and extra striate visual cortical
areas such as V2, V3, V4, and V5.

Ventral stream

Primary cortex transmits information to

two primary pathways
The dorsal stream and The ventral stream.
Visual input
from theresponsible
visual cortex
for form
Thedorsal streamis associated with motion, the
and posterior
object representation,conscious
temporal circuitry to the perception
of lobe to
position of objects in the world, engagement with
cortical visual
and is associated
processing with Long term memory
the environment and control of the eyes/arms
(especially when visual information is used to
visual perceptual processing can be defined in
a hierarchical model.
It consist of process of visual cognition , visual
memory, pattern recognition, visual scanning
and visual attention .
Hierarchical model of visual
perceptual processing
Visual memory and
pattern recognition

Visual scanning and inattention

Visual acuity, visual field and oculomotor

The highest order visual perceptual process in
the hierarchy is visual cognition.
These perceptual processes are supported by
three basic visual function that forms the
foundation of the hierarchy : Oculomotor
Control,Visual Fields ,Visual Acuity
Visual cognition : It is a ability to manipulate
and integrate visual inputs with other sensory
information to gain knowledge, solve
problems, formulate plans , and make
decisions.( For the complete cognitive
For example
Adult standing
at a distance.
Visual memory
Visual memory : visual cognition cannot occur
without the presence of visual memory.
The mental manipulation of visual stimuli
requires the ability to create and retain a
picture of the object in the minds eye while
the visual analysis is being completed.
Before the visual image can be stored in
memory , and individual must recognize the
pattern making up the image .
Pattern recognition, which sub-serves visual
memory in the hierarchy , it involves
identifying the object from the surroundings.
A salient feature is one that distinguishes a
particular object from another .
For example
Green apple and red apple

To see its general shape, contour and features like color,

shading, and texture .
Pattern recognition can not be accomplished
without the next process in the hierarchy :
visual scanning : It is accomplished through
the use of saccadic eye movements . A
saccade is a movement of the eye towards an
object of interest in the environment .
Visual attention
Visual scanning is actually a product of visual
attention .
Visual search occurs on two levels :
An automatic or reflexive level- (controlled by
brain stem) Any novel object moving or
sudden appearing in the peripheral visual
field, such as a flash of light. This response
serves to protect an individual from
unexpected intrusions in the environment.
A voluntary level- (directed by the cortex), is
complete for the explicit purpose of gathering
Visual attention
Visual attention is a critical prerequisite for visual
cognitive processing
If and how a person attends to an object or
information determines if and how that visual
input is analyzed by the CNS, which becomes the
basis for decision making .
People who do not attend to visual information
do not initiate a search for visual information , do
not complete pattern recognition , do not lay
down a visual memory and cannot use this visual
input for decision making .
Engagement of visual attention and the other
higher level processes in the hierarchy cannot
occur unless the CNS is receiving clear,
concise visual information from the
environment .
Visual input is provided through the visual
functions of oculomotor control, visual fields
and visual acuity.
Oculomotor control : It enables eye
movement to be completed quickly and
accurately and ensures perceptual stability .
Visual fields : Which lets the brain know
what's going on in the environment .
Visual acuity : Ensures that the visual
information sent to brain is accurate.
Disorders of visual perception are found in :
Intracranial compressing masses
Neurosurgical procedures
Demyelinating disorders
Neurodevelopmental conditions (eg, autism)
Neurodegenerative disease
Schizophrenia and depression.
Purpose of the
To identify the limitation in activity or
To link that limitation to presence of a visual
To develop an appropriate intervention plan
based on the results of the assessment .
Occupational therapy assessment of specific
visual perceptual impairments
Visual acuity : It is commonly measured by
Snellen fraction.
Normally :( 20/20) it means that a person can
see the letter that a person with normal vision
can see at 20 feet.
The common Defects of visual acuity are :
1. Myopia(nearsightedness),
2. Hyperopia(farsightedness)
3. Astigmatism- Itis an optical defect in which
vision is blurred due to the inability of the optics
of the eye to focus a point object into a sharp
focused image on the retina.

Assessed by :
LeaNumbers low vision test chart
and warren text card
Visual field
Visual field defect is caused due to damage to the
receptor cells in the retina optic pathway that relays
retinal information to CNS for processing results in a visual
field deficits .
Conditions occuring in VFD are :
Heminanopsia : There has been loss of vision in one half of
the visual fields in the eyes.
Homonymous : it means deficit is same in both the eyes.
The assessment of the VF is know as perimetry test these
ranges from simple confrontation test to more precise
imaging of a scanning laser opthalmoscope (SLO).
Visual field defects
Screening of visual field
Confrontation testing
Equipments: eye patch or patches
Set up : patient seated directly opposite to examiner,
approx 20 inches eye to eye .
Background behind examiner should be dark and
distraction free.
Procedure : patch the patient left eye and close or
patch your own right eye
Instruct patient to look at your left eye and tell him or
her you will be moving a target in from the side and
the patient is to indicate when the target is first seen.
Move target in from all angles
Compare the patient response with yours.
Position hands at 3 and 9 clock so that you
can just see your fingers . Ask the patient how
many fingers you are holding up .
A problem is indicated if the patient cannot
see the target when you do or does not see
both fingers simultaneously.
Visual skills for reading test provides an
effective way to measure the interference of
the VFD on reading performance.
Perimetry devices such as the Damato 30
point multifixation campimeter ( biVABA).
Visual attention and
Condition which occurs due to defect of VA and
scanning are :
Hemi- inattention : Instead of initiating from left to
right visual search pattern, clients with right
hemisphere injuries often begin and confine search to
right side .
Visual neglect : it is a combination of hemi-
inattention and left visual field defect (VFD).clients
with this condition show exaggerated inattention
towards the left half of the visual space surrounding
the body and often do not move the eye past midline
towards the left or turn head towards the left side .
Unilateral neglect
Hemispatial neglect, also called hemiagnosia,
hemineglect, unilateral neglect, spatial neglect,
unilateral visual inattention, hemi-inattention or
neglect syndrome is a neuropsychological condition
in which, after damage to one hemisphere of the brain
is sustained, a deficit in attention to and awareness of
one side of space is observed.
It is defined by the inability of a person to process and
perceive stimuli on one side of the body or
environment that is not due to a lack of sensation.
Unsworth, C. A. (2007). Cognitive and Perceptual Dysfunction. In T. J. Schmitz & S. B. OSullivan (Eds.), Physical
Rehabilitation (pp. 1149-1185). Philadelphia, F.A: Davis Company.
Spatial neglect may result from lesions of the dominant
parietal, temporal, or frontal cortex.
There are different types of unilateral neglect:(Eskes &
Butler, 2001)
Personal neglect
Peri-personal neglect
Extra-personal neglect
Brain Imaging Studies
Assessment of lower level visual functions
( visual acuity , oculomotor function and visual
Letter cancellation test
Trail making
Brain injury visual assessment battery for
adults.(Other specific scales are to be
discussed later on)
Scan board test
Described by warren
Consist of large 20 by 30 inch board with
a series of 10 numbers displayed in an
unstructured pattern .
The board is placed at the eye level and
centered at the clients midline .
The client is asked to scan the board
Point out all of the numbers that are
The examiner records the pattern the
client follows .
Comparision of search pattern : person with
visual field defect vs hemi- inattention
Visual field defect Hemi-inattention
Search pattern is Search pattern is
abbreviated toward blind asymmetrical:
fields initiated/confined to the
right side
Attempts to direct search No attempt to direct search
towards blind side toward left side
Search pattern is organized Search pattern is random
and generally efficient and generally inefficient
Clients rescans to check Client does not rescan to
accuracy of performance check accuracy of
Time spend on task is Client completes task
appropriate to level of quickly; level of efforts
difficulty applied is not consistent
with difficulty of task
From Warren M:Brain injury visual Assessment battery
Occulomotor function
Deficit in oculomotor control following brain
injury generally results from either of two
types of disruption
Specific cranial nerve
Disruption of central neural control of the
extra ocular muscles affecting the
coordination of eye movements .
Oculo motor function
The defects is associated with cranial nerve
injury .
Oculomotor nerve (3): impaired vertical eye
movements , lateral diplopia for near vision
tasks, dilation of pupil and impaired
accomodation , ptosis of eyelid.
Trochlear nerve (4) : impaired downward and
lateral eye movements, vertical diplopia for
near vision tasks
Abducence nerve (6) : impaired lateral eye
movements, lateral diplopia for far vision
Assessment of oculomotor function
Ask the client about the expercience of
diplopia :
o Look for the diplopia disappering when eye
o Which side lateral or vertical
o Far or near
o The next part of the assessment is observing
the client eye and eye movement for
1. The eye are observed for asymmetries in
pupil size , eyelid function and eye position
Look for ptosis
Tracking of the moving object : in figure of H
or X pattern
Note the point of convergence ( normally
approx 3 inches from the bridge of nose ).
Eye ball movement
Assessment of specific visual
perceptual impairments
Visual object Agnosia : caused due to lesion to the right occipital
lobe . In this the person is unable to recognize and identify an item
using visual means.
Assessment is performed by asking the individual to identify five
common objects by sight.
Color agnosia : Refers to inability to remember and recognize the
specific colors for common objects in the environment. Also know as
Central Achromatopsia
Assessment : present the client with two common objects that are
accurately colored and two objects that are not accurately colored
. Ask the patient to pick the object that are not accurately colored.
Color Anomia: refers to the clients inability to name the color of
the object. while the client understand the differences between
the different colors of objects, they are unable to name the color
of the object accurately .
Color anomia : ask the client to name the color
of various objects in their environment .
Metamorphopsia : refers to visual distortion of
objects, such as the physical properties of size
and weight .Assessment includes presenting
the client with various objects of different
weights and sizes.
Prosopagnosia : refers to an inability to
recognize and identify familiar faces caused
due to lesion of the right posterior hemisphere .
Non standardized test : to identify the names of
the people in photographs, with family
Simultanognosia : refers to the inability to
recognize and interpret a visual array as a
whole and is caused by lesion to the right
hemisphere of the brain .
The person is able to identify the individuals
components of a visual scene , but are unable
to recognize and interpret the gestalt of the
scene .
Assessment : presenting the client a
photograph of a detailed visual array .
Right left discrimination :

It is the inability to identify the right and left

sides of ones own body or of that of the
examiner .
The person with right and left discrimination
cannot tell the therapist which is the right arm
and which is the left .
It is caused due to lesion at the parietal lobe
of either hemisphere
Testing : ask the person to point to body part
on command, such as : right ear, left foot,
right arm.
Visual-spatial perception Disorders
It refers to appreciate the spatial arrangement of ones body,
objects in relationship to oneself, and relationship between
objects in space.
Figure-ground discrimination: it is a inability to visually
disctinguish a figure from the backgroung in which it is
The patient cannot locate items in a pocketbook or drawer,
locate buttons on a shirt.
It is caused due to parieto-occipital lesion of the right
hemisphere and less frequently the left hemisphere commonly
produce this disorder.
It can be assessed functionally in a variety of contexts . During
a dressing activity, or by asking in the client to pick one utensil
out of many utensils .
The Ayres Figure-ground Test( subtest of the southern California
sensory integration tests)
Form discrimination
Form discrimination : It is inability to perceive or
attend to subtle difference in form and shape .
The patient is likely to confuse objects of similar
shape or not to recognize an object placed in a
unusual position.
It is caused due to lesion at the parieto-temporo-
occipital region of the non-dominant lobe.
Testing : A number of items similar in shape and
different in size are gathered. The patient is
asked to identify them. Visual agnosia must be
ruled out first.
Spatial Relations
Spatial disorientation, is the inability to perceive the
relationship of one object in space to another object,
or to oneself.
It is caused due to lesion to the inferior parietal lobe
Testing : The patient may be unable to tell the time
from a clock because of difficulty in perceiving the
relative positions of the hands. Before testing
unilateral neglect and hemianopsia should be ruled
out .
Rivermead perceptual assessment battery(RPAB)
The Arnadottir OT-ADL Neurobehavioural Evaluation
Depth perception
In this the person experiences inaccurate
judgment of direction, distance, and depth.
Caused due to lesion in the posterior right
hemisphere in the superior visual association
To test the person is asked to fill a glass of
Position in space
It is inability to perceive and to interpret
spatial concepts such as up, down, under,
over, in, out, in front of, and behind.
The lesion is usually located in the non-
dominant parietal lobe.
Testing : to test function, two objects are
used, such as a shoe and a shoebox. The
patient is asked to place the shoe in different
position in relation to shoebox; for example, in
the box, on top of box or next to box.
Vertical disorientation: it is the distorted
perception of what is vertical . Caused due to
lesion in the non-dominant parietal lobe.
Test by asking the person to place the cane
vertically when it is placed horizontally .
Topographic disorientation: difficulty in
understanding and remembering relationship of
one location to another .
Caused due to lesion inferior parietal lobe or
occipital association cortex and occipito
temporal cortex.
Test by asking to describe or to draw a familiar
root such as the block in which he lives .
Standardized assessment
Toglias dynamic object search test : assess the visual
processing , visual scanning , and visual attention
AMPS( assessment of motor and process skills ): it
evaluates the performance skills necessary for
engagment in areas of occupation by assessing 16
motor skills and processing skills ( eg. Temporal
oraganization , organizing space and objects )
Loewenstein occupational therapy cognitive
assessment ( LOTCA) and Rivermead perceptual
assessment battery provide a comprehensive profile
of visual perceptual and motor skills and involve both
motor free and constructional functions.
A variety of other assessment tools require
either a verbal or a simple pointing response .
Motor-Free Visual perceptual Test revised ( MVPT-
Assess basic visual perceptual abilities
And an alternative version of the test present the
multiple choice in a vertical format to reduce the
interference of hemianopsia or visual inattention
The Test of Visual perceptual skills upper level
Hooper visual organization test
Minnesota paper Form Board Test
1. Motor-Free Visual Perception Test, Third
Edition (MVPT-3)

By Ronald P. Colarusso, EdD, and Donald D. Hammill, EdD

The Motor-Free Visual Perception Test (MVPT) is a
widely used, standardized test of visual
perception. This measure is meant to assess
visual perception independent of motor ability. It
was originally developed for use with children ,
however it has been used extensively with adults.
Original MVPT.
Contains 36 items.
Contains 40 items. Since theMVPT-Rincludes
children up to 12 years old, four items were added
to the items of theoriginal MVPTto accommodate
the increased age-range covered by the norms of
Contains 65 items.
Original MVPT and MVPT-R.
The test takes 10-15 minutes to administer, and 5
minutes to score (Brown et al., 2003).
Original MVPT and MVPT-R.
One point is given for each correct response. Raw
scores are then converted to age and perceptual
equivalents to allow for a comparison of the
patient's performance to that of a normative
group of same-aged peers.
The Developmental Test of Visual Perception:
Second Edition (DTVP)
Purpose: Measures both visual perception and visual
motor integration skills
Ages: 4 to 10 years
Administration Time: 45 minutes
Subtests include:
Visual-Motor Speed, Position in Space, Eye-Hand
Coordination, Copying Spatial Relations, Figure-Ground,
Visual Closure, Form Constancy.
The subtests are grouped into two categories:
Motor-Reduced Visual Perception and
Visual-Motor Integration.
Scoring is recorded as quotients in these areas. A
General Visual Perception Quotient is also generated.
The Complete Set includes Manual, Picture Book, 25
Profile/Examiner Record Forms, and 25 Response
Booklets, all in a storage box.
The TVPS-3 includes the following subtests:
The Test of Visual-Perceptual Skills, Third Edition:

Visual Discrimination
Visual Memory
Visual-Spatial Relationships
Form Constancy
Visual Sequential Memory
Visual Figure-Ground
Visual Closure
It Assess to determine the visual perceptual
strengths and weaknesses of students.
Items are presented in a multiple-choice format, and
responses can be made vocally (by letter of the
response choice) or by pointing to the answer
choice. This format can be used with students who
may have impairments in motor, speech, hearing,
neurological and cognitive functions.
It is untimed and takes about 25 minutes. Scoring is
quick and uncomplicated. Raw scores are reported
as scaled scores andpercentile ranksfor each
subtest; the overall total score is reported as a
standard score and percentile rank. Age-equivalents
are also provided for the subtest and overall scores.
Specific test Scales for Unilateral
Spatial Neglect
Albert's Test Unilateral spatial neglect (USN)
Behavioral Inattention Test Unilateral spatial neglect
Bells TestVisual neglect - extrapersonal space
Catherine Bergego Scale (CBS)Visual neglect -
extrapersonal space
Clock Drawing Test (CDT)Visuospatial and praxis abilities,
may determine attention and executive dysfunctions
Comb and Razor Test Unilateral spatial neglect (USN) -
personal space
Double Letter Cancellation Test (DLCT) Unilateral
spatial neglect (USN) in the near extrapersonal space
Draw-A-Man Test-Unilateral spatial neglect (USN) in
the personal and extrapersonal space (as well as the
presence of anosagnosia). Other constructs:
intellectual ability/cognitive function/body image
Line Bisection Test-Unilateral spatial neglect (USN)
Semi-Structured Scale for the Functional
Evaluation of Hemi-Inattention-Unilateral spatial
neglect (USN) - personal and extrapersonal space
Single Letter Cancellation Test (SLCT)-Unilateral
spatial neglect (USN) - extrapersonal space
Star Cancellation Test-Unilateral spatial neglect
(USN) - extrapersonal space

The test sheet is presented to the patient

at their midline. Some of the lines are
pointed out to him/her, including those to
the extreme right and extreme left. The
examiner asks the patient to cross out all
of the lines, and demonstrates what is
required by crossing out the 5 central lines
him/herself. The patient is encouraged to
cross out all the lines until he/she is
satisfied that they have all been crossed.
Time to administer
Less than 5 minutes
11x 8.5-inch page of paper with 41 lines 2 cm
in length each and pencil.
Draw a man test
Using a blank piece of
paper and a pencil, the
seated patient must draw
an entire man. The
picture is scored by
giving one point for the
presence of each of the
following body parts:
head, trunk, right arm,
left arm, right hand, left
hand, right leg, left leg,
right foot, and left foot.
Research Articles
Impact of Motor, Cognitive, and Perceptual Disorders on
Ability to Perform Activities of Daily Living After Stroke
by Louisette Mercier, MA et al . In (Stroke. 2001;32:2602-2608)

Background and PurposeThis study evaluates

the relative impact of motor, cognitive, and
perceptual deficits on functional autonomy with
100 elderly (aged 55 to 79 years) victims of
MethodsTwo different approaches were used for
measuring functional autonomy: the Functional
Autonomy Measurement System (Systme de
Mesure de lAutonomie Fonctionnelle [SMAF]) and
the Assessment of Motor and Process Skills
The Functional Autonomy Measurement System
(Systme de Mesure de lAutonomie Fonctionnelle
[SMAF]) is an instrument for evaluating autonomy that
was developed on the basis of the theoretical
framework of the World Health Organizations
international classification of impairments, disabilities,
and handicaps.
It evaluates 29 functions covering activities of daily
living (7 items), mobility (6 items), communication (3
items), mental functions (5items), and instrumental
activities of daily living (8 items). Each function is
scored on a 5-point scale (0, 0.5, 1, 2, and 3).
The Assessment of Motor and Process Skills (AMPS)
provides a measure of the quality of motor and process
skills when the subject carries out an activity of daily
living or a domestic activity.
Motor Factor
Evaluated byUpper extremity functional
hemiplegia (UEFH)
Cognitive Factor
Most of the various tests chosen to evaluate
cognitive functions were taken from a
neuropsychology battery called Protocole
dvaluation Neuropsychologique Optimal (PENO).
Perceptual Factor
Evaluation by MVPT-V
The Motor Free Visual Perception Test-Vertical (MVPT-V) evaluates visual
discrimination, figure-ground differentiation, consistency of form, visual
memory, and visual synthesis.
Bells test
A cancellation task using bells was developed by Gauthier et al and gives
a more refined evaluation of the degree of unilateral visual neglect than
previous cancellation tests).
Benton test
Spatial relation deficits were measured with the line orientation judgment
test, which was considered by Beaumont and Davidoff to be a test of
visuospatial functions.
OSOT battery
Three subtests were taken from the Ontario Society of Occupational
Therapy perceptual evaluation battery to measure visuoconstructional
Rey figure test
Visuoconstructional deficits/apraxia were also measured with the complete
detailed scoring system for the copy of Reys complex figure. Norms have
been established for neurologically healthy people and for various groups
of stroke patients.
Results:show that motor, cognitive, and
perceptual factors all make a significant
contribution to the variation in functional
autonomy and confirm the accuracy of the
model (93% of the variance is explained when
the SMAF is used to measure functional
autonomy, and 64% of the variance is
explained when the AMPS is used).
ConclusionsThe factors that make the
greatest contribution in explaining the
variance in functional autonomy are, in order
of importance, the motor factor, the perceptual
factor, and the cognitive factor.
Seeing The Gaps: A Systematic Review Of Visual
Perception Tools For Children With Hemiplegia. MEGAN
AULD, et al In 2011 disability and rehabilitation.

Aim visual perception difficulties are

common in children with cerebral palsy
hemiplegia, however it is not known which
assessment tool is the best for this population.
Method: Databases were searched for
assessments that: (i) measured visual
perception; (ii) were reported in studies with
children with hemiplegia and (iii) had
clinimetric data available to assessors.
Results: Three assessments met criteria: the Test of Visual
Perceptual Skills (TVPS), Motor-Free Visual Perceptual Test
(MVPT) and Developmental Test of Visual Perception
All three assessments demonstrate variable construct and
criterion validity with other clinical assessments.
The DTVP, MVPT and TVPS demonstrate high test-retest
reliability for total scores, but individual TVPS subtests are
less reliable.
There is considerable overlap in content between the
subtests of the examined assessments. There is, however,
substantial variation in the manner in which these subtests
are applied.
The MVPT is a discriminative and evaluative assessment
tool used in children aged 411 years. The MVPT displayed
excellent inter-rater reliability.
Clinical utility- All three assessments have high
clinical utility they are of a similar cost, do not
require training to implement and are relatively
easy to administer and score.
Conclusions: The TVPS is the most rigorously
investigated of the three assessments; however,
this systematic review has uncovered significant
flaws in both its validity and its reliability. The
TVPS has some significant flaws in its test
design, impacting both the validity and reliability
of the test. At present the DTVP and MVPT
demonstrate the strongest clinimetric properties
and would, thus, be recommended for clinical
Test-Retest Reliability of the Motor-FreeVisual
PerceptionTest Revised (MVPT-R) in Children
with and WithoutLearning Disabilities
Patricia A et al in 2002, Vol. 22, No. 3-4 , Pages 23-36
Aim and objective :The Motor-Free Visual Perceptual
TestRevised(MVPT-R) is an updated edition of the original test
with the addition of four items and normative data for 9-11-year-
old children. Test-retestreliabilitystudies on the MVPT-R are not
reported. The purpose of this paper is to report the test-retest
reliability of the MVPT-R in children with and without learning
disabilities. The MVPT-R was administered to 38 children with
identified learning disabilities and 37 control children (aged 7-10
years) on two separate occasions within a 2.5 week window of
Results suggest moderate test-retest reliability for the MVPT-R
with more stability in visual perceptual scores for children with
learning disabilities. This information will be helpful for therapists
using the MVPT-R as a descriptive measure for children.
Text book of physical rehabilitation sullivan.
Pedretti 6th edition
Unsworth, C. A. (2007). Cognitive and Perceptual
Dysfunction. In T. J. Schmitz & S. B. OSullivan
(Eds.), Physical Rehabilitation (pp. 1149-1185).
Philadelphia, F.A: Davis Company