Neurol Clin N Am
21 (2003) 387–416

Neuropsychologic assessment
of visual disorders
Margaret Lanca, PhDa,*, Beth A. Jerskey, MAb,
Margaret G. O’Connor, PhDc
a
Department of Psychiatry, Harvard Medical School, Boston, MA;
Department of Psychiatry, The Cambridge Hospital, Cambridge, MA, USA
b
Center for Clinical Biopsychology, Boston University, Boston, MA, USA
c
Department of Neurology, Harvard Medical School,
Boston, MA; Division of Behavioral Neurology,
Beth Israel Deaconess Medical Center, Boston, MA, USA

In this article, the authors focus on the neuropsychologic assessment of
patients who present with visual difficulties in the clinical setting. This type
of evaluation often is requested to assist with differential diagnosis and
to obtain information regarding the functional implications of a patient’s
visual problem. Several neurologic conditions affect brain structures that
mediate higher-order visual processes. Some cases of visual difficulties occur
in the context of diffuse brain damage, whereas others are the result of focal
insult or injury. Information regarding the nature and severity of the visual
problem may help establish a diagnosis of dementia, the prototype of diffuse
injury. Deficits in the analysis or construction of visual stimuli may emerge
early in the course of dementia, in which case they are associated with other
cognitive deficits and diffuse neuropathology. A detailed neuropsychologic
assessment may distinguish between forms of dementia. Visuospatial abilities may be disproportionately affected in patients with Lewy body disease,
whereas visual abilities may be relatively preserved early in Alzheimer’s
disease (AD) [1]. Aside from dementia, other neurologic disorders, such as
cerebrovascular accidents, may have circumscribed damage to occipital and
temporal brain regions that result in focal visual disturbances. In these
disorders, investigation of the cognitive and perceptual characteristics of the
visual problem may elucidate the locus of the brain lesion. In addition to

* Corresponding author. The Cambridge Hospital, Department of Psychiatry, Macht
Building, 1493 Cambridge Street, Cambridge, MA 02139.
E-mail address: margaret_lanca@hms.harvard.edu (M. Lanca).
0733-8619/03/$ - see front matter Ó 2003, Elsevier Inc. All rights reserved.
doi:10.1016/S0733-8619(02)00109-3

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providing information regarding the neural substrates of a visual problem,
careful assessment of the patient’s visual abilities provides valuable information about the patient’s functional status, capacity for independence,
and rehabilitative potential.
Formal neuropsychologic testing begins with a survey of a broad
spectrum of cognitive and perceptual domains. Assessment of intelligence,
attention, memory, and language skills allows the examiner to understand
the significance of the visual problem relative to other abilities. A profile
of strengths and weaknesses emerges that is of diagnostic value and serves
as a guide for remediation. The clinical assessment of visual problems is
embedded in this comprehensive examination geared toward identifying the
critical components of the visual deficit and probing associated deficits,
some of which may exacerbate the visual problem. One of the primary goals
of the evaluation is to obtain a detailed description of how the patient experiences the visual problem in everyday life. This description subsequently influences the tests that are chosen in the evaluation. During the
interview portion of the assessment, the medical history is reviewed and data
from previous evaluations are considered. Of particular relevance is information from ophthalmologic examinations regarding fundamental aspects
of visual processing (eg, stereopsis, color perception, form perception, movement detection, and so forth). This information provides the backdrop for
further assessment of problems that affect more complex attributes of visual
representations.
Neuroanatomic studies with humans and nonhuman primates suggest
that different neural systems subserve object recognition, object location
capacity, and constructional skills [2]. In light of these investigations, neuropsychologists have classified visual tasks according to the extent of
perceptual, spatial, or constructional processes involved in task performance
[3]. The authors use this framework in reviewing the tests used in the clinical
setting. As per the Benton and Tranel classification schema, visuoperceptual
tests selected for review focus on the analysis, synthesis, and identification of
visual stimuli. Visuospatial tests concentrate on spatial location, perception
of direction and distance, and visual neglect. Visuoconstructive tests focus
on the ability to draw or assemble visual stimuli in accordance with a specific
design or mental image. Finally, tests of visual attention and visual memory
are discussed.
In this article, a small sample of tests used for clinical assessment is
reviewed. Table 1 lists the measures reviewed and the visual domain under
which they fall. Case examples are presented under each major domain. In
some cases, the use of a qualitative, process approach to scoring is more
helpful in forming a diagnostic impression and detecting localization [4].
Examples of this approach are highlighted in subsequent sections. The
effects of visuoperceptual disorders on reading are not addressed in this
article. The interested reader should consider the following reading tests that
often are included in neuropsychologic evaluations: subtests from the

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Table 1
Sample of tests used for clinical assessment
Tests of visuoperception
Tests of visuospatial abilities
Benton Visual Form Discrimination Test
Line Bisection Test
Hooper Visual Organization Test
Mesulam’s Cancellation Test
Embedded Figures Test
Bell’s Test or Visual Neglect Test
Visual Object and Space Perception Battery
Benton Judgment of Line Orientation Test
Benton Facial Recognition Test
Visual Object and Space Perception Battery
The Eyes Test
Tests of visuoconstruction
Tests of visual attention and memory
Bender Visuonator Gestalt Test
Spatial Span Test
Clock Drawing Test
Visual Reproduction Test
Rey-Osterrieth Complex Figure Test
Ruff Figural Fluency Test
Block Design Test
Spatial Working Memory Test
Object Assembly Test
Object Working Memory Test
Biber Figure Learning Test
Warrington Recognition Memory Test

Boston Diagnostic Aphasia Examination [5], which provide information
regarding single letter reading, word reading, and paragraph comprehension, and the Woodcock Johnson Reading Test [6] and Wide Range
Achievement Test [7], which are valuable tools for assessment of reading
strategies with single words and longer passages. Reading comprehension
and reading speed are assessed with many tests including the Nelson-Denny
Test [8].
Many of these measures are multifactorial and may not test a single
component of visual functioning. One caveat to this is that no single test
score, in isolation of the patient’s history or other test scores, should be used
to make a clinical impression.
Assessment procedures
Visuoperceptual tests of object recognition
Deficits in visual analysis and synthesis for object recognition occur for
several reasons. Causes may include diminished visual acuity secondary to
peripheral factors and perceptual problems that are the result of damage to
cortical structures that mediate vision. If the patient has difficulty analyzing
the perceptual features of a given stimulus, he or she is at a deficit in many
other parts of the visual examination. There are some neurologic conditions,
such as Balint’s syndrome, where perception of parts of stimuli is intact but
the individual has difficulty integrating the visual details. In other conditions, such as visual agnosia and prosopagnosia (see articles elsewhere in
this issue and later discussion in this article of case studies DM and KT),
analysis and synthesis may be intact but the recognition of particular items
(such as objects or faces) may be impaired as a result of the patient’s
inability to access previous representations.

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Some of the tests presented in this section focus on the perception of
single features of a stimulus, whereas others focus on the integration of
perceptual elements for the purposes of identification or recognition. In
some tests, the individual is asked to identify a stimulus; other tasks require
the individual to associate the perceived stimulus with a previously stored
memory. In light of research findings indicating that different brain regions
mediate the perception of objects versus faces, these types of stimuli are
examined separately.
Benton Visual Form Discrimination Test
The Benton Visual Form Discrimination Test focuses on the visual
analysis of 2-D line drawings. The patient is asked to match 16 geometric
figures to identical figures embedded in four foil stimuli [9]. Distracter
stimuli differ from the target by small variations of displacement, rotation,
or distortion. Normative studies indicated that the majority of control
subjects obtain high scores on this test. One study found that in an older
population (ages 55 to 97), age and education but not gender were significantly associated with test performance in subjects without neurologic
concerns [10]. Because test performance is dependent on intact perception,
visual scanning, and object recognition, poor performance may be indicative
of lesions in many regions of the brain, including parietal and temporal
lesions; patients with bilateral-diffuse brain damage also demonstrate
increased deficits on this task [11].
Hooper Visual Organization Test
An exemplary illustration of the multifactoral nature of some neuropsychologic tests is provided by the Hooper Visual Organization Test [12].
This test not only requires visuoperceptual differentiation and conceptual
reorganization of object pieces, but also the correct naming of the integrated
object. Administration consists of 30 drawings of common items that have
been broken into two or more parts (Fig. 1). The patient is required to reconstruct the object mentally and then name it. Scoring is simply the total
number of correctly identified objects, although some items receive half
credit for partially correct responses. Test-retest reliability is moderate [13].
Construct validity studies have found high correlations between performance
on the Hooper and perceptual organization subtests of the Weschler Adult
Intelligence Scale–Revised (WAIS-R [14]) and object naming ability [15].
Patients with various brain lesions can perform poorly on this test partly
as a result of the multiplicity of task demands (eg, focus on features, contour, hemiattentional space, and overt verbal response). Therefore, it is important to examine the types of errors patients make. For example,
patients with right-hemisphere damage are prone to part and nonintegrated
errors. A prototypic response of someone with a visual neglect is that the
first image in Fig. 1 is ‘‘a flying duck’’ based on the fact that the tail of the
fish (the correct identification) in the upper right side of the figure resembles

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Fig. 1. Three items from the Hooper Visual Organization Test. (From Hooper HE. The Hooper
Visual Organization Test. Beverly Hills (CA): Western Psychological Services; 1958; with
permission.)

a head of a duck, whereas the head of the fish is in the left hemiattentional
field [4]. Patients with left-hemisphere damage make more language-based
errors. Schultheis and colleagues found that anomic subjects achieved
a significantly greater number of correct responses on a multiple-choice
version of the Hooper as opposed to the standard administration and that
overall performance was greatly improved when the object naming demand
was reduced [16].
Embedded Figures Test
Also known as the Hidden Figures Test and Figure-Ground Test, the
Embedded Figures Test (Fig. 2) is used to examine visual identification of
figures presented in a complex background. The primary version of this test
consists of 16 figures that are presented on the left half of a page [17]. On
the right half of the page are complex designs in which the target figure
is embedded. Patients are asked to search for and trace the target figure.
Timing and accuracy are measured. Normative studies reveal that healthy
adults are adept at performing this task and there are no effects of gender on
task performance [17]. Lesion analytic studies show that patients with righthemisphere damage perform more poorly than patients with left-hemisphere
damage on this task [18]. Other studies indicate that patients with anterior
lesions perform better than patients with posterior lesions when there is no
time constraint [19]. Patients with diffuse damage, such as AD, also may
have difficulty with this test underscoring that this test, like others, is
dependent on several cognitive abilities (eg, attention) and object identification [20].
Visual Object and Space Perception Battery
The Visual Object and Space Perception Battery [21] comprises nine
subtests, four of which focus on the perception and identification of letters
and visual line drawings. Each of these four tests assesses a particular

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Fig. 2. Sample items from the Embedded Figures Test. (From Spreen O, Benton AL. Embedded
Figures Test. Victoria (BC): Neuropsychological Laboratory, University of Victoria; 1969; with
permission.)

dimension of visual perception while minimizing the involvement of other
cognitive skills. Hence, these tests can be used with patients who have
aphasic difficulties or other problems that sometimes intrude on test performance. The Incomplete Letters Test examines perception of degraded
letters. Validity studies show that patients with right posterior lesions have
particular difficulties with regard to this type of task [21]. The Silhouettes
Test focuses on the ability to recognize common objects (ie, animals and
objects) that are presented in unusual, noncanonical views. Studies of this
test reveal that patients with right-hemisphere lesions have greater difficulty
identifying objects and animals than do patients with left-cerebral lesions or
nonlesion control participants [21]. The Object Decision Test requires the
patient to identify objects that are presented in a 2-D, silhouette fashion.
The Progressive Silhouettes is similar to the previous tasks in that it requires
the patient to recognize a common object that is presented from an unusual
90-degree angle and with few distinctive features. The distinctive features of
the object emerge over sequential images until the patient is able to

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recognize the object. The tenth and final image is presented from a lateral
perspective that is easily recognized. Studies show that patients with rightcerebral brain damage perform more poorly on this task than do patients
with left brain damage [21].
Benton Facial Recognition Test
The Benton Facial Recognition Test examines a patient’s ability to
discriminate facial features by requiring a patient to match target faces with
faces in which clothing and hair have been shaded out. The original test
consists of 22 stimulus cards and requires 54 matches (Fig. 3). The patient is
asked to match a front-view face with either an identical front-view face,
a three-quarter front-view face, or a front-view face with different lighting

Fig. 3. Three items from the Benton Facial Recognition Test. (From Benton AL, Hamsher K,
Varney NR, Spreen O. Contributions to neuropsychological assessment. New York: Oxford
University Press; 1983; with permission.)

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conditions. The first six items require only single responses, and the subsequent 16 items require three matches to each stimulus face. Normative
studies show that increased age and lower educational status have adverse
effects on test performance. Hemineglect related to parietal lesions may have
an adverse effect on recognition and may negatively affect a patient’s score
on this test. Temporal lobe regions, however, are more commonly implicated in performance on this task. Imaging studies show the importance of
right inferior occipitotemporal region for face recognition [22]. This test in
conjunction with the Warrington Test (addressed later), which measures
facial memory, can give rich information about the patient’s ability to
recognize and recall facial features.
The Eyes Test
There are several tests that focus on visual perception of emotion. One of
these, the Eyes Test, requires the individual to perceive and determine the
emotional expression of facial features that have been abstracted from larger
photographs [23,24]. A series of 25 photographs of the eye region of a human
face is presented. Each photograph has a different expression (eg, pensive,
playful, or indecisive,) and the patient is asked to choose one of four words
that best describes what the person in the photograph is thinking or feeling
(Fig. 4). Normative research has shown that gender affects performance:
women perform better on this task than do men. Adults with highfunctioning autism or Asperger’s syndrome have difficulty on this task. A
functional MRI (fMRI) study revealed amygdala activity during task performance in nonimpaired control participants, whereas amydgala activity was not observed in autistic participants [25].
Case study: patient DM
DM presented with visual processing problems in the context of a right
occipital hemorrhage in November 1999. Evacuation of the hematoma
revealed evidence of tumor, which subsequently was treated with radiation

Fig. 4. An item from the Eyes Test. (From Baron-Cohen S, Wheelwright S, Hill J, et al. The
‘‘Reading the Mind in the Eyes’’ Test revised version: a study with normal adults, and adults
with Asperger syndrome or high-functioning autism. J Child Psychol Psychiatry 2001;42(2):
241–51.)

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and chemotherapy. Residual symptoms included a left hemianopia, which
undermined spatial navigation and reading. He was unable to recognize
people and buildings, even those with which he had been familiar in the
past. Imaging studies (Fig. 5) showed an extensive medial occipital lesion
extending towards the posterior temporal lobe with some white matter
changes. Lesions also were noted in lingual and fusiform gyri, which may
have accounted for his prosopagnosia.
Evaluation findings revealed that DM was of high average to superior
intelligence. His verbal intelligence quotient (VIQ) was 111. In contrast,
nonverbal perceptual abilities were impaired leading to a performance
intelligence quotient (PIQ) that was below average (PIQ = 70). The
magnitude of the discrepancy between his VIQ and PIQ is consistent with
right-hemisphere brain disease. Performance on tasks of visuoperceptual abilities revealed salient deficits. Assessment with Goldman perimetry
confirmed evidence of a left hemianopia. There was no evidence of visual
neglect on a letter cancellation task (discussed later), but DM needed to
frequently readjust his field of vision in order to see all of the targets. Face
perception and line orientation detection were impaired on the Benton
tasks (face perception: 32/54, <percentile; detection of line orientation:
13/30, <1.5th percentile). DM had a great deal of difficulty with tasks
from the Visual Object and Space Perception Battery (see later discussion).
Consistent with a right medial temporal lesion, there was evidence of
a material specific memory problem. His recognition of words was superior
(49/50), whereas facial recognition was almost at chance (30/50; <percentile). Recall of orally presented short stories was superior (99th

Fig. 5. Brain imaging study of patient DM.

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percentile), but recall of visually displayed stimuli fell in the borderline
impaired range (fifth percentile).
Visuospatial and hemineglect tests
Previous studies have shown that object location is mediated by different
neural systems from those involved in object recognition [2]. In this section,
tests that focus on components of spatial analysis are presented. The first
few tests are concerned with the phenomenon of hemispatial neglect, a problem that typically emerges in the context of right cerebral damage. Subsequently, tests focusing on the detection of spatial location, direction, and
distance are reviewed. Patients with left-hemisphere damage may demonstrate
difficulties with spatial analysis; however, damage to right cerebral structures is considered more problematic in this aspect of visual processing
[26,27]. Another aspect of space perception, topographic orientation, may
also decline in the wake of damage to right cerebral brain regions. A review
of the literature did not find specific clinical tests that measure topographic
orientation in real space. Consequently, tests that focus on this aspect
of visual perception are not reviewed in this article.
Line Bisection Test
The Line Bisection Test is used to assess visual neglect by requiring
patients to bisect lines of varying lengths (Fig. 6) [28]. Performance is
evaluated by measuring the extent to which the patient’s bisection deviates
from the actual midpoint of the line. Short lines are less likely to elicit
a deviation from the center than long lines [29]. Patients with visual field
defects and neglect make the greatest errors, usually by underestimating the
side of the line opposite to the defective field [30]. Barton and Black found
that hemianopic patients without neglect bisect the line biased in the

Fig. 6. The Line Bisection Test. (From Schenkenberg T, Bradford DC, Ajax ET. Line bisection
and unilateral visual neglect in patients with neurologic impairment. Neurol 1980;30:509–17.)

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direction opposite to that seen in neglect [31]. Although this test is useful for
assessing visual neglect, for many patients with right-hemisphere lesions,
multiple trials of the test are important because neglect does not necessarily
appear on every trial. One recent study by Ferber and Karnath found that
the line bisection test missed 40% of their neglect patients, while the Letter
Cancellation Test and Bell’s Test (see later discussion) missed identifying
only 6% [32]. Test-retest correlations for this test version are high [33].
Mesulam’s Cancellation Test
Developed by Mesulam [34], this test is used to assess visual neglect and
visual scanning abilities by requiring patients to pick out target stimuli in
a visual array. There are four conditions, two of which focus on scanning for
shapes and two of which focus on scanning for letters. Items are arranged
either in organized columns and rows or they are displayed in a random
fashion. Patients’ performances are analyzed with respect to the number and
distribution of items identified in the four quadrants of the page. Mesulam
recommended that the patient be given a different colored pencil after
every 10 targets in order to document search strategy. A study by Uttl and
Pilkenton-Taylor investigated various letter cancellation tasks in a sample of
healthy adults between the ages of 18 and 91 years [35]. The results of this
research showed that there was a large age-related decline in the speed of the
letter cancellation performance and no age-related differences in the spatial
distribution of cancellation errors. Mesulam [34] demonstrated that patients
with right-sided lesions tended to begin on the right side of the page or in the
center of the page and used a more random search strategy. Patients with
left-hemisphere lesions typically start on the left side, systematically scan,
and, even in the presence of right visual field cut, still cancel target items
on the right side. These patients also tend to be more accurate and faster
at detecting geometric figures than letters. Additional support for the
predominant role of the right hemisphere in visual scanning has been
demonstrated in neuroimaging studies [36]. More specifically, neocortical
activation was observed in the right anterior cingulated gyrus, in the
intraparietal sulcus of the right posterior parietal cortex, and in mesial and
lateral premotor cortices.
Bell’s Test or Visual Neglect Test
As with the previous two tests, the purpose of Bell’s Test [37] is to assess
visual scanning by asking the patient to identify target stimuli on a page with
multiple stimuli. The test consists of a sheet of paper with seven lines of 35
distracter figures (eg, bird, key, and so forth) and five targets figures (ie, bells).
The target figures are arranged so that each appears in equal columns on the
page. The patient initially is asked to name items that the examiner points to.
If unable to do so because of language problems, he or she is asked to place
cards representing each object on top of the object to ensure that the patient
can recognize the target and the distracters. The examiner then presents the

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test copy and asks the patient to circle all the bells with a pencil. Accuracy
and speed are recorded. Studies show that patients with right-hemisphere
lesions are more likely to neglect of the left hemifield on this test [38–40].
Neither sex nor education is shown to influence test performance.
Benton Judgment of Line Orientation Test
The Benton Judgment of Line Orientation Test [41] focuses on the
individual’s ability to estimate the angular relationships between two lines
and match this angle with other line segments that are arranged in a fanline formation (Fig. 7). Normative data indicate that only 5% of normal
controls scored below 63% accuracy [42]. Performance on this test declines
with age [43]. A recent fMRI study reveals robust bilateral superior parietal
lobe activation in ten right-handed controls [44]. This finding was corroborated by data from a cohort of patients with impairments of either
right or left parietal lobe damage or with right parietal damage associated
with a more severe deficit.
Visual Object and Space Perception Battery
Four subtests of the Visual Object and Space Perception Battery focus on
simple features of spatial analysis. These tasks are designed to minimize the

Fig. 7. Stimuli from the Benton Judgment of Line Orientation Test. (From Benton AL,
Hamsher K, Varney NR, Spreen O. Contributions to neuropsychological assessment. New York:
Oxford University Press; 1983; with permission.)

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importance of cognitive skills other than those critical for space perception.
The Dot Counting Test probes for single point localization and spatial
scanning. The patient is asked to count the number of black dots on a card.
The Position Discrimination and Number Location Tests focus on the
individual’s ability to determine the relative positions of stimuli in 2-D
space. In the Position Discrimination test, the patient is asked to indicate
which of two dots is in the center of a square. In the Number Location Test,
the patient is asked to match the position of a number stimulus in one
square with the position of a dot in another square. The Cube Analysis Test
focuses on analysis of 3-D space. In this task, the patient is asked to examine
a 2-D drawing that represents a 3-D arrangement of blocks. He or she
is asked to determine the number of blocks in the arrangement taking
into consideration that some of the blocks may be hidden by others.
Performance on this task depends on the patient’s ability to interpret spatial
relationships. As with the other tests in the Visual Object and Space
Perception Battery, investigations of these four tasks show that damage to
right-hemisphere brain regions impedes performance more than damage to
left-brain structures [21].
Case Study: patient MA
MA was a 68-year-old woman referred for testing to provide information regarding her functional status in light of a history of a right parietal
glioblastoma multiforme. MA underwent a total resection of the tumor,
radiation therapy, and chemotherapy. In the aftermath of these events, she
experienced a left inferior quadrantanopsia, left sided neglect, dressing
apraxia, difficulty navigating familiar routes, trouble reading, difficulty dialing phone numbers, decreased attention, worsening peripheral vision, and
mild visual blurriness. Imaging studies (Fig. 8) were consistent with right
parietal and occipital brain damage.
Performance on tests of baseline intelligence fell within the normal range.
MA demonstrated mild problems in working memory, but she performed
normally on tests of attention, language skills, and reasoning. MA’s
memory for day-to-day events was wholly intact. She was well oriented and
knowledgeable about personal events. There was evidence, however, of
a material specific memory problem in that recognition of words from the
Warrington Recognition Memory Test was average (44/50; 75th percentile),
whereas facial recognition was impaired (31/50; <fifth percentile).
MA’s basic perceptual abilities were impaired. She demonstrated
hemispatial neglect when assessed with double simultaneous stimulation.
Performance on the Letter Cancellation Test revealed impaired scanning.
Whereas most individuals scan from left to right, patients who have sustained damage to right brain regions often begin scanning on the right side
of space. In like manner, MA began in the upper right quadrant of space
and she scanned vertically in a leftward direction until she came to the center of the page, at which point she returned to the right half of the page.

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Fig. 8. Brain imaging study of patient MA.

MA neglected to note any of the 30 items in left space (Fig. 9). Scanning
problems also were noted on a task requiring her to count a random array of
dots on the Warrington Visual Object and Space Perception Battery. Her
perceptual identification of degraded letters was impaired. She had difficulty
on a task requiring her to judge spatial relations between visual stimuli (2/
10). Her solution of block design puzzles from the WAIS-III was impaired;
there was evidence of broken configuration and failure to appreciate gestalt.
Visuoconstruction tests
Visuoconstructive disturbances occur when there is a failure in organizing
the spatial relations among parts of a visually perceived or imagined object.
Given its broad definition, this construct encompasses a variety of spatial
tasks, so that it is difficult to localize a specific area of the brain dedicated to
preserving visuoconstructive ability. For example, a patient may be asked
to assemble blocks to form a design, draw a design from memory, or
copy a design. These drawings can consist of simple geometric figures (eg,
squares) or more complex designs that have a 3-D element to them (eg, cube
drawings). Clearly, these diverse tasks are not equivalent in their cognitive
demands on sustained attention, perceptual acuity, and motor skills. The
nature and level of difficulty of each task must be considered when assessing
visuoconstructional ability. The patient’s reported difficulties should be
closely examined when selecting the most appropriate tests to assess specific
c
Fig. 9. An example of MA’s hemineglect on the Cancellation Test. (From Muselam MM.
Principles of behavioral neurology. Philadelphia: FA Davis; 1985.)

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disturbances. In the next section, a few tests that demand simple and
complex visuomotor abilities are reviewed.
Bender Visuomotor Gestalt Test
The Bender Visuomotor Gestalt Test entails copying a series of nine 2-D
line drawings on a blank sheet of paper (Fig. 10). The patient’s productions
then are rated according to degree of accuracy and integration. Because of
its simplicity, the Bender Visuomotor Gestalt Test is a valuable screening
instrument for assessing perceptual-motor abilities in a variety of patients,
especially those with low motivational levels, neurologic problems, and
psychiatric conditions [45]. The test tends to be a better screening test for
visual deficits than a diagnostic tool, because it does not provide detailed
information about specific brain damage. Aside from this limitation, the
Bender Visuomotor Gestalt Test often is used in the clinical setting perhaps
because of its brief, economic, and extensive research norms [46]. Watkins
and colleagues found that the Bender Visuomotor Gestalt Test was the sixth
most frequently used test among clinical psychologists [47].
Several scoring systems have been developed for the Bender Test, each
with advantages and disadvantages. Hutt and Briskin [48], and later Lacks

Fig. 10. Items from the Bender Gestalt Test. (From Hutt ML. The Hutt adaptation of the
Bender-Gestalt test. 4th edition. New York: Grune and Stratton, 1985; with permission.)

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[49], outlined 12 ‘‘essential discriminator errors’’ (rotational, fragmentation,
perseveration, and so forth) for assessing brain damage, although substantial empiric evidence about normative performance and the use of this
classification for anatomic and functional diagnosis does not exist. Interscorer reliabilities for the more popular scoring systems are fairly high. Testretest reliabilities over a 3- to 12-month interval ranged from .57 to .79 [4].
Clock Drawing Test
Neurologists’ bedside examinations of cognitive impairment have for
many years required the patient to draw a clock [50]. This straightforward
test is used to assess visuospatial and visuoconstuction skills and is sensitive
to a variety of neurologic disorders. The patient is asked to draw a clock
on a blank sheet of paper [38,51]. Several scoring systems and versions of
the test are used [52]. Traditionally, patients were asked to set the time at
20 minutes after 8 o’clock; however, more recent versions of this test have
requested patients to indicate the time as 10 minutes after 11 o’clock,
because these numbers are actually on the face of a clock and, consequently,
the task is more demanding [4]. Some versions of the Clock Drawing Test
require the patient to draw the face of a clock on predrawn circles, whereas
others require the patient to draw the circle and the corresponding numbers.
In addition, patients often are asked to copy a drawing of clock. Because
there may be dissociation based on the task demand (eg, oral command versus copy), it is recommended that the patient complete both conditions [4].
Despite limited normative data, the simplicity of the Clock Drawing Test
makes it one of the most used tests for the screening of dementia, although it
does not differentiate well between forms of dementia [53]. There is good
test-retest reliability for this test [54] and practice effects have not been
reported. Early studies indicated that impaired performance on the Clock
Drawing Test was the result of lesions in right or bilateral temporoparietal
brain areas [51]. In such cases, qualitative analysis of task performance may
be instructive. For example, errors of spatial disorganization tend to be
associated with right parietal lesions, whereas errors of task (eg, adding
numbers and arranging the spatial layout) may be associated with frontal
lesions [55].
Rey-Osterrieth Complex Figure Test
The Rey-Osterrieth Complex Figure Test (ROCF) was introduced first by
Rey [56] in 1941 as a test for brain damaged individuals. Three years later,
the test was standardized by Osterrieth [57]. Although originally developed
to assess visual memory impairment, the ROCF in recent years has been
reported to assess a variety of visual functions, including visuoperceptual
and constructional skills. The original administration asked the patient to
copy a complex figure (Fig. 11) and then, without warning, reproduce it
from memory three minutes later. More recent versions require the patient
to reproduce the figure from memory immediately after copying it, and

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Fig. 11. The Rey-Osterrieth Complex Figure. (From Osterreith PA. Le test de copie d’une figure
complex: contribution a l’etude de la perception et de la memoire. Arch Psycol 1944;30:286–356;
with permission.)

then again between 20 minutes to one hour after the original copy trial.
Traditional scoring systems have focused on the accuracy of the drawing,
and these systems tend to have high inter-rater reliability [58,59]. Some
investigators have devised qualitative scoring systems that focus on the
strategy that the individual employs in copying the ROCF [60,61]. These
scoring systems can be helpful in localizing brain damage. For example,
patients with frontal lobe lesions have difficulty planning their approach to
the overall figure, whereas patients with right-hemisphere lesions may have
difficulty attending to the left half of the figure. (See Fig. 12 for an example
of patient with right-hemisphere brain disease.)
Chervinsky et al [62], identified several cognitive functions necessary for
task performance: visual perception, visuospatial organization, and memory
(recall condition). A deficit in any of these domains suggests dysfunction in
corresponding brain areas. Visual perception deficits resulting in a distorted
copy of the figure may occur as a result of damage to posterior brain

Fig. 12. Patient with right-hemisphere brain damage: copy of the Rey-Osterrieth Complex.
(From Ostereith PA. Le test de copie d’une figure complex: Contribution a l’etude de la
perception et de la memoire. Arch Psychol 1944;30:286–356; with permission.)

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405

regions. Organizational problems, characterized by a piece-meal approach
to the ROCF, often occur as a result of damage in frontal systems. Impairments in memory for the ROCF may occur as a result of right medial
temporal damage. Age may have an adverse effect on recall accuracy, with
older adults losing twice as much information as younger adults between
copy and recall [63]. Studies assessing the influence of education levels with
ROCF performance have been not been conclusive [60,64].
Block Design Test
The Block Design Test requires the analysis and synthesis of spatial
relations, visuomotor coordination, nonverbal concept formation and
perceptual organization. In this test, the patient employs logic and reasoning
to solve spatial relationships by using 3-D red, white, and half-red, halfwhite blocks to copy designs. The designs are arranged in increasing complexity. Accuracy and speed of completion are measured. The Block Design
Test is sensitive to a wide range of neurologic disorders but, by and large,
patients with right-hemisphere damage perform most poorly [65]. Qualitative analyses of error type reveal that extent of broken configuration errors
is related to severity and laterality of brain injury; patients with righthemisphere damage perform most poorly [66]. Qualitative scoring also
provides rich information about the patient’s overall functional status.
Based on standard scoring, incorrect responses all receive a score of zero.
Reasons for this, however, ‘‘may run the gamut from eating the blocks (in
a confusional state), all the way to a flawless, systematic but slow construction (completed in 65 seconds, or five seconds over the time limit) of
a nondemented patient with Parkinson’s Disease’’ [4]. Extensive normative
data based on a nation-wide sample is subdivided into groups ranging from
16 to 89 years of age. Performance on this test decreases with age, even when
slowness in an elderly population is taken into consideration [67].
Object Assembly Test
The Object Assembly Test from the WAIS-III assesses a patient’s
perceptual-motor coordination, visual organization, and mental flexibility.
The patient is presented with a series of five puzzles, one at a time, and is
asked to assemble the pieces to form a common object. Time to completion
and accuracy are measured. Normative data are available based on age
groups ranging from 16 to 89 years. Unfortunately, this test is vulnerable
to a high degree of performance fluctuation, partly because of a potential
to solve the puzzle accidentally by fitting parts together. It has a low
correlation with other subtests of the WAIS-III, indicating that it is not
highly predictive of general intelligence. Strategies used to complete the
Object Assembly Test may be mediated by different brain regions. For
example, patients with left-hemisphere lesions more often attempt to use
edge alignment strategies based on contours, whereas patients with righthemisphere lesions try to put the pieces together with a focus on details [4].

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Case study: patient AA
AA was a 72-year-old African American woman who presented with
memory difficulties in the context of global cognitive decline. Even though
she was oriented, AA misplaced personal belongings and she had difficulty
recalling details of conversations and events. Despite these difficulties, AA
continued to live in senior housing with assistance from family members
who helped with finances and medications. Formal testing revealed that AA
had significant deficits in memory, naming, reasoning, visual construction,
visual organization, graphomotor speed, and attention. Her clinical history
and the pattern of test results were consistent with early stage AD.
As with many patients who have dementia, AA encountered considerable
difficulties on tasks of visuoconstructive skills that are highly dependent on
planning and organization. She had difficulty copying simple geometric
designs and her copy of a cube was significantly distorted. She could not
correctly place the numbers on a clock face (Fig. 13). AA’s prominent
visuoconstructive deficits underscore the fact that these types of problems
often occur in the context of diffuse brain damage.
Tests of visual attention and memory
Assessment of visual attention and memory allows the examiner to
determine whether or not the individual can retain visual information over

Fig. 13. Patient AA: the Clock Drawing Test. (From Freedman M, Kaplan E, Delis D, et al.
Clock drawing: a neuropsychological analysis. New York: Oxford University Press; 1994; with
permission.)

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short or long time intervals in order to guide ongoing behavior. Visual
attention is a broad term that encompasses attention span, divided attention, processing speed, and sustained attention. In this section, tests that
focus on visual span of attention and visual fluency are presented. Visual
memory includes visual working memory and long-term visual memory.
Visual working memory refers to the retention and manipulation of information that is in conscious awareness. Long-term visual memory can be
broken down into anterograde memory (ie, acquisition of new information)
and retrograde memory (ie, retrieval of information that predates an insult
or injury to the brain). Memory problems may occur for many reasons,
including normal aging, depression, and neurologic conditions. Circumscribed memory difficulties, as seen in patients with amnesia, suggest damage to hippocampal circuitry. Information regarding visual aspects of
memory is important for rehabilitative purposes and for the identification of
lesion location.
Spatial Span Test
The Spatial Span Test (Fig. 14), a subtest of the Wechsler Memory ScaleIII (WMS-III [68]), provides information regarding the amount of visual
information that an individual can retain ‘‘on line.’’ The examiner points
to a sequence of 3-D blocks on a board and the patient is required to repeat
the same sequence. The number of blocks pointed to increases with each
subsequent trail. There are two conditions: in the forward condition,
repetition of the identical sequence is required; in the reverse condition, the
patient is asked to imitate the sequence in reverse order. Because the reverse
spatial span task requires manipulation of new information and storage, this
test also can be seen as a test of visual working memory. Research also
shows that patients with right-hemisphere damage perform worse than lefthemisphere patients on this test [69]. Recent findings find that patients with

Fig. 14. The Corsi Block-Test. (From Milner B. Interhemispheric differences in the localization
of psychological processes in man. Br Med Bull 1971;27:272–77; with permission.)

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lesions in the posterior part of the parietal or occipital lobe perform
especially worse on spatial-memory tasks [70].
Visual Reproduction Test
Another visual memory subtest from the WMS-III [68] is Visual
Reproduction. In this test, a series of five designs are shown to the patient
one at a time for 10 seconds. After each design is presented and then
removed from sight, the patient is asked to draw it immediately from
memory. Later, there is a 30-minute delayed memory condition that is made
up of several tasks, including having the patient draw the designs from
memory, having the patient identify designs seen earlier from 48 designs
including original and distractor designs, asking the patient to draw the
designs while looking at them, and asking the patient to match a target
design on the top of the page to six designs on the bottom. Scoring is based
on four conditions: immediate and delayed recall of the design (based on
accuracy of the copied design), recognition, copy, and discrimination.
Delaney and colleagues found that laterality of lesion did not affect
immediate recall of these stimuli [71]. This may in part be the result of the
simplicity of the designs, which may encourage verbal encoding. Lateralized
differences, however, did appear at the 30-minute delay condition, showing
that patients with right temporal lesions obtained significantly lower scores
their left temporal lesion counterparts or normal controls. Complementing
this finding, a construct validity study using Visual Reproduction found that
the delayed reproduction measures of visual memory were more valid
than the traditional immediate reproduction administrations, which were
more closely associated with visual-perceptual-motor abilities [72]. One
recent MRI study investigating the relationship between extrahippocampal
limbic structures and memory functioning with patients with temporal lobe
epilepsy (TLE) found that immediate visual reproduction performance was
significantly related to the right and left amygdala volumes and right mammillary body volume. Only the right amygdala and right mammillary body
volume, however, were associated with the delayed Visual Reproduction
trial. Results suggest that visual memory may be uniquely associated with
extrahippocampal volumes in patients with TLE [73].
Ruff Figural Fluency Test
The Ruff Figural Fluency Test focuses on capacity for fluid and divergent
thinking, ability to flexibly shift attention from one line of thinking to
another, and planning strategies [74]. The patient is presented with a sheet of
paper with a set of 35 boxes containing dot configurations. The patient is
asked to connect two dots or more using straight lines and to make as many
patterns as possible within a 60-second time frame. Test-retest reliability
was moderate [74]. There was no effect of gender on task performance,
but increased education and younger age have been associated with better

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409

performance on this task. Figural fluency is sensitive to right frontal dysfunction [75].
Spatial Working Memory Test
Some developers are attempting to bring procedures developed primarily
for cognitive neuroscience research into the neuropsychology clinic, using
computerized administration, response collection, and scoring [76,77]. This
test focuses on the individual’s ability to retain visual stimuli in memory
over short delay intervals and with distraction [78]. Stimuli are flashed
briefly at random locations on a computer display and the patient touches
the screen locations where they recall seeing the stimuli, after varying delays
and distraction. A touch-sensitive screen on the computer records the exact
location and time of each response and determines how the spatial accuracy
of response decreases with increasing delay. An interesting feature of this
test is that the difficulty level of the matching process is manipulated
dynamically based on the patient’s performance, becoming easier if they
make errors and becoming more difficult if they do well. This level of
difficulty is then used in subsequent trials with longer delays to determine
if there is a working memory deficit, independent of individual differences
in perceptual competency. Healthy individuals performing this test show
activations of the superior parietal cortex (bilaterally) and parts of the
medial and superior frontal cortex [79].
Object Working Memory Test
The Object Working Memory Test is another computer-based test
focusing on the early component of memory. In this paradigm, the patient is
asked to match a complex visual pattern to a previously displayed stimulus.
Test difficulty once again is calibrated according to the individual’s performance; if the individual has difficulty with the matching procedure, the
test automatically becomes easier and the converse takes place in the event
that the individual performs well. The level of difficulty at which 84% of
items are matched correctly is then used in subsequent trials with longer
delay intervals. In this task, visual working memory can be determined apart
from individual differences in perceptual competency. Initial imaging studies
have indicated that task performance is mediated by the superior parietal
cortices and medial and superior frontal cortices [80].
Biber Figure Learning Test
The Biber Figure Learning Test (BFLT) is a test of nonverbal memory
that was designed to measure recall and recognition of information that
exceeds attention span limitations. The task is designed to complement
many of the verbally based list learning tasks that are used in clinical
examinations (eg, Rey Auditory Verbal Learning Test and the California
Verbal Learning Test). As a result of parallel design features, a comparison
between the BFLT and the verbal tasks can be used to provide information
regarding material specific aspects of memory. The individual is presented

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with a series of 15 geometric figures, presented one at a time (Fig. 15). After
the presentation of the entire series, the patient is asked to draw the designs
from memory. The same series of designs are presented four more times.
After each presentation, recall is tested. After the fifth trial, a distractor set
of stimuli is presented. Recall for the distractor items may be impaired as
a result of proactive interference. In other words, memory for the original
set of 15 designs may interfere with the individual’s ability to learn new
items. After recall of the distractor list, recall of the original list is tested.
Fifteen to thirty minutes later, delayed recall is examined. Subsequently,
delayed recognition of the original designs, which are embedded in a group
of foil items, is examined. Information obtained from this test may help
determine laterality of brain damage. In at least one study, performance
on this task was associated with relative deficits in right temporal brain
regions [81].
Warrington Recognition Memory Test
The Warrington Recognition Memory Test is one of a handful of
tests that provide useful information regarding material-specificity. Some
patients present with material-specific memory disorders whereby there is
dissociation between verbal and nonverbal memory. It is often difficult,
however, to compare verbal with nonverbal memory because memory tasks
vary along dimensions other than material specificity. For instance, most
tasks of verbal memory use an auditory modality of presentation (ie, words
or stories are read aloud) and information is presented in a serial fashion,
whereas nonverbal memory tasks employ a visual modality with simultaneous presentation of material. In this visual memory test, recognition of 50
nonverbal stimuli (faces) and 50 verbal stimuli (words) is examined. In the
first condition, patients are shown 50 words one at a time at a rate of three
seconds per stimulus and then are asked to identify each previously viewed

Fig. 15. Stimuli from the Biber Figure Learning Test (From Glosser G, Ryan L, Fedio P.
Validation of a new visual memory test in post temporal lobectomy patients. Presented at the
National Academy of Neuropsychology meeting. Pittsburgh, 1992; with permission.)

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411

word from a choice of two words. In the second condition, there is a similar
forced-choice recognition task with 50 black-and-white photographs of male
faces. The patient is then shown two faces (one previously seen and one
distractor) and asked to point to the picture that previously seen.
Validation studies show that patients with right-hemisphere lesions are
significantly impaired in facial recognition, whereas their word recognition
may be intact [82]. Morris and colleagues studied patients who had undergone unilateral temporal lobectomy and found that patients with right
temporal lobectomies were significantly worse than the left lobectomy group
on the faces subtest of this test and, conversely, that left temporal lobectomy
patients were significantly worse than patients with right lobectomy on
the word portion of the test [83]. Furthermore, the facial memory subtest
was relatively sensitive and specific in detecting impairment in the right
lobectomy patients, whereas the verbal subtest was less sensitive in detecting
effects of the left lobectomy group. Also, patients with left cerebral damage
perform poorly on the facial and verbal recognition conditions of this test,
but their word recognition is disproportionately impaired consistent with
the site of their lesions.
Case study: patient KT
KT was a 36-year-old woman who presented with cognitive and
perceptual problems in the context of hypoxic-ischemic brain damage
secondary to an episode of respiratory arrest at age six. In the aftermath of
this episode, KT demonstrated visual processing problems. Her acuity was
diminished (20/80 in the right eye and 20/400 in the left). Visual pursuit was
impaired in all directions. Saccades were normal in speed and accuracy.
There was evidence of a partial homonymous inferior left quadrantanopsia.
Higher-order visual processing problems also were noted. KT was alexic
and identified as a letter-by-letter reader. She was unable to recognize
friends and family members by their faces and often relied on voices,
clothes, and context as identifying cues. Imaging studies (Fig. 16) revealed
atrophy in calcarine and peristriate cortices, most notably the right fusiform
and biparietal regions. Despite her prominent visual problems, KT was
bright and accomplished. She graduated from college and obtained several
master’s degrees. At the time of evaluation, she indicated interests in poetry,
English literature, and church history.
KT’s performance on tests of general cognitive abilities was extremely
variable, with superior performance on tasks measuring fund of information, vocabulary, comprehension of social norms, and verbal concept
formation. In contrast, she demonstrated impaired performance on tasks
of processing speed and perceptual organization. There was a significant discrepancy between verbal intelligence (VIQ = 124) and nonverbal
intelligence (PIQ = 69). Her low scores on the visual tests were the result
of reduced visual acuity, motor slowness, and problems with visual
integration. There was evidence of material-specific memory deficits on

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Fig. 16. Brain imaging study of patient KT.

the Warrington Recognition Memory Test, where recognition of words was
perfect (50/50) but recognition of faces was impaired (29/50, <fifth
percentile). Facial discrimination on the Benton Facial Recognition Test
was impaired (<first percentile). Identification of famous faces (such as the
face of Princess Diana) was impaired (4/73) but she benefited from verbal
cuing (67/73), indicating that she was familiar with the famous individuals.
Her poor performance on tasks of facial perception and facial memory was
consistent with an apperceptive prosopagnosia. Performance on the Visual
Object and Space Perception Battery was variable, with adequate performance on tests of shape detection (40/40), spatial scanning (9/10), and
location discrimination (10/10). Impaired performance was seen on tests
of object recognition (15/40), position discrimination (12/20), and analysis
of complex spatial relationships (5/10). Performance on the Benton Line
Orientation Test was average (40th percentile). Solution of puzzles was lowaverage on the WAIS-III; there was no evidence of broken configuration or
failure to appreciate gestalt.
Summary
This article introduces the reader to a sample of visual tests used in the
neuropsychologic assessment of patients who present with various visual
deficits. As discussed, patients often present with visual abnormalities that
cannot be assessed exclusively during the opththalmologic examination,
partly because these problems extend beyond the fundamental aspects
of visual processing. Visual problems occur in the context of focal or diffuse brain damage. Neuropsychologic evaluation can provide valuable
diagnostic information and information regarding functional strengths and
weaknesses.
Many visual tests have been developed for clinical use. Some of these
tests have been validated with lesion analytic or neuroimaging studies,

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413

which highlight the areas of the brain presumed necessary for task
performance. Knowledge regarding the neural substrates of test performance allows the clinician to identify the neuropathologic correlates of test
failure, which, in turn, is relevant to differential diagnosis. A profile of
functional strengths and weaknesses emerges contributing to the treatment
of the patient with a visual disorder.
In this article, the authors present a subset of visual tests used primarily
in the clinical setting. Some of these tests measure lower-level visual deficits
(eg, Judgment of Line Orientation) and others measure higher-level visual/
cognitive deficits (eg, ROCF). Although no firm delineation of test subtypes
exists, the authors divide the tests into general categories of visuoperceptual,
visuospatial, visuoconstructive, and visual attention/memory. Ultimately, it
is incumbent on a trained neuropsychologist to select appropriate visual
tests based on the patient’s described symptoms and the referral question.
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