Visual Neglect

NORA
NEURO OPTOMETRIC REHABILITATION ASSOCIATION, INTL
PO Box 14934 Irvine, Santa Ana CA 92623-4934

Phone: 1-866 2C-BETTR (866-222-3887)
Web site: WWW.NORA.CC email: [email protected]

CLINICAL PEARLS
Visual Neglect
Author Unknown

Visual neglect, also known as unilateral spatial neglect, visual spatial inattention, or
hemi-inattention, creates a diagnostic dilemma for the rehabilitation practitioner. The neglect
patient is inattentive to an entire hemi-space, e.g. the left or right half of their dinner
plate/table. This is not a visual field loss, but it acts like onebecause if one cannot attend to
objects in visual space, one cannot bring them into conscious perception. Functionally, visual
neglect is worse than a visual field loss, as there is no drive to compensate. The visual
inattention is unattended. Visual neglect may exist with or without unilateral motor neglect
where limbs on that side of space are unattended and may appear paralyzed. On an automated
visual field test visual neglect will often appear as a homonymous hemianopia (i.e. complete
blindness on the same side of the visual field in each eye). Both homonymous hemianopia and
visual neglect are relatively common in brain injury. Indeed, in severe brain injury they may
both be presentgenerally affecting the same side of space.

So how does one differentiate visual neglect from hemianopia? Taking the anatomical
evidence, behavioral history, and some special testing together, the practitioner can almost
always make an accurate diagnosis. Neglect varies in degree and may have altitudinal
componentsi.e. upper or lower field more neglected.
While homonymous hemianopia is generally due to extensive unilateral occipital lobe damage,
visual neglect is most commonly due to damage in either the frontal or parietal lobes. The
neglected field is contra lateral to the lesion. Left hemifield neglect is most common. There
seem to be both head centric and body centric aspects to neglect. (Note: This means that the
common practice of teaching visual neglect patients to turn their head instead of making them
turn their eyes may actually imbed the pattern of neglect.)
Frontal lobe neglect affects exploratory motor programs for reaching, saccades, and fixation to
the affected side.
Posterior parietal damage affects attention to the internal sensory map on the neglected side
and is generally more severe.

Symptoms: Include difficulty with mobility, veering away from the defect, visual midline shift,
spatial confusion, and difficulty reading because the patient misses the beginnings or ends of
words or lines.
Diagnosis: Is multifactorial. If specific lesions have been diagnosed, the anatomy of the brain
injury itself will be helpful. T History, line bisection, cross out tasks, scan board testing, and
observation of behavior are all useful here is a well developed test available (the Behavioral
Inattention Test), but it is often impractical in the clinic.

A combined cross out and line bisection test is a simple, quick screener, which you can
make for your own use. Use a legal size piece of paper oriented horizontally. Draw
straight lines, most horizontal, some vertical, (none intersecting) space randomly on the
paper until the paper is filled. At least 30% of the lines should be longer than 4 cm. The
shorter lines provide a control condition to show that the patient can do the task and
provide distracters for the cross-out portion of the task. The paper is taped to the
table horizontally, centered on the patients midline. The patient is instructed to bisect
each of the lines on the paper by drawing a small mark across the center point of each
line. Patients with severe visual neglect will not bisect all of the lines, missing the ones
toward the edge of the paper in the neglected field. Patients with visual neglect,
without hemianopia, will bisect longer lines (> 4 cm) away from the unattended field;
they do not see the end of the line in the unattended field. Patients with hemianopia
without neglect will often bisect the line toward the visual field defect,
overcompensating for their known defect. A person who tests like a hemianope on the
visual field, but bisects all of the lines accurately may be a hemianope who compensates
well, or they may have both a hemianopia and a mild visual neglect. Other historical,
anatomical and behavioral information should be used to determine which.

Why is it important to differentiate hemianopsia from neglect? The patient with visual
neglect is much more likely to be injured again, as they are not careful to attend to the
neglected side during mobility. They are also more easily confused in spatially
demanding situations. Many hemianopes can learn to drive again with special aids such
field expanding prism systems. Patients with visual neglect clearly

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NORA

NEURO OPTOMETRIC REHABILITATION ASSOCIATION, INTL

PO Box 14934 Irvine, Santa Ana CA 92623-4934

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