International Congress Series 1282 (2005) 16 20

www.ics-elsevier.com

Neurological and visual impairmentstrategies

for assessment
Lorraine Baskett*
RBS.RVIB.VAF Ltd, Client and Community Services, 4 Mitchell Street, Enfield, NSW 2134, Australia

Abstract. RBS.RVIB.VAF, trading as Royal Blind Society, receives a significant number of referrals
for the provision of assessments and/or training to clients with both neurological and vision
impairment. The techniques for assessing a client with a vision impairment only, are quite different to
those for a client with a vision and neurological impairment. As a provider of services to clients who
have a vision impairment or are blind, it is important that we spend time working with those clients
who will benefit from these services, and that we can identify appropriate referrals. One of the
primary difficulties with assessment is to determine the individual impacts of the vision and
neurological status. A client may present as having a vision difficulty from a functional point of
view, for example making a cup of tea, but sometimes it is the perceptual processes that have been
affected rather than the vision per se. This paper will explore some of the assessment techniques that
can be carried out by any rehabilitation worker, to determine exactly where the clients primary
difficulties lie. It is based on Mary Warrens pyramid model for visual perception assessment. It will
include details of each stage of the visual perceptual process and provide simple examples for
screening each of these stages. The paper aims to provide service providers with the skills necessary
to identify clients who will benefit from our vision specialist services, and those who may be referred
on to more appropriate services. D 2005 Published by Elsevier B.V.
Keywords: Neurological impairment; Visual perceptual process; Assessment

1. Introduction
RBS.RVIB.VAF Ltd (trading as Royal Blind Society) receives a significant number of
referrals for the provision of assessment and/or training to clients with both vision and
neurological impairment. Bearing in mind that Royal Blind Society is an organization with
* Tel.: +61 2 67613528; fax: +61 2 67613678.
E-mail address: Ibasket@rbs.org.au.
0531-5131/ D 2005 Published by Elsevier B.V.
doi:10.1016/j.ics.2005.05.093

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main city offices as well as rural centers where staff need to travel hundreds of kilometers
between clients, it is important that staff are able to accurately assess for clients that would
benefit from the services of a vision impairment/blindness agency.
The techniques for providing assessment and training to a client with a vision
impairment only, are often quite different to providing services for a client with a vision
and neurological impairment. It is important for the agencies credibility as an excellent
service provider that staff who provide assessment and training programs to clients, are
competent in the techniques required to provide appropriate services to clients with vision
and neurological impairment. It is also a time and cost saving measure that identified staff
are competent in this area. Clients that are not appropriate for training need to be identified
straight away, rather than after a number of staff hours have been spent traveling and
providing services.
RBS.RVIB.VAF Ltd (trading as Royal Blind Society) have trained staff in the practical
use of Mary Warrens [1] framework for assessment. Staff are provided with training to
enable them to assess whether a clients functional difficulties are due to ocular reasons or
other neurological reasons. In this way, the most appropriate service option can be
provided. The set of tools a staff member takes with them is practical, functional and can
work in major clinical centers or in a clients home in a remote regional area. This paper
will discuss these techniques and screening tools.
2. Framework for assessment
In order to explain the assessment (or as we prefer to call it, screening procedures), it is
necessary to understand Mary Warrens framework for assessment in a functional sense.
What are the possible functional presentations for clients along each level of the
framework? To use visual perceptual function for adaptation, all levels of the hierarchy
must work together.
The foundational skills are necessary to generate an image. They are the basis to vision
and include oculomotor control, visual fields and visual acuity. If a client is unable to see
the image in total, their functioning in various tasks may be compromised.
Visual attention is a vital skill for complex visual processing. Attention is completed
both focally and peripherally. It drives analysis and then decision making, and is
dependent on the demands placed upon it.
Visual scanning is the basis for pattern recognition. People generally scan in an organized
systematic pattern e.g. right to left, left to right, top to bottom, bottom to top, clockwise,
anticlockwise. Visual scanning involves a visual search which can be cognitively driven. A
human scans to the eye/face first when seeing someone new, then to the other features.
Pattern recognition involves identifying the salient (detail and specific) features of an
object and integrates this to bring together the whole picture.
Visual memory is necessary so that a visual image can be retained and the information
mentally manipulated.
Visual cognition refers to the ability to mentally manipulate visual information and
integrate it with other information to solve problems, formulate plans and then make decisions.
A practical example to demonstrate this framework from a functional point of view is
making a cup of tea or coffee. The foundational skills allow a person to fixate on the cup,

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kettle, coffee jar (oculomotor skills); see all the items on the table (visual fields); and read
the jar labels or see the contrast between the liquid and cup (visual acuity). The person
needs to be able to focus on the task and attend to all the different components of the task
(visual attention). Each item on the table needs to be systematically searched (visual
scanning); the salient features of the individual items on the table need to be identified e.g.
cup rim and handle, kettle spout (pattern recognition) and then mentally retained so that it
is known that the cup is for pouring into and the kettle is what you pour from (visual
memory). All this information needs then to be used to complete the task of making a cup
of tea without assistance (visual cognition). A breakdown in any of these processes can
result in the person being unable to complete the task, and present as having a vision
difficulty.
3. Assessment/screening
The following suggestions can assist in the screening of clients with suspected visual or
visual perceptual difficulties. This screening can give the therapist, rehabilitation worker,
an idea of which level in the hierarchy the breakdown occurs. This can then assist in the
development of an appropriate training and/or therapy program, or referral to other
services. It also saves time from using inappropriate training techniques.
Screening simply gives you an idea of where to begin. You can always refer to another
more appropriate professional if needed e.g. ophthalmologist, orthoptist, occupational
therapist. If you record your behavioral observations, you can always liaise with other
professionals after the session and discuss your findings. The following are some simple
ideas to assist with this screening process.
3.1. Visual acuities
Use the Logmar chart to screen for near vision acuities. You will need to pay attention
to lighting, contrast, outside distractions, etc. You may need to utilize matching techniques
if the client is unable to name or identify letters because of other neurological difficulties.
3.2. Visual fields
Confrontation testing has been found to be the easiest form of screening for a nonvision assessment specialist. Remember that you should sit directly in front of the client
face to face with them. With this form of screening, you are simply measuring their visual
fields against your own. Try and ensure that the client is looking at your nose all the time if
possible, though this is often difficult if the client has problems with oculomotor control or
attention. Screen one eye at a time and ensure that you check left and right sides as well as
upper and lower fields.
3.3. Oculomotor dysfunction
You can simply use a pen or two to screen for difficulties with the four main areas of
oculomotor control: fixation, vergence, saccadic and pursuit eye movements.
Fixation can be checked by asking the client to fixate their gaze on the pen. Ensure that
the pen is stationary when you ask them to fixate on it, as well as using different areas of
the visual field.

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To screen for vergence difficulties, ask the client to fixate on the pen as you move it
from an arms length away to just in front of their nose. Make sure that you observe the
movements of their eyes inwards as you move the pen towards them.
To screen for pursuit eye movement difficulties, move the pen across the person from
left to right, right to left, top to bottom and reverse and diagonally and ask the person to
follow the pen with their eyes. Remember that if they have a visual field deficit, they may
be unable to perform this task in their affected field.
To screen for saccadic eye difficulties, ask the client to fixate on a pen that you are
holding to one side of them. Then ask them to look at your nose. Repeat this exercise with
the pen starting in different positions.
3.4. Visual inattention
To screen for visual inattention, any line bisection task will suffice e.g. Alberts Test of
Visual Neglect. You are looking to see if the client manages to reach both sides of the
paper, if they have an organized pattern of looking, and whether they recheck their work.
A person with inattention will probably not reach the left side of the page, will bisect lines
closer to the right perimeter than the left, and will have a scattered pattern of looking.
Alternatively, any cancellation tasks can be utilized.
3.5. Visual scanning
Visual scanning is closely linked to visual inattention and can often be picked up during
line bisection tasks. An alternative simple screening tool involves a packet of cards.
Spread the cards over a table from left to right visual fields and ask the client to identify
(point, pick up) specific numbers, suits. Observe the client to see if there is a pattern to
their scanning and if they recheck the cards. You may need to only use a few cards instead
of the whole pack to avoid visual and cognitive overload.
3.6. Pattern recognition
As you are checking if the client can identify salient features of an object, copying tasks
are an ideal, simple activity. Ask the client to copy a simple figure such as a flower, face or
cup and see if they identify the important features.
3.7. Visual memory/visual cognition
Observe the client completing a functional task such as making a cup of coffee. Are
they able to plan the task, sequence the steps appropriately, identify between the cup/
kettle/coffee when their foundational skills are intact and can they complete the task
without confusion or prompting?
The above tasks are useful for screening purposes only and may require further
investigation from appropriate professionals.
4. Conclusion
Visual and neurological impairment can present an interesting variety of presentations
in a client. As vision professionals, it is important that we work with those clients who
actually have a vision impairment that can be assisted with vision enhancement and vision

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substitution techniques. The framework for assessment provides a simple way of

understanding the visual process from an ocular and neurological viewpoint. The
screening tools suggested have been found to be useful in identifying those clients who
will benefit from the expertise of a blindness/vision impairment agency, and those that
may be better served by other professionals.
Reference
[1] M. Warren, Evaluation and Treatment of Visual Dysfunction, OT, Victoria, Australia, 1997, Australia.