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out tasks such as looking at a series of objects or connecting a series of dots by lines; often only one of a series of objects can be found, even though the visual elds seem to be full One essential feature of the Balint syndrome appears to be a failure to properly direct oculomotor function in the exploration of space Thus it is closely related to simultanagnosia and to a special visual disorder of spatial summation (a type of amorphosynthesis) In almost all reported cases of the Balint syndrome, the lesions have been bilateral, often in the vascular border zones (areas 19 and 7) of the parieto-occipital regions, although rare instances of optic ataxia alone have been described within a single visual eld contralateral to a right or left parieto-occipital lesion The neuropsychologic aspects of the syndrome and several interesting historical notes, including the attribution of original reporting to Inouye, can be found in the comprehensive review by Rizzo and Vecera Prosopagnosia This term (from the Greek prosopon, face, and gnosis, knowledge ) was introduced by Bodamer for a type of visual defect in which the patient cannot identify a familiar face by looking at either the person or a picture, even though he knows that a face is a face and can point out its features Such patients also cannot learn to recognize new faces They may also be unable to interpret the meaning of facial expressions or to judge the ages or distinguish the genders of faces In identifying persons, the patient depends on other data, such as the presence and type of glasses or moustache, the type of gait, or sound of the voice Similarly, species of animals and birds and speci c models or types of cars cannot be distinguished from one another, but the patient can still recognize an animal, bird, or car as such Other agnosias may be present in such cases (color agnosia, simultanagnosia), and there may be topographic disorientation, disturbances of body schema, and constructional or dressing apraxia Visual eld defects are nearly always present Some neurologists have interpreted this condition as a simultanagnosia involving facial features Another interpretation is that the face, though satisfactorily perceived, cannot be matched to a memory store of faces Levine has found a de cit in perception, characterized by insuf cient feature analysis of visual stimuli The small number of cases that have been studied anatomically and by computed tomography scanning and MRI indicate that prosopagnosia is most often associated with bilateral lesions of the ventromesial occipitotemporal regions (Damasio et al), but there may be exceptions that are attributable to unilateral damage A variant of this disorder is characterized by a speci c dif culty with facial matching or discrimination from partial cues, such as portions of the face or a pro le The distinction between this de cit and the usual type of prosopagnosia rests on the use of tests that do not require memory of a speci c face This dif culty with facial matching and discrimination is more likely to be seen with lesions of the right than of the left posterior hemisphere Closely allied and often associated with prosopagnosia is a subtle syndrome of loss of environmental familiarity, in which the patient is unable to recognize familiar places The patient may be able to describe a familiar environment from memory and locate it on a map, but he experiences no sense of familiarity and gets lost when faced with the actual landscape In essence, this is an environmental agnosia This syndrome is associated with right-sided, medial temporo-occipital lesions, although in some patients, as in those with prosopagnosia, the lesions are bilateral (Landis et al) To be distinguished from environmental agnosia is the visual disorientation and disorder of spatial (topographic) localization, al-.

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ready discussed under Parietal Lobes (page 403) Patients with the latter disorder, in distinction to those with environmental agnosia, are unable to orient themselves in an abstract spatial setting (topographagnosia, or loss of topographic memory) Such patients cannot draw the oor plan of their house or a map of their town or the United States and cannot describe a familiar route, as from their home to their place of work, or nd their way in familiar surroundings This disorder is of interest insofar as it suggests that there are two separate processes for spatial orientation one for the actual space, ie, environmental (temporo-occipital), and one for the abstract topography of space (parietal) Visual Agnosia for Words (Alexia without Agraphia) See Chap 23 and further on in this chapter in the discussion of alexia without agraphia, under the Disconnection Syndromes Color Agnosia Here one must distinguish several different aspects of identi cation of colors, such as the correct perception of color (the loss of which is called color-blindness) or the naming of a color The common form of retinal color-blindness is congenital and is readily tested by the use of Ishihara plates Acquired colorblindness due to a cerebral lesion, with retention of form vision, is referred to as central achromatopsia Here the disturbance is one of hue discrimination; the patient cannot sort a series of colored wools according to hue (Holmgren test) and may complain that colors have lost their brightness or that everything looks gray Achromatopsia is frequently associated with visual eld defects and with prosopagnosia Most often the eld defects are bilateral and tend to affect the upper quadrants However, full- eld achromatopsia may exist with retention of visual acuity and form vision There may also be a hemi- or quadrant-achromatopsia without other abnormalities, although special testing is required to reveal this defect These features, together with the usually associated prosopagnosia, point to involvement of the inferomesial occipital and temporal lobe(s) and the lower part of the striate cortex or optic radiation (Meadows; Damasio et al) The existince of a central achromatopsia is not surprising in view of the animal studies of Hubel, which identi ed sets of cells in areas 17 and 18 that are activated only by color stimuli A second group of patients with color agnosia have no dif culty with color perception (ie, they can match seen colors), but they cannot reliably name them or point out colors in response to their names They have a color anomia, of which there are at least two varieties One is typically associated with pure word-blindness, ie, alexia without agraphia, and is best explained by a disconnection of the primary visual areas from the language areas (see further on) In the second variety, the patient fails not only in tasks that require the matching of a seen color with its spoken name but also in purely verbal tasks pertaining to color naming, such as naming the colors of common objects (eg, grass, banana) This latter disorder is probably best regarded as a form of anomic aphasia, in which the aphasia is more or less restricted to the naming of colors (Meadows) According to Damasio and associates, the lesion has involved the mesial part of the left hemisphere at the junction of the occipital and temporal lobes, just below the splenium of the corpus callosum All their patients also had a right homonymous hemianopia as a result of destruction of the left lateral geniculate body, optic radiation, or calcarine cortex The Theoretical Problem of Visual and Other Agnosias From the foregoing discussion, it is apparent that the term visual agnosia applies to a series of visual perceptive disorders that include, in varying combinations, faults of discrimination, identi cation, and.

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