{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T11:54:48Z","timestamp":1781610888349,"version":"3.54.5"},"reference-count":28,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2026,6,9]],"date-time":"2026-06-09T00:00:00Z","timestamp":1780963200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JEMR"],"abstract":"<jats:p>Background: The conventional Hess\u2013Lancaster test is widely used to assess ocular misalignment across diagnostic gaze positions, but it relies on subjective responses and manual recording. Virtual reality may provide a more standardized framework for ocular motility assessment. Objectives: To evaluate the agreement and within-method repeatability of point-by-point deviation measurements obtained with the conventional Hess\u2013Lancaster test and a VR-based Hess\u2013Lancaster assessment implemented in Dicopt Pro. Methods: This cross-sectional observational study included 52 adults with suspected or diagnosed ocular motility disorders. Participants underwent both assessments using the same predefined gaze positions. Agreement was assessed using Bland\u2013Altman analysis, concordance correlation coefficients, mean absolute differences, and mixed-effects modeling. Repeatability was evaluated in a subset with repeated measurements using session-to-session differences and intraclass correlation coefficients. Results: The VR-based assessment showed moderate agreement with the conventional test, with a mean concordance correlation coefficient of 0.57 for both eyes. Mean bias was 1.22 prism diopters for the right eye and 0.10 prism diopters for the left eye. Repeatability estimates were moderate-to-good, with ICC values ranging from 0.62 to 0.83, although repeated measurements were available only in a subset of participants. Conclusions: The VR-based Hess\u2013Lancaster assessment showed small mean differences and moderate agreement with the conventional test, although both methods should be interpreted within the context of the complete clinical examination.<\/jats:p>","DOI":"10.3390\/jemr19030067","type":"journal-article","created":{"date-parts":[[2026,6,11]],"date-time":"2026-06-11T05:50:58Z","timestamp":1781157058000},"page":"67","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Conventional Versus Virtual Reality-Based Hess\u2013Lancaster Assessment: Agreement and Repeatability in Ocular Motility Evaluation"],"prefix":"10.3390","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6715-1047","authenticated-orcid":false,"given":"Francisco","family":"Povedano-Montero","sequence":"first","affiliation":[{"name":"Optometry and Vision Department, Faculty of Optics and Optometry, Complutense University of Madrid, 28037 Madrid, Spain"},{"name":"Hospital Doce de Octubre Research Institute (i+12), 28041 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-5517-0997","authenticated-orcid":false,"given":"\u00c1lvaro","family":"Perales-Serrano","sequence":"additional","affiliation":[{"name":"Optometry and Vision Department, Faculty of Optics and Optometry, Complutense University of Madrid, 28037 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniela","family":"Le\u00f3n Lobo","sequence":"additional","affiliation":[{"name":"Optometry and Vision Department, Faculty of Optics and Optometry, Complutense University of Madrid, 28037 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-6211-9348","authenticated-orcid":false,"given":"Rut","family":"Gonz\u00e1lez-Jim\u00e9nez","sequence":"additional","affiliation":[{"name":"Optometry and Vision Department, Faculty of Optics and Optometry, Complutense University of Madrid, 28037 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0998-6430","authenticated-orcid":false,"given":"Ricardo","family":"Bern\u00e1rdez-Vilaboa","sequence":"additional","affiliation":[{"name":"Optometry and Vision Department, Faculty of Optics and Optometry, Complutense University of Madrid, 28037 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8359-4224","authenticated-orcid":false,"given":"Juan","family":"Cedr\u00fan-S\u00e1nchez","sequence":"additional","affiliation":[{"name":"Optometry and Vision Department, Faculty of Optics and Optometry, Complutense University of Madrid, 28037 Madrid, Spain"},{"name":"Applied Vision Research Group, Faculty of Optics and Optometry, Universidad Complutense de Madrid, 28037 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,9]]},"reference":[{"key":"ref_1","unstructured":"Von Noorden, G.K., and Campos, E.C. (2002). Binocular Vision and Ocular Motility: Theory and Management of Strabismus, Mosby. [6th ed.]."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"166","DOI":"10.3368\/aoj.56.1.166","article-title":"The Hess screen test","volume":"56","year":"2006","journal-title":"Am. Orthopt. J."},{"key":"ref_3","first-page":"57","article-title":"Screen tests used to map out ocular deviations","volume":"305","author":"Roodhooft","year":"2007","journal-title":"Bull. Soc. Belge Ophtalmol."},{"key":"ref_4","first-page":"201","article-title":"Ein einfaches messendes Verfahren zur Motilit\u00e4tspr\u00fcfung der Augen","volume":"35","author":"Hess","year":"2010","journal-title":"Z. Augenheilkd."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1080\/09273972.2020.1871382","article-title":"Divergence bias in Hess compared to Harms screen strabismus testing","volume":"29","author":"Dysli","year":"2021","journal-title":"Strabismus"},{"key":"ref_6","first-page":"660","article-title":"Three-dimensional Hess screen test with binocular dual search coils in a three-field magnetic system","volume":"42","author":"Bergamin","year":"2001","journal-title":"Investig. Ophthalmol. Vis. Sci."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1849","DOI":"10.1016\/j.ophtha.2017.06.020","article-title":"Strabismus measurements with novel video goggles","volume":"124","author":"Weber","year":"2017","journal-title":"Ophthalmology"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Orduna-Hospital, E., Maurain-Orera, L., Lopez-de-la-Fuente, C., and Sanchez-Cano, A. (2023). Hess Lancaster screen test with eye tracker: An objective method for the measurement of binocular gaze direction. Life, 13.","DOI":"10.3390\/life13030668"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1177\/1545968313503219","article-title":"Efficacy and feasibility of home-based training for individuals with homonymous visual field defects","volume":"28","author":"Aimola","year":"2014","journal-title":"Neurorehabilit. Neural Repair"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Martino Cinnera, A., Verna, V., Marucci, M., Tavernese, A., Magnotti, L., Matano, A., D\u2019acunto, C., Paolucci, S., Morone, G., and Betti, V. (2024). Immersive virtual reality for treatment of unilateral spatial neglect via eye-tracking biofeedback: RCT protocol and usability testing. Brain Sci., 14.","DOI":"10.3390\/brainsci14030283"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Otero-Curr\u00e1s, C., Povedano-Montero, F.J., Bern\u00e1rdez-Vilaboa, R., Rojas, P., Gonz\u00e1lez-Jim\u00e9nez, R., Mart\u00ednez-Florent\u00edn, G., and Cedr\u00fan-S\u00e1nchez, J.E. (2026). Virtual reality-based dichoptic therapy in acquired brain injury: Functional and symptom outcomes. J. Clin. Med., 15.","DOI":"10.3390\/jcm15031004"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"167","DOI":"10.1136\/bjophthalmol-2018-313173","article-title":"Artificial intelligence and deep learning in ophthalmology","volume":"103","author":"Ting","year":"2019","journal-title":"Br. J. Ophthalmol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e2714","DOI":"10.1002\/brb3.2714","article-title":"A window into eye movement dysfunction following mTBI: A scoping review of magnetic resonance imaging and eye tracking findings","volume":"12","author":"McDonald","year":"2022","journal-title":"Brain Behav."},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Duchowski, A. (2003). Eye Tracking Methodology: Theory and Practice, Springer.","DOI":"10.1007\/978-1-4471-3750-4"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"44","DOI":"10.1038\/s41591-018-0300-7","article-title":"High-performance medicine: The convergence of human and artificial intelligence","volume":"25","author":"Topol","year":"2019","journal-title":"Nat. Med."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"556","DOI":"10.3758\/s13428-018-1144-2","article-title":"1D CNN with BLSTM for automated classification of fixations, saccades, and smooth pursuits","volume":"51","author":"Startsev","year":"2019","journal-title":"Behav. Res. Methods"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"3597","DOI":"10.1109\/JBHI.2024.3371893","article-title":"The use of machine learning in eye tracking studies in medical imaging: A review","volume":"28","author":"Ibragimov","year":"2024","journal-title":"IEEE J. Biomed. Health Inform."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"466","DOI":"10.1002\/uog.5256","article-title":"Reliability, repeatability and reproducibility: Analysis of measurement errors in continuous variables","volume":"31","author":"Bartlett","year":"2008","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Grudzi\u0144ska, E., Durajczyk, M., Grudzi\u0144ski, M., Marchewka, \u0141., and Modrzejewska, M. (2024). Usefulness assessment of automated strabismus angle measurements using innovative strabiscan device. J. Clin. Med., 13.","DOI":"10.20944\/preprints202401.0677.v1"},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Mehringer, W., Wirth, M., Risch, F., Roth, D., Michelson, G., and Eskofier, B. (2021, January 1\u20135). Hess screen revised: How eye tracking and virtual reality change strabismus assessment. Proceedings of the 2021 43rd Annual International Conference of the IEEE Engineering in Medicine & Biology Society (EMBC), Virtual.","DOI":"10.1109\/EMBC46164.2021.9631002"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"3609","DOI":"10.1038\/s41433-023-02566-0","article-title":"Feasibility study of an automated strabismus screening test using augmented reality and eye-tracking (STARE)","volume":"37","author":"Nixon","year":"2023","journal-title":"Eye"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"330","DOI":"10.1111\/j.1475-1313.2011.00851.x","article-title":"Statistical methods for conducting agreement (comparison of clinical tests) and precision (repeatability or reproducibility) studies in optometry and ophthalmology","volume":"31","author":"McAlinden","year":"2011","journal-title":"Ophthalmic Physiol. Opt."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Cedr\u00fan-S\u00e1nchez, J.E., Bern\u00e1rdez-Vilaboa, R., S\u00e1nchez-Alamillos, L., Medina-Galdeano, M., Otero-Curr\u00e1s, C., and Povedano-Montero, F.J. (2026). Relationship Between Humphrey Automated Perimetry and Virtual Reality-Based Perimetry: A Constant dB Offset and Normative Data. Appl. Sci., 16.","DOI":"10.3390\/app16031351"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1503","DOI":"10.1038\/eye.2017.97","article-title":"Stepping into the virtual unknown: Feasibility study of a virtual reality-based test of ocular misalignment","volume":"31","author":"Nesaratnam","year":"2017","journal-title":"Eye"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"20552076241308713","DOI":"10.1177\/20552076241308713","article-title":"Accuracy of virtual reality in automated measurement and diagnosis of strabismus","volume":"10","author":"Wang","year":"2024","journal-title":"Digit. Health"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1016\/j.jcm.2016.02.012","article-title":"A guideline of selecting and reporting intraclass correlation coefficients for reliability research","volume":"15","author":"Koo","year":"2016","journal-title":"J. Chiropr. Med."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Hartness, E.M., Jiang, F., Zamba, G.K.D., Allen, C., Bragg, T.L., Nellis, J., Dumitrescu, A.V., and Kardon, R.H. (2025). Automated strabismus evaluation: A critical review and meta-analysis. Front. Neurol., 16.","DOI":"10.3389\/fneur.2025.1620568"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"e2240","DOI":"10.1089\/tmj.2024.0115","article-title":"The role of telemedicine in strabismus assessment: A narrative review and meta-analysis","volume":"30","author":"Wong","year":"2024","journal-title":"Telemed. e-Health"}],"container-title":["Journal of Eye Movement Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1995-8692\/19\/3\/67\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T11:26:07Z","timestamp":1781609167000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1995-8692\/19\/3\/67"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,9]]},"references-count":28,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["jemr19030067"],"URL":"https:\/\/doi.org\/10.3390\/jemr19030067","relation":{},"ISSN":["1995-8692"],"issn-type":[{"value":"1995-8692","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,9]]}}}