http://www.ncbi.nlm.nih.

gov/pubmed/11222524
Invest Ophthalmol Vis Sci. 2001 Mar;42(3):660-7.
Three-dimensional Hess screen test with
binocular dual search coils in a three-field
magnetic system.
Bergamin O
1
, Zee DS, Roberts DC, Landau K, Lasker AG, Straumann D.
Author information
Abstract
PURPOSE:
To establish an objective Hess screen test that allows a simultaneous and binocular analysis of all
three axes of eye rotation.
METHODS:
In orthotropic and strabismic human subjects, both eyes were recorded with dual scleral search
coils in a three-field magnetic system. Before mounting the search coil annuli on the eyes, the
voltage offsets of each channel and the relative magnitudes of the three magnetic fields were
determined. For calibration, subjects were only required to fix monocularly on a single reference
target. During fixation of targets on the Hess screen by the uncovered eye, the three-dimensional
eye position of both the occluded and the viewing eye was simultaneously measured.
RESULTS:
For clinical interpretation, an easy to understand graphical description of the three-dimensional
Hess screen test was developed. Positions of orthotropic and strabismic eyes tended to follow
Listing's law, which in both eyes allowed the determination of the primary position, that is, the
position of gaze from which pure horizontal and pure vertical movements do not lead to an
ocular rotation about the line-of-sight. To a first approximation, the location of primary position
is a result of the summation of the individual rotation axes of the six extraocular muscles and
thus can be used to infer which muscle is paretic.
CONCLUSIONS:
The three-dimensional Hess screen test with binocular dual search coils in a three-field magnetic
system is an objective method to assess the ocular alignment in three dimensions with high
precision. From these recordings, the clinician can relate deviations of primary position to
specific eye muscle palsies.
http://www.ncbi.nlm.nih.gov/pubmed/11222524
Ocular rotation axes during dynamic
Bielschowsky head-tilt testing in unilateral
trochlear nerve palsy.
Weber KP
1
, Landau K, Palla A, Haslwanter T, Straumann D.
Author information
Abstract
PURPOSE:
To explain the positive Bielschowsky head-tilt (BHT) sign in unilateral trochlear nerve palsy
(uTNP) by the kinematics of three-dimensional eye rotations.
METHODS:
Twelve patients with uTNP monocularly fixed on targets on a Hess screen were oscillated (+/-
35 degrees, 0.3 Hz) about the roll axis on a motorized turntable (dynamic BHT). Three-
dimensional eye movements were recorded with dual search coils. Normal data were collected
from 11 healthy subjects.
RESULTS:
The rotation axis of the viewing paretic or unaffected eye was nearly parallel to the line of sight.
The rotation axis of the covered fellow eye, however, was tilted inward relative to the other axis.
This convergence of axes increased with gaze toward the unaffected side. Over entire cycles of
head roll, the rotation axis of either eye remained relatively stable in both the viewing and
covered conditions.
CONCLUSIONS:
In patients with uTNP, circular gaze trajectories of the covered paretic or unaffected eye during
dynamic BHT are a direct consequence of the nasal deviation of the rotation axis from the line of
sight. This, in turn, is a geometrical result of decreased force by the superior oblique muscle
(SO) of the covered paretic eye or, according to Hering's law, increased force parallel to the
paretic SO in the covered unaffected eye. The horizontal incomitance of rotation axes along
horizontal eye positions can be explained by the same mechanism.

http://www.ncbi.nlm.nih.gov/pubmed/11222524
Incomitance of ocular rotation axes in
trochlear nerve palsy.
Weber KP
1
, Palla A, Landau K, Haslwanter T, Straumann D.
Author information
Abstract
Strabismus due to palsy of a single muscle in one eye is always incomitant, which is a
consequence of Hering's law of equal innervation. We asked whether this law had similar
consequences on the orientation of ocular rotation axes. Patients with unilateral trochlear nerve
palsy were oscillated about the nasooccipital (= roll) axis (+/-35 degrees, 0.3 Hz), and
monocularly fixed on targets on a head-fixed Hess screen. Both the covered and uncovered eyes
were measured with dual search coils. The rotation axis of the covered eye (paretic or healthy)
tilted more nasally from the line of sight when gaze was directed toward the side of the healthy
eye. The rotation axis of the viewing eye (paretic or healthy), however, remained roughly aligned
with the line of sight. We conclude that incomitance due to eye muscle palsy extends to ocular
rotation axes during vestibular stimulation.












http://www.ejournalofophthalmology.com/ejo/ejo55.html
Hess Charting

Dr. Jitendra Jethani,MS, DO, DNB, FNB
Correspondance: Consultant,Pediatric Ophthalmology & Strabismus Clinic,T V Patel Eye
Institute,Salatwada, Baroda- 390001email: xethani@rediffmail.com

It aids in the diagnosis of ocular motility defects. It measures the deviation and the amount of
underaction and overaction of muscles. It is a repeatable and reliable record of the condition and
is therefore a good way to show improvement or deterioration of the condition.
Principle:
The principle is foveal projection. The chart is plotted based on the Herings and Sherringtons
law of innervation. The dissociation of two eyes is by the means of colors or mirrors (as in Less
screen). Now foster torches are used for projection of the target.
There is an illuminated Hess screen on which each target can be lit up in turn and its position
indicated by the patient using a linear green light. Less screen used the principle of mirror.
Method:
The test is performed with each eye fixating in turn. It is done at 50 cms. Patient wears
complimentary red and green glasses. Left eye is tested first followed by right eye. The read
glasses are placed on the right eye first (Red for right, R for R)
The chart has electronically operated board
with small red lights. The red lights can be illuminated as needed separately. The foster torch is
of green light and is in patients hand. Patient is asked to place the green light in each of the
points on the red light as illuminated on the chart. Next the goggles are changed and the left eye
has red goggles and the eye to be tested is right eye.
Recording:
The recording, as mentioned above, is done first with the red glass over the red eye and repeated
with red over the left eye. The eye that has the red glass is the fixing eye. The eye with the green
glass is the eye being tested. The required points are joined to form an inner and the outer square.
Precautions:
The patients head must remain straight through out the procedure/ test. Occasionally, it becomes
necessary to hold the head in the correct position. The foveae must have a common visual
direction
Indications:
Any patient who complains of double vision should be tested on Hess chart. Specific indications
are
a. All patients of incomitant strabismus with normal retinal correspondence (NRC).
b. Patients of esophoria or intermittent Esotropia of divergence weakness type to rule out
6th nerve palsy.
c. To provide a baseline in conditions likely to develop defective ocular movements like in
thyroid related orbitopathy.
Interpretation:
The interpretation of Hess chart is done on basically three broad parts
a. Hess Chart (position)
The basic principle of Hess chart if foveal projection therefore the higher field belongs to the
higher eye. This is opposite of diplopia charting where the higher image is of the lower eye.
Position of the central dot indicates whether the deviation is in primary position or not. The
position of the central dot is to be seen both fixing right eye and fixing left eye.
b. Hess Chart (size)
The variation in the size of the Hess chart of each eye is due to the Herings law. Small field
belongs to the eye with primary limitation of movement. Underaction can be seen with the
inward movement of the dots and therefore the whole curve. Maximum displacement occurs in
the direction of the affected muscle if the patient has presented early before the spread of
comitance.
Overaction can be seen by noting the outward displacement of the dots. Maximum displacement
occurs in the direction of the main action of the overacting contralateral synergist in the larger
field.
Overaction can be seen by noting the outward displacement of the dots. Maximum displacement
of the dots occurs in the direction of the main action of the overacting contralateral synergist in
the larger field.
If the inward and outward displacement is less marked, secondary underactions and overactions
are present as a result of the development of muscle sequel. Outer field should be examined for
small underactions and overactions which may not be apparent on the inner field.
A narrow field restricted in opposing directions of movement denotes a mechanical restriction of
ocular movement. Equal sized field denote either symmetrical limitation of movement in both
eyes or a non paralytic strabismus
c. Hess Chart (Shape and measurements)
Each small square on the grid subtends 50 at the working distance of 50 cm, therefore the
amount of deviation can be calculated. In primary position, the amount could be calculated by
fixing either eye by the displacement of the pointer from the centre dots. The amount of
underaction and overaction can be calculated in the various positions and hence the amount of
excursions can also be calculated. Cyclotropia can also be measured in the degrees by the torsion
placement of the chart. A linear pointer can also be used to calculate the same.
Value:
It can be used to assess the progress of the disorder. It helps in finding out whether the
underaction in a particular gaze is improving or not. This could help the ophthalmologist in
planning the treatment and evaluate the results. However, a Hess chart should not be viewed in
isolation; importance of a good clinical ocular motility examination cannot be understated. Apart
from the clinical examination, diplopia charting and binocular visual field testing also helps in
the better management of the patient.
Few clinical examples

Example 1
Bilateral Superior oblique palsy
Both the charts are to be seen carefully. It is obvious that both the charts show superior oblique
underaction. There is a contra lateral inferior rectus overaction. Both the fields are extorted. The
midline is shifted in both eyes indicating diplopia in primary position (torsional). Right eye
shows slightly greater underaction of superior oblique.
Both the charts appear extorted. This was a patient of traumatic bilateral superior oblique palsy.
Example 2
Both the eyes show small fields. Overaction is seen in both the eyes on the nasal side. Inner field
is closer to outer one so likely to be fresh palsy then an old/ recovered one. Midline is shifted
nasally therefore the eyes are also shifted nasally. The patient had a bilateral lateral rectus palsy
of recent onset.
Example 3
Right eye field in this example is smaller and the left eye field is larger. The outer upper line is
closer to the inner line; the lower one is at a distance. The superior function is lost, that is the
inferior oblique and the superior rectus is underacting. The central point is moved downwards so
diplopia is there in primary position
This was a patient of the entrapment of the inferior rectus.
Example 4
The field of right eye is smaller compared to the left eye. There is an obvious underaction of
inferior oblique. Superior rectus of left eye shows overaction. This was a patient of Right eye
inferior oblique palsy. It is important to distinguish this from a Browns syndrome which may be
acquired and may show a similar picture. However, it could be easily distinguished as the inner
and outer field would be closer and extremely asymmetric. Clinically, it can be distinguished
easily with Guytons exaggerated force duction test.