Virtual reality perimetry in the management of glaucoma

With the explosion of virtual reality (VR) technology, it has quickly become evident that there is a strong use case for VR devices in eye care to aid in clinical diagnosis and detection, improve the patient experience, and potentially improve screening and access to care in underserved areas. I have been quite interested in whether wearable VR devices can replicate the accuracy of traditional threshold visual field testing. We all know that standard bowl perimetry is difficult for patients and time-consuming for staff.

There is now a wide variety of commercially available VR headsets with perimetry capabilities. At Bascom Palmer, we have evaluated many of them, and I coauthored a recent systematic review of the published literature on VR, comparing the validity and capabilities of various VR headsets (see systemic review sidebar).¹ Devices from 2 large ophthalmic manufacturers were not available at the time and were not evaluated: The Zeiss Matrix is still not for sale in the US, and the RadiusXR Inspire Pro, distributed by Topcon, is a newer version of the one we evaluated. Other devices in the systematic review may also have undergone upgrades since publication.

In my experience, VR perimetry is already excellent for screening and monitoring of glaucoma suspects. It can be relied upon for long-term monitoring of glaucoma in some patients, but perhaps not yet all. In considering VR devices, clinicians should consider measures of validity compared with the gold standard Humphrey Field Analyzer (HFA) and should also consider how the device will fit into typical examination and pretesting protocols in their own clinics. Here, I will delve into each of these topics in more detail.

Glaucoma suspects

Patients with ocular hypertension or other risk factors for glaucoma who have not yet developed a visual field defect should be monitored carefully for conversion to perimetric glaucoma. Given that progression in glaucoma suspects can typically be detected earlier with structural imaging such as optical coherence tomography (OCT),¹ we typically combine measures of IOP, OCT, and visual field to ensure that we identify any changes as early as possible. I believe that a 24-2 visual field test on a well-validated VR headset is just as reliable as a traditional HFA visual field in this setting.

I would guess the vast majority of our patients would say they prefer the VR headset to traditional bowl perimetry because of its comfort, test speed, and similarity to a gaming device (Figure). Patients with claustrophobia and much older patients may feel intimidated by or uncomfortable with the technology. Fortunately OCT becomes more important and may be better at detecting early progression in these patients.

Long-term monitoring of glaucoma

For long-term monitoring of patients with early and early-moderate glaucoma, repeated measurement over time with the threshold 24-2 (or 24-2C) visual field is our standard of care. In these patients, I find VR perimetry to be very effective, with fairly good congruity between traditional bowl perimetry and VR perimetry. Ideally, when determining progression, you would also like to see good congruity between visual fields and OCT, and in my experience, so far, we have been able to see that. The VR perimetry options are easier for some patients and may make the overall visual field testing experience better, which in turn, may result in better adherence with follow-up eye exams that are so important for monitoring progression. When indicated, visual field testing can be billed to Medicare or commercial insurance, regardless of which perimetry device is used.

Although the data for the VR devices that we use support accuracy over the full range of glaucoma, we don’t yet have the same level of algorithmic progression analysis software with VR headsets that is available on the HFA, so we still rely on standard perimetry for the evaluation of patients with sight-threatening moderate to severe glaucoma. I am excited to see what the future holds and am optimistic that VR devices may someday replace bowl perimetry altogether, even in more advanced glaucoma. My goal is to offer a better experience for patients that doesn't compromise on reliability and still has the same—or potentially even better—sensitivity and specificity in the detection of glaucoma and its progression.

Investigating options

As VR devices proliferate, it can be challenging for doctors to determine which ones offer the best clinical value. I recommend that doctors who are considering acquiring a VR headset for perimetry try out multiple devices at a large national or regional optometry meeting to get an initial sense of their capabilities and how they work. As you narrow down your choice, it is important to get feedback from colleagues with personal experience. Here are the features on which I recommend focusing:

Comparison to the standard of care. If you intend to use a VR headset in the treatment of patients with glaucoma, high levels of specificity and sensitivity, comparable to HFA, are the most important selection criteria. Our recent peer-reviewed meta-analysis evaluates the commercially available devices on these metrics.¹

The patient experience. Pay attention to how the device feels when worn, and how user-friendly the patient interface is. Some VR platforms offer instruction for patients in multiple languages; some can be worn over the patient’s regular glasses, or the prescription can be input into the device.

Available tests. Multiple types of perimetry testing are available on the VR platforms. For me, the 24-2 threshold test is the most important, but I also use a 30-2 visual field for patients with known or suspected neurological problems. Others may find that confrontation fields for rapid screening or an Esterman visual field for driving exams are important features. VR platforms also offer many applications beyond perimetry, such as visual acuity, pupillometry, extraocular motility, cover testing, color vision, and more. In my opinion, VR devices are already better than most of us at identifying afferent pupillary defects and motility problems, so they can become a real asset in the clinic.

Integration. It is important to ensure that the VR system you choose integrates with your electronic health records system and with other diagnostic devices to ensure workflow efficiency and automated data flow.

The future is bright

I see great potential for VR perimetry to improve access in rural areas where there are not enough clinicians. These devices could also be implemented in retail stores or pharmacies to facilitate earlier screening of patients who are not getting regular eye exams and alert them to the need to see an eye doctor. Already, VR headsets can augment the resources of existing doctors and staff. When I first started using VR headsets to do preliminary testing, they were not fast enough to have a meaningful impact on patient throughput in a well-run clinic. But in just a few short years, that has all changed. Today, the device could allow a doctor and 2 technicians to see, for example, 35 patients per day instead of 30, simply by streamlining the pretesting process. That will continue to improve as more testing is refined and validated and could make a significant difference in patient access and clinician burnout as our patient loads increase.

VR devices are rapidly evolving as artificial intelligence and other component technologies advance and as manufacturers invest in platform upgrades. This is a fascinating time to start using VR for the benefit of your patients and your practice.

References

1. Zhang X, Dastiridou A, Francis BA, et al; Advanced Imaging for Glaucoma Study Group. Comparison of glaucoma progression detection by optical coherence tomography and visual field. Am J Ophthalmol. 2017;184:63-74. doi:10.1016/j.ajo.2017.09.020

2. Vera J, Glazier AN, Dunbar MT, Ripkin D, Nafey M. Evaluating the clinical validity of commercially available virtual reality headsets for visual field testing: a systematic review. Vision (Basel). 2025;9(4):80. doi:10.3390/vision9040080