Esterman Visual Field Testing Using a Virtual Reality Headset in Glaucoma

Purpose To test the use of a virtual reality visual field headset (VRVF) for implementation of the Esterman visual field (EVF) test as compared to standard automated perimetry (SAP) among people with glaucoma. Design Experimental design Subjects Patients with mild to severe glaucoma ranging from 10 to 90 years who presented for follow-up at a glaucoma clinic in Miami, Florida were eligible. Intervention A virtual reality visual field headset implementing the EVF test. Main Outcome Measures Point-by-point concordance between original VRVF EVF test results and SAP EVF test results was calculated using the Kappa statistic. Five glaucoma-trained ophthalmologists were then asked to rate all anonymized SAP and VRVF tests as a “pass” or “failure” based on Florida state law. Concordance between SAP and VRVF was secondarily assessed with a conditional logistic regression based on pass-failure determinations. Inter-rater agreement on test pass-failure determinations was also calculated. Finally, test results on SAP vs. VRVF were compared based on Esterman Efficiency Score (EES), the number of correct points divided by the number of total points, and duration of testing. Results Twenty-two subjects were included in the study with ages ranging from 14-78 years old. Concordance between VRVF and SAP test using point-by-point analysis was poor (κ=0.332, [95% CI: 0.157, 0.506]) and somewhat increased using pass-failure determinations from ophthalmologists (κ=0.657, [95% CI: 0.549, 0.751]). Ophthalmologists were more likely to agree amongst themselves on pass-failure determinations for VRVF tests (κ=0.890, [95% CI: 0.726, 0.964]) than for SAP (κ=0.590, [95% CI: 0.372, 0.818]); however, VRVF demonstrated significantly lower EES than SAP (median EES difference: 4.5 points, p=0.021). Conclusion This pilot study is the first to assess the implementation of the EVF test using a virtual reality headset. Based on the weak overall agreement between VRVF and SAP, the current VRVF EVF test is not an acceptable determinant of driver’s licensing. However, ophthalmologists were more likely to agree amongst themselves on VRVF test reports than on SAP reports. With further testing and improvement, virtual reality may eventually become a portable and convenient method for administering the EVF test.