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 with 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. Methods: Participants performed the EVF test on both SAP and VRVF. Five glaucoma-trained ophthalmologists were then asked to rate all anonymized SAP and RVF tests as a "pass" or "failure" based on Florida state law. Main Outcome Measures: Point-by-point concordance between original VRVF EVF test results and SAP EVF test results was calculated using the Kappa statistic. Concordance between SAP and VRVF was secondarily assessed with a conditional logistic regression based on the pass-failure determinations by the glaucoma-trained ophthalmologists. Interrater agreement on test pass-failure determinations was also calculated. Finally, test results on SAP versus 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 to 78 years old. Concordance between VRVF and SAP test using point-by-point analysis was poor ( x = 0.332, [95% confidence intervals {CI}: 0.157, 0.506]) and somewhat increased using pass-failure determinations from ophthalmologists ( x = 0.657, [95% CI: 0.549, 0.751]). Ophthalmologists were more likely to agree amongst themselves on passfailure determinations for VRVF tests ( x = 0.890, [95% CI: 0.726, 0.964]) than for SAP ( x = 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). Conclusions: 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.