Standard automated perimetry (SAP) is the primary method for practitioners to conduct visual field testing of the optic nerve, retina, and eyelid, as well as for select neurologic diseases. Most eyecare practitioners own an SAP system, such as the Humphrey Field Analyzer (HFA; Zeiss) or the Haag Streit Octopus (Haag-Streit), which have historically been the standard of care. The accuracy of these machines left the visual field market generally unaltered for decades, with neither substantial nor novel advances in technology.
Virtual Reality Visual Fields
In recent years, the advent of virtual reality visual field (VRVF) technology has presented itself as an alternative testing method. Options include Virtual Eye (Virtual Vision), Vivid Vision Perimetry (Vivid Vision), the VisuALL Field Analyzer (Olleyes), the C3 Field Analyzer (Alfaleus and Remedio), and the Radius XR system (Radius XR). These FDA-registered devices offer several advantages over traditional SAP systems because they are lightweight, are easily portable, do not require a dedicated room, and provide multilingual audio instructions, thereby reducing the need for monitoring by dedicated staff. With these benefits in mind, we trialed 2 VRVF headsets over a 2-month period as an adjunct to our HFA to evaluate their impact at 2 locations in high-volume clinics.
Our practice intakes approximately 60 to 70 patients per day per ophthalmic practitioner, with an average of 14 of these patients needing visual field testing. Due to the volume of patients requiring lengthy exams on our HFA machines, it was historically necessary to schedule their visual fields on a separate day to maximize our practice’s patient turnover. Visual field testing was typically booked 1 to 2 months prior to an appointment, with a dedicated technician able to complete 15 to 20 visual fields per day.
Virtual reality VF devices provide the opportunity to conduct visual field testing on the same day as their comprehensive exam. We were able to conduct the testing anywhere throughout our facilities. We selected a VRVF device that had multiple modes of use, which included exams for the detection of visual field loss for glaucoma, ptosis, and neurodegeneration.
Each patient was assessed to determine whether the VRVF or a conventional SAP would be more beneficial based on their perceived abilities to take the tests with minimal staff direction. This yielded about 75% of patients who could benefit from using the VRVF. The remainder were scheduled for SAP per our typical protocol so that a dedicated technician could assist them throughout the duration of the examination.
The VRVF headsets can be used anywhere there is an internet connection, and links to the examination software that is accessible on any computer, tablet, or mobile device. Our technicians spent an average of 5 minutes explaining the procedure, verifying compliance, queueing the exam, and chart recording the results. After the exams were initiated, our technicians were able to exit the room to handle other tasks.
Of the 82 patients included in this assessment, most had glaucoma (90%), with some ptosis (7%) and a few neurological cases (3%). In total, 92% of the patients successfully completed the exam without intervention, with only 8% requiring redirection or rescheduling on the Humphrey visual field SAP system. Test times averaged 6.5 minutes for both eyes. Following the exam, the physician read and communicated the results to the patient, which took an average of 1.5 minutes. Therefore, the total room time that was required for VRVF testing averaged 13 minutes. There were no discrepancies between VRVFs and historic SAPs and therefore no need for a follow-up SAP.
Increased patient satisfaction was expressed in almost all patients upon query, due to factors including decreased exam time, no need for a return visit, and immediate communication of results by the physician. VRVF significantly reduced the SAP load and increased work efficiency for technicians, the front office, and the billing department.
As with traditional SAPs, VRVF tests are covered by reimbursement with the same CPT codes, therefore providing equal revenue (averaging $65 at our locations). We calculate the procedural cost of conducting visual fields on our Humphrey visual field, SAP at $45 per patient, producing about $20 profit per examination. With the reduced scheduling, staffing, and billing costs associated with VRVF testing, we calculate the procedural cost is reduced to $25 per patient, doubling our profit margin at $40 per exam. Furthermore, when examining an identical time frame, we experienced a 20% increase in visual field testing due to its ease of use, ability to conduct same-day testing, and decreased no-shows. Our yearly profit was calculated to conservatively increase the bottom line of an average glaucoma specialist by $36,000 per year by using VRVF over separate-day SAP when applicable.
The purchase price of our VRVF device is about 25% that of traditional SAP and does not require any additional monthly subscription costs. Based on our profit margin calculations, the payoff of the device can be expected in just a few months, depending on patient volumes.
Our use of VRVFs significantly increased customer satisfaction, engagement, and follow-up. Virtual reality VFs also improve practice profitability and reduce the strain on employees, particularly during this ubiquitous era of staffing issues. We look forward to further incorporating the use of VRVFs throughout our practice. GP