Virtual reality device-based automated perimetry (VRAP) could soon change what the practice of ophthalmology looks like. Glaucoma specialists are caring for an ever-expanding population of glaucoma patients. The COVID-19 pandemic forced many ophthalmologists to take a hard look at practice workflow as it existed and decide which parts were true necessities and which were expendable. For the glaucoma practice, perimetry is not expendable, and VRAP has the potential to help with growing patient populations and challenges with practice workflow and economics. This article presents features of VRAP devices as well as some practical advice to consider for those in the market or in the early stages of implementation.

The Patient Experience

One does not need to be a glaucoma specialist to have encountered patients who are resistant or reluctant to perform perimetry testing. I incorporated VRAP into my practice in 2020, and 6 months later, I formally surveyed patients over a 1-month period who had performed at least 1 traditional tabletop standard automated perimetry (SAP) test and 1 VRAP within the previous 12 months. More than 100 patients agreed to fill out the brief survey. When asked which type of perimetry device they preferred, 96% indicated they preferred the VRAP device over the traditional table-mounted device. There was a freeform section of the survey providing patients an opportunity to explain the reasons for their choice. Comfort and easy-to-understand audio guidance were the most common responses.

Cost

From a practice economics perspective, every VRAP device available in the United States costs roughly half as much as its larger tabletop counterpart. There are both lease and purchase options, as well as trial periods, so my best advice is select the option that works for you. If you are considering multiple devices, then volume is your bargaining chip, and some good advice that has served me well is to remember that almost everything is negotiable.

Staffing

In the age of the Great Resignation, staffing seems to be a constant challenge, and the economics of health care are not getting any more favorable. Using VRAP devices requires significantly fewer staff members to administer fields. Prior to the pandemic, our practice had been administering one-on-one testing, averaging around 10,000 fields per year across all providers. With VRAPs in our practice, one staff member administers 3 fields simultaneously with the assistance of the audio guidance and coaching provided by the device, available in multiple languages. It takes staff about 1 business day to be proficient in administering VRAP testing, so there is typically minimal reduction in productivity or slowdown in daily workflow.

Reimbursement and Other Practice Considerations

Based on our average reimbursement per field, reduction in staff utilization, and increase in testing capacity within our practice, this resulted in a 5-figure increase in annual revenue per device. We were also able to offer VRAP testing to patients who previously could not perform traditional fields due to physical limitations, such as being wheelchair bound or having limited neck or back mobility. We were also able to increase our testing frequency to meet AAO preferred practice pattern guidelines based on glaucoma severity, whereas prior to this implementation, even with all traditional SAP devices full steam ahead, we were often unable to provide the capacity for guideline-based field testing frequency for our entire practice’s patient roster.

The Physician User Experience

In terms of ease of use from the physician’s perspective, a glaucoma specialist would likely be comfortable interpreting results and implementing the device into daily practice within the first day of use. Intentional or not, VRAP results graphics and visual organization are strikingly similar to those of industry-leading devices, which shortens the learning curve. A steep learning curve increases buy-in on new technology.

Troubleshooting

VRAP devices are smaller than traditional perimetry devices and therefore are easier to fix when there is a problem. Manufacturers provide customer service for both software and hardware issues. Over the past 3 years in our practice, occasionally there have been devices out of service, but the customer support has been fast and effective. Usually, the fix was not a hardware issue but a software bug, which was resolved remotely, but there were a few instances in which the VRAP devices themselves needed to be replaced due to a hardware issue. These scenarios resolved quickly, and I would probably not even have known about them if our practice administrator had not notified me. One can also overnight a package tha is the size of a shoebox, whereas traditional devices need to wait for an on-site technician, which can take weeks.

Patient Considerations

Although VRAP and the traditional SAP devices produce results that are quite similar in most cases, there will be differences, just as there is often test-to-test variability, even on the same device with the same patient from visit to visit. Despite their similarities, VRAP devices and traditional tabletop devices are not interchangeable. In our practice, we introduced the new VRAPs to all good candidates (most patients), then we let them decide which they preferred, and adhered to that choice for comparability’s sake.

The glaucoma specialist can help guide the patient’s decision. Sometimes, the patient prefers VRAP but performs more reliably using the traditional SAP devices, so both patient comfort and reliable results will guide the glaucoma specialist when recommending one device or the other. Patients typically take a recommendation when they understand that their ophthalmologist is helping guide their decision.

I have performed VRAP testing on myself, and I find the headset to be comfortable and the audio instructions easy to understand, but I have good hearing, no physical limitations, and I don’t care about my hair. In our practice, patients have made comments about the wearable device messing up their hair, being heavy, slipping out of position, or being disorienting. When we first implemented the VRAPs, the process of fitting the devices to patients took our technicians several minutes. With time and experience, it now takes seconds. Our office did just receive an adjustable stand that holds the VRAP at face level. This could help with both the device weight and hair issues.

Conclusion

Winston Churchill once said, “Never let a good crisis go to waste.” There are some changes the pandemic brought us that I can do without, but there are also some positives. I suppose I have COVID to thank for finally getting me to take the plunge into VRAP devices for my practice.

There might be practices for which VRAP devices will not be a good fit, but I find it hard to think of a situation in which that would be the case, for practices big or small, glaucoma-centric or otherwise. During our practice’s implementation, VRAP checked all 3 of the important boxes — patient, staff, and clinician — in terms of ease of use. It made sense from an economics and workflow efficiency perspective, and the technology has proven to deliver equivalent accuracy and utility compared to our traditional tabletop SAP devices.

I predict that as the VRAP industry matures and technology improves, they will be smaller, lighter, faster, smarter, and generally better for clinical practice. I imagine performing perimetry could be akin to slipping on a pair of comfortable sunglasses in the future. Data collected by continued use will improve algorithms for detection of progression, and artificial intelligence may eventually offload some of the work of interpretation from the clinician. For those ophthalmologists who are considering giving VRAP devices a try, I would suggest taking advantage of the trial periods offered by many of these companies. The future is already here, it just isn’t evenly distributed yet. GP

James T. Murphy, MD, is a glaucoma specialist with ReFocus Eye Doctors in Greenwich, Connecticut. He reports no relevant disclosures. Reach him at jamestmurphyiiimd@gmail.com.