Virtual reality tool may offer easier vision testing, early research shows

Could a virtual reality headset offer a cheaper, easier, and more comfortable method of testing a person's vision, particularly among patients with a degenerative eye condition called geographic atrophy? It’s a question that ophthalmologists like Jesse Smith, MD, an associate professor in the University of Colorado Anschutz Department of Ophthalmology, are exploring — and preliminary findings indicate positive potential. 

In a small study of 24 patients with geographic atrophy at the Sue Anschutz-Rodgers Eye Center, Smith and his co-investigators compared a standard method of testing a patient's central vision — called microperimetry — with a VR-based test. Ultimately, the preliminary study found that the VR test delivered similar results to the microperimetry test, indicating the VR headset may be a good alternative to assess patients’ vision, particularly when it comes to testing the effectiveness of new drugs developed to treat geographic atrophy. However, further studies are needed to confirm these findings, he notes.

“Microperimetry is very useful, especially when we want to assess if drugs provide functional vision benefits, but at the same time, it’s not a very practical test. The question is: Is there a better way to do it?” Smith says. “That’s what spawned this study.”

Geographic atrophy — a rising condition

Geographic atrophy is the most advanced form of dry age-related macular degeneration (AMD), a potentially vision-threatening eye disease that primarily affects older adults. Essentially, the light-sensing cells of the retina are absent in part of the eye, leading to patients losing a lot of the central part of their vision, Smith explains.

“When you lose tissue, it’s called atrophy. The reason we use the word ‘geographic’ is because the shape where the photoreceptors are missing can almost look like the shapes of islands on a map — an archipelago of lost tissue,” he says. “We use our central vision for reading, recognizing people’s faces, driving, and so on, so having geographic atrophy can really diminish a person’s independence and their function.”

As of 2019, an estimated 19.8 million Americans aged 40 and older had AMD, according to the Centers for Disease Control and Prevention. The American Academy of Ophthalmology explains that one in five people with AMD are estimated to have geographic atrophy. Risk factors include a family history of AMD, aging, and smoking.

“This condition is becoming more common because people are living longer and it is genetically related. It’s more common in people who trace their roots back to Northern or Eastern Europe,” Smith says. “Over the years, we’ve gotten better at slowing down the disease progression, but a challenge is that no one has invented a way to restore lost vision.” 

The importance of functional tests

In 2023, the Food and Drug Administration approved two drugs called Syfovre (pegcetacoplan) and Izervay (avacincaptad pegol) for treating geographic atrophy. These drugs are delivered through an eye injection. However, the European Medicines Agency, which is the European equivalent of the FDA, did not approve Syfovre, saying the studies did not show the drug had “clinically meaningful benefits for patients.”

“Some of the criticism of these newer drugs is that the data the FDA used to approve them did not demonstrate functional benefits — so it looked like the disease progression slowed down compared to a sham injection, but that didn’t coincide with an actual functional benefit for the patients,” Smith says. “If we’re going to treat people, we want to improve their life in some way. Now, there’s a lot more interest in assessing people’s vision and demonstrating functional benefits because there is so much interest in these geographic atrophy drugs.”

Microperimetry is a type of visual field test that assesses the central part of a person’s vision, making it a useful method of testing the function of the area of the retina that allows reading or driving, he explains. It involves a patient looking into a device in an eye clinic that evaluates how sensitive different points in the central retina are to light, revealing potential blind spots.

“Microperimetry is often thought of as the gold standard to assess what a patient’s central visual field looks like. It's good at assessing damage from diseases of the macula, which is responsible for central vision,” he says. “It plots specific points of sensitivity onto a map so the ophthalmologist can see how sensitive a certain point of the macula is. It gives a lot of good information about a patient's function.”

VR vs microperimetry

However, there are some drawbacks to microperimetry, Smith explains. It is a bulky machine that takes up space in the clinic, it requires a technician to walk the patient through the visual field test, it is costly, and it is time consuming. Considering these limitations, Smith decided to explore the viability of VR headsets as an alternative.

“VR headsets are interesting because there are actually more companies that manufacture these headsets than there are published articles supporting their use in geographic atrophy, so the evidence is thin at this point," he says. “What we wanted to do was partner with the company Genentech to assess whether a VR-based visual field test could replicate the results of microperimetry.”

For the VR-based test, a patient puts a headset on and sees a cartoon virtual assistant who walks them through how to take the test. The patient also holds a small trigger button in their hand, pushing the button whenever they see a tiny point of light in some portion of their visual field.

“The headset tracks where the patient is looking. That way, we can make sure that the patient is not looking around for the light. Instead, they should be looking straight ahead so we can assess if they can see the light at specific points in the visual field,” he says.

‘Faster, easier, more comfortable, cheaper’

As part of the study, Smith and his colleagues conducted the microperimetry test once and the VR-based test twice on a cohort of 24 patients with geographic atrophy.

“We wanted to make sure that the two VR tests agreed with each other before comparing whether they agreed with the microperimetry test,” he says. “Ultimately, we found a really tight statistical correlation that seemed to indicate that you can get the same information from a VR-based test as you can with microperimetry. We tested 68 points in the visual field, and as we compared that grid of 68 points, the information from both tests kept agreeing with each other.”

The patients answered a preference survey after completing the testing, and overall, their feedback indicated they found the VR headset to be more comfortable and easier to use. The headsets are also beneficial because they are less expensive than microperimetry, they take less time to use, and they don’t take up room in the clinic since they can be stored in a cabinet, Smith notes. However, microperimetry has the advantage of showing a physical image of the retina and associating the sensitivity of a given point in the eye with that image — something the VR test does not do.

“If you have two options that provide mostly the same information, and one of those options seems to be faster, easier, more comfortable, cheaper, and takes up less room, you likely will opt for that one,” he says. “But this is a preliminary, 24-patient study, so further, larger studies are needed on this.”

Smith recently presented these findings during The Retina Society’s 58th Annual Scientific Meeting in Chicago, and he is working with his co-investigators to publish the research. Given the need for more treatments for geographic atrophy, he is interested in further exploring the viability of using VR-based tests in clinical trials to assess if a drug is effective at improving patients’ vision.

“For regulators to approve a new drug, the clinical trial needs to show functional benefit to a patient’s vision. I think this study shows that VR-based assessments may be a reasonable clinical trial endpoint to demonstrate that,” he says. “In ophthalmology, we’re always working to improve our methods, and I think this is another example of how we try to better our processes to help patients.”

Note: This project was supported by a collaboration between CU Anschutz and Roche/Genentech.