Systematic Review of VR Perimeters Highlights Importance of Dynamic Range, Field of View

Overall, Heru demonstrated the most consistent clinical validity in this literature review, supported by strong agreement metrics, efficient testing and technological sophistication. However, these findings are based on a single peer-reviewed study, and additional independent research is needed to confirm the reproducibility and generalizability of the device’s clinical performance. Photo: Heru. Click image to enlarge. Virtual reality (VR)-based perimetry headsets provide a portable, immersive testing environment that minimizes distractions and external light interference, potentially enhancing the reliability of visual field assessments. Patients also find it a more comfortable experience than conventional perimetry. However, the performance of commercially available headset options has not been consistent across available studies due to heterogeneity in hardware configurations, software algorithms and testing protocols. A recent systematic review published in the journal Vision synthesized data from 19 studies, evaluating the clinical validity of several VR headsets for visual field testing to provide eyecare professionals with insights that can help them make informed decisions about incorporating VR perimetry into their clinical practice. The paper highlighted key differences in clinical applicability and methodological rigor across device categories by examining diagnostic performance, population-specific variability and technical design.“I believe our paper’s biggest contribution is that it provides the first comprehensive, systematic overview of the commercially available options in this space, creating an evidence-based hierarchy in a crowded and often confusing market,” says paper coauthor Mark Dunbar, OD, of Bascom Palmer Eye Institute in Miami. In the following interview, Dr. Dunbar provides additional insights and context to help readers interpret the paper’s findings.What the Research ShowsAccording to Dr. Dunbar, several devices demonstrated “clinically acceptable validity” in studies, but their performance varies widely, at least as evidenced by the published literature to date. The headsets themselves are also outfitted with somewhat different technology from product to product, making direct comparisons difficult. The paper highlighted that platforms with advanced features such as gaze tracking, a wide dynamic range and high correlation to the Humphrey Field Analyzer (HFA) across all stages of disease are the strongest candidates for clinical integration. “By laying out the evidence in this way, we’ve provided a framework to help clinicians look past marketing claims and make informed decisions that will ultimately lead to better care for their patients.” For example, all FDA-registered devices with high reliability included integrated eye-tracking systems and used either SITA-like or threshold algorithms. By contrast, uncertified or low-complexity systems lacking gaze tracking exhibited higher fixation losses and lower agreement metrics. FDA-registered systems evaluated in this review included the Heru, VisuAll, PalmScan VF2000, Radius XR, Virtual Field and Virtual Vision. Among these, the Heru had demonstrated the strongest evidence of validity, according to the paper. This device also offered one of the shortest testing durations (about four minutes) and incorporated advanced features like gaze tracking, making it particularly suited for both routine clinic uses and remote monitoring. However, these results derive from a single validation study, as was pointed out in the paper, highlighting the need for further research to confirm reproducibility across broader populations.Also note that the Heru device was developed at Bascom Palmer, where Dr. Dunbar is Director of Optometric Services. Neither he nor his coauthors reported relevant financial conflicts of interest at the time of publication of their systematic review, but Dr. Dunbar has since developed a consulting relationship with the company.The VisuAll was the most extensively investigated system, with five scientific studies to date. These studies’ findings suggested that, while the device performs well in certain adult populations with glaucoma, its validity may be limited in early-stage disease and pediatric subjects. Despite FDA registration, PalmScan VF2000, Radius XR, Virtual Field and Virtual Vision also exhibited greater variability in clinical performance.The paper notes differences in field of view among the devices (within the headset class and compared to HFA), and links this to potential weaknesses in identifying early glaucomatous changes. “The differences in field of view are not trivial,” says Dr. Dunbar, “and a device’s inability to assess the far periphery could indeed compromise its utility, particularly for identifying early glaucomatous changes that often manifest peripherally.” Dr. Dunbar points out that while field of view is an important specification, “the more critical performance characteristics that speak directly to a device’s clinical performance are its dynamic range, its correlation to the Zeiss HFA and its intraclass correlation coefficients (ICCs),” he says. “A headset with a restricted dynamic range, as was found in one 2024 validation study of the Radius XR, may systematically underestimate defect severity, which is a significant limitation for clinical grading and monitoring,” Dr. Dunbar notes. “A device with high correlation and strong ICCs, on the other hand, is less likely to miss subtle defects or mischaracterize deep ones.”Similarly, devices like the PalmScan VF2000, which, according to Shetty et al. (2022), “shows considerable variability across different quadrants, or the VisuAll, which, as noted by Griffin et al. (2024), demonstrated a significant drop-off in performance in mild disease, “present challenges for reliable long-term monitoring,” Dr. Dunbar explains. Furthermore, Phu et al. (2024) found that a device like Virtual Field, “despite having acceptable global correlations, showed a weaker ICC of 0.47 for pointwise sensitivity, which may limit its ability to detect small, localized defects—a critical factor in monitoring for subtle progression.”To mitigate these risks, Dr. Dunbar recommends prioritizing a platform that has demonstrated the highest possible correlation and agreement with the HFA across all key metrics (MD, MS, and PSD). Clinical Adoption and Future WorkDr. Dunbar says that a clinician’s concern about switching a stable, long-term glaucoma patient from HFA to a headset is entirely valid. In many instances, the provider may have years of visual fields to compare and, as a result, there is reluctance to start over, especially when many VR visual field technologies may not measure up to the existing gold standard technology.  “What are you actually gaining beyond perhaps a better testing experience?,” he wonders, echoing many.  Without longitudinal studies assessing progression detection, distinguishing true progression from inter-platform variability is a major clinical challenge.The “gray areas” where clinicians should be most cautious are when using devices that have a fundamentally different measurement scale than the Zeiss HFA, Dr. Dunbar emphasizes. “For a platform that demonstrates robust clinical performance—meaning both an adequate field of view and high fidelity to the HFA across key indices—its utility is much greater,” Dr. Dunbar suggests. He believes that such a device could be confidently used for efficient screening and potentially diagnosis and baseline testing. “Its speed and patient-friendly interface allow for testing a much wider population than would ever be feasible with a traditional perimeter, increasing the probability of early case finding,” he says. Given sufficient correlation to HFA, “a device that performs at this level provides clinicians with a powerful, flexible tool for both screening and diagnosis.”The paper also suggests that future improvements in display technology and light calibration will be essential for VR perimetry to match the diagnostic accuracy of conventional perimeter systems.On the research front, there remains much validation work to be done. “It is necessary to achieve the standardization of testing protocols, obtain broader population validation (including pediatric and neuro-ophthalmic cases) and develop further longitudinal studies assessing progression detection,” the study authors wrote in their paper. “From a practical standpoint, devices with regulatory clearance and strong validation may help mitigate geographic and socioeconomic disparities in access to perimetry.”The relative dearth of published studies to draw from despite several years of clinical availability for VR headset perimetry fuels skepticism and uncertainty that needs to be dispelled through future studies.However, the need for independent validation is a crucial part of the scientific process and should not be viewed as a weakness of the initial research, Dr. Dunbar points out. “When a new technology or platform emerges with class-leading results from its pivotal validation study, as we noted was the case for Heru in the Johnson et al. (2023) paper, it naturally sets a new benchmark,” he says. “The call for independent replication is a testament to the significance of those initial findings,” and signals that the results are important enough to warrant confirmation by the broader scientific community. “This process of independent validation is how a technology moves from ‘promising’ to becoming a new, widely accepted standard of care,” Dr. Dunbar says. “It’s a sign of a technology leading the field, not lagging it.”Click here for the journal source. Vera Jesúsm Gkazuer AN, Dunbar MT, et al. Evaluating the clinical validity of commercially available virtual reality headsets for visual field testing: a systematic review. Vision. 2025;9(4):80. This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.