VR perimetry (Virtual Reality Perimetry; VRP) is a technique that uses a VR headset to perform visual field testing in an immersive environment.
Visual field testing is central to glaucoma diagnosis. Standard Automated Perimetry (SAP) is the clinical standard, but it requires monocular occlusion, strict head positioning, and maintaining central fixation 1). The EGS 5th Edition (European Glaucoma Society Guidelines) strongly recommends visual field testing for initial evaluation 3). The AAO PPP (American Academy of Ophthalmology Preferred Practice Pattern) also recommends visual field assessment using SAP 4).
Glaucoma affects approximately 80 million people worldwide, and this number is expected to increase to 112 million by 2040 2). To address the growing patient population, more convenient visual field testing methods are needed.
The initial prototype of VRP was the PeriScreener developed by Aravind Eye Hospital. It was a low-cost device combining Google Cardboard, two Android devices, and a Bluetooth clicker. As of 2025, more than 10 types of VRP devices exist, including Oculus Quest, TPP, VirtualEye, AVA, VisuALL, Virtual Field, and Radius 1).
Because it uses a VR headset, it is portable, low-cost, and can be performed regardless of body position. It has equivalent visual field defect detection ability to SAP while being more convenient. It is also expected to be applied to home testing and telemedicine. For details, see the section “Challenges of Conventional Visual Field Testing and Background of VRP”.
VRP itself is a testing method and differs from subjective symptoms of the disease. The following describes the experiential characteristics of patients undergoing the test.
The specifications of each device are shown below.
| Device | Background Luminance | Notes |
|---|---|---|
| Sb-C (Zeiss VR One plus) | 0.05 cd/m² | MS correlation r=0.8151) |
| TPP | 10 cd/m² | MD difference 0.21 dB1) |
| VisuALL (Olleyes) | 1–3 cd/m² | AUC 0.981, 5) |
| AVA | 9.6 cd/m² | ICC=0.93–0.961) |
| Radius | 10 cd/m² | MD r=0.941) |
| Virtual Field | 0.218 cd/m² | FDA approved1) |
| C3 Field Analyzer | 4 cd/m² | AUC 0.77–0.861) |
Smartphone-based type
Dedicated head-mounted type
Eye tracking / innovative input type
EEG/BCI-based type
As of 2025, Virtual Field, which has received FDA approval, and VisuALL, which allows simultaneous binocular testing, are attracting attention. However, due to a lack of standardization among devices, the device adopted varies by facility1).
Conventional SAP (Standard Automated Perimetry) has the following limitations.
Convenience
Portable: Lightweight headset makes it easy to carry.
Flexible posture: Can be performed in sitting, lying, or standing positions2).
Low cost: Utilizes off-the-shelf VR devices, keeping equipment costs low2).
Simultaneous testing of multiple patients: Parallel testing using multiple devices is possible2).
Remote and home applications
Home testing: More frequent testing can be expected to detect early progression1, 2).
Cloud integration: Test data can be stored in the cloud for remote monitoring2).
Bedridden and wheelchair accessible: Can be performed on patients who are difficult to test with conventional SAP.
Mentioned in EGS 5th Edition: The possibility of home monitoring using mobile apps is noted3).
In mild glaucoma, accuracy tends to decrease. Although severity classification shows high agreement (κ = 0.91–0.93), further validation is needed for early detection 1). When early glaucoma is suspected, combined use with SAP is recommended.
The test procedure for a typical VRP (e.g., VisuALL) is described.
Shows the agreement of key evaluation metrics.
| Device | MD Correlation | Notes |
|---|---|---|
| Virtual Field | r=0.87 | Fixation loss VRP 0.05 vs SAP 0.131) |
| Radius | r=0.94 | Staging κ=0.91~0.931) |
| VisuALL | r=0.871~0.879 | AUC 0.981, 5) |
| AVA | ICC=0.93~0.96 | 24-2 and 10-21) |
In a meta-analysis of 14 studies, the MD correlation between VRP and SAP was generally good, ranging from r=0.77 to 0.941). Only about half of the studies performed Bland-Altman analysis1).
VRP tends to underestimate MS and defect size in glaucoma and overestimate them in healthy individuals1). It has also been reported that accuracy decreases with higher severity1).
Binocular testing with VisuALL has the advantage that the eye with poor fixation can be assisted by fixation of the healthy eye 5).
Slagle et al. (2025) reported a patient with congenital glaucoma (age 23) who had a central scotoma in the left eye 5). Although HFA only yielded unreliable results over 5 years, binocular testing with VisuALL successfully obtained reproducible visual fields of the left eye.
The same metrics as SAP are used.
MD correlation is good (r=0.77–0.94), but standardization between devices is insufficient 1). Follow-up with the same device is desirable; if changing devices, consider re-establishing baseline.
Conventional SAP presents static stimuli at fixed positions within a bowl perimeter (Goldmann type) and measures threshold sensitivity by varying luminance.
VRP reproduces similar stimulus presentation within a head-mounted display. Background luminance varies widely by device (0.05–25 cd/m²), and many devices differ from SAP’s HFA (31.5 asb ≈ 10 cd/m²) 1). Most devices use the Goldmann III stimulus 1).
The following threshold strategies are used 1).
Manual Method
Button click: Same input method as conventional SAP. Used in most devices.
Wireless clicker: Uses a handheld device. Press the button when you perceive the target.
Visual Grasp
Eye-tracking type: Method adopted by VirtualEye. No button operation required.
Principle: Detects changes in gaze direction (saccades) via eye tracking. Utilizes reflexive saccades driven by the M-cell system input 1).
EEG/BCI
nGoggle method: Brain Computer Interface using electroencephalography (EEG).
Principle: Objectively detects visual field responses using multifocal steady-state visual evoked potentials (mfSSVEP). Eliminates patient operation errors.
In VisuALL, each eye has an independent display, and targets are presented alternately. The Dynamic Matrix algorithm compensates for mild convergence insufficiency 5). Its application for detecting non-organic visual impairment has also been proposed 5).
The background luminance of Sb-C (0.05 cd/m²) is very low, which may prevent proper measurement of the hill of vision in the macula 1). Caution is needed because the luminance characteristics of each device affect interpretation of results.
A 2025 systematic review (14 studies, 10 devices) concluded that VRP shows strong potential for glaucoma visual field assessment 1). However, the lack of test-retest reproducibility data is identified as the major challenge 1).
Hekmatjah et al. (2025) systematically reviewed 14 studies and confirmed generally good agreement between VRP and SAP (MD correlation r=0.77–0.94) 1). Only about half of the studies performed Bland-Altman analysis, and standardization across devices was noted as insufficient.
The EGS 5th Edition mentions the potential of home monitoring using mobile apps 3). The concept of utilizing frequent home VRP test data for trend analysis has also been proposed 6). The Japan Glaucoma Society Guidelines for Glaucoma (5th Edition) also emphasize the importance of visual field testing 6).
The following are listed as research needed in the future 2).
Technical improvements, standardization of protocols, and accumulation of longitudinal studies are necessary1, 2). It holds potential for home monitoring and telemedicine, and the EGS 5th Edition also recognizes this possibility3). At present, it has not completely replaced SAP, but it is expected to become more widespread as a complementary test.
