With the advent of the first head-mounted, automated perimetry device in 2018, the course of research, development and investment in the diagnostic space was forever altered. That first device was the VF2000 Focus, a virtual reality (VR) visual field test headset from Micro Medical Devices. Since then, the industry has grown to encompass more than 20 companies, each offering multiple devices with various features and an expanded array of diagnostics that go well beyond perimetry.

As a glaucoma specialist who has been following this market since shortly after it came to life, I am surprised by the rate at which new companies enter (and, in some cases, exit) the space. I’ve observed that, as the wearable device market matures, it homogenizes so that outliers become less likely to succeed.

The main question that practices must answer is not whether wearable technology would be a sound investment, but which device offers the diagnostics, customer service and convenience that best fit the needs of the practice. (See sidebar, “Making an Informed Decision”) To answer that question, we must first ask some others:

Which device is most comparable to traditional devices?

There is no simple comparison. Unlike traditional devices, wearable devices are screen-based. And while they are designed to perform as similarly as possible, they will always be apples and oranges. It is not advisable to have patients switch freely between traditional and wearable devices. 

Traditional devices offer a standardized set of testing protocols, whereas some wearable devices offer only a subset of these, so be sure to obtain a comprehensive list of all field protocols available and ensure that this is acceptable to all physicians who plan to use these devices.

Are the new devices as accurate as traditional ones?

Most of the wearable devices have studies validating their accuracy against a traditional device. However, the quality and robustness of those studies is variable, so be sure to pay attention to study size and inter-test correlation parameters. 

For the purposes of accurate progression analysis, once a patient shows a preference for a particular testing modality, they should consistently use that one. Assuming the patient performs equally well on both devices, I leave that choice to the patient.

What is the level of patient and staff satisfaction with wearable devices?

After administering thousands of field tests with wearable devices, I have found that they shine in terms of satisfaction. Patients find the testing experience—dare I say—enjoyable. Among my patients who have previously performed traditional field testing, more than 90% prefer the wearable devices when given the option. These devices are lightweight, effectively exclude ambient light, and accommodate many body positions, thus allowing successful testing of patients who have previously been unable to perform field testing. 

As with any new device, there is a staff learning curve, but I have found that a technician with very little experience can master administration of a VR field test within the course of an average office day. Thanks to the ease of use from setup, to testing, to data upload into EHR, adoption of this new technology is unlikely to disrupt the usual office workflow. In fact, the high level of patient satisfaction means that my staff no longer need to take time out to walk across the office and interrupt the physician with news that a patient refuses to perform field testing. 

What else should be considered when shopping for a VR field device?

Look for devices offering static and kinetic perimetry, and threshold and suprathreshold testing. Many of the wearable devices take advantage of their screen-based technology and have expanded testing to include other diagnostics that improve office workflow, including visual acuity, pupillometry, color vision testing, and sometimes extraocular motility. While some of these additional tests are not directly reimbursable by insurers, I have found value in improved office efficiency. All devices upload to and integrate with existing EHR solutions but be sure to ask for this process to be demonstrated live, in case any IT bugs need to be worked out.

What is the cost-benefit analysis?

Across the board, wearable devices provide a higher return on investment. A typical lease costs a few hundred dollars per month, so if your practice performs 4 to 5 fields per month, that is the break-even point from a direct insurance reimbursement perspective. This does not consider how additional testing modalities could improve workflow and office efficiency, which are more difficult to directly measure. In many ways, the financial benefit argument is the easiest one to make for wearable devices. If you represent a large office or a practice with many locations, always remember that wearable devices are easily transportable. If you are anticipating a large volume of testing, there is always room for negotiation with these relatively small companies that are fighting for survival in a rapidly expanding, highly competitive industry.

In summary, implementing wearable diagnostic technology offers many benefits. Results are clinically accurate and valid such that I feel confident making treatment decisions based on wearable device data. Patients find the testing experience more enjoyable, and staff prefer the ease-of-use. The devices easily pay for themselves, improve office efficiency, integrate with existing EHR systems, and are in my experience more reliable than traditional devices, so consider an upgrade to the virtual world for 2025. OM