1
|
Berneshawi AR, Shue A, Chang RT. Glaucoma Home Self-Testing Using VR Visual Fields and Rebound Tonometry Versus In-Clinic Perimetry and Goldmann Applanation Tonometry: A Pilot Study. Transl Vis Sci Technol 2024; 13:7. [PMID: 39102241 PMCID: PMC11309035 DOI: 10.1167/tvst.13.8.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 02/22/2024] [Indexed: 08/06/2024] Open
Abstract
Purpose This pilot study aimed to assess the feasibility, accuracy, and repeatability of unsupervised, at-home, multi-day glaucoma testing using the Olleyes VisuALL Virtual Reality Platform (VRP) and the iCare HOME handheld self-tonometer. Methods Participants were trained to use two U.S. Food and Drug Administration-registered or approved devices before conducting self-tests at home over 3 consecutive days. The iCare HOME intraocular pressure (IOP) measurements were collected four times daily per eye, and VRP visual field tests were performed once daily. The results were compared with one in-clinic Humphrey Field Analyzer (HFA) visual field test performed on the day of device training, iCare HOME measurements by the trainer, and the last five Goldmann applanation tonometer (GAT) results. Results Of 15 enrolled participants, nine of them (60%) completed the study. The six excluded participants could not self-measure using iCare HOME. There was significant correlation between the average mean deviation (MD) values of the at-home VRP tests and in-clinic HFA test (r2 = 0.8793, P < 0.001). Additionally, the average of the sensitivities in five of six Garway-Heath sectors were significantly correlated. VRP test duration was also shorter than in-clinic HFA testing (P < 0.001). Finally, at-home tonometry yielded statistically similar values compared to trainer-obtained iCare HOME values. The mean and range of at-home tonometry were also statistically similar to those for in-clinic GAT, but at-home tonometry demonstrated higher maximum IOP values (P = 0.0429). Conclusions Unsupervised, at-home, multi-day glaucoma testing using two devices resulted in the capture of higher maximum IOPs than in the clinic and good MD correlation of VRP with HFA. However, 40% of participants could not self-measure IOP using iCare HOME. Translational Relevance The study findings suggest that at-home remote glaucoma monitoring correlates with in-office testing and could provide additional information for glaucoma management, although patients had more difficulty with the iCare HOME than the VRP.
Collapse
Affiliation(s)
- Andrew R. Berneshawi
- Department of Ophthalmology, Stanford University School of Medicine, Stanford, CA, USA
| | - Ann Shue
- Department of Ophthalmology, Stanford University School of Medicine, Stanford, CA, USA
| | - Robert T. Chang
- Department of Ophthalmology, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
2
|
Häner NU, Chen HY, Lincke JB, Shang X, Zinkernagel MS, Unterlauft JD. [Virtual reality perimetry and home perimetry]. DIE OPHTHALMOLOGIE 2024; 121:586-591. [PMID: 38871972 DOI: 10.1007/s00347-024-02058-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 04/14/2024] [Accepted: 05/22/2024] [Indexed: 06/15/2024]
Abstract
In this article virtual reality (VR)-based procedures for home perimetry (HP) are described and an overview is given of which procedures can already be used today.
Collapse
Affiliation(s)
- Nathanael Urs Häner
- Inselspital, Universitäts-Augenklinik Bern, Freiburgstr., 3010, Bern, Schweiz
| | - Hsin-Yang Chen
- Inselspital, Universitäts-Augenklinik Bern, Freiburgstr., 3010, Bern, Schweiz
| | | | - Xiao Shang
- Inselspital, Universitäts-Augenklinik Bern, Freiburgstr., 3010, Bern, Schweiz
| | | | | |
Collapse
|
3
|
Nascimento e Silva R, Kim JA, Li Y, Chen C, Chaudhry AF, Berneshawi AR, Zhang M, Villarreal A, Liu J, Shue A, Chang DS, Chang RT. Repeatability of a Virtual Reality Headset Perimeter in Glaucoma and Ocular Hypertensive Patients. Transl Vis Sci Technol 2024; 13:14. [PMID: 38899952 PMCID: PMC11193066 DOI: 10.1167/tvst.13.6.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 04/15/2024] [Indexed: 06/21/2024] Open
Abstract
Purpose The VisuALL S is an automated, static threshold, virtual reality-based perimeter for mobile evaluation of the visual field. We examined same-day and 3-month repeatability. Methods Adult participants with a diagnosis of glaucoma or ocular hypertension underwent two VisuALL 24-2 Normal T- Full threshold strategy tests at baseline and one additional exam at 3 months for each eligible eye. Spearman, intraclass correlation coefficients (ICCs), and Bland-Altman plots were used to assess the correlation of individual point sensitivities and mean deviation (MD) among three tests. Results Eighty-eight eyes (44 participants) were included. Average age was 68.1 ± 14.3 years, and 60.7% were male. VisuALL MD was highly correlated between tests (intravisit: r = 0.89, intervisit: r = 0.82; P < 0.001 for both). Bland-Altman analysis showed an average difference in intravisit MD of -0.67 dB (95% confidence interval [CI], -6.04 to 4.71 dB) and -0.15 dB (95% CI, -8.04 to 7.73 dB) for intervisit exams. Eight-five percent of pointwise intravisit ICCs were above 0.75 (range, 0.63 to 0.93), and 65% of pointwise intervisit ICCs were above 0.75 (range, 0.55 to 0.91). Conclusions VisuALL demonstrated high correlation of MD between tests and good repeatability for individual point sensitivities among three tests in 3 months, except at the points around the blind spot and superiorly. Translational Relevance The preliminary reproducibility results for VisuALL are encouraging. Its portable design makes it a potentially useful tool for patients with glaucoma, enabling more frequent assessments both at home and in clinical settings.
Collapse
Affiliation(s)
| | | | - Yihao Li
- Genentech, Inc., South San Francisco, CA, USA
| | - Chen Chen
- Genentech, Inc., South San Francisco, CA, USA
| | - Anisa F. Chaudhry
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Miao Zhang
- Genentech, Inc., South San Francisco, CA, USA
| | | | - Jocelyn Liu
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ann Shue
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Dolly S. Chang
- Genentech, Inc., South San Francisco, CA, USA
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Robert T. Chang
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA, USA
| |
Collapse
|
4
|
Selvan K, Mina M, Abdelmeguid H, Gulsha M, Vincent A, Sarhan A. Virtual reality headsets for perimetry testing: a systematic review. Eye (Lond) 2024; 38:1041-1064. [PMID: 38036608 PMCID: PMC11009299 DOI: 10.1038/s41433-023-02843-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/05/2023] [Accepted: 11/13/2023] [Indexed: 12/02/2023] Open
Abstract
Standard automated perimetery is considered the gold standard for evaluating a patient's visual field. However, it is costly and requires a fixed testing environment. In response, perimetric devices using virtual reality (VR) headsets have emerged as an alternative way to measure visual fields in patients. This systematic review aims to characterize both novel and established VR headsets in the literature and explore their potential applications within visual field testing. A search was conducted using MEDLINE, Embase, CINAHL, and the Core Collection (Web of Science) for articles published until January 2023. Subject headings and keywords related to virtual reality and visual field were used to identify studies specific to this topic. Records were first screened by title/abstract and then by full text using predefined criteria. Data was extracted accordingly. A total of 2404 records were identified from the databases. After deduplication and the two levels of screening, 64 studies describing 36 VR headset perimetry devices were selected for extraction. These devices encompassed various visual field measurement techniques, including static and kinetic perimetry, with some offering vision rehabilitation capabilities. This review reveals a growing consensus that VR headset perimetry devices perform comparably to, or even better than, standard automated perimetry. They are better tolerated by patients in terms of gaze fixation, more cost-effective, and generally more accessible for patients with limited mobility.
Collapse
Affiliation(s)
- Kavin Selvan
- Genetics and Genome Biology (GGB) Program, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada.
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Mina Mina
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hana Abdelmeguid
- Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Canada
| | - Muhammad Gulsha
- Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Canada
| | - Ajoy Vincent
- Genetics and Genome Biology (GGB) Program, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Abdullah Sarhan
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- RetinaLogik Inc., Calgary, Alberta, Canada
| |
Collapse
|
5
|
Chia ZK, Kong AW, Turner ML, Saifee M, Damato BE, Backus BT, Blaha JJ, Schuman JS, Deiner MS, Ou Y. Assessment of Remote Training, At-Home Testing, and Test-Retest Variability of a Novel Test for Clustered Virtual Reality Perimetry. Ophthalmol Glaucoma 2024; 7:139-147. [PMID: 37619815 DOI: 10.1016/j.ogla.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 07/08/2023] [Accepted: 08/15/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVE To assess the feasibility of remotely training glaucoma patients to take a 10-session clustered virtual reality (VR) visual field (VF) test (Vivid Vision Perimetry [VVP-10]) at home, analyze results for test-retest variability, and assess correspondence with conventional perimetry. DESIGN Cross-sectional study. SUBJECTS Twenty-one subjects with glaucoma were enrolled and included in the feasibility assessment of remote training. Thirty-six eyes were used for test-retest analysis and determination of concordance with the Humphrey Field Analyzer (HFA). METHODS Subjects were provided with a mobile VR headset containing the VVP-10 test software and trained remotely via video conferencing. Subjects were instructed to complete 10 sessions over a 14-day period. MAIN OUTCOME MEASURES Feasibility was determined by the number of subjects who were able to independently complete VVP-10 over the 14-day period after 1 remote training session. The intraclass correlation coefficient (ICC) for average fraction seen across 10 sessions and the standard error (SE) of the mean were primary outcome measures for assessing test-retest variability. Correlation with HFA mean sensitivity (MS) across eyes, was a secondary outcome measure. RESULTS Twenty subjects (95%) successfully completed the VVP-10 test series after 1 training session. The ICC for VVP-10 was 0.95 (95% confidence interval [CI], 0.92-0.97). The mean SE in units of fraction seen was 0.012. The Spearman correlations between VVP-10 average fraction seen and HFA MS were 0.87 (95% CI, 0.66-0.98) for moderate-to-advanced glaucoma eyes, and decreased to 0.67 (95% CI, 0.28-0.94) when all eyes were included. CONCLUSIONS Remote training of patients at home is feasible, and subsequent remote clustered VF testing using VVP-10 by patients on their own, without any further interactions with caregivers or study staff, was possible. At-home VVP-10 results demonstrated low test-retest variability. Future studies must be conducted to determine if VVP-10, taken at home as convenient for the patient, may be a viable supplement to provide equivalent or complementary results to that of standard in-clinic assessment of visual function in glaucoma. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
Collapse
Affiliation(s)
- Zer Keen Chia
- Department of Ophthalmology, UCSF School of Medicine, San Francisco, California
| | - Alan W Kong
- Department of Ophthalmology, UCSF School of Medicine, San Francisco, California
| | - Marcus L Turner
- Department of Ophthalmology, UCSF School of Medicine, San Francisco, California
| | - Murtaza Saifee
- Department of Ophthalmology, UCSF School of Medicine, San Francisco, California
| | - Bertil E Damato
- Department of Ophthalmology, UCSF School of Medicine, San Francisco, California
| | | | | | - Joel S Schuman
- Glaucoma Service, Wills Eye Hospital, Philadelphia, Pennsylvania; Vickie and Jack Farber Vision Research Center, Wills Eye Hospital, Philadelphia, Pennsylvania; Department of Ophthalmology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael S Deiner
- Department of Ophthalmology, UCSF School of Medicine, San Francisco, California
| | - Yvonne Ou
- Department of Ophthalmology, UCSF School of Medicine, San Francisco, California.
| |
Collapse
|
6
|
Bradley C, Ahmed IIK, Samuelson TW, Chaglasian M, Barnebey H, Radcliffe N, Bacharach J. Validation of a Wearable Virtual Reality Perimeter for Glaucoma Staging, The NOVA Trial: Novel Virtual Reality Field Assessment. Transl Vis Sci Technol 2024; 13:10. [PMID: 38488433 PMCID: PMC10946691 DOI: 10.1167/tvst.13.3.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/04/2024] [Indexed: 03/19/2024] Open
Abstract
Purpose Compare estimated sensitivities of SITA-Standard to the RATA-Standard algorithm of the Radius virtual reality perimeter (VRP), and measure concordance in glaucoma staging. Methods One hundred adult glaucoma patients-half with suspect or mild glaucoma, and half with moderate or severe-from five clinics performed four 24-2 visual field tests during a single visit, two with the Humphrey Field Analyzer (HFA) and two with Radius, in randomized order: HRHR or RHRH. Only one eye was tested per participant. We used the Wilcoxon rank sum test with Bonferroni correction to compare distributions of estimated sensitivities across all 54 test locations over the 15 to 40 dB measurement range of the Radius. Weighted kappa measured concordance in glaucoma staging between two masked glaucoma experts using Medicare definitions of severity. Results A total of 62 OD and 38 OS eyes were tested. Estimated sensitivities for SITA-Standard and RATA-Standard were not significantly different for OD, but were for OS-likely because of SITA-Standard OD and OS being significantly different in our sample, but not for RATA-Standard. Low agreement was observed between 15 to 22 dB. Concordance in glaucoma staging was high for both graders: kappa = 0.91 and kappa = 0.93. Average test duration was 298 seconds for RATA-Standard and 341 seconds for SITA-Standard. The correlation in mean deviation was 0.94. Conclusions Estimated sensitivities of RATA-Standard are comparable to SITA-Standard between 23 to 40 dB with high concordance in glaucoma staging. Translational Relevance Radius VRP is statistically noninferior to HFA when staging glaucoma using Medicare definitions.
Collapse
Affiliation(s)
- Chris Bradley
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Iqbal Ike K. Ahmed
- Department of Ophthalmology and Vision Sciences, University of Utah, Salt Lake City, UT, USA
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Howard Barnebey
- Specialty Eyecare Centre, Bellevue, WA, USA
- Department of Ophthalmology, University of Washington, Seattle, WA, USA
| | | | | |
Collapse
|
7
|
Alvarez-Falcón S, Wang B, Taleb E, Cheung NL, Scriven CA, Priestley Y, El-Dairi M, Freedman SF. Performance of VisuALL virtual reality visual field testing in healthy children. J AAPOS 2024; 28:103802. [PMID: 38219921 DOI: 10.1016/j.jaapos.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/10/2023] [Accepted: 10/15/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Virtual reality field testing may provide an alternative to standard automated perimetry. This study evaluates a virtual reality game-based automated perimetry in a healthy pediatric population. METHODS A prospective series of pediatric patients at one institution who performed VisuALL perimetry (Olleyes Inc, Summit, NJ) using a game-based algorithm. Participants were examined by an experienced pediatric optometrist or ophthalmologist, who confirmed that there was no evidence of ocular disease expected to affect visual fields. Testing was performed binocularly, with the child wearing their spectacle correction in place. Age, refractive error, test duration, false positives, and stereoacuity were evaluated for associations with performance on VisuALL, as defined by mean deviation (MD) and pattern standard deviation (PSD). RESULTS A total of 191 eyes of 97 patients (54% female) were included, with a mean age of 11.9 ± 3.1 years. The average MD was -1.82 ± 3.5 dB, with a mean foveal sensitivity of 32.0 ± 4.7 dB. Fifty-nine eyes (30.9%) had MD < -2 dB. Better performance, as assessed by MD and PSD, was associated with shorter test duration (P < 0.001) and older age (P < 0.001). False positives (P = 0.442), wearing spectacles (P = 0.092), Titmus stereoacuity (P = 0.197), and refractive error (P = 0.120) did not appear to be associated with improved performance, adjusting for age as a covariate. CONCLUSIONS VisuALL virtual reality field testing was well tolerated in this pediatric study cohort. Older age and shorter test duration were associated with better performance on field testing.
Collapse
Affiliation(s)
| | - Bo Wang
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland
| | - Emma Taleb
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina
| | - Nathan L Cheung
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina
| | - Chelsea A Scriven
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina
| | - Yos Priestley
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina
| | - Mays El-Dairi
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina
| | - Sharon F Freedman
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina.
| |
Collapse
|
8
|
Chen YX, Meyerov J, Skalicky SE. Online Circular Contrast Perimetry via a Web-Application: Establishing a Normative Database for Central 10-Degree Perimetry. Clin Ophthalmol 2024; 18:201-213. [PMID: 38269363 PMCID: PMC10807269 DOI: 10.2147/opth.s440964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/23/2023] [Indexed: 01/26/2024] Open
Abstract
Purpose To establish a normative database using a central 10-degree grid pattern for the online circular contrast perimetry (OCCP) application. Participants Fifty participants with mean age 65 ± 13 years were selected for this study. One eye from each participant that met inclusion criteria was randomly included in the cohort. Methods The web-application delivered online 52-loci perimetry in a central 10-degree pattern using circular flickering targets. These targets consist of concentric sinusoidal alternating contrast rings. Users were guided by the application to the correct viewing distance and head position using in-built blind spot localization and webcam monitoring. A spinning golden star was used as the fixation target and patients performed the test in a darkened room following standard automated perimetry (SAP). Results The reliability rates and global indices for OCCP were similar to SAP. OCCP mean sensitivity reduced with age at a similar rate to SAP. Mean sensitivity per loci of 10-degree OCCP was greater than SAP by 1.24 log units (95% CI 1.23 to 1.26) and obeyed a physiological hill of vision. Small differences existed in mean sensitivities between OCCP and SAP which increased with increasing spot eccentricity. Mean deviation (MD) displayed good agreement between the two tests. Conclusion Central 10-degree online circular contrast perimetry via a computer-based application has comparable perimetric results to standard automated perimetry in a normal cohort.
Collapse
Affiliation(s)
- Yang X Chen
- St Vincent’s Hospital Clinical School, University of Melbourne, Melbourne, VIC, Australia
| | - Joshua Meyerov
- Department of Surgery Ophthalmology, University of Melbourne, Melbourne, VIC, Australia
| | - Simon E Skalicky
- Department of Surgery Ophthalmology, University of Melbourne, Melbourne, VIC, Australia
- Glaucoma Investigation and Research Unit, the Royal Victorian Eye and Ear Hospital, Melbourne, VIC, Australia
| |
Collapse
|
9
|
Phu J, Wang H, Kalloniatis M. Comparing a head-mounted virtual reality perimeter and the Humphrey Field Analyzer for visual field testing in healthy and glaucoma patients. Ophthalmic Physiol Opt 2024; 44:83-95. [PMID: 37803502 PMCID: PMC10952716 DOI: 10.1111/opo.13229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/16/2023] [Accepted: 08/23/2023] [Indexed: 10/08/2023]
Abstract
PURPOSE To compare clinical visual field outputs in glaucoma and healthy patients returned by the Humphrey Field Analyzer (HFA) and virtual reality (Virtual Field, VF) perimetry. METHODS One eye of 54 glaucoma patients and 41 healthy subjects was prospectively tested (three times each in random order) using the HFA and VF perimeters (24-2 test grids). We extracted and compared global indices (mean deviation [MD] and pattern standard deviation [PSD]), pointwise sensitivity (and calculated 'equivalent' sensitivity after accounting for differences in background luminance) and pointwise defects. Bland-Altman (mean difference [Mdiff ] and 95% limits of agreement [LoA]) and intraclass correlation analyses were performed. RESULTS The VF test was shorter (by 76 s) and had lower fixation losses (by 0.08) and false-positive rate (by 0.01) compared to the HFA (all p < 0.0001). Intraclass correlations were 0.86, 0.82 and 0.47 for MD, PSD and pointwise sensitivity between devices, respectively. Test-retest variability was higher for VF (Mdiff 0.3 dB, LoA -7.6 to 8.2 dB) compared to the HFA (Mdiff -0.3 dB, LoA -6.4 to 5.9 dB), indicating greater test-retest variability. When using each device's underlying normative database, the HFA detected, on average, 7 more defects (at the p < 0.05 level) out of the 52 test locations compared to this iteration of VF in the glaucoma cohort. CONCLUSIONS Virtual Field returns global results that are correlated with the HFA, but pointwise sensitivities were more variable. Differences in test-retest variability and defect detection by its current normative database raise questions about the widespread adoption of VF in lieu of the HFA.
Collapse
Affiliation(s)
- Jack Phu
- School of Optometry and Vision ScienceUniversity of New South Wales SydneyKensingtonNew South WalesAustralia
- Centre for Eye HealthUniversity of New South Wales SydneyKensingtonNew South WalesAustralia
- Faculty of Medicine and HealthUniversity of SydneyCamperdownNew South WalesAustralia
- Concord Clinical SchoolConcord Repatriation General HospitalConcordNew South WalesAustralia
- School of Medicine (Optometry)Deakin UniversityWaurn PondsVictoriaAustralia
| | - Henrietta Wang
- School of Optometry and Vision ScienceUniversity of New South Wales SydneyKensingtonNew South WalesAustralia
- Centre for Eye HealthUniversity of New South Wales SydneyKensingtonNew South WalesAustralia
| | - Michael Kalloniatis
- School of Optometry and Vision ScienceUniversity of New South Wales SydneyKensingtonNew South WalesAustralia
- School of Medicine (Optometry)Deakin UniversityWaurn PondsVictoriaAustralia
| |
Collapse
|
10
|
Wang B, Alvarez-Falcón S, El-Dairi M, Freedman SF. Performance of virtual reality game-based automated perimetry in patients with childhood glaucoma. J AAPOS 2023; 27:325.e1-325.e6. [PMID: 38597674 DOI: 10.1016/j.jaapos.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/22/2023] [Accepted: 08/29/2023] [Indexed: 04/11/2024]
Abstract
PURPOSE To evaluate VisuALL, a game-based automated perimetry device, utilizing virtual reality (VR) goggles, in a cohort of patients with childhood glaucoma. METHODS In this prospective series, the results of consecutive patients with childhood glaucoma performing both VisuALL VR field (VRF) and Humphrey visual field (HVF) 24-2 testing were compared. A masked ophthalmologist graded both VRF and HVF tests for field defects (three clustered abnormal points in total or pattern deviation plot). VRF testing was performed binocularly and with the child's own spectacles. The two devices were assessed with respect to agreement of (1) global indices, such as mean deviation (MD) and pattern standard deviation (PSD), (2) point-by-point sensitivity, and (3) the ability to detect visual field defects determined by a grader. RESULTS A total of 39 children (77 eyes) were enrolled, with mean age 14.1 ± 3.6 years; 3 patients (5 eyes) could not complete the HVF. Average HVF MD was -6.3 ± 6.4 dB. There was strong correlation between VRF and HVF for MD (R = 0.68, P < 0.001), PSD (R = 0.78, P < 0.001), and point-by-point sensitivity (R = 0.63, P < 0.001). Bland Altman analysis showed no systematic difference between VRF and HVF in assessing MD and PSD. Of 72 eyes having results for both modalities, 63 (87.5%) had agreement between VRF and HVF with respect to the presence/absence of any field defect, and 52 (72.2%) had agreement regarding the presence/absence of fixation-threatening field loss. CONCLUSIONS VRF is comparable to the gold standard HVF in both identification and quantification of visual field deficits in pediatric glaucoma patients and may offer a valuable supplement or alternative to standard automated perimetry.
Collapse
Affiliation(s)
- Bo Wang
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina; Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Mays El-Dairi
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina
| | - Sharon F Freedman
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina.
| |
Collapse
|
11
|
Freeman SE, De Arrigunaga S, Kang J, Zhao Y, Roldán AM, Lin MM, Elze T, Liebman D, Chang DS, Friedman DS. Participant Experience Using Novel Perimetry Tests to Monitor Glaucoma Progression. J Glaucoma 2023; 32:948-953. [PMID: 37671465 DOI: 10.1097/ijg.0000000000002296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/07/2023] [Indexed: 09/07/2023]
Abstract
PRCIS Participant surveys taken after using tablet-based and smart visual function analyzer (SVFA) perimetry tests suggest that patients may prefer novel perimetry tests over traditional visual field machines. PURPOSE Compare patient experience using the IMOvifa SVFA and the tablet-based Melbourne Rapid Fields visual field (VF) tests to the Humphrey Field 24-2 Swedish Interactive Threshold Algorithm Standard. PATIENTS AND METHODS Prospective observational cohort study on adult participants with diagnoses of glaucoma suspect, ocular hypertension, or glaucoma. Participants attended 2 study visits ~3 months apart. During the first visit, participants were trained to use the 2 novel perimeters, took 1 test on both new devices and the Humphrey Field Analyzer, then were surveyed. Participants received tablets and performed weekly tablet VF tests at home between study visits. At the final study visit, participants re-took the VF tests and completed the same surveys. RESULTS Eighty-one participants were surveyed twice. At the baseline survey, participants preferred the SVFA (71.7%) and tablet tests (69.2%) over the Humphrey VF. Most were willing to perform weekly monitoring at home on the SVFA (69.1%) and tablet (75.4%). Participants generally had a "very good" overall experience when testing on the SVFA (71.6%) and tablet (90.1%). At the final visit, fewer participants were willing to test on the tablet daily (23.5% to 9.9%; P = 0.02 for change) and more were willing to test monthly (18.5% to 33.3%; P = 0.03 for change). CONCLUSION Users reported a preference for novel VF devices. Overall participant experience using these devices was positive, supporting the feasibility of home monitoring of VFs from an experience perspective.
Collapse
Affiliation(s)
- Sandra E Freeman
- Department of Ophthalmology, Massachusetts Eye and Ear, Boston, MA
| | | | - Joyce Kang
- Department of Ophthalmology, Massachusetts Eye and Ear, Boston, MA
| | - Yan Zhao
- Department of Ophthalmology, Massachusetts Eye and Ear, Boston, MA
| | - Ana M Roldán
- Department of Ophthalmology, Massachusetts Eye and Ear, Boston, MA
| | - Michael M Lin
- Department of Ophthalmology, Massachusetts Eye and Ear, Boston, MA
| | - Tobias Elze
- Department of Ophthalmology, Massachusetts Eye and Ear, Boston, MA
| | - Daniel Liebman
- Department of Ophthalmology, Massachusetts Eye and Ear, Boston, MA
| | - Dolly S Chang
- Genentech, Inc. South San Francisco
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, CA
| | - David S Friedman
- Department of Ophthalmology, Massachusetts Eye and Ear, Boston, MA
| |
Collapse
|
12
|
Wong KA, Ang BCH, Gunasekeran DV, Husain R, Boon J, Vikneson K, Tan ZPQ, Tan GSW, Wong TY, Agrawal R. Remote Perimetry in a Virtual Reality Metaverse Environment for Out-of-Hospital Functional Eye Screening Compared Against the Gold Standard Humphrey Visual Fields Perimeter: Proof-of-Concept Pilot Study. J Med Internet Res 2023; 25:e45044. [PMID: 37856179 PMCID: PMC10623222 DOI: 10.2196/45044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 04/01/2023] [Accepted: 05/31/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND The growing global burden of visual impairment necessitates better population eye screening for early detection of eye diseases. However, accessibility to testing is often limited and centralized at in-hospital settings. Furthermore, many eye screening programs were disrupted by the COVID-19 pandemic, presenting an urgent need for out-of-hospital solutions. OBJECTIVE This study investigates the performance of a novel remote perimetry application designed in a virtual reality metaverse environment to enable functional testing in community-based and primary care settings. METHODS This was a prospective observational study investigating the performance of a novel remote perimetry solution in comparison with the gold standard Humphrey visual field (HVF) perimeter. Subjects received a comprehensive ophthalmologic assessment, HVF perimetry, and remote perimetry testing. The primary outcome measure was the agreement in the classification of overall perimetry result normality by the HVF (Swedish interactive threshold algorithm-fast) and testing with the novel algorithm. Secondary outcome measures included concordance of individual testing points and perimetry topographic maps. RESULTS We recruited 10 subjects with an average age of 59.6 (range 28-81) years. Of these, 7 (70%) were male and 3 (30%) were female. The agreement in the classification of overall perimetry results was high (9/10, 90%). The pointwise concordance in the automated classification of individual test points was 83.3% (8.2%; range 75%-100%). In addition, there was good perimetry topographic concordance with the HVF in all subjects. CONCLUSIONS Remote perimetry in a metaverse environment had good concordance with gold standard perimetry using the HVF and could potentially avail functional eye screening in out-of-hospital settings.
Collapse
Affiliation(s)
- Kang-An Wong
- National University of Singapore, Singapore, Singapore
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
| | - Bryan Chin Hou Ang
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
| | - Dinesh Visva Gunasekeran
- National University of Singapore, Singapore, Singapore
- Singapore Eye Research Institute, Singapore, Singapore
- Raffles Medical Group, Singapore, Singapore
- Eye-ACP, Duke-NUS Medical School, Singapore, Singapore
| | - Rahat Husain
- Singapore Eye Research Institute, Singapore, Singapore
- Eye-ACP, Duke-NUS Medical School, Singapore, Singapore
- School of Medicine, University of New South Wales, Sydney, Australia
| | - Joewee Boon
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
| | - Krishna Vikneson
- School of Medicine, University of New South Wales, Sydney, Australia
| | - Zyna Pei Qi Tan
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
| | - Gavin Siew Wei Tan
- Singapore Eye Research Institute, Singapore, Singapore
- Eye-ACP, Duke-NUS Medical School, Singapore, Singapore
- Singapore National Eye Center, Singapore General Hospital, Singapore, Singapore
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore, Singapore
- Eye-ACP, Duke-NUS Medical School, Singapore, Singapore
- Singapore National Eye Center, Singapore General Hospital, Singapore, Singapore
- Tsinghua Medicine, Tsinghua University, Beijing, China
| | - Rupesh Agrawal
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
- Singapore Eye Research Institute, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| |
Collapse
|
13
|
Toyokuni H, Sakamoto M, Ueda K, Kurimoto T, Yamada-Nakanishi Y, Nakamura M. Test-retest repeatability of the imo binocular random single-eye test and Humphrey monocular test in patients with glaucoma. Jpn J Ophthalmol 2023; 67:578-589. [PMID: 37392238 DOI: 10.1007/s10384-023-01007-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 05/25/2023] [Indexed: 07/03/2023]
Abstract
PURPOSE To evaluate the reproducibility of the imo binocular random single-eye test (BRSET) and Humphrey Field Analyzer (HFA) monocular test in patients with glaucoma. STUDY DESIGN Retrospective observational study. METHODS We measured the visual fields (VF) of patients with glaucoma using the BRSET and HFA. All tests were repeated two months later. Mean sensitivity (MS), mean deviation (MD), sensitivity at each test location, and reliability indices were compared between the test days. Wilcoxon signed-rank test, interclass correlation coefficient (ICC), correlation coefficients, and Bland-Altman plots were generated for analysis. RESULTS We analyzed the VFs of 46 patients with glaucoma. There were no test-retest differences for MS and MD, and ICCs were > 0.9 for MS and MD in both perimeters. Inter-test correlations for MS and MD were high. The limits of agreement (LoAs) (lower, upper limit) between test days for MS were (- 3.4, 4.0) for BRSET and (-3.3, 3.0) for HFA. The LoA for MD was (- 3.3, 3.8) for BRSET and (- 3.2, 2.9) for HFA. Sensitivity at each testing location was more variable between testing days for BRSET than for HFA. For reliability indices, LoAs between testing days were wider for BRSET than for HFA. CONCLUSION The imo BRSET showed similar reproducibility to HFA in MS and MD. However, sensitivity at each test location varied more for BRSET than for HFA. Further studies are needed to verify the reproducibility of the imo BRSET.
Collapse
Affiliation(s)
| | - Mari Sakamoto
- Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Kaori Ueda
- Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Takuji Kurimoto
- Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Yuko Yamada-Nakanishi
- Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Makoto Nakamura
- Division of Ophthalmology, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| |
Collapse
|
14
|
Heinzman Z, Linton E, Marín-Franch I, Turpin A, Alawa K, Wijayagunaratne A, Wall M. Validation of the Iowa Head-Mounted Open-Source Perimeter. Transl Vis Sci Technol 2023; 12:19. [PMID: 37747414 PMCID: PMC10528495 DOI: 10.1167/tvst.12.9.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/04/2023] [Indexed: 09/26/2023] Open
Abstract
Purpose To assess the validity of visual field (VF) results from the Iowa Head-Mounted Display (HMD) Open-Source Perimeter and to test the hypothesis that VF defects and test-retest repeatability are similar between the HMD and Octopus 900 perimeters. Methods We tested 20 healthy and nine glaucoma patients on the HMD and Octopus 900 perimeters using the Open Perimetry Interface platform with size V stimuli, a custom grid spanning the central 26° of the VF, and a ZEST thresholding algorithm. Historical data from the Humphrey Field Analyzer (HFA) were also analyzed. Repeatability was analyzed with the repeatability coefficient (RC), and VF defect detection was determined through side-by-side comparisons. Results The pointwise RCs were 2.6 dB and 3.4 dB for the HMD and Octopus 900 perimeters in ocular healthy subjects, respectively. Likewise, the RCs were 4.2 dB and 3.5 dB, respectively, in glaucomatous patients. Limits of agreement between the HMD and Octopus 900 perimeters were ±4.6 dB (mean difference, 0.4 dB) for healthy patients and ±8.9 dB (mean difference, 0.1 dB) for glaucomatous patients. Retrospective analysis showed that pointwise RCs on the HFA2 perimeter were between 3.4 and 3.7 dB for healthy patients and between 3.9 and 4.7 dB for glaucoma patients. VF defects were similar between the HMD and Octopus 900 for glaucoma subjects. Conclusions The Iowa Virtual Reality HMD Open-Source Perimeter is as repeatable as the Octopus 900 perimeter and is a more portable and less expensive alternative than traditional perimeters. Translational Relevance This study demonstrates the validity of the visual field results from the Iowa HMD Open-Source Perimeter which may help expand perimetry access.
Collapse
Affiliation(s)
- Zachary Heinzman
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Edward Linton
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Iván Marín-Franch
- Computational Optometry, Atarfe, Spain
- Southwest Eye Institute, Tavistock, UK
| | - Andrew Turpin
- Curtin School of Population Health, Curtin University, Bentley, Western Australia, Australia
| | - Karam Alawa
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Anushi Wijayagunaratne
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Michael Wall
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| |
Collapse
|
15
|
Grau E, Andrae S, Horn F, Hohberger B, Ring M, Michelson G. Teleglaucoma Using a New Smartphone-Based Tool for Visual Field Assessment. J Glaucoma 2023; 32:186-194. [PMID: 36730078 DOI: 10.1097/ijg.0000000000002153] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 11/21/2022] [Indexed: 02/03/2023]
Abstract
PRCIS COVID-19 underlines the importance of telemedical diagnostics. The smartphone-based campimetry (Sb-C) is a newly developed digital application allowing visual field testing using a head-mounted device and a smartphone. It enables visual field screening remotely from a clinic. BACKGROUND Sb-C is a newly developed tool for functional ophthalmic diagnosis. This study aimed to examine the comparability of the Sb-C and Octopus 900 to ensure ophthalmological care in times of social distancing. METHODS Total 93 eyes were included in the study. After an ophthalmological examination, the visual field was tested by the Octopus program G1 and by the smartphone-based campimeter. The Sb-C was performed using VR glasses and an iPhone 6. The software Sb-C was downloaded and installed as SmartCampiTracker app and is examining the 30-degree visual field with 59 test positions corresponding to the G pattern of Octopus G1. Sensitivities were recorded and saved on the app. In addition, test-retest reliability was tested on 6 ophthalmologically healthy participants. RESULTS The group comprised 48 women and 45 men (mean age: 62.52±12.2 y) including 19 controls, 17 patients with ocular hypertension, 11 preperimetric glaucomas, and 46 perimetric glaucomas. The mean sensitivity (MS) of all points of G1 perimetry was 23.13 dB (95% CI, 22.08-24.18). The MS of the Sb-C was 21.23 dB (95% CI, 20.37-22.08). The correlation between the mean MS measured by G1 perimetry and the Sb-C was strong ( r =0.815, P <0.05). The test-retest reliability showed a correlation of r =0.591 ( P <0.05) . CONCLUSIONS With some technical adjustments, the Sb-C shows promise for screening glaucoma and monitoring disease progression remotely from an ophthalmologic clinic.
Collapse
Affiliation(s)
- Elisabeth Grau
- Department of Ophthalmology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg
| | - Stefan Andrae
- Department of Ophthalmology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg
| | - Folkert Horn
- Department of Ophthalmology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg
| | - Bettina Hohberger
- Department of Ophthalmology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg
| | - Matthias Ring
- Department of Computer Science, Machine Learning and Data Analytics Lab, Friedrich-Alexander-University Erlangen-Nürnberg (FAU)
| | - Georg Michelson
- Department of Ophthalmology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg
- Talkingeyes and More GmbH, Henkestraße, Erlangen, Germany
| |
Collapse
|
16
|
Chen YT, Yeh PH, Cheng YC, Su WW, Hwang YS, Chen HSL, Lee YS, Shen SC. Application and Validation of LUXIE: A Newly Developed Virtual Reality Perimetry Software. J Pers Med 2022; 12:1560. [PMID: 36294698 PMCID: PMC9605009 DOI: 10.3390/jpm12101560] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/11/2022] [Accepted: 09/12/2022] [Indexed: 12/02/2023] Open
Abstract
PURPOSE To report the application of LUXIE and validate its reliability by comparing the test results with those of Humphrey Field Analyzer 3 (HFA3). METHODS In this pilot study, we prospectively recruited participants who had received HFA3 SITA standard 30-2 perimetry and tested them with LUXIE on the same day. LUXIE is a software designed for visual field testing cooperating with HTC Vive Pro Eye, a head-mounted virtual reality device with an eye-tracking system. The test stimuli were synchronized with eye movements captured by the eye-tracking system to eliminate fixation loss. The global, hemifields, quadrants, glaucoma hemifield test (GHT) sectors, and point-by-point retinal sensitivities were compared between LUXIE and HFA3. All participants were asked to fill out a post-test user survey. RESULTS Thirty-eight participants with 65 eyes were enrolled. LUXIE demonstrated good correlations with HFA3 in global (r = 0.81), superior hemifield (r = 0.77), superonasal, superotemporal, and inferonasal quadrants (r = 0.80, 0.78, 0.80). The user survey showed that participants were more satisfied with LUXIE in operating difficulty, comfortability, time perception, concentration, and overall satisfaction. CONCLUSIONS LUXIE demonstrated good correlations with HFA3. Fixation loss could be eliminated in LUXIE with the eye-tracking system. The application of virtual reality devices such as the HTC Vive Pro Eye makes telemedicine and even home-based self-screening visual field tests possible. KEY MESSAGES 1. Virtual reality perimetry is a developing technology that has the potential in telemedicine, and home self-screening visual field tests. 2. LUXIE demonstrated good correlations with Humphrey Field Analyzer 3 in visual field retinal sensitivities.
Collapse
Affiliation(s)
- Yen-Ting Chen
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Ophthalmology, New Taipei Municipal Tucheng Hospital, New Taipei City 236, Taiwan
| | - Po-Han Yeh
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Ophthalmology, New Taipei Municipal Tucheng Hospital, New Taipei City 236, Taiwan
| | - Yu-Chun Cheng
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Wei-Wen Su
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Yih-Shiou Hwang
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Henry Shen-Lih Chen
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Yung-Sung Lee
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Su-Chin Shen
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| |
Collapse
|
17
|
Daka Q, Mustafa R, Neziri B, Virgili G, Azuara-Blanco A. Home-Based Perimetry for Glaucoma: Where Are We Now? J Glaucoma 2022; 31:361-374. [PMID: 35394454 DOI: 10.1097/ijg.0000000000002022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 03/11/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To systematically summarize the current literature on home-based perimeters for glaucoma. METHODS A systematic review was conducted in accordance with the PRISMA-DTA checklist. Studies reporting portable perimeters designed for home use were retrieved from electronic databases and handsearching of reference lists of relevant publications. Studies reporting diagnostic accuracy data were evaluated with the QUADAS-2 tool and using standard automated perimetry as the reference standard. Other aspects of the technology such as detection of disease progression and patient acceptability were also included. Data were reported in a narrative and tabular format. RESULTS Of 18 included studies, 10 evaluated tablet-based perimeters, 4 evaluated web-based perimeters, and 4 evaluated head-mounted displays. Most studies used a clinic or laboratory setting. All studies reporting diagnostic accuracy data had high risk of bias in at least one domain. Across studies, sensitivity ranged from 54% in detecting mild to 91% in detecting moderate/severe glaucoma patients from controls, while specificity was between 50% and 100% for any form of glaucoma. The reported acceptability was high but had high risk of bias. CONCLUSION Several promising technologies designed for home-based perimetry have been reported. Current studies used a controlled setting in highly selected populations. There is uncertainty on the performance and value of home-based perimetry for glaucoma. Additional efforts are required to elucidate the ability of the home-based perimeters to detect glaucoma and disease progression in real life situations.
Collapse
Affiliation(s)
- Qëndresë Daka
- Department of Pathophysiology, Medical Faculty, University of Prishtina
- University Clinical Centre of Kosova, Prishtinë, Kosovo
| | - Rona Mustafa
- Department of Pathophysiology, Medical Faculty, University of Prishtina
| | - Burim Neziri
- Department of Pathophysiology, Medical Faculty, University of Prishtina
- University Clinical Centre of Kosova, Prishtinë, Kosovo
| | - Gianni Virgili
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
- Eye Clinic, Department NERUOFARBA, University of Florence, Florence, Italy
| | - Augusto Azuara-Blanco
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| |
Collapse
|
18
|
Greenfield JA, Deiner M, Nguyen A, Wollstein G, Damato B, Backus BT, Wu M, Schuman JS, Ou Y. Virtual Reality Oculokinetic Perimetry Test Reproducibility and Relationship to Conventional Perimetry and OCT. OPHTHALMOLOGY SCIENCE 2022; 2:100105. [PMID: 36276927 PMCID: PMC9562375 DOI: 10.1016/j.xops.2021.100105] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/15/2021] [Accepted: 12/15/2021] [Indexed: 11/27/2022]
Abstract
Purpose Vivid Vision Perimetry (VVP; Vivid Vision, Inc) is a novel method for performing in-office and home-based visual field assessment using a virtual reality platform and oculokinetic perimetry. Here we examine the reproducibility of VVP Swift and compare results with conventional standard automated perimetry (SAP) and spectral-domain (SD) OCT. Design Cross-sectional study. Participants Fourteen eyes of 7 patients with open-angle glaucoma (OAG) (average age, 64.6 years; 29% women) and 10 eyes of 5 patients with suspected glaucoma (average age, 61.8 years; 40% women) were enrolled. Methods Patients with OAG and suspected glaucoma were enrolled prospectively and underwent 2 VVP Swift examinations. Results were compared with 1 conventional SAP examination (Humphrey Visual Field [HVF]; Zeiss) and 1 SD OCT examination. Main Outcome Measures Mean sensitivity (in decibels) obtained for each eye in 2 VVP Swift test sessions and a conventional SAP examination, thickness of the retinal nerve fiber layer (RNFL) and ganglion cell complex (GCC) for the SD OCT examination, and mean test durations of the VVP Swift and SAP examinations. Results The mean test duration of VVP Swift in both eyes (8.5 minutes) was significantly shorter (P < 0.001) than SAP (12.2 minutes). The average absolute difference of the mean sensitivity between the 2 VVP Swift sessions was found to be 0.73 dB (95% confidence interval [CI], 0.40–1.06). A statistically significant association was found between average mean sensitivity measurements from the VVP and mean deviation (MD) measurements obtained by the HVF with a Pearson correlation coefficient of 0.86 (95% CI, 0.70–0.94; P < 0.001). Mean visual sensitivity measurements from the VVP Swift test were significantly associated with average RNFL thickness (r = 0.66; P = 0.014) and GCC thickness (r = 0.63; P = 0.02), whereas the correlation coefficients between HVF MD and RNFL and GCC were 0.86 (P < 0.001) and 0.83 (P < 0.001), respectively. Conclusions Our results demonstrated that the VVP Swift test can generate reproducible results and is comparable with conventional SAP. This suggests that the device can be used by clinicians to assess visual function in glaucoma.
Collapse
Affiliation(s)
- Jason A. Greenfield
- Department of Ophthalmology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York
| | - Michael Deiner
- Department of Ophthalmology and Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Anwell Nguyen
- Department of Ophthalmology and Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Gadi Wollstein
- Department of Ophthalmology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York
- Department of Biomedical Engineering, NYU Tandon School of Engineering, New York, New York
- Department of Neural Science, NYU School of Arts and Sciences, New York, New York
| | - Bertil Damato
- Department of Ophthalmology and Proctor Foundation, University of California, San Francisco, San Francisco, California
- Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | | | - Mengfei Wu
- Department of Ophthalmology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York
| | - Joel S. Schuman
- Department of Ophthalmology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York
- Department of Biomedical Engineering, NYU Tandon School of Engineering, New York, New York
- Department of Neural Science, NYU School of Arts and Sciences, New York, New York
- Department of Electrical and Computer Engineering, NYU Tandon School of Engineering, New York, New York
- Department of Neuroscience and Physiology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York
| | - Yvonne Ou
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California
- Correspondence: Yvonne Ou, MD, Department of Ophthalmology, University of California, San Francisco, 10 Koret Way, K141, San Francisco, CA 94143.
| |
Collapse
|
19
|
Ma MKI, Saha C, Poon SHL, Yiu RSW, Shih KC, Chan YK. Virtual Reality and Augmented Reality- Emerging Screening and Diagnostic Techniques in Ophthalmology: a Systematic Review. Surv Ophthalmol 2022; 67:1516-1530. [PMID: 35181279 DOI: 10.1016/j.survophthal.2022.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/07/2022] [Accepted: 02/11/2022] [Indexed: 11/24/2022]
Abstract
In healthcare, virtual reality (VR) and augmented reality (AR) have been applied extensively for many purposes. Similar to other technologies such as telemedicine and artificial intelligence, VR and AR may improve clinical diagnosis and screening services in ophthalmology by alleviating current problems, including workforce shortage, diagnostic error, and underdiagnosis. In the past decade a number of studies and products have used VR and AR concepts to build clinical tests for ophthalmology, but comprehensive reviews on these studies are limited. Therefore, we conducted a systematic review on the use of VR and AR as a diagnostic and screening tool in ophthalmology. We identified 26 studies that implemented a variety of VR and AR tests on different conditions, including VR cover tests for binocular vision disorder, VR perimetry for glaucoma, and AR slit lamp biomicroscopy for retinal diseases. In general, while VR and AR tools can become standardized, automated, and cost-effective tests with good user experience, several weaknesses, including unsatisfactory accuracy, weak validation, and hardware limitations, have prevented these VR and AR tools from having wider clinical application. Also, a comparison between VR and AR is made to explain why studies have predominantly used VR rather than AR.
Collapse
Affiliation(s)
| | - Chinmoy Saha
- Department of Ophthalmology, Li Ka Shing Faculty of Medicine, University of Hong Kong
| | | | | | - Kendrick Co Shih
- Department of Ophthalmology, Li Ka Shing Faculty of Medicine, University of Hong Kong
| | - Yau Kei Chan
- Department of Ophthalmology, Li Ka Shing Faculty of Medicine, University of Hong Kong.
| |
Collapse
|
20
|
Soans RS, Renken RJ, John J, Bhongade A, Raj D, Saxena R, Tandon R, Gandhi TK, Cornelissen FW. Patients Prefer a Virtual Reality Approach Over a Similarly Performing Screen-Based Approach for Continuous Oculomotor-Based Screening of Glaucomatous and Neuro-Ophthalmological Visual Field Defects. Front Neurosci 2021; 15:745355. [PMID: 34690682 PMCID: PMC8526798 DOI: 10.3389/fnins.2021.745355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/13/2021] [Indexed: 11/15/2022] Open
Abstract
Standard automated perimetry (SAP) is the gold standard for evaluating the presence of visual field defects (VFDs). Nevertheless, it has requirements such as prolonged attention, stable fixation, and a need for a motor response that limit application in various patient groups. Therefore, a novel approach using eye movements (EMs) - as a complementary technique to SAP - was developed and tested in clinical settings by our group. However, the original method uses a screen-based eye-tracker which still requires participants to keep their chin and head stable. Virtual reality (VR) has shown much promise in ophthalmic diagnostics - especially in terms of freedom of head movement and precise control over experimental settings, besides being portable. In this study, we set out to see if patients can be screened for VFDs based on their EM in a VR-based framework and if they are comparable to the screen-based eyetracker. Moreover, we wanted to know if this framework can provide an effective and enjoyable user experience (UX) compared to our previous approach and the conventional SAP. Therefore, we first modified our method and implemented it on a VR head-mounted device with built-in eye tracking. Subsequently, 15 controls naïve to SAP, 15 patients with a neuro-ophthalmological disorder, and 15 glaucoma patients performed three tasks in a counterbalanced manner: (1) a visual tracking task on the VR headset while their EM was recorded, (2) the preceding tracking task but on a conventional screen-based eye tracker, and (3) SAP. We then quantified the spatio-temporal properties (STP) of the EM of each group using a cross-correlogram analysis. Finally, we evaluated the human-computer interaction (HCI) aspects of the participants in the three methods using a user-experience questionnaire. We find that: (1) the VR framework can distinguish the participants according to their oculomotor characteristics; (2) the STP of the VR framework are similar to those from the screen-based eye tracker; and (3) participants from all the groups found the VR-screening test to be the most attractive. Thus, we conclude that the EM-based approach implemented in VR can be a user-friendly and portable companion to complement existing perimetric techniques in ophthalmic clinics.
Collapse
Affiliation(s)
- Rijul Saurabh Soans
- Department of Electrical Engineering, Indian Institute of Technology – Delhi, New Delhi, India
- Laboratory of Experimental Ophthalmology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Remco J. Renken
- Department of Biomedical Sciences of Cells and Systems, Cognitive Neuroscience Center, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - James John
- Department of Electrical Engineering, Indian Institute of Technology – Delhi, New Delhi, India
| | - Amit Bhongade
- Department of Electrical Engineering, Indian Institute of Technology – Delhi, New Delhi, India
| | - Dharam Raj
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Saxena
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Radhika Tandon
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Tapan Kumar Gandhi
- Department of Electrical Engineering, Indian Institute of Technology – Delhi, New Delhi, India
| | - Frans W. Cornelissen
- Laboratory of Experimental Ophthalmology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| |
Collapse
|
21
|
Stapelfeldt J, Kucur SS, Huber N, Höhn R, Sznitman R. Virtual Reality-Based and Conventional Visual Field Examination Comparison in Healthy and Glaucoma Patients. Transl Vis Sci Technol 2021; 10:10. [PMID: 34614166 PMCID: PMC8496417 DOI: 10.1167/tvst.10.12.10] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Purpose Clinically evaluate the noninferiority of a custom virtual reality (VR) perimetry system when compared to a clinically and routinely used perimeter on both healthy subjects and glaucoma patients. Methods We use a custom-designed VR perimetry system tailored for visual field testing. The system uses Oculus Quest VR headset (Facebook Technologies, LLC, Bern, Switzerland), that includes a clicker for participant response feedback. A prospective, single center, study was conducted at the Department of Ophthalmology of the Bern University Hospital (Bern, Switzerland) for 12 months. Of the 114 participants recruited 70 subjects (36 healthy and 34 glaucoma patients with early to moderate visual field loss) were included in the study. Participants underwent perimetry tests on an Octopus 900 (Haag-Streit, Köniz, Switzerland) as well as on the custom VR perimeter. In both cases, standard dynamic strategy (DS) was used in conjunction with the G testing pattern. Collected visual fields (VFs) from both devices were then analyzed and compared. Results High mean defect (MD) correlations between the two systems (Spearman, ρ ≥ 0.75) were obtained. The VR system was found to slightly underestimate VF defects in glaucoma subjects (1.4 dB). No significant bias was found with respect to eccentricity or subject age. On average, a similar number of stimuli presentations per VF was necessary when measuring glaucoma patients and healthy subjects. Conclusions This study demonstrates that a clinically used perimeter and the proposed VR perimetry system have comparable performances with respect to a number of perimetry parameters in healthy and glaucoma patients with early to moderate visual field loss. Translational Relevance This suggests that VR perimeters have the potential to assess VFs with high enough confidence, whereby alleviating challenges in current perimetry practices by providing a portable and more accessible visual field test.
Collapse
Affiliation(s)
- Jan Stapelfeldt
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Serife Seda Kucur
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Nina Huber
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - René Höhn
- Department of Ophthalmology, Bern University Hopsital, Bern, Switzerland
| | - Raphael Sznitman
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| |
Collapse
|
22
|
Groth SL. New Strategies for Automated Perimetry: Historical Perspective and Future Innovations. J Curr Glaucoma Pract 2021; 15:103-105. [PMID: 35173390 PMCID: PMC8807935 DOI: 10.5005/jp-journals-10078-1321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Groth SL. New Strategies for Automated Perimetry: Historical Perspective and Future Innovations. J Curr Glaucoma Pract 2021;15(3):103-105.
Collapse
Affiliation(s)
- Sylvia L Groth
- Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
23
|
[Telemedical applications in ophthalmology in times of COVID-19]. Ophthalmologe 2021; 118:885-892. [PMID: 34406461 PMCID: PMC8371418 DOI: 10.1007/s00347-021-01470-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 11/02/2022]
Abstract
BACKGROUND During the coronavirus disease 2019 (COVID-19) pandemic access to and utilization of ophthalmologic healthcare providers was partially restricted. OBJECTIVE This article provides an overview of already available tele-ophthalmologic applications for better care during the pandemic as well as those still under development. MATERIAL AND METHODS The study included an analysis of current scientific publications, analysis of unrestricted screening applications in smart device app stores as well as telemetric medical products specifically designed for home monitoring and discussion of the requirements of an integrated ophthalmologic video consultation. RESULTS There is significant interest in tele-ophthalmologic applications and devices as evidenced by a rise in the number of relevant publications. Freely available screening tests for smart phones and tablets are as a rule currently not validated and show significant discrepancies from established standard tests. Telemetric medical devices show great potential for home monitoring in chronic ophthalmologic diseases but must first become established in the clinical routine. CONCLUSION There is an unmet need for systematic analysis, development and validation of telemedical applications and medical products for ophthalmology in order to advantageously utilize the potential of telemedicine and to incorporate this into an ophthalmologic video consultation.
Collapse
|
24
|
Phu J, Kalloniatis M. Patient and technician perspectives following the introduction of frontloaded visual field testing in glaucoma assessment. Clin Exp Optom 2021; 105:617-623. [PMID: 34402753 DOI: 10.1080/08164622.2021.1965461] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
CLINICAL RELEVANCE Frontloaded visual field testing (twice per eye per session) is well-tolerated by patients and technicians, representing a viable strategy that can be implemented in routine clinical practice to capture enough clinical perimetry data for effective disease diagnosis, surveillance and management. BACKGROUND To determine the experiences of patients and technicians following the implementation of frontloaded visual field testing (multiple tests per eye within the same session) in a glaucoma service. METHODS This was a retrospective, cross-sectional study. A written questionnaire was administered to patients (three questions) attending the glaucoma service at the Centre for Eye Health for glaucoma assessment and to their administering perimetry technicians (two questions). The questionnaire was administered after static automated perimetry (24-2 SITA-Faster on the Humphrey Field Analyzer) was performed twice for each eye (frontloaded) within the same session. Respondents were asked to provide a 1-5 Likert scale response to questions that targeted operational issues for frontloaded visual field testing. Responses were correlated against to demographic (age, gender, ethnicity) and clinical (diagnosis, refractive error, visual field indices, test duration) parameters. RESULTS Approximately 90% of patient respondents agreed that frontloaded visual field testing was clearly explained to them, that they were comfortable during the test, and would prefer completing the tests at a single visit rather than returning to repeat the test. Most technician respondents were also able to keep their patients comfortable. 13% of technician respondents felt they ran late during the session, but on average, the total test duration for four visual field tests was 13 minutes, including breaks. There was no correlation found between demographic and clinical factors, and the responses. CONCLUSIONS Frontloaded visual field testing was well-tolerated by patients and technicians. Strategies that may be helpful for other clinics to adopt this new paradigm are described.
Collapse
Affiliation(s)
- Jack Phu
- Centre For Eye Health, University of New South Wales, Kensington, NSW, Australia
| | - Michael Kalloniatis
- Centre For Eye Health, University of New South Wales, Kensington, NSW, Australia
| |
Collapse
|
25
|
Iskander M, Ogunsola T, Ramachandran R, McGowan R, Al-Aswad LA. Virtual Reality and Augmented Reality in Ophthalmology: A Contemporary Prospective. Asia Pac J Ophthalmol (Phila) 2021; 10:244-252. [PMID: 34383716 PMCID: PMC9167643 DOI: 10.1097/apo.0000000000000409] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Most published systematic reviews have focused on the use of virtual reality (VR)/augmented reality (AR) technology in ophthalmology as it relates to surgical training. To date, this is the first review that investigates the current state of VR/AR technology applied more broadly to the entire field of ophthalmology. METHODS PubMed, Embase, and CINAHL databases were searched systematically from January 2014 through December 1, 2020. Studies that discussed VR and/or AR as it relates to the field of ophthalmology and provided information on the technology used were considered. Abstracts, non-peer-reviewed literature, review articles, studies that reported only qualitative data, and studies without English translations were excluded. RESULTS A total of 77 studies were included in this review. Of these, 28 evaluated the use of VR/AR in ophthalmic surgical training/assessment and guidance, 7 in clinical training, 23 in diagnosis/screening, and 19 in treatment/therapy. 15 studies used AR, 61 used VR, and 1 used both. Most studies focused on the validity and usability of novel technologies. CONCLUSIONS Ophthalmology is a field of medicine that is well suited for the use of VR/AR. However, further longitudinal studies examining the practical feasibility, efficacy, and safety of such novel technologies, the cost-effectiveness, and medical/legal considerations are still needed. We believe that time will indeed foster further technological advances and lead to widespread use of VR/AR in routine ophthalmic practice.
Collapse
Affiliation(s)
- Mina Iskander
- Department of Ophthalmology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York, US
| | - Titilola Ogunsola
- Department of Ophthalmology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York, US
| | - Rithambara Ramachandran
- Department of Ophthalmology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York, US
| | - Richard McGowan
- Department of Epidemiology and Health Promotion, NYU College of Dentistry, New York, New York, US
| | - Lama A. Al-Aswad
- Department of Ophthalmology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York, US
- Department of Population Health, NYU Langone Health, NYU Grossman School of Medicine, New York, New York, US
| |
Collapse
|