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Reimagining Retinal Testing with Virtual Reality Perimetry: Enhancing Endpoint Precision in Geographic Atrophy Clinical Trials
Introduction
Geographic Atrophy (GA) and Age-Related Macular Degeneration (AMD) require precise longitudinal monitoring of retinal sensitivity and disease progression. Conventional microperimetry methodologies, while effective for mapping scotomas and quantifying functional deficits, present significant logistical challenges including clinic-based administration requirements and extended testing durations. These limitations compromise patient adherence and adversely affect data quality and integrity in clinical trial settings.
At Vivid Vision, we’re exploring a new, more convenient, way to measure retinal sensitivity at home using virtual reality (VR) technology and a natural-fixation perimetry technique combined with lesion-customized grids. The latest study of Vivid Vision Perimetry (VVP), led by Dr. Karl Csaky at Retina Foundation of the Southwest and supported by Regeneron, demonstrates that an at-home VR-based vision test not only matches the accuracy of in-clinic microperimetry but also provides even greater precision.
These exciting findings were presented on February 12, 2025 at the Macula Society’s “IMAGING I AND MACULAR DISEASE” session1. Here’s a quick rundown of the study and what it means for the future of visual field testing. If you'd like to see the full presentation, get in touch with us.
Why Develop a VR-Based Test for GA?
Geographic Atrophy, an advanced form of Age-Related Macular Degeneration, leads to progressively larger areas of damaged retina. Measuring how well someone can see around these damaged areas is vital for tracking the disease and evaluating new treatments. However, traditional microperimetry tests have some drawbacks:
- They can be time-consuming and require frequent clinic visits.
- They might lack the ability to tailor test points around each patient’s unique lesion.
- Consistent positioning and fixation can be challenging, leading to variability in results.
Our goal was to solve these challenges with:
- An at-home solution to reduce the need for frequent clinic visits.
- A customizable test layout that targets each individual’s damaged and healthy retinal regions.
- Improved reliability and precision in tracking vision changes over time.
How We Did It
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Customization via a Web-Based Interface
Using the participant’s retinal images (including FAF and OCT scans), we identified where the damage (lesion) was located on the retina and mapped out exactly where to place test stimuli. We also corrected for each participant’s natural eye position and any possible rotation of the eye (cyclotorsion). -
Deployment to a VR Headset
Each customized test was then loaded into the VR headset running our Vivid Vision Perimetry (VVP) software. This allowed participants to do the test from the comfort of home. -
Test Bundle: 10 Sessions Over 5 Days
After a quick in-clinic training session, participants took the headset home and completed 10 test sessions in just 5 days. On average, each session took under 20 minutes. -
Comparisons with Microperimetry
Meanwhile, each participant also underwent traditional microperimetry (MAIA) in the clinic, so we could compare test-retest variability, mean sensitivity values, and fixation precision.
Example of lesion-customized grids placed on the physiological blind spots of a normally-sighted person. VVP is precise enough to measure individual blood vessels leaving the optic nerve head.
What We Found
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Reduced Test-Retest Variability
Repeated measurements with our VR test showed a variability of just 0.23 dB (SE for the mean of 10 sessions) compared to 0.87 dB for standard microperimetry (SD across 2-3 visits). VVP produced more consistent and stable results over multiple sessions substantially enhancing the statistical power to detect clinically meaningful changes in retinal sensitivity -
Near-Perfect Adherence
Participants completed almost 100% of their assigned at-home sessions. This high compliance mirrors findings from a 2024 study (Chia et al.)2 in glaucoma patients using a similar VR approach. -
Excellent Agreement with Traditional Testing
Across all participants, the mean retinal sensitivity values from the VR test closely matched those measured by the MAIA microperimeter. -
Improved Fixation Precision
We measured eye movement accuracy by placing test stimuli around the physiological blind spot revealing significantly improved precision with VVP (0.55°) versus MAIA microperimetry (1.2°; p<0.05).
Example of lesion-customized grids placed on the physiological blind spots of a normally-sighted person. VVP is precise enough to measure individual blood vessels leaving the optic nerve head.
Why This Matters
Key insights from the latest study of Vivid Vision Perimetry (VVP), led by Dr. Karl Csaky at Retina Foundation of the Southwest and supported by Regeneron
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Spatially-Resolved Functional Assessment: The lesion-customized stimulus placement enables precise mapping of functional deficits in relation to structural abnormalities. This spatial co-registration of structure and function provides unprecedented resolution in quantifying disease progression, particularly valuable for evaluating therapeutic effect in perilesional regions where treatment efficacy may first manifest.
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Enhanced Statistical Power and Reduced Sample Requirements: The substantial reduction in test-retest variability translates directly to increased statistical power while maintaining equivalent power to detect treatment effects.
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Enhanced Protocol Adherence and Data Integrity: At-home administration enables significantly higher frequency of testing for longitudinal assessment. Our near 100% protocol adherence minimizes missing data points and strengthens statistical analyses.
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Operational Efficiencies for Multi-Center Trials: Centralized deployment and standardized administration by the centralized reading center minimize site-to-site variability, reducing the need for extensive site training and validation. This streamlined approach enables global, multi-center phase II/III studies.
What’s Next?
We’re thrilled about the potential of this at-home VR approach for a wide range of eye conditions. As our partnerships with industry continue to expand, we’ll refine the technology further, exploring:
- Larger cohorts for greater statistical power.
- Additional retinal diseases where early intervention and consistent monitoring can change treatment outcomes.
- Combining VR perimetry data with AI-driven insights for even more personalized care.
Get Involved!
Vivid Vision Perimetry offers a validated solution for enhancing the precision and efficiency of functional endpoints in geographic atrophy clinical trials. Our team has extensive experience implementing this technology in industry-sponsored studies with:
- Customized endpoint design tailored to specific trial protocols
- Comprehensive training and certification programs for site personnel
- Full data management and dataset delivery
- Innovation partnerships for novel digital endpoints
For pharmaceutical and biotechnology companies seeking to accelerate clinical development timelines or enhance the statistical power of GA therapeutic programs, our dedicated business development team is available to discuss implementation strategies for upcoming clinical trials.
Contact our Clinical Partnerships team to schedule a technical presentation or to request our VVP information package. Early engagement during protocol development is recommended to optimize study design and maximize the benefits of high-precision functional endpoints.
References
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Csaky, K. Use of a novel individualized, clustered at-home virtual reality perimetry test to measure retinal sensitivity in patients with Geographic Atrophy (GA). Macula Society. Charlotte Harbor, Florida, USA. 12 February 2025. https://www.xcdsystem.com/maculasociety/program/5G2onFx/index.cfm
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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. Ophthalmology Glaucoma. 2024;7(2):139-47.