Use of a Novel Virtual Reality-Based Pupillography Device for Glaucoma Management: Cross-Sectional Cohort Pilot Study

Current standard methods in monitoring glaucoma progression, like optical coherence tomography (OCT) and standard automated perimetry (SAP), have limitations in certain cases. Automated relative afferent pupillary defect (RAPD) and pupillary light reflex (PLR) testing may offer more objective alternatives. This pilot study aimed to evaluate whether RAPD could sufficiently distinguish between the two eyes in asymmetrical glaucoma, and thus could lay the foundation for using the PLR of a single eye to monitor progression longitudinally.

Twenty-one patients underwent quantitative PLR measurements using a virtual reality headset. RAPD was calculated by subtracting the amplitude of PLRs between eyes. Both RAPD and relative SAP (measured using the mean defect or MD) results were correlated to the thickness of the peripapillary retinal nerve fiber layer (RNFL), as measured by OCT.

Data from 18 patients was analyzed after exclusions. RAPD significantly correlated with differences between the two eyes as measured by RNFL thickness (Pearson r = 0.79, p = 0.05). MD differences correlated slightly better with RNFL differences (Pearson r = 0.87, p < 0.05). RAPD and MD combined yielded an improved prediction of RNFL differences by 5% compared to using MD only.

RAPD measurements reliably detected asymmetries in optic nerve damage in glaucoma patients. SAP measurements correlated better with OCT results than RAPD results. However, SAP and RAPD combined led to an improved prediction of RNFL thickness. This could possibly allow us to use PLR only over longer periods of time to monitor glaucomatous optic nerve damage in a single eye in the future.