Modernizing Visual Field Testing in Irish Community Optometry

Glaucoma is quietly becoming one of Ireland's most significant public health challenges. It

is estimated that 3% of people over 50 in Ireland has glaucoma, and based on the country's

growing and ageing population, the level of the disease is expected to rise by a third over

the coming decade. Yet awareness remains alarmingly low: almost 40% of the Irish

population do not know what glaucoma is, despite it being the world's leading cause of

irreversible blindness. (Eye Doctors Ireland; Fighting Blindness, The State of Ireland's Eye

Health Report 2022)

The consequences for the healthcare system are already visible. The annual cost of sight

loss and blindness in Ireland was estimated at €2.67 billion before the pandemic, and

demand for glaucoma services is expected to rise by 33% in the next decade. Hospital

ophthalmology departments are under sustained pressure, and backlogs remain a

persistent concern. (Fighting Blindness, The State of Ireland's Eye Health Report 2022)

Early detection of glaucoma is key to preventing later sight loss - and regular sight tests

are the only way to detect symptomless glaucoma before irreversible damage occurs. This

makes community optometry a critical first line of defence. Industry bodies are calling for

an expanded role for community optometrists in a wider adoption of shared care services

with ophthalmologists to meet current and future demand. (Eye Doctors Ireland; Fighting

Blindness, The State of Ireland's Eye Health Report 2022)

In this context, the tools available to community optometrists matter more than ever.

Faster, more reliable, and more flexible visual field testing is no longer a convenience - it

is a structural necessity for sustaining quality eye care at scale across Ireland.

About the Practice Nölke Opticians - Advanced community optometry in Waterford

Picture: The team of Nölke Opticians

Nölke Opticians is an independent advanced optometry practice based in Waterford, South

East Ireland, serving a population of over 135,000 across a competitive local landscape

that includes nine optometry practices, five private ophthalmology clinics, and a large

regional public hospital ophthalmology department.

The practice brings together four optometrists and eight optical assistants across a 315

sqm ground floor facility, with clinical specialisms spanning OCT imaging, Optomap retinal

photography, visual fields, myopia management, dry eye, low vision, contact lenses, and

an advanced audiology service including a vestibular balance clinic.

At its head is Kjell Nölke, who qualified from Dublin Institute of Technology in 1993 before

building his experience across a broad range of settings — hospital eye departments at St

Thomas's and St Peter's in London, independent and retail practices, and time working in

Sydney, Perth and Queenstown. He returned to the UK before founding Nölke Opticians in

Waterford in 2004, drawing on over a decade of diverse clinical experience to establish

what has become one of the region's most comprehensive community eye care practices.

Existing Limitations - The constraints of traditional perimetry in a busy multi-optometrist practice

Before integrating VisionOneTM, visual field testing at Nölke Opticians relied on a Zeiss

Humphrey Field Analyzer - a clinically established device, still used today for Esterman

tests required for driver assessments, but one that comes with practical constraints in a

busy multi-optometrist setting.

The Humphrey occupies a shared room alongside a Myah topographer, making scheduling

across a four-optometrist team more complex. Its workflow is slow: printed reports must

be manually scanned into patient files, and the fixed location of the device limits

flexibility throughout the practice day.

Beyond the operational friction, visual field testing itself presents a longer-standing

clinical challenge. Glaucoma patients who have done the test many times are often

resistant to repeating it - confirming a pattern of field loss and tracking progression from

one visit to the next remains consistently difficult. For less mobile patients, the physical

demands of positioning at a traditional bowl perimeter add a further layer of difficulty,

sometimes compromising both comfort and the reliability of results.

Implementation of VisionOneTM - Two years of progressive integration across the

practice

Nölke Opticians introduced VisionOneTM two years ago, initially as a complementary tool

alongside the existing Humphrey Field Analyzer. Over time, as the team became

increasingly familiar with the system, it has grown into the practice's primary visual field

testing platform - used routinely across all four optometrists in their day-to-day clinical

work.

The most immediate operational shift was one of flexibility. With the Humphrey confined

to a single shared room, visual field testing had always required careful scheduling

coordination across the team. VisionOneTM changed that dynamic entirely: as Kjell puts it,

"it is faster to work with and much more flexible in that the optometrist can do the test in their own room." For a practice of this size and complexity, that flexibility alone represents a significant workflow improvement.

The clinical performance of the system has matched the operational benefits. Kjell

highlights the SORS program in particular, noting that "the SORS program works

exceptionally well allowing fast results" - delivering reliable outcomes that maintain

clinical validity while meaningfully reducing test duration. Where traditional perimetry

strategies can be time-consuming and tiring for patients, SORS enables a more efficient

examination without compromising the quality of the output.

Data management has also been transformed. Results are stored online and immediately

accessible, making it straightforward to retrieve and compare a patient's previous tests at

any subsequent visit. There is no printing, no manual scanning, and no risk of results being

misplaced or delayed. For longitudinal glaucoma monitoring - where tracking progression

across multiple visits is clinically essential - this represents a practical and meaningful

improvement over paper-based workflows.

A further detail worth noting is the prescription holder insert. For patients who wear

refractive correction, the insert allows precise alignment between the eye, the lens, and

the target stimulus - improving both the accuracy and the comfort of the test for a patient

group that represents a significant proportion of any optometry practice's caseload.

As Kjell observes,

"VisionOne has addressed many of these difficulties allowing practitioners a new methodology in patient comfort, clinically approved examinations, that are repeatable and accessible throughout the practice."

Perhaps the most striking illustration of VisionOneTM's flexibility, however, comes from outside the practice altogether. Kjell carries out domiciliary visits for patients who are unable to attend the clinic, and has taken VisionOneTM with him on home visits. On one such occasion, he notes, "I have used it on request for a patient who it transpired had an undiagnosed hemianopia following a stroke." It is a compelling example of what becomes possible when clinical-grade visual field testing is no longer tied to a fixed room and a stationary device. For patients who cannot travel, that portability is not simply a

convenience - it can be the difference between a diagnosis being made or missed entirely.

Patient Experience - Comfort, acceptance, and reduced resistance to testing

One of the most immediate and consistent observations since introducing VisionOneTM has

been the response from patients. The VR headset format is still a novelty for many - and

that novelty works in the clinician's favour. Patients engage with the test differently from

the outset, approaching it with curiosity rather than apprehension.

As Kjell describes it,

"Patients very much enjoy the experience - it feels less stressful to them, many saying it is less intimidating" than conventional bowl perimetry. That shift in perception has a direct impact on how well patients perform during testing.

For less mobile patients, the comfort difference is particularly meaningful. Traditional

bowl perimeters place real physical demands on patients - maintaining a fixed position,

leaning forward, keeping still for extended periods. For elderly patients or those with

posture and mobility limitations, this can be genuinely difficult, and the resulting

discomfort often affects the reliability of the test. VisionOneTM removes much of that

friction, making the experience more manageable and the results more consistent.

The impact on glaucoma patients deserves particular attention. These are patients who

know the test well, have repeated it many times. That resistance is not simply a matter of

attitude; it reflects years of an experience that is tiring, repetitive, and often

uncomfortable. VisionOneTM meaningfully changes that dynamic. The shorter test duration,

the more natural format, and the reduced physical burden all contribute to a higher level

of acceptance - and better compliance directly supports the repeat testing that glaucoma

monitoring depends on.

For patients with refractive correction, the prescription holder insert provides an

additional practical benefit - improving alignment between eye, lens, and stimulus target,

and ensuring that the test is both more comfortable and more clinically accurate for this

group.

Clinical and Operational Outcomes - What two years of use has delivered

Picture: The PeriVision system in use at Nölke Opticians

After two years of integration, the impact of VisionOneTM at Nölke Opticians is visible

across both the clinical and operational dimensions of the practice.

The most immediate gain has been speed. The SORS program delivers reliable visual field

results in a fraction of the time required by traditional strategies, reducing the burden on

patients and freeing up appointment time across a busy four-optometrist schedule. That

efficiency compounds across the team: with each optometrist able to test independently

in their own room, the practice has effectively multiplied its visual field testing capacity

without adding equipment or dedicated space. The bottleneck created by a single shared

device has been removed entirely.

Reliability and repeatability have also improved - and the two are connected. Better

patient cooperation, driven by a more comfortable and less intimidating experience,

translates directly into more consistent results. For glaucoma monitoring in particular,

where confirming a pattern of field loss often requires repeat testing and where

progression assessment depends on the comparability of results across visits, this

improvement is clinically significant.

The shift to online data storage has streamlined longitudinal follow-up in a way that

paper-based workflows simply cannot match. Previous results are immediately accessible

at any appointment, enabling straightforward side-by-side comparison without the delays

or gaps that manual scanning and physical filing can introduce. The administrative burden

associated with printing and scanning has been eliminated entirely.

Finally, the domiciliary use case stands as perhaps the most tangible illustration of what

VisionOneTM makes possible beyond the walls of the practice. The identification of an

undiagnosed hemianopia in a patient who had suffered a stroke - detected during a home

visit using VisionOneTM - is a concrete clinical outcome that would not have been

achievable with traditional fixed equipment. It is a reminder that portability is not simply

an operational convenience; in the right circumstances, it carries real diagnostic and

patient safety implications.

Reflections on the Industry - What Nölke Opticians reflects about the future of community eye care

The experience at Nölke Opticians speaks to something larger than a single practice's

technology choice. It illustrates how well-equipped independent community optometrists

can meaningfully expand their clinical capacity - not by adding rooms, staff, or

infrastructure, but by adopting tools that are faster, more flexible, and better suited to

the realities of modern practice.

In a county served by a large regional hospital ophthalmology department, the ability to

perform reliable, efficient visual field monitoring in-house is not a marginal improvement.

It reduces unnecessary referrals, supports earlier detection, and allows the practice to

take on a greater share of the monitoring burden that would otherwise fall to

already-stretched secondary care services. As glaucoma prevalence continues to rise

across Ireland, that capacity matters.

The multi-optometrist model at Nölke Opticians also demonstrates something important

about how device flexibility translates into real-world value. A single VisionOneTM unit,

accessible to four clinicians across their own consultation rooms, delivers far more than a

single fixed device ever could. The return on that flexibility is felt every day, across every

appointment.

And then there is the domiciliary dimension - perhaps the clearest example of what

becomes possible when clinical-grade testing is no longer tied to a fixed location. Bringing

visual field testing to patients who cannot attend a practice is something traditional

equipment simply cannot offer. The hemianopia case is a striking illustration, but the

broader principle applies to any patient for whom attending a clinic is difficult: portability

extends the reach of care to those who need it most.

Ultimately, what VisionOneTM represents at Nölke Opticians is not a replacement for clinical

expertise - it is a tool that allows that expertise to go further. More patients tested, more

reliably, more comfortably, and in more settings. That is what modern community

optometry increasingly demands, and it is what the best independent practices are

already delivering.