Objective Assessment of Activity Limitation in Glaucoma with Smartphone Virtual Reality Goggles: A Pilot Study

Democratizing Health Care in the Metaverse: How Video Games can Monitor Eye Conditions Using the Vision Performance Index: A Pilot Study

Objective

In a world where digital media is deeply engrained into our everyday lives, there lies an opportunity to leverage interactions with technology for health and wellness. The Vision Performance Index (VPI) leverages natural human-technology interaction to evaluate visual function using visual, cognitive, and motor psychometric data over 5 domains: field of view, accuracy, multitracking, endurance, and detection. The purpose of this study was to describe a novel method of evaluating holistic visual function through video game-derived VPI score data in patients with specific ocular pathology.

Design

Prospective comparative analysis.

Participants

Patients with dry eye, glaucoma, cataract, diabetic retinopathy (DR), age-related macular degeneration, and healthy individuals.

Methods

The Vizzario Inc software development kit was integrated into 2 video game applications, Balloon Pop and Picture Perfect, which allowed for generation of VPI scores. Study participants were instructed to play rounds of each video game, from which a VPI score was compiled.

Main Outcome Measures

The primary outcome was VPI overall score in each comparison group. Vision Performance Index component, subcomponent scores, and psychophysical inputs were also compared.

Results

Vision Performance Index scores were generated from 93 patients with macular degeneration (n = 10), cataract (n = 10), DR (n = 15), dry eye (n = 15), glaucoma (n = 16), and no ocular disease (n = 27). The VPI overall score was not significantly different across comparison groups. The VPI subcomponent "reaction accuracy" score was significantly greater in DR patients (106 ± 13.2) versus controls (96.9 ± 11.5), P = 0.0220. The VPI subcomponent "color detection" score was significantly lower in patients with DR (96.8 ± 2.5; p=0.0217) and glaucoma (98.5 ± 6.3; P = 0.0093) compared with controls (101 ± 11). Psychophysical measures were statistically significantly different from controls: proportion correct (lower in DR, age-related macular degeneration), contrast errors (higher in cataract, DR), and saturation errors (higher in dry eye).

Conclusions

Vision Performance Index scores can be generated from interactions of an ocular disease population with video games. The VPI may offer utility in monitoring select ocular diseases through evaluation of subcomponent and psychophysical input scores; however, future larger-scale studies must evaluate the validity of this tool.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

Kinetic Perimetry on Virtual Reality Headset

OBJECTIVE

We present a portable automatic kinetic perimeter based on a virtual reality (VR) headset device as an innovative and alternative solution for the screening of clinical visual fields. We compared the performances of our solution with a gold standard perimeter, validating the test on healthy subjects.

METHODS

The system is composed of an Oculus Quest 2 VR headset with a clicker for participant response feedback. An Android app was designed in Unity to generate moving stimuli along vectors, following a standard Goldmann kinetic perimetry approach. Sensitivity thresholds are obtained by moving centripetally three different targets (V/4e, IV/1e, III/1e) along 24 or 12 vectors from an area of non-seeing to an area of seeing and then transmitted wirelessly to a PC. A Python real-time algorithm processes the incoming kinetic results and displays the hill of vision in a two-dimensional map (isopter). We involved 21 subjects (5 males and 16 females, age range 22-73 years) for a total of 42 eyes tested with our proposed solution, and results were compared with a Humphrey visual field analyzer to test reproducibility and efficacy.

RESULTS

isopters generated with the Oculus headset were in good agreement with those acquired with a commercial device (Pearson's correlation values r > 0.83 for each target).

CONCLUSIONS

we demonstrate the feasibility of VR kinetic perimetry by comparing performances between our system and a clinically used perimeter in healthy subjects.

SIGNIFICANCE

proposed device leads the way for a portable and more accessible visual field test, overcoming challenges in current kinetic perimetry practices.

Contrast sensitivity in glaucoma patients with visual field defects at different locations

Contrast sensitivity (CS) is closely associated with vision-related quality of life in glaucoma patients. This cross-sectional study was performed to determine the relationship between CS and visual field (VF) sensitivity (VFS) according to the hemifield location of VF defects in 238 patients with primary open-angle glaucoma (POAG) who underwent 24-2 standard automated perimetry and CS measurement on the same day. Of the 238 eyes, 83, 58, and 47 eyes had VF defects in the superior, inferior and both hemifields, respectively, and 50 had no VF defects in either hemifield. Significant correlations between CS and VFS in all sectors were observed in the entire cohort (R² = 0.103-0.315, all P < 0.001). However, CS poorly represented VF defects in eyes with single superior (R² = 0.037-0.086) or inferior (R² = 0.107-0.222) hemifield defects. Eyes with bi-hemifield VF defects showed significant correlations between VFS and CS at 0.3 m in all sectors (R² = 0.200-0.406), but the correlation between VFS and CS at 5 m was significant only in the inferior sector (R² = 0.224-0.348 vs. 0.081-0.126 in the inferior and superior sectors, respectively). Correlations between CS and VFS were dependent on CS distances and the presence of bi-hemifield VF defects. Although CS may not correlate with VFS in eyes with single-hemifield VF defects, it may reflect visual disability in eyes with bi-hemifield defects.

Test Reliability and Compliance to a Twelve-Month Visual Field Telemedicine Study in Glaucoma Patients

Background: Our primary aim is to quantify test reliability and compliance of glaucoma patients to a weekly visual field telemedicine (VFTM) schedule. A secondary aim is to determine concordance of the VFTM results to in-clinic outcomes. Methods: Participants with stable glaucoma in one eye were recruited for a 12 month VFTM trial using the Melbourne Rapid Fields (MRF-home, MRFh) iPad application. Participants attended routine 6 month clinical reviews and were tasked with weekly home monitoring with the MRFh over this period. We determined compliance to weekly VFTM (7 + 1 days) and test reliability (false positives (FPs) and fixation loss (FL) <33%). A secondary aim considered concordance to in-clinic measures of visual field (MRF-clinic (MRFc) and the Humphrey Field Analyzer (HFA)) in active participants (≥10 home examinations and 5 reliable HFA examinations). The linear trend in the MRFh mean deviation (MD) was compared to the HFA guided progression analysis (GPA) using Bland−Altman methods. Data are shown as the mean ± standard deviation. Results: Forty-seven participants with a mean age of 64 ± 14.6 years were recruited for the trial. The VFTM uptake was 85% and compliance to weekly home monitoring was 75% in the presence of weekly text reminders in the analysed group (n = 20). The analysed group was composed of test subjects with five reliable in-clinic HFA examinations (GPA analysis available) and who submitted a minimum of 10 MRFh examinations from home. Of the 757 home examinations returned, approximately two-thirds were reliable, which was significantly lower than the test reliability of the HFA in-clinic (MRFh: 65% vs. HFA: 85%, p < 0.001). The HFA-GPA analysis gave little bias from the MRFh slope (bias: 0.05 dB/yr, p > 0.05). Two eyes were found to have clinical progression during the 12 month period, and both were detected by VFTM. Conclusions: VFTM over 12 months returned good compliance (75%) to weekly testing with good concordance to in-clinic assays. VFTM is a viable option for monitoring patients with glaucoma for visual field progression in between clinical visits.

Metaverse and Virtual Health Care in Ophthalmology: Opportunities and Challenges

ABSTRACT

The outbreak of the coronavirus disease 2019 has further increased the urgent need for digital transformation within the health care settings, with the use of artificial intelligence/deep learning, internet of things, telecommunication network/virtual platform, and blockchain. The recent advent of metaverse, an interconnected online universe, with the synergistic combination of augmented, virtual, and mixed reality described several years ago, presents a new era of immersive and real-time experiences to enhance human-to-human social interaction and connection. In health care and ophthalmology, the creation of virtual environment with three-dimensional (3D) space and avatar, could be particularly useful in patient-fronting platforms (eg, telemedicine platforms), operational uses (eg, meeting organization), digital education (eg, simulated medical and surgical education), diagnostics, and therapeutics. On the other hand, the implementation and adoption of these emerging virtual health care technologies will require multipronged approaches to ensure interoperability with real-world virtual clinical settings, user-friendliness of the technologies and clinical efficiencies while complying to the clinical, health economics, regulatory, and cybersecurity standards. To serve the urgent need, it is important for the eye community to continue to innovate, invent, adapt, and harness the unique abilities of virtual health care technology to provide better eye care worldwide.

Applications of Extended Reality in Ophthalmology: Systematic Review

BACKGROUND

Virtual reality, augmented reality, and mixed reality make use of a variety of different software and hardware, but they share three main characteristics: immersion, presence, and interaction. The umbrella term for technologies with these characteristics is extended reality. The ability of extended reality to create environments that are otherwise impossible in the real world has practical implications in the medical discipline. In ophthalmology, virtual reality simulators have become increasingly popular as tools for surgical education. Recent developments have also explored diagnostic and therapeutic uses in ophthalmology.

OBJECTIVE

This systematic review aims to identify and investigate the utility of extended reality in ophthalmic education, diagnostics, and therapeutics.

METHODS

A literature search was conducted using PubMed, Embase, and Cochrane Register of Controlled Trials. Publications from January 1, 1956 to April 15, 2020 were included. Inclusion criteria were studies evaluating the use of extended reality in ophthalmic education, diagnostics, and therapeutics. Eligible studies were evaluated using the Oxford Centre for Evidence-Based Medicine levels of evidence. Relevant studies were also evaluated using a validity framework. Findings and relevant data from the studies were extracted, evaluated, and compared to determine the utility of extended reality in ophthalmology.

RESULTS

We identified 12,490 unique records in our literature search; 87 met final eligibility criteria, comprising studies that evaluated the use of extended reality in education (n=54), diagnostics (n=5), and therapeutics (n=28). Of these, 79 studies (91%) achieved evidence levels in the range 2b to 4, indicating poor quality. Only 2 (9%) out of 22 relevant studies addressed all 5 sources of validity evidence. In education, we found that ophthalmic surgical simulators demonstrated efficacy and validity in improving surgical performance and reducing complication rates. Ophthalmoscopy simulators demonstrated efficacy and validity evidence in improving ophthalmoscopy skills in the clinical setting. In diagnostics, studies demonstrated proof-of-concept in presenting ocular imaging data on extended reality platforms and validity in assessing the function of patients with ophthalmic diseases. In therapeutics, heads-up surgical systems had similar complication rates, procedural success rates, and outcomes in comparison with conventional ophthalmic surgery.

CONCLUSIONS

Extended reality has promising areas of application in ophthalmology, but additional high-quality comparative studies are needed to assess their roles among incumbent methods of ophthalmic education, diagnostics, and therapeutics.

Emergence of non-artificial intelligence digital health innovations in ophthalmology: A systematic review

The prominent rise of digital health in ophthalmology is evident in the current age of Industry 4.0. Despite the many facets of digital health, there has been a greater slant in interest and focus on artificial intelligence recently. Other major elements of digital health like wearables could also substantially impact patient-focused outcomes but have been relatively less explored and discussed. In this review, we comprehensively evaluate the use of non-artificial intelligence digital health tools in ophthalmology. 53 papers were included in this systematic review - 25 papers discuss virtual or augmented reality, 14 discuss mobile applications and 14 discuss wearables. Most papers focused on the use of technologies to detect or rehabilitate visual impairment, glaucoma and age-related macular degeneration. Overall, the findings on patient-focused outcomes with the adoption of these technologies are encouraging. Further validation, large-scale studies and earlier consideration of real-world barriers are warranted to enable better real-world implementation.

Visual field improvement in neglect after virtual reality intervention: a single-case study

A patient suffering from visuo-spatial neglect was investigated as a special interest case during a study on the effectiveness of "restorative approaches" after visual field loss. This patient trained with our newly developed Virtual Reality (VR) system "Salzburg Visual Field Trainer" for 254 days. Perimetric results show a visual field expansion of 48.8% (left eye) and 36.8% (right eye) translating to an improvement of approximately 5.5° to 10.5° of visual angle. Further, subjective self-report shows improvements of up to 317% in visual field functionality. Our results indicate that patients suffering from visuo-spatial neglect could benefit from a VR-based restorative intervention.

Evaluating multidisciplinary glaucoma care: visual field progression and loss of sight year analysis in the community vs hospital setting

Background

A variety of shared care models have been developed, which aim to stratify glaucoma patients according to risk of disease progression. However, there is limited published data on the rate of glaucoma progression in the hospital vs community setting. Here we aimed to compare rates of glaucomatous visual field progression in the Cambridge Community Optometrist Glaucoma Scheme (COGS) and Addenbrooke’s Hospital Glaucoma Clinic (AGC).

Methods

A retrospective comparative cohort review was performed. Patients with five or more visual field tests were included. Zeiss Forum software was used to calculate the MD progression rate (dB/year). Loss of sight years (LSY) were also calculated for both COGS and AGC.

Results

Overall, 8465 visual field tests from 854 patients were reviewed. In all, 362 eyes from the AGC group and 210 eyes from COGS were included. The MD deterioration rate was significantly lower in the COGS patients compared with the AGC group (−0.1 vs −0.3 dB/year; p < 0.0001). No patients in the COGS group were predicted to become blind within their lifetime by LSY analysis. Fifteen patients were at risk in the AGC group.

Conclusion

This service evaluation shows that COGS is an effective scheme to stratify lower risk glaucoma patients, increasing the capacity within hospital eye services. COGS patients have a lower rate of visual field deterioration compared to AGC patients. Effective communication between community and tertiary schemes is essential to facilitate transfer of patients requiring further hospital management reliably and efficiently, with the potential for low-risk patients to be followed safely in the community.

Contrast Sensitivity and Glaucoma

Spatial contrast sensitivity decline occurs in different types and stages of glaucoma. In this short review we discuss methods of assessing contrast sensitivity, the role of contrast sensitivity in the pathogenesis of glaucoma and its practical application in clinical practice.

The Effects of Consumer-grade Virtual Reality Headsets on Adult Visual Function

INTRODUCTION

Consumer-grade virtual reality (VR) headset is being used with increasing frequency nowadays, however, the effect on visual function is not clear.

OBJECTIVES

We here investigate whether using VR headset changes adults' visual function and take into account the possible factors.

METHODS

We compared the uncorrected distant visual acuity (UDVA), uncorrected near visual acuity (UNVA), best corrected visual acuity (BCVA), low contrast visual acuity (LCVA), glare visual acuity (GVA), refractive error (RE), amplitude of accommodation (ACC), and pupil diameter (PD) before and after using VR headset 10 mintues at a time twice per day for 2 successive weeks in 40 volunteers with a mean age of 28.6 years. Differences in these 8 parameters before vs. after VR headset use were analyzed using SPSS 22.0.

RESULTS

In our study, we found that the amplitude of accommodation had significantly increased by 0.53 (F = 5.673; P = .006) after using, while visual acuity, refractive error and pupil diameter did not show statistically significant changes (P > .05). Correlation test showed that there was no significant correlation between any two parameters on visual function.

CONCLUSION

It is discovered that using a consumer-grade VR headset 10 minutes at a time twice daily for 2 weeks improved the amplitude of accommodation of adults dramatically, while neither visual acuity nor refractive error was affected.

ABBREVIATIONS

VR: visual reality; UDVA: uncorrected distant visual acuity; UNVA: uncorrected near visual acuity; BCVA: best corrected visual acuity; LCVA: low contrast visual acuity; GVA: glare visual acuity; RE: refractive error; ACC: amplitude of accommodation; PD: pupil diameter; 3D: three-dimensional; VDTS: visual display terminal syndrome; FOV: field of view; SEQ: spherical equivalent diopter.

Seeing other perspectives: evaluating the use of virtual and augmented reality to simulate visual impairments (OpenVisSim)

Simulations of visual impairment are used to educate and inform the public. However, evidence regarding their accuracy remains lacking. Here we evaluated the effectiveness of modern digital technologies to simulate the everyday difficulties caused by glaucoma. 23 normally sighted adults performed two everyday tasks that glaucoma patients often report difficulties with: a visual search task in which participants attempted to locate a mobile phone in virtual domestic environments (virtual reality (VR)), and a visual mobility task in which participants navigated a physical, room-scale environment, while impairments were overlaid using augmented reality (AR). On some trials, a gaze-contingent simulated scotoma-generated using perimetric data from a real patient with advanced glaucoma-was presented in either the superior or inferior hemifield. The main outcome measure was task completion time. Eye and head movements were also tracked and used to assess individual differences in looking behaviors. The results showed that the simulated impairments substantially impaired performance in both the VR (visual search) and AR (visual mobility) tasks (both P < 0.001). Furthermore, and in line with previous patient data: impairments were greatest when the simulated Visual Field Loss (VFL) was inferior versus superior (P < 0.001), participants made more eye and head movements in the inferior VFL condition (P < 0.001), and participants rated the inferior VFL condition as more difficult (P < 0.001). Notably, the difference in performance between the inferior and superior conditions was almost as great as the difference between a superior VFL and no impairment at all (VR: 71%; AR: 70%). We conclude that modern digital simulators are able to replicate and objectively quantify some of the key everyday difficulties associated with visual impairments. Advantages, limitations, and possible applications of current technologies are discussed. Instructions are also given for how to freely obtain the software described (OpenVisSim).

Patient-reported Outcomes, Functional Assessment, and Utility Values in Glaucoma

In clinical glaucoma research, the measurement of patient reported outcomes, functional assessment of disability, and health economic impact is critical. However, valid, time-efficient and comprehensive tools are not available and several current instruments lack in the appropriate precision for measuring the various dimensions of glaucoma-related quality of life (QoL), including functioning and mobility. Furthermore, statistical methods are inconsistently and sometimes incorrectly used in otherwise sound clinical studies. Standardizing and improving methods of patient-centered data collection and analysis in glaucoma studies are imperative. This paper outlines recommendations and provides a discussion of some of the pertinent issues relating to the optimization of patient-reported outcomes research in glaucoma.

Vision Parameters Most Important to Functionality in Glaucoma

Purpose

To determine the importance of various vision parameters to functionality in glaucoma.

Methods

Vision was measured using seven parameters: visual acuity (VA), contrast sensitivity (CS), integrated visual field (IVF), area under the log CS function (AULCSF), color vision, stereoacuity, and VA with noise (ViN). Likelihood ratio testing (LRT) determined if the full set of visual parameters significantly explained variability in 10 functional outcomes. For outcomes where the visual contribution was significant, dominance analysis determined the relative importance of the various visual parameters.

Results

The analysis included 151 glaucoma patients. Mean age was 70 ± 6.8 years, and 47% were men. Significant visual contributions (LRT P < 0.05) were noted for glaucoma quality of life (GQL-15), reading speed, driving cessation, daily steps, and base of support while walking, but not for fear of falling, balance, gait velocity, stride velocity, and stride length while walking (LRT P > 0.05). The most important parameter (and percent contribution) to vision-explained variability were AULCSF for daily steps (45%), IVF for base of support (35%), VA for reading speed (34%), CS for GQL-15 (30%), and VA for driving cessation (26%).

Conclusions

Measures of visual ability are important for several aspects of quality of life and functionality. The most important vision parameter for functionality differs depending on the domain studied. Reading and driving were explained by VA and IVF sensitivity. On the other hand, GQL-15 and daily steps were more heavily influenced by CS and AULCSF, which are rarely performed clinically.

Beyond intraocular pressure: Optimizing patient-reported outcomes in glaucoma

Glaucoma, an irreversible blinding condition affecting 3-4% adults aged above 40 years worldwide, is set to increase with a rapidly aging global population. Raised intraocular pressure (IOP) is a major risk factor for glaucoma where the treatment paradigm is focused on managing IOP using medications, laser, or surgery regimens. However, notwithstanding IOP and other clinical parameters, patient-reported outcomes, including daily functioning, emotional well-being, symptoms, mobility, and social life, remain the foremost concerns for people being treated for glaucoma. These outcomes are measured using objective patient-centered outcome measures (PCOMs) and subjective patient-reported outcome measures (PROMs). Studies using PCOMs have shown that people with glaucoma have several mobility, navigational and coordination challenges; reading and face recognition deficits; and are slower in adapting to multiple real-world situations when compared to healthy controls. Similarly, studies have consistently demonstrated, using PROMs, that glaucoma substantially and negatively impacts on peoples' self-reported visual functioning, mobility, independence, emotional well-being, self-image, and confidence in healthcare, compared to healthy individuals, particularly in those with late-stage disease undergoing a heavy treatment regimen. The patient-centred effectiveness of current glaucoma treatment paradigms is equivocal due to a lack of well-designed randomized controlled trials; short post-treatment follow-up periods; an inappropriate selection or availability of PROMs; and/or an insensitivity of currently available PROMs to monitor changes especially in patients with newly diagnosed early-stage glaucoma. We provide a comprehensive, albeit non-systematic, critique of the psychometric properties, limitations, and recent advances of currently available glaucoma-specific PCOMs and PROMs. Finally, we propose that item banking and computerized adaptive testing methods can address the multiple limitations of paper-pencil PROMs; customize their administration; and have the potential to improve healthcare outcomes for people with glaucoma.

Are We There Yet? Immersive Virtual Reality to Improve Cognitive Function in Dementia and Mild Cognitive Impairment

Background and Objectives

Cognitive training therapies may delay cognitive deterioration in dementia. There is potential to enhance delivery through immersive virtual reality (IVR), as removing potential distractors for cognitively impaired individuals can enhance their experience, resulting in increased engagement. Evidence in this field is emerging and not yet synthesized. We aimed to summarize research investigating the use of IVR in dementia to evaluate the current extent of use, acceptability, feasibility, and potential effectiveness. We also aimed to identify gaps in current research and to create a set of recommendations in utilizing this therapy.

Research Design and Methods

A systematic literature review was conducted. Our review was registered with PROSPERO, registration number: CRD42019122295. We undertook searches of five databases, article references, and citations. Key authors in the field of health care VR were also contacted to identify additional papers. Articles were assessed for inclusion by two researchers independently. Data were extracted using standardized forms.

Results

Our search identified a total of 2,824 citations, following screening for duplicates and application of inclusion and exclusion criteria, five studies were included for analysis. Included studies were heterogeneous, with small sample sizes and mixed outcomes.

Discussion and Implications

We were unable to reach definitive conclusions over the use, acceptability, and effectiveness of IVR for dementia and mild cognitive impairment. Future studies should focus on ensuring their interventions are truly immersive, developing more robust controls and account for the rapid rate of obsolescence in digital technologies.

Novel Means of Clinical Visual Function Testing among Glaucoma Patients, Including Virtual Reality

Computed perimetry remains the gold standard of visual field measurement among glaucoma patients. However, several emerging technologies, made possible by advances in computer programming, smartphone, tablet, or virtual reality, allow alternative means of visual function assessment. These new visual tests may one day have a useful complementary role in visual field testing and to bridge the gap between perimetry and daily experience. Many of these emerging technologies have distinct practical advantages over Ganzfield bowl-based computed perimetry. This paper outlines a discussion of some of these emerging techniques in visual function assessment in glaucoma.