• The Future of Virtual Reality in Ophthalmology Is Already Here

    Fast-evolving virtual reality programs are rapidly moving into health care. But in ophthalmology, the concept of virtual reality has already been around for decades. 

    In virtual reality, the user is immersed in a simulated environment. An early VR interface for procedural training called ORIS (like a cousin of the EYESi – VRmagic, Mannheim, German) was produced almost 30 years ago. 

    Since then, technology has advanced tremendously. VR headsets are smaller and more affordable. Some options on the market even cost less than a new cell phone. Everything that is done outside of VR can now be imagined inside VR, from clinic visits to surgeries to training programs. Here are some of the exciting applications.

    Clinical Applications

    Portable, inexpensive VR devices create opportunities for home monitoring of disease progression (e.g. glaucoma or amblyopia), similar to a Holter monitor for cardiac arrhythmias. Home tests that are transmitted to the clinician can inform a treatment team about when to schedule follow-up or alter treatments. Home monitoring has the potential to catch disease progression early. Home monitoring also provides an opportunity for longitudinal data collection for research.

    A variety of VR interfaces have already been designed, including a portable headset compatible with smartphone for measuring visual-evoked potentials and fields, and home-based visual field testing. Study results indicate that these interfaces produce clinical data that are reliable when compared with Humphrey visual fields obtained in clinic. Other VR devices aim to measure data beyond visual fields, such as limitations in activities of daily living. On one smart phone-compatible system, patients with glaucoma interpret street signs and road hazards via a VR headset.

    Some authors hypothesize that VR could provide therapy via visual training. So far there is a paucity of randomized controlled studies to demonstrate this.

    Surgical Applications

    Virtual reality technology in the operating room enhances surgeons’ visualization of robotic surgeries. Many pelvic surgeries are now done by robotic instruments controlled by a surgeon who sits at remote controls. One example is the da Vinci Surgical System, designed specifically for minimally invasive surgeries.

    Similarly, headsets for ocular surgeons have been designed to provide three-dimensional views of anatomy, as well as a mode of transmitting real-time experience to viewers around the world. Several groups have designed interactive, intraoperative optical coherence tomography (OCT). These intraoperative OCTs produce a volumetric section with which the surgeon can interact by manipulating the scale, rotation and other parameters of the section. Imagine how retina surgery might be different if the surgeon (virtually) stood on the retina with Superman-like “OCT-vision.”

    Training Applications

    Virtual surgical training devices, such as the EYESi, have been implemented within many residency programs. Most studies on the effectiveness of these devices are small with fewer than 50 trainees in the research cohort. Many of these studies report outcome measures (e.g. self-reported confidence) that are difficult to extrapolate to standardized, clinically meaningful outcomes. Many do not adequately control for confounding variables. 

    Alcon, a division of the pharmaceutical giant Novartis, uses education grants to create VR content for education. At past annual meetings, the company has demonstrated the beginnings of a VR eyeball, A person can stand in a virtual eyeball and look around the inside of the eye. 

    VR is changing the way ophthalmologists practice and operate. The possibilities range from access to health care at home to new approaches in the operating room. Challenges include simulator sickness (similar to motion sickness), privacy of transmitted data and meaningful validation of the benefits of the technology. 

    The future of ophthalmology should be imagined in VR.

    About the authors: Jeffrey H. Pettey, MD, is the John Moran Eye Center director of education and an assistant professor at the University of Utah Department of Ophthalmology and Visual Sciences. Ariana M. Levin, MD, is a resident at the University of Utah School of Medicine.