New dimensions in eye care with virtual reality technology

Last month, a new contender to the virtual reality (VR) technology scene arrived in the form of Sony’s PlayStation VR. It follows the launches of the Oculus Rift and HTC Vive VR headsets earlier this year but potentially marks an important milestone for this erging technology due to its lower price point.Some have speculated that the new entrant is more likely to bring VR technology into mainstream consumer use than its predecessors for this reason.However, the potential for VR technology exceeds far beyond consumer recreational value, and its increasing affordability also appears to be driving its adoption in other industries, including optometry and ophthalmology.LENS DONSTRATIONS{{quote-A:R-W:450-I:2-Q: The future will for sure see more innovative tools coming to support optometry. -WHO:Ms Diane Ceccarelli, marketing director for Essilor Australia and New Zealand}}In May this year, Essilor launched the Nautilus VR donstration tool in Australia, presenting it for the first time at the O-Show in Melbourne.Designed specifically for practice use, the Nautilus headset provides patients with an interactive 360° experience of different Essilor lenses and coatings in a variety of different virtual settings so that they can make an informed decision prior to purchase.Ms Diane Ceccarelli, marketing director for Essilor Australia and New Zealand, said there had been “extrely enthusiastic feedback” from the profession upon the technology’s introduction and that more than 20 New Zealand practices had already signed on, with at least 30 Australian practices expressing interest.“This is the first immersive do tool which allows us to explain the differences among lenses inside the practice,” she said. “It helps the practices to differentiate and also brings the discussion with the patient to another level.”Kosmac & Clens Optometrists, which has five practices located in regional Victoria, was among the first Australian businesses to adopt the new technology, introducing Nautilus to its Bendigo store in May this year.Operations manager Ms Michelle Thurlow said the Nautilus had been a great donstration tool for patients and training tool for new staff.{{image4-a:l-w:400}}“Staff have used the Nautilus to donstrate the difference between multifocal designs and have upsold as a result of the donstration,” she said.“Patients feel more confident in their choices when they are well educated. Being able to experience the effects and benefits of lens coatings and treatments through VR powers the patients to make educated choices.”In addition to increasing sales and improving patient service, Ms Thurlow said the Nautilus had helped the practice win the Bendigo Business Excellence Award for Professional Service.“The [awards] judges were suitably impressed with the way our company braces changes in technology and thoroughly enjoyed the donstration given to th of the Nautilus,” she explained.Ms Ceccarelli said the Nautilus software would be updated regularly to include all new Essilor lenses, and suggested the donstration tool would not be the company’s last foray into VR technology.“Essilor R&D has been using VR for more than 10 years to design Varilux lenses and we are now leveraging on this expertise for this simple to use, consumer-friendly donstration tool,” she said. “The future will for sure see more innovative tools coming to support optometry.”VISION THERAPYAnother way in which VR has been adapted for optometry is in vision therapy.US-based Vivid Vision, which formerly traded as Diplopia after a beta launch in 2013, has developed a VR product designed to help patients with amblyopia, strabismus and convergence insufficiency achieve normal binocular vision through fun games and exercises.Co-founder and chief of optometry Dr Tuan Tran explained that Vivid Vision used a head-mounted VR display to allow the clinician to control the stimulus to each eye.“[It] allows us to control the viewing condition and rove the variables, such as lighting and distance, from the display,” he said. “This allows us to adjust the contrast, size, and speed of objects only seen in the amblyopic eye along with starting activities at their angle of deviation. All of this is done without a need for physical filters or lenses.”Since the product’s official commercial launch in October 2015, more than 50 practices worldwide have adopted Vivid Vision, including three in Australia.Mr George Sahely, director of 20/20 Sight + Style Optometrists in Mornington, Victoria, said he had been following the start-up company for two years with great interest before finally gaining the opportunity to purchase Vivid Vision in July this year, just prior to the product’s local launch at the Australasian College of Behavioural Optometrists’ national conference in Sydney.“In providing in-office vision therapy, our patients expect us to be up to date in both clinical knowledge and technology,” Mr Sahely said. “Vivid Vision nicely complents other innovative therapies we offer such as the Neuro-Vision Rehabilitator (NVR) and VTS4.”{{image5-a:r-w:400}}He commented that while it was still “early days” – and although some patients had experienced the nausea that has been found to be a possible side effect of any VR technology – the introduction of Vivid Vision had helped to differentiate the practice: “VR certainly has the ‘wow’ factor for our patients.”Vivid Vision began clinical trials at the University of California, San Francisco in July 2014. Vivid Vision founder and chief executive officer Mr James Blaha said the company had received initial results from this study but that due to the primary investigator’s move to a different university, their release was on hold.“The researchers are still considering whether to publish what they have now or to wait and continue the research at a different institution so we can get a larger sample size,” he explained.Mr Blaha added that the company was also expecting to begin clinical trials at the University of California, Berkeley by the end of the year.REALISTIC TESTING ENVIRONMENTSIn addition to optometry, VR technology has multiple potential applications within ophthalmology.A study published in Ophthalmology in June 2015 described the use of VR to evaluate balance control in glaucoma patients. People with glaucoma are said to have a more than three times higher risk of falling than those without the condition.The study was undertaken by a multidisciplinary team of researchers, including ophthalmologists, vision scientists and engineers from the US, Brazil, and the Netherlands, and involved 42 patients with open-angle glaucoma and 38 healthy subjects as a control.Participants were asked to stand on a force platform, a device that measures balance and movent, and their postural stability was evaluated while they were presented with both static and moving visual stimuli via a VR headset.{{image6-a:l-w:400}}The results showed that during simulated movent, participants made balance adjustments that were an average of 30–40% more pronounced in glaucoma patients than in control subjects. The researchers hypothesised that the glaucoma patients’ pronounced lack of balance control could be related to the loss of retinal ganglion cells caused by the disease, which leads to slower visual processing and impaired motion perception.The use of VR in this study was said to have provided a more realistic testing environment compared to traditional testing methods.“Measures from traditional static visual field tests do not mimic the visual conditions that occur day-to-day,” senior author Dr Felipe Medeiros stated. “With further refinent of this method, we hope that the approach could one day be used to identify patients at high risk of falling so that preventative measures can be ployed at an earlier stage.”SURGICAL TRAININGClinical Associate Professor Nitin Verma, a Royal Australian and New Zealand College of Ophthalmologists (RANZCO) board mber who has been involved in teledicine since 1997, believes VR technology holds great potential to improve surgical training.“Eventually, all surgical training videos will be able to be adapted for VR so trainees can get the depth not available in 2D videos,” he said. “If you look to the left you’ll see what the scrub nurse is doing; if you look to the right you’ll see what the assistant is doing. It will become more real.”VR has already been ployed for training purposes overseas. In June 2014, Dr Thomas Gregory, an orthopaedic surgeon teaching at the Paris Descartes University, performed what was said to be the first surgery filmed specifically for the Oculus Rift at the European Georges Pompidou Hospital in Paris. This was achieved by attaching two cameras at Dr Gregory’s eye level so that the entire procedure could be recorded in stereoscopic 3D with a 180° field of view.{{quote-A:R-W:450-I:3-Q: The advent of VR and augmented reality has opened up a lot of new doors and great opportunities for teleophthalmology. -WHO:Clinical Associate Professor Nitin Verma, a Royal Australian and New Zealand College of Ophthalmologists (RANZCO) board mber}}The project was funded by the MOVEO Foundation and it was said the team was now working to develop a syst whereby surgery could be viewed live from anywhere in the world using VR.Beyond delivering training, Clin Assoc Prof Verma suggested VR could also be used to measure a trainee’s performance on a specific technique.“VR gives you a standard operating environment, so you’ll be able to see whether someone has reached a level of competency as compared to their peers using the same environment,” he explained.“We used to have wet labs where you had animal eyes to train on and now we’ll soon have dry labs where you’ll be able to simulate the surgery without any animal tissue.“Using VR, you’ll be able to get trainees to go through the movents, use the instruments, and look down the microscope in a controlled environment so that you can see whether they’re ready to move to the next step or to operate on a human eye.”FUTURE OF VRIn terms of how he predicted VR would evolve, Clin Assoc Prof Nitin Verma said he believed it would mostly be in image capture technology.“Taking better photographs that can be adapted for 3D without having to use two cameras and using software to help adapt things to VR – those are aspects that are still to evolve and that I think will be the next step,” he said.“The display has now become easy but there’s still a bottleneck in getting the actual images to feed into a VR headset, and imaging is still a bit cumbersome, complex and expensive.{{image7-a:l-w:400}}“Also, once we have 3D imaging systs, when an optometrist or doctor wants to refer a patient to an ophthalmologist, or when an ophthalmologist wants a second opinion, they’ll be able to take pictures in 3D and use VR to get a much better quality image of the eye. It’ll be much easier for us to see a probl in 3D rather than in 2D because then you can get the depth, which is also useful for screening diseases such as diabetic retinopathy and maculopathy.“The advent of VR and augmented reality has opened up a lot of new doors and great opportunities for teleophthalmology.”Adding his own opinion, Mr Sahely said, “No doubt technology is advancing at an exponential rate, and we need to move forward with it. To stand still is to drift far behind.“I’m too old to be a visionary, though one can see VR being used both in the testing process for refractive errors and binocularity, in addition to allowing a patient to experience the effects of a new optical correction, or a visual disease state, in a pseudo-real world.”Ms Thurlow agreed VR would be used more and more as a tool within optical dispensing but noted that it was important not to forget that “it all starts with building a rapport and getting to know your patient”.“Technology-savvy patients will brace this type of donstration tool [Nautilus] while others will not feel as comfortable using it and will still prefer to touch, read and listen to the dispenser explain the value and benefits of lens designs, coatings and treatments,” she said.“Once you know your patient, you will know the best donstration tool to use with th.”Ms Thurlow’s comment serves as an important rinder that while technology such as VR can significantly enhance what can be achieved in optometry and ophthalmology, it cannot replace the human care delivered by individual clinicians.

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