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In the report in this issue of JAMA Ophthalmology by Lam et al1 on the application of virtual reality (VR) simulation of daily activities to evaluate vision-associated disability in patients with moderate to severe glaucoma, authors asked a simple yet very important clinical question: can real-world visual performance be estimated with VR simulations to inform clinicians about the patient’s vision-associated disability? In other words, can we visualize the levels of disability that patients are experiencing? In this study, they designed 5 interactive VR environments that included supermarket shopping and stair and city navigations in daytime and nighttime to simulate the daily activities in a local community and tested them on patients with glaucoma and healthy individuals.
Results show that patients with glaucoma took significantly longer to complete the simulated task of shopping and navigation at nighttime and encountered more collisions along the simulated path of navigation in both daytime and nighttime compared with healthy individuals. When vision-associated disability was defined as outside of the 95% CI of healthy control participants, 59% of patients with glaucoma had vision-associated disability in at least 1 of the 5 interactive VR simulated tasks.
Authors also found that vision-associated disability was task dependent and lighting condition dependent. For example, while there were significant differences in the duration of stair and city navigations between patients with glaucoma and healthy individuals at nighttime, no differences were detected in daytime.
Visual field testing is the gold standard in glaucoma visual function evaluation. It is essential for diagnosing glaucoma and monitoring glaucoma progression. However, it is difficult to translate visual field deterioration to real-world performance of daily activities.
On multivariate analysis,1 binocular visual field sensitivity and age were found to be significantly associated with the duration of supermarket shopping and nighttime navigation and collisions in daytime and nighttime navigation. For example, for each decibel decrease in binocular visual field sensitivity, the risk of collision increased by 1.06-fold in the daytime navigation and 1.15-fold in the nighttime navigation. Future research may enlighten us on the association between the location and type of visual field defects or the structural changes of the optic nerve and VR-assessed functional disability.
In this study, vision-associated disability from VR simulation correlated well with visual field sensitivity. However, a portion of patients with glaucoma and healthy individuals could not complete the VR simulation. In addition, 40% of patients with moderate to advanced glaucoma did not have significant vision-associated disability, and patients with glaucoma had a better mean performance in real-world environments than in VR simulations. As the name states, this is virtual as opposed to real; VR has a limitation in that it may not be realistic enough. However, it has the advantage to provide an opportunity to mimic the real environment by allowing the assessment of some important daily activities, such as navigation in house or outside without exposing patients to the risk of collision or fall. Advancement in technology with increasing computation capacity will certainly overcome this limitation to create a more realistic simulated environment that one day may be indistinguishable from the real-world experience. Nevertheless, it would be informative to understand why some individuals could not complete the VR simulation and how to overcome this limitation. Could it be simply involving technical difficulties, or does it involve cognitive dysfunction, age effects, severity of disease, or other ocular or systemic comorbidities? This information may help improve the VR design.
The authors1 should be commended for demonstrating that VR simulation can provide us with a new perspective of how visual impairment affects patients. The logical step would be about what the next action or direction to take.
Most of the current research on VR development in ophthalmology focuses on disability assessment, disease diagnosis, and monitoring, while other studies aim at better defining, qualifying, and quantifying a visual disability to generate functional data and standard for research purposes.2,3 A more ambitious and clinically relevant goal would be to apply VR simulation technology in visual rehabilitation, such as improving patient’s safety by avoiding fall or collision and training patients with visual dysfunction to recover some lost function.4
Authors were keen to point out that findings in VR experience, such as the task-specific and lighting-specific difficulties experienced by the patient, would allow eye care professionals to devise appropriate treatment, visual aids, and counselling to improve quality of vision and quality of life in patients with glaucoma.1 I agree wholeheartedly that this will be the most important benefit of the VR technology. Future design in VR simulation will need to be specific to the patient’s living environment and habits to be applicable and must be validated by comparison with real-world performance instead of using a standardized VR simulated environment. For instance, the VR simulations created in this study1 were designed specifically for patients residing in a major metropolitan city with a huge population packed in a relatively small geographic area. These simulations may not be transferrable to a different city or applied to another group of patients with different cultures, backgrounds, and living habits.
In the academic practice I work with, trainees are required to take a visual field test to experience firsthand the test they order for their patients with glaucoma. This is done because patients may not care how much we know until they know how much we care. We may have the opportunity to take a VR simulation test and tell patients that we more easily understand the difficulties they experience.
Corresponding Author: Simon K. Law, MD, Stein Eye Institute, 100 Stein Plaza 2-235, Los Angeles, CA 90095 (email@example.com).
Published Online: March 19, 2020. doi:10.1001/jamaophthalmol.2020.0391
Conflict of Interest Disclosures: None reported.
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Law SK. Virtual Reality Simulation to Identify Vision-Associated Disability in Patients With Glaucoma. JAMA Ophthalmol. Published online March 19, 2020. doi:10.1001/jamaophthalmol.2020.0391
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