Comparison of virtual reality performance between a healthy individual (A) and a patient with glaucoma (B) in a supermarket shopping task. Participants were asked to identify 10 shopping items from a rack. In this example, the patient with glaucoma took 167.5 seconds to complete the shopping and incorrectly identified 1 item, while the healthy individual took 39.7 seconds to correctly identify 10 shopping items without misidentification. MD indicates mean deviation; VFI, visual field index.
Comparison of virtual reality performance between a healthy individual (A) and a patient with glaucoma (B) in the nighttime stair navigation task. Participants were asked to walk up and then down 2 flights of stairs. In this example, the healthy individual took 179.5 seconds whereas the patient with glaucoma took 465.1 seconds to complete the navigation. The numbers of collisions during the navigation were 0 and 3, respectively. MD indicates mean deviation; VFI, visual field index.
Comparison of virtual reality performance of a patient with glaucoma in the daytime (A) and nighttime (B) stair navigation task. In this example, the patient with glaucoma took almost double the time required in daytime navigation (93.4 seconds) to complete the nighttime navigation (181.6 seconds). The number of collisions was 1 in daytime navigation and 6 in nighttime navigation. MD indicates mean deviation; VFI, visual field index.
Comparison of virtual reality performance between a healthy individual (A) and a patient with glaucoma (B) in the nighttime city navigation task. The participants navigated a virtual distance of approximately 90 m in a city area modeled on Hong Kong. In this example, the healthy individual took 78.7 seconds whereas the patient with glaucoma took 167.8 seconds to complete the navigation. The numbers of collisions during the navigation were 0 and 1, respectively. MD indicates mean deviation; VFI, visual field index.
Comparison of virtual reality performance of a patient with glaucoma in the daytime (A) and nighttime (B) city navigation task. In this example, the patient with glaucoma took almost double the time required in the daytime navigation (85.1 seconds) to complete the nighttime navigation (167.8 seconds). The number of collisions was 2 in the daytime navigation and 1 in the nighttime navigation. MD indicates mean deviation; VFI, visual field index.
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Lam AKN, To E, Weinreb RN, et al. Use of Virtual Reality Simulation to Identify Vision-Related Disability in Patients With Glaucoma. JAMA Ophthalmol. 2020;138(5):490–498. doi:10.1001/jamaophthalmol.2020.0392
Can real-world visual performance be estimated with virtual reality simulations to assess vision-related disability in patients with glaucoma?
In this cross-sectional study including 98 individuals with glaucoma, vision-related disability was associated with task and lighting condition in patients with glaucoma, with 8.0% to 30.7% having vision-related disability in supermarket shopping, stair navigation, or city navigation. A higher proportion of patients had vision-related disability in nighttime (30.0%-30.7%) than daytime (8.0%-19.8%) navigations.
These results appear to support the hypothesis that virtual reality simulation augments the evaluation of visual disability in clinical care by providing clinicians a new perspective to understand how visual impairment imparts vision-related disability in patients with glaucoma.
Clinical assessment of vision-related disability is hampered by the lack of instruments to assess visual performance in real-world situations. Interactive virtual reality (VR) environments displayed in a binocular stereoscopic VR headset have been designed, presumably simulating day-to-day activities to evaluate vision-related disability.
To investigate the application of VR to identify vision-related disability in patients with glaucoma.
Design, Setting, and Participants
In a cross-sectional study, 98 patients with glaucoma and 50 healthy individuals were consecutively recruited from a university eye clinic; all participants were Chinese. The study was conducted between August 30, 2016, and July 31, 2017; data analysis was performed from December 1, 2017, to October 30, 2018.
Measurements of visual acuity, contrast sensitivity, visual field (VF), National Eye Institute 25-item Visual Function Questionnaire Rasch score, and VR disability scores determined from 5 VR simulations: supermarket shopping, stair and city navigations in daytime, and stair and city navigations in nighttime. Duration required to complete the simulation, number of items incorrectly identified, and number of collisions were measured to compute task-specific and overall VR disability scores. Vision-related disability was identified when the VR disability score was outside the normal age-adjusted 95% confidence region.
Main Outcomes and Measures
Virtual reality disability score.
In the 98 patients with glaucoma, mean (SD) age was 49.8 (11.6) years and 60 were men (61.2%); in the 50 healthy individuals, mean (SD) age was 48.3 (14.8) years and 16 were men (32.0%). The patients with glaucoma had different degrees of VF loss (122 eyes [62.2%] had moderate or advanced VF defects). The time required to complete the activities by patients with glaucoma vs healthy individuals was longer by 15.2 seconds (95% CI, 5.5-24.9 seconds) or 34.1% (95% CI, 12.4%-55.7%) for the shopping simulation, 72.8 seconds (95% CI, 23.0-122.6 seconds) or 33.8% (95% CI, 10.7%-56.9%) for the nighttime stair navigation, and 38.1 seconds (95% CI, 10.9-65.2 seconds) or 30.8% (95% CI, 8.8%-52.8%) for the nighttime city navigation. The mean (SD) duration was not significantly different between the glaucoma and healthy groups in daytime stair (203.7 [93.7] vs 192.9 [89.1] seconds, P = .52) and city (118.7 [41.5] vs 117.0 [52.3] seconds, P = .85) navigation. For each decibel decrease in binocular VF sensitivity, the risk of collision increased by 15% in nighttime stair (hazard ratio [HR], 1.15; 95% CI, 1.08-1.22) and city (HR, 1.15; 95% CI, 1.08-1.23) navigations. Fifty-eight patients (59.1%) with glaucoma had vision-related disability in at least 1 simulated daily task; a higher proportion of patients had vision-related disability in nighttime city (27 of 88 [30.7%]) and stair (27 of 90 [30.0%]) navigation than in daytime city (7 of 88 [8.0%]) and stair (19 of 96 [19.8%]) navigation. The overall VR disability score was associated with the National Eye Institute 25-item Visual Function Questionnaire Rasch score (R2 = 0.207).
Conclusions and Relevance
These findings suggest that vision-related disability is associated with lighting condition and task in patients with glaucoma. Virtual reality may allow eye care professionals to understand the patients’ perspectives on how visual impairment imparts disability in daily living and provide a new paradigm to augment the assessment of vision-related disability.
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