Applications of Extended Reality in Ophthalmology: Systematic Review

Abstract

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.

Augmented Reality in Ophthalmology: Applications and Challenges

“…For example, EYESI, a surgical simulator. A systematic review reported that 38 publications had held evaluation experiments on it (70). As a result, the development of AR in medical education is more mature than in other fields in ophthalmology.…”

“…In addition, compared to VR, the vision of AR simulation is more realistic and vivid because it is based on the natural environment. However, the evaluation of AR simulators is still lacking (70). In public education, obstacles still exist in evaluating several disease simulations, such as simulating the vision of color blindness.…”

Metaverse and Virtual Health Care in Ophthalmology: Opportunities and Challenges

“…79 Heads-up surgery is another application of extended reality technology using a 3D camera to capture images from a stereomicroscope for presentation on a 3D display for greater surgeon maneuverability and comfort. 69 At present, studies have demonstrated noninferiority of heads-up surgery in comparison with conventional microscope surgery in postoperative outcomes and complications. 80,81 In particular, researchers compared the use of 3D heads-up microscope with traditional ophthalmic microscope for pars-plana vitrectomy in 50 eyes, and found heads-up surgery demonstrated greater ergonomics and comfort for the surgeon, without compromising on safety, with no major complications and similar operating times.…”

“…The most common surgical procedure simulated was cataract surgery followed by vitreoretinal procedures, 62,65 along with other glaucoma and corneal surgeries 66 . Several studies evaluated the use of extended reality as a tool for education in ophthalmoscopy 67 and optometry training, 68 and found that simulators demonstrated efficacy and validity in improving surgical and ophthalmoscopy skills 69 …”

“…Finally, despite the deluge of potential applications of immersive technology in ophthalmology, 69 use of these applications in an immersive application for patients with eye disease may remain challenging for those with low vision. Patients that have certain illnesses such as glaucoma and associated defects in segments of the visual field may be unable to appreciate the full content in a 3D or VR simulation due to their patchy vision 99 .…”