Looking Into a Virtual Future

Thirty years ago, it was hard to imagine that computer programmers – those computer gurus who as school students sat in darkened rooms and played Space Invaders 24/7 – would rule the world. Yet today programming influences almost every aspect of our lives. Programmers are the hip entrepreneurs of society, wrestling with futuristic concepts, taking financial risks and if they’re good, making big money.

Three young Americans who were recently in Australia are on this trajectory. James Blaha, Manish Gupta and Tuan Tran, OD started Vivid Vision in 2014, a company that develops virtual reality games to treat amblyopia and strabismus.

The company’s story is hardly unique – it was born out of CEO James Blaha’s self-serving desire to correct his own amblyopia and strabismus.

When they put the headset on and start playing, they are shell shocked – they’ve never seen anything like this – we find it fun to watch

Mr. Blaha created a software program that enabled him to view a three-dimensional cube in space when wearing a virtual reality headset. By adjusting the interocular contrast so that his lazy eye saw the cube in greater contrast than his dominant eye, his suppression zones shrank, enabling him to experience stereopsis in just one session. He decided he was onto a winner.

Mr. Blaha approached his friend, programmer Manish Gupta who’d just left IBM, and asked whether he’d be interested in working with him to develop virtual reality games that would train the eyes of other people with amblyopia and strabismus. Then he went in search of funding.

At that time, technology company Leap Motion was looking to fund start-up companies interested in developing software to use in conjunction with its mobile virtual reality platform, which is now integrated into headsets.

“There are a lot of different incubators and accelerators out there, but we applied for the Leap Motion accelerator because their software allows us to track hand movements so that we could incorporate eye-hand coordination tasks into our gameplay,” explained Mr. Gupta.

“They wanted to fund something medical – something that would make a difference in people’s lives, and we fitted that requirement perfectly.”

Soon after receiving the pre-seed funding, Mr. Blaha and Mr. Gupta approached optometrist Tuan Tran who had just completed his residency in

paediatrics, vision therapy and rehabilitation with the Southern College of Optometry.

“James and I had tech programming backgrounds but we were missing the eye care expertise and that’s what Tuan provided,” explained Mr. Gupta.

Although initial funding wasn’t much, it enabled them to live in San Francisco for a few months, provided them with office space, and introduced them to experts who offered advice on their business model.

It also allowed them to further refine the product, by testing it with eye care professionals and patients at two beta sites. “Fourteen months of product testing and development felt like forever at the time and we had to make a few compromises on our living standards,” joked Mr. Gupta.

As it turned out, that was all that was needed. Having moved to San Francisco in February 2014, by April 2015 they had sold their first Vivid Vision product to an optometrist. Today in Australia, Vivid Vision is distributed by France Medical.

Since their first sale, Vivid Vision’s three founders have experienced a whirlwind of international travel to attend conferences around the world. “Before I started with Vivid Vision, I’d been on a plane once,” said Dr. Tran, now 32. “In the past eight weeks, I have travelled 250,000km around the world talking to eye care professionals about the technology.”

Dr. Tran said enabling eye care professionals to experience first-hand the engaging nature of the virtual reality experience and the power of the software to individualise treatments has been incredibly valuable.

“Optometrists have been waiting for a tool like this to treat amblyopia and strabismus. When they put the headset on and start playing, they are shocked – they’ve never seen anything like this. We find it fun to watch. Immediately they can see how engaging the software is, and they want to play more. Most importantly, they see the results. Sometimes it’s hard to get them to stop playing!”

Sally Doyle, practice owner at Fitzroy North Eye Centre in Melbourne, said when she saw Vivid Vision demonstrated at the Australian College of Behavioural Optometry’s national conference in 2016, she knew it would appeal to her patients.

“We have a lot of strabismics and amblyopes – both adults and children. I could see Vivid Vision would be a really good tool to help us with those patients and to make vision therapy as enjoyable as possible. They undertake up to a year of vision therapy with us and there’s a lot to do, so this makes it more fun. In an ideal world, patients would come in three times a week and use home training, but most come in just once a week for about one hour then do training at home.”

Ms. Doyle’s vision therapist, Lindsay Konschuh, has experienced the impact of Vivid Vision from both sides of the equation. She works hands-on with the practice’s amblyopic and strabismic patients and is also working to treat her own strabismus.

“We invested in Vivid Vision a year ago and initially I used it once a week, in conjunction with my regular vision therapy,” said Ms. Konschuh. “More recently I started using it two to three times a week and I’m noticing that I’m gaining stereoacuity. I’m also more aware of when my non-dominant eye shuts off, so I can remind myself to use both eyes.”

She said the patients she treats receive a combination of regular vision therapy and Vivid Vision. “Typically they will come in to the practice once a week. We spend 15 minutes going through the exercises they’ve been doing at home, then 40 minutes working with the headset. They are always eager to move on to the headset because it’s about playing games and it’s so much fun.”

So how does it work?

Whereas early attempts to immerse people in a virtual setting were severely limited by cost, latency (if the wearer moved their gaze they would have to wait for the visual perspective to catch up) and consequently nausea, new technologies offer a very different proposition. The latest virtual reality headsets enable the visual to follow a wearer’s shifting gaze so quickly that it’s impossible for the brain to detect delay.

In the case of Vivid Vision, its virtual reality software is used in conjunction with a customised VR computer system.

The patient slips the headset on and plays a series of games that Mr. Gupta says have been developed so that even some two-year-olds have been able to play them and have fun.

As they play, an optometrist, ophthalmologist, vision therapist, or technician observes on screen what the patient is seeing and how they are responding in their immersive 3D virtual environment. Then, the eye care professional uses a touch screen to make adjustments that increase or decrease the level of difficulty, and in doing so, train both eyes to work together.

For example, to train and fine tune 3D vision, the patient is asked to pop bubbles that float in front of them, working their way from the closest bubble to the furthest. The binocular disparity decreases as the patient selects the correct response.

For anti-suppression training, they’re asked to navigate a spaceship through an asteroid field and fly through blue and green targets to score points. The red obstacles are to be avoided as they come with penalties. The professional decreases the inter-ocular contrast as the patient works their way through each level, making the lazy eye work harder and /or punishing the dominant eye so that it’s acuity equates to that of the lazy eye to overcome suppression.

Targets can be created for one eye or both eyes so that both monocular and binocular vision can be tested and trained.

Virtual prisms can be applied in the games so patients with strabismus can fuse the targets and strengthen their binocular vision.

Acuity can be improved by increasing and decreasing the size of the icons displayed in each game.

Ms. Konschuh said remaining in the room with the patient during each Vivid Vision session ensures she can make adjustments to games, observe the patient’s response and remind them when necessary, to continue to use their non-dominant eye.

“Increasing or decreasing the level of gaming difficulty during sessions also provides patients with direct and immediate feedback about how their eyes are working together,” she said.

“I think this is going to change the way vision therapy is done and I can see Vivid Vision developing more games and programs that give more vision feedback for the patient over time.” She said adding to the repertoire of games available would also keep patients engaged. With treatment plans for strabismus and amblyopia extending for a minimum of 12 months, it’s easy to understand why.

OPSM Eyehub

Connie Tsang, from OPSM Eye Hub in Hawthorn, is another optometrist who is noticing the advantages of using Vivid Vision. Having used the system for a few months now, she says the system opens new possibilities for treatment.

“Vivid Vision allows the optometrist to make step-by-step modifications and load each activity as the patient progresses in a 3D environment. One of the main advantages is that it is fun, so patients are happy to do it and it is great for children and adults alike. A common reaction when first experiencing the program is, ‘Oh wow this is so cool!’. Parents find it easier as well because there is no homework involved. Both factors are great for compliance which is important for success,” she said.

“For amblyopia treatment, Vivid Vision therapy can be done concurrently with patching or instead of patching where compliance is poor. It’s fantastic to have such a fun alternative to patching and other amblyopia treatments that can not only improve visual acuity but also stereoacuity.”

She said Vivid Vision has opened up more possibilities for our strabismus patients. “We can do activities at their angle of deviation before and after surgery, or even reduce the angle during treatment… Vergence dysfunctions can be treated in a fun and interactive way with vergence and jump duction activities all included.”

At Home Treatment

Vivid Vision’s virtual reality treatment can be further enhanced with its home system, which is effectively a VR headset that can hold a mobile phone. The eye care professional provides a set of games the patient can play at home. Although these games cannot yet be adjusted during the sessions, results can be viewed remotely and adjusted for the next session. With the right hardware, optometrists can continue to track their patient’s treatment and response remotely.

Being a new technology, Ms. Konschuh said there are “some kinks and quirks” to be fixed with the home system, however it was well on the way to being a useful complement to the practice based training program.

According to OPSM a virtual reality training program involves a minimum of six 30-minute sessions at the practice over three to four weeks. Depending on the customers’ condition, they may require several blocks of treatment over a longer time frame. In terms of return on investment, Vivid Vision estimates that the equipment will have paid for itself with just 10 patients completing the treatment plan.

Having launched Vivid Vision just over two years ago, there are already 90 practices world-wide that have invested in the system, and already, the company is looking for new applications for its technology. “Currently, users can play the ‘games’ with a game controller, a touch controller that simulates the hand, or their physical hand (Leap Controller).

These three have various advantages; for instance, a patient who cannot use their arm properly is able to function better with the game controller; the touch controller has better latency and reaction, making it better for our sports vision games; the Leap device puts the patient’s hand into the environment, and this is typically the best since it mimics real eye-hand coordination. Eventually, we will have a fourth option that uses eye-tracking. This isn’t available to the public yet, but it will allow us to work purely on eye movements for patients with saccadic dysfunction or those working on improving eye movement in sports,” explained Dr. Tran. He said another potential development would be the creation of a home vision gym which would help patients to maintain eye health. “We’re staring at computer screens for eight hours a day so creating training exercises to make sure our focusing power and convergence is working well, that we’re blinking regularly, and so on, would be useful for preventing vision problems from occurring.”

“We’re also working on developing better tools for optometrists to screen and monitor for eye disease, which will make a valuable contribution to scientific research.”

Healthcare in a Frame

In California, VSP Global’s innovation lab, known as The Shop, is developing the first wearable tech prototype from a healthcare company to seamlessly integrate health-tracking technology into a pair of optical frames.

Dubbed ‘Project Genesis’, the project has been in secret development over the past 12 months, overseen by Shop co-leads Jay Sales and Leslie Muller.

“As disruption continues to change our industry, VSP Global businesses need to stay ahead of the curve and provide forward-thinking solutions that meet the changing eye care and eyewear needs of consumers,” said Rob Lynch, CEO of VSP Global. “With an understanding of a rapidly changing marketplace and increased expectations from our clients and members, The Shop’s purpose is to drive technological advancements that are helping to shape tomorrow’s optical industry.”

Project Genesis features sensor technology, housed within the temple of a pair of Dragon Alliance frames, that tracks steps, calories burned, activity time and distance travelled. The device syncs via Bluetooth to a custom application, also designed by The Shop, that the wearer can use to monitor their activity in real time through data visualisation and personalised feedback.

The Shop is currently beta testing the first version of the prototype with 26 VSP Global employees at its Sacramento headquarters. Participants from the company’s employee wellness program have been providing real-time feedback to engineers and designers, allowing for rapid improvements to the prototype’s initial hardware and software designs.

“Wearable technology is exploding right now – some of it could be considered hype, some of it could be considered the start of a personalised medicine revolution,” said Mr. Sales. “The Genesis prototype is just that. It’s a first step at providing a deeper or richer level of contextualised health data through a device that a large portion of our members are already utilising every day.”

Contextual Health is the concept of tracking one’s health metrics (steps, calories, heart rate, posture, gait, and much more) over time. By analysing the data, the wearer has the potential to start identifying trends and behaviours that could create a more proactive healthcare model.

As America’s largest vision benefits company,¹ providing patients with this level of information makes sense.

“Ultimately, this is not about just tracking steps and calories. The goal with this project is to build on these initial capabilities and, in the future, provide our members with contextual health data about themselves that they can then use to feel empowered and make better decisions in their lives,” said Mr. Sales. Presumably, doing so will also result in savings on payouts for VSP Vision Care.

Safilo has also launched wearable technology, referred to as Safilo X and developed in conjunction with Interaxon, world leaders in consumer brain sensing technology.

Described as “the first ever brain sensing eyewear platform”, the SafiloX platform has been built on Smith’s Lowdown Focus glasses and it was launched at the Consumer Electronics Show in Las Vegas in January this year.

Designed for athletes and enthusiasts, the new “smart” sunglasses collect information about the wearer’s mental status via two sensors on the temple tips and three sensors on the nose pad which detect brainwaves and eye movement.

The glasses are connected via Bluetooth to a phone or tablet and, through an app via headphones, provide weather inspired sound clues: when the wearer’s mind is agitated the user will hear strong waves crashing and when they are able to get back to focus, the sound will be one of tranquil waves. Birds chirping sound when the wearer manages to maintain focus for an extended period of time. According to Safilo X, by having the sound feedback wearers can learn how to control their mental focus with breathing and this will become easier time after time.

The sunglasses also feature additional sensors like UVA and UVB, temperature, gyroscope, magnetoscope, etc. These will allow the development and integration of many other applications in the future.

Tackling Global Eye Health

It’s not only patients who are reaping the benefits of virtual reality. Recently, Brien Holden Vision Institute and colleagues from Queensland University of Technology (Australia), conducted a study on fourth and fifth year optometry students to evaluate the influence that simulated learning environments can have on clinical refraction performance.

The Institute was trialling a Virtual Refractor to augment traditional learning and teaching approaches to refraction, with the intention of increasing the speed and accuracy of clinical subjective refraction. They wanted to know how it would impact learning.

The case-control study, which involved 20 students using the Virtual Refractor technology and 20 students receiving traditional training, found that simulated learning environments “can positively influence clinical subjective refraction outcomes for less experienced optometry students and may be of benefit in increasing the skills of novice refractionists to levels appropriate for commencing supervised clinical interactions.”

As well as being an effective learning and teaching tool, study co-author, Neilsen De Souza, Global Business Director at Brien Holden Vision Institute said, “the simulated learning environment allows us to remotely track the process of clinical refraction undertaken by a user and identify steps that have been skipped or performed incorrectly.

“This innovation allows us to deliver targeted training interventions to ensure refraction is performed accurately and efficiently. It will also allow us to understand how refraction is performed in different countries across the world. We hope that this will lead to better student engagement, but also cost savings for schools with less student supervision and use of clinical facilities when learning refraction for the first time.”

In the United States, Orbis International – which stemmed from an alliance between the medical and aviation industries – has equipped its latest Flying Eye Hospital, a remodelled MD-10 aircraft, with teaching facilities that include two Eyesi virtual reality simulators developed by US company VRmagic, along with an operating theatre. The world’s only accredited ophthalmic training hospital aboard an MD-10 aircraft, earlier this year the Flying Eye Hospital delivered a two-week ophthalmic training program in Vietnam alongside two local hospitals, Can Tho Eye Hospital (CTEH) and Can Tho Children’s Hospital (CTCH).

The Flying Eye Hospital provides medical education that is tailored for local ophthalmologists, nurses, anaesthesiologists, biomedical engineers and technicians through lectures, case discussions, observation, hands-on training, workshops and symposiums. The program in Can Tho focussed on training in six subspecialties of ophthalmology including glaucoma, retina, retinopathy of prematurity (ROP), oculoplastics, pediatric cataract and strabismus. Orbis also trained the staff at the eye clinic at CTCH to screen for common eye problems seen in children in the region, including retinopathy of prematurity, which is on the rise in middle-income countries like Vietnam.

The virtual reality simulators enable medical professionals to be trained on retinal examinations using virtual patients, allowing essential skills training to take place in a safe controlled environment, without patient risk and independent of patient flow and a hospital’s routine.

VRmagic introduced the first Eyesi Surgical simulator for training of vitreoretinal surgery in 2001. In 2005, the Eyesi platform was expanded with a training interface and corresponding software modules for cataract surgery.

In 2009, VRmagic expanded its product range for education in ophthalmology by introducing Eyesi Indirect Ophthalmoscope, an augmented reality simulator that allows for realistic training of binocular indirect ophthalmoscopy as well as training the diagnosis of retinal diseases.

According to VRmagic, simulator-based training has been included into the US medical education guidelines and some European countries, such as the United Kingdom are following suit. In Denmark, the main ophthalmic programs have made it mandatory for their residents to complete the simulator-based curriculum successfully before entering the operating room.

A spokesperson from VRmagic said, “Simulation gives medical students the opportunity to experience a wide range of pathologies, independently from patient flow. Our virtual reality simulators offer a highly immersive learning environment and a risk-free opportunity to learn from mistakes before entering the operating theatre. At the same time, simulator-based curricula enable medical programs and associations to establish standards in education. Moreover, simulators offer the means for evidence-based evaluation and certification.”

Virtual reality has become a reality.

Reference
1. www.vsp.com/about-vsp.html