Virtual Reality: A 21st Century Ophthalmic Teaching Tool

Virtual reality (VR) technologies have introduced new opportunities for improving ophthalmic patient care. Numerous studies have already demonstrated the potential of employing VR applications in ophthalmologic diagnostics, visual field analysis and visual rehabilitation.^1-3 But in addition to these clinical applications, virtual reality is instigating substantial changes to medical education and ophthalmic training, with the aim of improving accessibility to quality educational resources and lowering costs.⁴

In 2023, the American Academy of Ophthalmology (AAO) established a partnership with private industry to expand the accessibility and the quality of pediatrics education for ophthalmology trainees by creating a VR-based educational product.  

The partnership between the AAO and healthcare technology company FundamentalXR has resulted in the development of a VR-based educational platform with a particular focus on pediatric ophthalmology. These new educational approaches have the potential to change how educators instruct their students and perhaps even how surgery is performed among the next class of ophthalmologists.

What Virtual Reality Can Offer Ophthalmic Educators

Currently, a major gap in ophthalmology education, particularly in surgical education, is the limited opportunity for trainees to gain hands-on clinical experiences in a supervised environment that allows them to develop skills in a stepwise manner prior to operating on patients. Not only do ophthalmology residents and fellows have inequitable access to these resources, but they also have significant variability in exposure to various ocular pathologies, patient populations, and clinical scenarios. For example, various studies have cited limited access to surgical training in phacoemulsification cataract surgery, the most common surgery completed by ophthalmologists, in developing countries.^5,6 

Similarly, other studies found ophthalmology residents in rural settings or training during pandemic lockdowns, such as the 2019 coronavirus pandemic, did not have sufficient exposure to non-surgical clinical skills required for certain populations, such as pediatric or indigenous patients. ^7-10 As a result a significant portion of ophthalmology trainees complete their education without performing key procedures, making dissatisfaction with surgical skills upon graduating training programs common.¹¹ 

Given the need for extensive surgical knowledge combined with the realities of limited educational resources or access, VR presents a unique opportunity for ophthalmology trainees to meet these demands in an effort to improve patient outcomes. Virtual reality offers ophthalmology trainees the opportunity to obtain and practice surgical skills in a reproducible, low-risk and simulated environment. Several successful VR platforms, including the Eyesi and HelpMeSee, have shown to demonstrate reproducible efficacy in improving surgical performance, reducing intraoperative complication rates and expediting the learning curve for cataract and retinal surgery. ^12-14 Ophthalmology residents trained on VR platforms have been shown to achieve better patient safety outcomes once they start operating compared to those trained solely on patients, as it enables objective assessment and feedback that is not present in traditional clinical training. ^12,14,15

Anuradha Khanna, MD, the Vice Chair of Education of the Department of Ophthalmology at Loyola University Chicago, has worked to advance VR-based ophthalmology education since 2014. Dr Khanna created the OcuSim Virtual Reality training lab at Loyola University, which exposes ophthalmology residents and pre-clerkship medical students to ocular anatomy, physiology and basic knowledge that they would otherwise be exposed to via a two-dimensional textbook image. 

“Typically a learner would read and then conceptualize it and then create a 3D model [of ocular anatomy],” she explains. “The problem is, I have no idea what they are conceptualizing. Instead, I want them to experience an eyeball rather than conceptualize it. Using this teaching method, the conceptual clarity is enhanced. The simulation for [practicing] procedural skills has been proven and accepted in all specialties, so what I have done is brought simulation to the classroom and transformed learning into deep understanding.”

An Overview of Virtual Reality in Ophthalmology Education

The existing platforms for VR in ophthalmology education typically fall under 1 of 3 categories: 

• Surgical Simulators: This category represents VR technologies that aim to provide surgical skills training through means of high repetition, supervised simulations that the user can master in stages.⁴ These surgical simulators rely on presenting its users with a VR simulated environment that is presented on either a VR wearable headset or is visualized by looking through eye pieces of a simulated surgical microscope. These systems often, but not always, rely on haptic feedback tools, simulated heads, or eyes, or both. They usually incorporate a surgical display system similar to those in actual operating rooms. The most common VR platforms utilized for surgical simulation include Eyesi (Haag Streit), MicroVisTouch (3-Dmed), HapticVR™ (FundamentalXR), Alcon Fidelis™ (Alcon), HoloLens (MicroSoft), Apple Vision Pro (Apple Inc.), and HelpMeSee.^16-25
   
• Non-Surgical Clinical Simulators: This category represents VR technologies that aim to provide non-surgical clinical skills training through means of high repetition, supervised simulations that the user can master in stages.²⁶ Similar to surgical simulator platforms, the non-surgical clinical skills platforms utilize VR wearable headsets, simulated slit lamps or even phone-based virtual spaces to develop physical exam skills through translational, stepwise simulation learning modules such as examining for pupillary reflexes, assessing anterior and posterior compartment anatomy, or assessing for an array of common pediatric ophthalmic diseases and conditions.^27-30
• Learning Libraries/Interactive Education: This category involves VR based educational simulations aimed to be used by ophthalmology trainees to grow general knowledge and connect with other trainees. The most common platforms include the Holo Eye Anatomy library, the Eye MG AR library, the Eye MG Holo library, the OcuSim library, the Metaverse and MetaMed.^31-39 These tools are designed to build virtual communities that cross geographic barriers and supplement trainees education with self-guided materials. 

The AAO and FundamentalXR Collaboration

The collaboration between AAO and FundamentalXR began with a mission to develop a novel non-surgical clinical simulator. For years prior, AAO had been partnering with the Knights Templar Eye Foundation to improve pediatric ophthalmology education given the variable levels of exposure to pediatric ocular pathology and conditions in residency programs.⁴⁰ To address these gaps, the AAO launched 3 free browser-based simulators between 2015 and 2020. Each simulator was dedicated to a relevant pediatric condition, with the first dedicated to simple strabismus, the second to complex strabismus, and the last to retinoscopy.^41-43 Following these pilot projects, the AAO and Knights Templar Eye Foundation offered a VR-based simulation for retinopathy of prematurity (ROP).  

Retinopathy of prematurity which is currently on the rise due to improved survival rates of preterm and low birth-weight infants, can be a challenging exam for learners to master.^44,45 Ophthalmology residents’ exposure to neonatal patients varies significantly based on program resources and structure.^46-48  

Following a year of collaborative development the AAO and FundamentalXR officially launched their VR-based ROP simulator, which was first on display at the 2024 annual AAO meeting in Chicago.⁴⁹ With the use of a MetaQuest VR headset, the ROP simulator brings users into an immersive neonatal intensive care unit to practice various modules for ROP diagnosis and treatment, including indirect ophthalmoscopy, scleral depression and injection or laser therapy. The simulator features a diverse library of ROP fundoscopy images, stepwise instructional design and ability to practice in a realistic simulated environment without the limitations of working with an in-person neonatal patient. 

The launch of the initial prototype has already been incorporated in the educational structure of several accredited ophthalmology residency programs, including Case Western Reserve University, the University of California, San Francisco, and Oregon Health & Sciences University, as well as residency programs in Chile and Nigeria.  

Given the success of their first product launch, the AAO and FundamentalXR plan to expand upon their ROP simulator and develop additional VR-based non-surgical clinical simulators for other common pediatric ophthalmology diseases and conditions. 

While no project has formally been announced by AAO, they will likely expand upon the retinopathy library from their ROP simulator to include other common retinal conditions in pediatrics and create a similar product for strabismus.    

Dr Khanna’s pedagogical work at the individual institutional level applies to the broader partnership between AAO and FundamentalXR. “The most exciting part of this movement is that much of the progress we have been able to make has been student-led. In order to keep fueling this learning-initiated wave, we need our own community members to be a champion in leadership and to make these educational platforms more available, through apps or free-prototypes.” She credits much of the value of AAO and FundamentalXR’s collaboration to its mission of accessibility and broadening the possibilities of medical education. “Our biggest hurdle is that [VR technologies] traditionally have not been marketed well, so it is our job to spread the word and show the ophthalmology community what is possible.” 

How Future Innovators Can Get Started 

Certainly the next chapter of ophthalmology education will be shaped by the current and future work of the American Academy of Ophthalmology and FundamentalXR collaboration, but it will require similar partnerships in scale and scope to continue to push the limits of what is possible. Daniel Mummert, the Director of Online Education at the American Academy of Ophthalmology, has led multiple educational initiatives bridging educational tools with ophthalmology learners themselves, including the collaboration between the Academy and FundamentalXR. Mummert has detailed the lessons learned from the early achievements of the AAO and FundamentalXR collaboration, and references the following guide as a starting point for future academic organizations and industry partners who are interested in making an impact in this unfolding area of ophthalmology. 

1. Decide what you want to teach and why:

 “The strength of the Academy’s collaboration with FundamentalXR was that we identified a single educational gap [variable access to educational experiences to prepare residents to manage ROP] and set our sights on educational outcomes, not commercial success,” Mummert says. “Because of our focused mission, we were able to partner with FundamentalXR, who shared an interest in addressing that gap and allowed for both to become the drivers of that cause.” For Mummert and the Academy, this is an approach that educators in ophthalmology can emulate when instituting VR tech. “Identifying the areas in which a virtual experience can best bolster training can inform institutions about where to first implement these tools,” Mummert shares.

2. Demonstrate something to stakeholders within a reasonable amount of time:

Mummert also shares that while this project was focused on educational outcomes and not on financial profits, these two organizations were being funded by stakeholders of the Knights Templar Eye Foundation. “Within 12 months, the Academy and FundamentalXR were not only able to produce an initial product, but also demonstrate the value and further potential this platform offers its users. Future collaborators will likely need to balance their shared vision with a pragmatic approach to demonstrate that their product can be developed within a reasonable amount of time, ideally within the span of 12 to 18 months,” Mummert recommends.  

3. Incorporate user testing as early and frequently as possible:

The Academy and FundamentalXR partnership also highlighted the strengths of piloting the product with their target audience, a talking point Mummert highlights as a must-have for the sustainability and longevity of an educational program like this. “The Academy made the decision to involve ophthalmology residency program directors early on in the development of the product to get the platform in the hands of residents to improve the interface as much as possible within the first year. Not only can this build stronger relationships with a future user base, but it will also better cater to community needs and develop a product that isn’t just another flashy gadget.”