Ophthalmology takes the plunge into the metaverse

The 2022 Digital Ophthalmic Society meeting was the first ever eye care conference to be held in a space station, or at least that is what it looked like.

The attendees were able to hop around the galactic convention center and zip around on helicopters because they were in a virtual reality space known as the metaverse. Connecting with colleagues in different parts of the world has become commonplace, particularly because of pandemic-related advances and incentives to stay home. However, the complete immersion of the metaverse gave Ranya Habash, MD, and colleagues a chance to try something new.

“We know that with virtual platforms like Zoom, you can be anywhere you want,” Habash told Healio/Ocular Surgery News in an interview within the metaverse. “But this experience is totally different. It’s an immersive extension of reality.”

Theodore Leng, MD, MS, first started hearing about the metaverse a few years ago with an increased interest in web3 applications and Facebook rebranding its parent company as Meta.

“There’s been a trend of tech companies moving into the space,” he said. “It has a lot of potential for different people in entertainment, communications and so forth. But for us in academic ophthalmology, people like myself saw a huge opportunity to get involved to use it for scientific and medical education.”

Meta meetings

As a peer-to-peer communication platform, Leng said the metaverse is hard to beat, at least in a digital or remote situation.

“It’s better than Zoom, Microsoft Teams or any sort of screen-based meeting environment because it’s much more immersive,” he said. “When you’re using a virtual reality headset, you really do feel like you’re right there with the person you’re talking with. You actually have a sense of reality that you don’t get when you’re on Zoom.”

Each user within the metaverse can create an avatar, a customizable representation of themselves that can walk and talk inside the digital space. Want to wear a suit and tie, scrubs or even a space suit? Those options are all available in the program the Digital Ophthalmic Society (DOS) used for its first metaverse meeting.

The meeting’s custom-built space station had a large stage complete with a podium and screen to display slides and surgical videos. Presenters — or at least their avatars — could sit on couches and take part in panel discussions with their colleagues from across the globe.

The rest of the conference space had room for attendees to break out and explore. There were areas for smaller discussions and even room for industry sponsors to display their devices at a massive scale for inspection by physicians. In the metaverse meeting, audio was crisp and surrounded listeners, while surgical videos were presented in crystal-clear 3D.

This might seem like a lot to take in at once, but a unique feature of the metaverse, known as spatial audio, gives users a chance to focus on what they are close to without being bombarded by noise from around the digital space. As the user gets closer to the audio source, it gets louder. Back away, and it gets quieter, giving the user a chance take part in smaller conversations that would not be possible on a platform like Zoom.

“I think spatial audio is one of the key aspects of the metaverse,” S.K. Steven Houston III, MD, said. “During the conference, I could grab a few people and say, ‘Let’s go to the back.’ There, we could have our own conversations while listening to the presentations and seeing the slides, but no one else in the auditorium could hear us. It’s just like stepping away during a conference to have those side conversations. That’s the amazing part of these spaces. You can have those interactions that you couldn’t otherwise have when you attended meetings remotely.”

Leng said these interactions are not possible on Zoom.

“If you’re 10 paces away from another group of people having a conversation, and you’re just talking to the two people next to you, you’re not hearing everyone else in the same room,” he said. “Unlike being on Zoom, where you might have a group of 100 people, but only one can talk at once, you could be in a virtual space with a hundred people and only be talking to one other person.”

Habash said that the metaverse grew out of the third wave of innovation in the world wide web and computing.

“There have been three versions of the internet,” she said. “The first was the text-based, read-only disk operating system. In web2, you could participate. That could mean posting stuff on Facebook or Instagram. That was the rise of social media. With web3, applications and services use a decentralized blockchain. There is no central database. The software lives in everyone’s pockets, essentially, with their devices, and it uses AI to create a more adaptive, more intelligent user experience.”

What makes the metaverse unique, Houston said, is that it gives users a new dimension of reality, or at least that is the goal.

“It’s a universe within a universe,” he said. “It’s an immersive virtual space where the user interaction mimics the real world. It’s going to represent a broad shift in how we interact with technology.”

Future education

Much like nonfungible tokens seek to decentralize artwork and cryptocurrency seeks to decentralize traditional currency, Houston said the metaverse will bring about more decentralized person-to-person interactions by simulating the real world.

“Whether it’s decentralized servers or the blockchain, you’re going to see NFTs and crypto as the underlying building blocks of the metaverse,” he said. “It will let you go anywhere and be able to simulate what the real world is but in a virtual space much better than what we can do now.”

Eric Rosenberg, DO, a co-founder of the DOS, said the applications for the metaverse in medicine and ophthalmology were clear from the beginning. He called it a perfect next-generation platform for physician engagement and knowledge transfer, particularly when considering how technology in medicine is evolving in general.

“We’re limited by current technologies in order to educate the next generations of ophthalmologists,” he said. “These newer technologies, like 3D digital visualization and electronic modalities that are coming into play, are going to keep redefining what medicine is and how to transfer knowledge. With this platform, physicians are going to be able to glean more information earlier in their training.”

Rosenberg said that the growth of the metaverse and improvement in virtual reality will likely yield faster adoption and improved surgical techniques.

“You’re able to see what’s, in essence, going on in 3D,” he said. “And the eye is an extremely 3D object that requires an understanding of all dimensions, including time, for all pathologies.”

While using the metaverse as a digital meeting space might be the easiest way to integrate it into medicine right now, some physicians are already branching out and trying to tap into its other uses.

Houston, Habash and Rosenberg have already pulled together other leaders in their field to conduct grand rounds in the metaverse.

“Zoom is fine for the consumer, but it’s more just for the consumption of content. You’re not really interacting unless you’re on a one-on-one call,” Houston said. “Ultimately, in the future, there is going to be stuff going on 24/7, and people will be able to just come and go. The nice thing about that is there are no geographic boundaries.”

He foresees things such as live surgical streaming coming from surgeons around the world.

“People can hang out with a bunch of their colleagues and watch the best surgeons in the world and learn from them,” he said.

Leng said some newer technology is already positioned to integrate with the metaverse. Alcon and its Ngenuity visualization system can record surgery in 3D, making it perfect for virtual reality viewing.

“It’s so much better for education,” he said. “We can actually see what the surgeon is seeing. The maneuvers and the different tips they give are much more poignant than when you see them in a normal video.”

Education is a large part of what makes the metaverse appealing for physicians, but Habash said it is already expanding into the next step of surgical prep. She said there was a recent case in which a team of surgeons practiced how to separate conjoined twins through the metaverse.

“It was one of the most complex surgeries on record,” she said. “Surgeons in London trained surgeons in Brazil to perform this surgery, and they were able to successfully complete it after practicing with AR and VR over and over again. It is like using a surgical navigator or surgical GPS to navigate these complicated surgeries ahead of time.”

Habash said another exciting aspect of the metaverse and web3 in general is the potential to improve connected care through precision medicine, virtual care and decentralized clinical trials.

“Being decentralized, you can structure clinical trials in a way that enables patients from every corner of the globe to participate from wherever they are,” she said.

While the first metaverse DOS meeting was considered a success, Rosenberg said it was not without its hiccups. There were connectivity issues, and it took people some time to get acclimated to the program, but the benefits were clear.

“There’s a lot of value in having a meeting where you don’t need to fly people in to attend,” Rosenberg said. “This offers opportunity to people who may not otherwise be able to attend based on a number of reasons. Maybe their clinic hours don’t allow it, or they could be a working parent. The barriers to entry for some of these real-life meetings can be just as big. As newer technologies and concepts develop, you want to be able to offer access without restricting the people who maybe need it the most.”

After getting acclimated, attendees of all ages, from those in their 20s to those in their 80s, reported having a positive experience at the DOS metaverse meeting.

“Once you’re over that small learning curve, the rest is pretty intuitive,” Rosenberg said. “It’s nothing different from what you would do at a real meeting. We’re able to emulate things we usually do in real-life meetings in the metaverse and maybe offer an ancillary service to those people.”

Rosenberg went into the metaverse meeting expecting it to be a tough sell for some people, but there was a lot less resistance than expected.

“People are tired of the current modalities that exist for education,” he said. “It’s very two-dimensional in many ways other than it just being on a 2D screen. It’s not interactive at all, and it’s not conducive to a proper education, or at least in a way that we’re used to learning it.”

He said when people attend conferences on Zoom, it can be easy for their attention to drift. They try to multitask and do not get the full learning experience they may receive at a scientific meeting. Once the physicians put on the virtual reality headsets, Rosenberg said a lot of those worries melted away.

“I have a mentor who taught me a lot through my residency. He’s a world-famous cornea surgeon, but technology is not his strong suit,” he said of one of the attendees. “When he put that headset on, he told me it was the coolest thing he had done in his career. Ophthalmologists are progressive beings, and we’re always leveraging technology to benefit our patients. This should be no different.”

Hardware limitations

The technology, while exciting, is not without its drawbacks and limitations. Leng said the hardware is still in its infancy and can have trouble rendering the virtual environments and participants. When the platform was tested before launching the DOS meeting, Leng said it was able to handle a handful of people but struggled a bit when the group grew to more than 50. Instead of full people, he said there were floating heads and hands.

“The ability to render other people’s avatars is directly correlated with the processing power of the hardware you’re using,” he said. “Each person’s headset has to be able to render other people’s avatars and what they’re doing. It’s not quite scalable yet. When you get a lot of people in a room, the hardware is limited.”

One of the biggest limitations of the metaverse, Habash said, is that people are still trying to understand what they can do with it.

“People think the metaverse is just about gaming or social networking, but we’ve demonstrated real medical value,” she said. “What we’re trying to do is get rid of those preconceived notions and invite people to come into these spaces to interact for themselves. Once they get in, they’re going to have a different opinion than what they thought before.”

Houston said devices such as the Oculus Quest are a relatively affordable option for people who want to try virtual reality. However, VR headsets are not for everyone. He said it is not uncommon for people to get dizzy when taking part in some aspects of the metaverse, for example, a helicopter ride at the DOS meeting.

“I get motion sick in boats if we’re in rough seas. I know not to ride the helicopter,” he said. “The nice thing about what we’re doing is that people can even start out coming in on their iPad or laptop, and it can still be a very immersive experience.”

Houston sees a lot of potential in using virtual reality and the metaverse in more parts of daily practice, possibly to even interact with patients. However, he knows not every ophthalmologist is ready for that.

“It’s a new realm of possibility, and we have to walk before we run,” he said. “Once they get more comfortable, and they’re coming into these spaces all the time, then you can start to roll out more advanced aspects.”

• For more information:
• Ranya Habash, MD, can be reached at Bascom Palmer Eye Institute, 900 NW 17th St., Floor 3, Miami, FL 33136; email: ranya@habash.net.
• S.K. Steven Houston III, MD, can be reached at Florida Retina Institute, 95 Columbia St., Orlando, FL 32806; email: shouston3@gmail.com.
• Theodore Leng, MD, MS, can be reached at Byers Eye Institute at Stanford University School of Medicine, 2452 Watson Court, MC 5353, Palo Alto, CA 943033; email: vision.md@gmail.com.
• Eric Rosenberg, DO, can be reached at SightMD, 100 Manetto Hill Road, Suite 202, Plainview, NY 11803; email: ericr29@gmail.com.

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