Virtual reality and augmented reality headsets have been taking the video game market by storm, allowing players to immerse themselves into new worlds and interact freely with games from their living rooms. Now that the technology is advancing, eye-care researchers and technology companies are beginning to figure out new ways to develop these devices to benefit the lives of patients with age-related macular degeneration.

VR vs. AR

Many people who’ve tested head mounted displays understand the difference between VR and AR, but there are also differences to how these technologies impact AMD patients. 

“Virtual reality technology helps you immerse with the virtual world of your interest in which you’re not connected to the real world,” explains Sarika Gopalakrishnan, PhD, a post-doctoral research fellow at Envision Research Institute. “Augmented reality is very different. That helps enhance the view of the real world, which is incorporated in most of the electronic vision enhancement systems for low vision.” Although Dr. Gopalakrishnan prefaces that AR technology devices control the majority of the wearable electronic vision enhancement system (wEVES) landscape, there are devices with VR capabilities that can benefit patients with AMD.

“The lines between VR and AR are blurring as new devices come along, but typically VR produces a wider field of view and a brighter image than AR-style devices,” says Andrew Miller, MS, a post-graduate researcher for the Vision and Hearing Science Research Center at Anglia Ruskin University in Cambridge, UK. “These features are clearly of potential benefit to people with vision impairment.”

There may be a reason for why most wEVES use AR technology rather than VR. “VR-style devices tend to be heavier and are often housed in an enclosed headset compared to a much lighter and more open AR equivalent,” says Dr. Miller. “The weight of the VR devices has been shown by others to be off-putting and a cause for abandonment of wEVES. When we showed devices to people with AMD, we found a very similar initial response with people questioning if they would be able to use them for anticipated tasks as well as thinking their appearance was strange and off-putting rather than high-tech.”

wEVES and Ocular Diseases

It should be understood that wEVES aren’t solely marketed towards AMD. Rather, they can be used for a number of low-vision conditions and pathologies. “My research work has proved that these augmented reality devices not only help people with AMD, but with most of the ocular conditions that cause low vision,” says Dr. Gopalakrishnan. “So, most of these head-mounted displays are designed with a wide range of magnification, variable contrast, adjustable brightness, different viewing modes, along with image enhancements, which help the eye to process the same images much easier. That’s how these devices are helpful for anyone with low vision. These devices are helping people perform their vision functions more efficiently and independently.” 

In one of her studies, Dr. Gopalakrishnan has found that these devices work well for patients with cone dystrophy, retinitis pigmentosa and optic atrophy along with AMD.¹ She explained that most devices in Western countries are marketed towards AMD, but these devices also provide comprehensive lists online for all ocular conditions that could benefit from the use of wEVES. For example, eSight lists the following conditions on their website:

• cataracts;
• central vision loss;
• cone rod dystrophy;
• diabetic retinopathy;
• diabetic vision loss;
• glaucoma;
• legal blindness;
• macular degeneration;
• ocular albinism;
• optic atrophy;
• optic nerve hypoplasia;
• retinopathy of prematurity; and
• Stargardt disease.

Research has shown that wEVES may benefit a low-vision patient’s visual acuity. In Dr. Gopalakrishnan’s study on the role of head-mounted augmented reality devices on improving visual functions of individuals with low vision, she observed 100 patients with ocular conditions presented earlier in this article.¹ The patients’ distance visual acuity improved from 1.1 (0.7) to 0.15 (0.6) logMAR when using an AR device. Also, their near vision improved from 0.6 (0.7) to 0.3 (0.1) logMAR and their visual function score improved from 0.35 (0.26) to 1.89 (1.90).

“We need to be clear in understanding that these devices aren’t a replacement treatment for AMD or any other disease,” cautions Dr. Gopalakrishnan. “So, people need to follow the advice from their ophthalmologist to control the progression of their ocular condition, including AMD. Medical treatment, or surgical treatment, is the first level of treatment. These devices aren’t considered to be treatment options. These are additional enhancement devices. If nothing works for them, either surgically or medically, and the ophthalmologist has tried their best to improve their patient’s vision, but it’s not at 100 percent, then to fill that gap, these devices can help make it 100 percent.”

Adverse Effects

“VR devices tend to completely immerse the user in virtual reality, cutting them off from the outside world,” mentions Dr. Miller. “This loss of contact with the real world can have the potential to produce side effects such as headaches, nausea and seasickness symptoms in some individuals, and these symptoms are seen regularly in people using simulators or headsets. Thankfully these symptoms tend to be mild and often wear off quickly when the device is removed, so they can limit the time a device can be used comfortably. There’s also been some research that tends to indicate that people with visual impairments may be slightly less sensitive to these symptoms than people who are fully sighted.”

In a study to understand how vision impairments affect self-motion perception when using a head-mounted display, researchers from Australia observed candidates with normal vision, and AMD and glaucoma candidates with near-normal visual acuities.² They studied participants’ experiences with self-motion in depth, or linear vection, spatial presence and cybersickness, or headaches and nausea. They found that AMD patients had greater vection strength and spatial presence when compared to participants with normal vision, while glaucoma had low vection strength and spatial presence. Additionally, they cited that the AMD and glaucoma groups both reported a reduction in the severity of cybersickness compared to candidates in the normal vision group. 

Dr. Gopalakrishnan added that eye strain (asthenopia) is another common effect from excessive use of wEVES. She explained that patients who are claustrophobic, pregnant or epileptic may not be great candidates for these low-vision devices. According to her experiences using several devices, she noted that a warning screen does appear on the display of most devices, cautioning individuals that they may experience symptoms and that the device shouldn’t be used by everyone.

Patient Satisfaction

In the end, wEVES are meant to help patients with low vision. Dr. Miller conducted a qualitative investigation of the views of patients with AMD who’ve tested out these systems.³ “It was really interesting to understand that a lot of our current supporting solutions for vision impairment associated with AMD centered on the need to improve reading ability, and this is a key requirement for anyone with AMD. However, we tend to have less suitable solutions for other tasks such as recognizing faces or completing tasks in the midrange. It was interesting to hear people imagining their usefulness for creative tasks, not just the practical, considering that they would be suited to returning to an enjoyment of the arts or craft-work for example, or even just looking at their grandchildren’s faces.”

From the study, Dr. Miller states that the devices “may be reframed by users to focus predominately on sedentary tasks taking place in isolation at home.” He goes on to explain, “This view was driven by our participants’ views based on the appearance of an AR and VR-style device that we showed them. They felt the devices didn’t appear high-tech, but instead described them as otherworldly, feeling that the use of the device around others would make them feel uncomfortable even if the device solved the practical problem at hand. As we discussed in that article, it may well be that with wider adoption of headsets in the gaming and work environment may ultimately make these devices more socially acceptable and ultimately support the use by people with a visual impairment.”

Currently, Dr. Gopalakrishnan is researching how wEVES can benefit low-vision patients in the workplace. “These devices are enabling them to work as equally as a normally sighted person and with effective speed and accuracy,” she explains.

It’s the patient’s life at home where these devices become the most beneficial. “There’s enough evidence that these devices are really helpful in changing the lifestyles of people at home,” says Dr. Gopalakrishnan. “They’re able to see much better with these devices, so they’re able to recognize facial expressions of their family and friends, watch television, read newspapers, magazines and use appliances. So, there’s a lot of tasks that they’re able to do with these devices. It’s really changing their lifestyles at home and they’re feeling happy with that.”

The eSight 4 can be connected to the charging cable while the user wears the headset in order to maintain prolonged use without changing the batteries. This feature works well for stationary tasks. (Courtesy eSight).

wEVES on the Market

The market for wEVES continues to grow and advance with new devices and technology releasing every year. Here are some devices to improve the lives of patients with AMD and other low-vision conditions.

• eSight 4. ESight 4 is the latest vision enhancement system from eSight, marketed for all-day comfort and use. According to their user guide, this device is equipped with a camera on the front of the headset along with an ambient light sensor, a recording light and a focus sensor. To increase comfort and stability, eSight added a halo band that wraps around the forehead that can be adjusted for size. The right arm of the headset includes a touch pad for user control, a power button and a status indicator to signal whether the device is booting up, ready for use, in sleep mode or if an error occurred. 

According to their website, ESight 4’s display has a system acuity greater than 20/20 on the Snellen chart. Inside the headset are two dual independent high-resolution OLED color screens, which can be repositioned to fixate on the center of the user’s eyes. Additionally, there are two rechargeable lithium-ion batteries that hold approximately three hours of charge each. Only one battery is needed to power eSight, while the other can be charging, then swapped out after three hours of use. 

Patients who are struggling to use the touch pad to control their settings can choose to use the remote control compatible with eSight 4. This remote provides advanced controls allowing the user to raise or dim brightness levels, switch between focusing on objects near and far, as well as zoom magnification. These functions can also be controlled using eSight’s Apple and Android mobile apps. 

ESight 4 comes with 256 GB of storage allowing the user to capture and store images within the device. Additionally, there are three built-in speakers for more immersive experiences. This device is also set to work with WiFi, Bluetooth and HDMI inputs in order to project smartphone and television displays onto the screens of the headset. There’s also the option of downloading eCast and eMirror mobile apps as an additional way of projecting smartphone images onto the headset’s display. 

The user guide states that eSight shouldn’t be worn when driving, operating machinery or any other visually demanding activity for which there is an inherent risk of injury or death. When the visor for the headset is fully down over the eyes, then the user is limited to sedentary tasks, like reading, writing and watching television. But when the visor is partially up, the user can still receive benefits from the headset while walking or interacting with friends and family. 

• IrisVision Live 2.0. Equipped with Samsung smartphone technology, the IrisVision Live 2.0 comes with a 1440x3120 display and a 50 MP camera, according to their website. The display offers a 70-degree field of view with different viewing modes. One particular mode, RP Mode, is designed for glaucoma and retinitis pigmentosa patients to allow them to regain their peripheral vision by shrinking their field of view. 

According to their user guide, IrisVision Live 2.0 begins in Focus Mode, allowing the user to adjust the focus of the display before using other functions. Users should understand that they’ll need to wear their distance prescription glasses when setting up and using this headset. 

After setup is complete, users have the option of using voice commands to control IrisVision Live 2.0. They can ask the device to take photos, reduce or raise brightness, zoom in and out of images, and enlarge text while reading. Additionally, photos can be stored in the photo gallery on the IrisVision headset. 

IrisVision Live 2.0 comes equipped with speakers for various uses. Users can connect their device to WiFi and watch videos controlled by voice commands. These videos can be played, paused and even magnified to help the user see more clearly. Furthermore, some text may still be too small or difficult for a user to read. That’s why IrisVision added optical character recognition that’ll scan text and read it aloud for the user.

The design for IrisVision Live 2.0 is made up of a visor with a Samsung display connected to adjustable straps that wrap around the sides and top of the user’s head. Instead of adding a battery pack to the back of the strap for multiple rechargeable batteries, this device uses a wireless charging pad. However, there’s an option to connect a magnetic braided power cable to allow the user to connect their device to an external battery pack to allow for longer use of the device. 

According to their user guide, IrisVision Live 2.0 should be kept dry and out of direct sunlight. They preface that no users should be wearing this headset while walking or driving a vehicle. For patients with a pacemaker, IrisVision warns not to wear the headset around the neck on a lanyard. Also, if the user turns on accessibility options on the display unit or locks themselves out of the screen, then the device won’t function correctly.

• NuEyes e3+. This device has four tracking cameras, a depth sensor, gyroscope and a proximity sensor. The company says the device helps the user watch television, read, cook or paint while viewing everything through an Ultra HD camera. NuEyes e3+ is marketed as a wearable magnifier with inter-pupillary distance adjustments allowing the user to focus images and adjust diopter ranges. Therefore, the user can go glasses-free with it. 

NuEyes e3+ is equipped with optical character recognition and text-to-speech functions. This device responds to voice commands to adjust settings, but two handheld wireless controllers (one for each hand) are implemented to modify the users viewing experience. 

NuEyes is implementing their e3+ technology into the Vive XR Elite. This uses extended reality technology, which, according to Vive’s website, is an umbrella term for VR, AR, and mixed reality. This type of technology allows the user to switch easily from environment to environment without having to be immersed in a virtual world while walking or augmented reality while watching television. 

Besides the technology added by Vive, NuEyes e3+’s display comes with a 110-degree field of view, magnification up to 18x, and variable contrast options. The display offers a resolution of 1920x1920 pixels per eye and the headset tracking allows for six degrees of freedom (6DoF). Three degrees of freedom only allows the headset to track the rotational movement of the head, but it can’t compute for walking, crouching, sitting or standing up. 6DoF allows the headset to track more movements from the user as they tend to their daily activities. 

Additionally, according to their website, NuEyes e3+ comes with two rechargeable batteries with up two hours of continuous power each. For comfort, the headset can be adjusted, although there’s only a single band that wraps around the head. Instead, the battery pack is contained in a compartment at the back of the headband along with an added cushion for extra comfort and stability.

There are many more devices on the market, and as they advance, physicians and patients may find new ways to use the technology to better their lives. “When smartphones and tablets arrived, they brought sweeping changes to many people with visual impairments, bringing a previously unthought level of accessibility to a mainstream device,” says Dr. Miller. “With the release of new headsets by major manufacturers, it’s wonderful to be looking at the start of a new era of potential support for people with sight impairment. However, it’s still unclear at this time how significantly these devices will be adopted by people with sight loss, including those with AMD.”

Dr. Colvard is a surgeon at the Colvard-Kandavel Eye Center in Los Angeles and a clinical professor of ophthalmology at the Keck School of Medicine of the University of Southern California. Dr. Charles is the founder of the Charles Retina Institute in Germantown, Tennessee.

Drs. Gopalakrishnan and Miller have no financial interests to disclose.

^{1. Gopalakrishnan S. Role of head mounted augmented reality device in improving visual function of individuals with low vision. Investigative Ophthalmology & Visual Sciences 2023;64:8:5522.}

^{2. Luu W, Zangerl B, Kalloniatis M, Palmisano S, Kim J. Vision impairment provides new insight into self-motion perception. Investigative Ophthalmology & Visual Sciences 2021;62:2:4.}

^{3. Miller A, Macnaughton J, Crossland MD, Latham K. “I’m like something out of star wars”: A qualitative investigation of the views of people with age-related macular degeneration regarding wearable electronic vision enhancement systems. Disability and Rehabilitation 2023;1:10.}