Medical Applications of VRAlex Wendland (CTO of Luminopia)

1© 2016: These slides may not be copied or reproduced without explicit permission from Luminopia, Inc.

Alex Wendland

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Luminopia● Founded in September, 2015● Using VR to treat ocular disorders

○ Starting with Amblyopia

● Preparing to start two clinical trials○ Boston Children’s Hospital○ Southern School of Optometry

● Scientific Board of Advisors has 8 members○ Nation’s leading Ophthalmologists, Optometrists, Vision Therapists and Amblyopia

Researchers

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What/Why This Talk?

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How can VR be used to treat medical disorders?

How can a startup economically and efficiently approach VR?

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Current Applications of VR

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Luxury Entertainment

Gaming & Video Media

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VR Gaming● Stealing all the headlines● $10 billion market by 2022 (Grand View Research, Oct 2015)● Dozens of new gaming titles

○ Millions of dollars in development

● Oculus sold for $2 billion to Facebook

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VR Gaming Difficulties● One of the hardest applications of VR● Rapid movement of gaming causes:

○ Player nausea■ However, this is quickly improving

○ Difficulty with head tracking○ The problem of lateral movement○ Lag due to high spec requirements for intense environment rendering

● Benefit: drives the technology forward

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VR Video Media● New frontier of cinematography● Sundance 2016 had over 30 VR related experiences● Is it similar to 3D TVs?

○ 3D TVs were expected to occupy 86% of the market by 2014 (Digital TV News, 2009)○ Consumers didn’t see value add of the product, chose to mostly ignore it

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Luxury entertainment is good for driving technology forward, but it is only a small aspect of the greater impact that VR

technology can have on all facets of life

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VR + Medical Treatment

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VR and Ocular Treatment: Neuroplasticity● VR controls a person’s entire visual stimulus

○ This allows for specific, precise handling of environmental input in a way that is difficult or impossible without VR

● VR can be used improve mechanical ocular disorders○ For example, if a user has cross eyes, the distance between the screens can be adjusted to

slowly over time to force the user’s eyes to properly realign■ This is still undergoing clinical trials, and has not yet been publicly released

● VR can take advantage of neuroplasticity○ Many ocular disorders are non mechanical issues, and instead manifest themselves in the

brain

○ VR can control the visual input to the brain, and therefore can be used to manipulate perception in a way that promotes treatment

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Case Study: Amblyopia● Amblyopia is a developmental disorder which results from physiological

alterations in the visual cortex early in life (Ciuffreda, Levi, & Selenow, 1991).● It is considered the most frequent cause of vision loss in infants and young

children aside from refractive error, affecting roughly 1–4% of the population worldwide (Birch, 2013; Drover et al., 2008; Friedman et al., 2009; McKean-Cowdin et al., 2013; Multi-Ethnic Pediatric Eye Disease Study (MEPEDS) Group, 2009; Williams et al., 2008).

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● Children wear eye patches on their strong eye for ~18 months, 2 hours a day● “The standard treatment for childhood amblyopia is occlusion therapy

(patching the good eye), with 120 hours of occlusion resulting in, on average, a one-line improvement in visual acuity at 6 years of age” (Stewart, 2007)

● Fails to work on people over 13 years of age

Case Study: Amblyopia - Current Treatment

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Case Study: Amblyopia - Current Research● A dichoptic custom-made action video game as a treatment for adult

amblyopia by Dr. Levi, at UC Berkeley○ Adults with unilateral amblyopia were assigned to either play the dichoptic action game (n =

23; ‘game’ group), or to watch movies monocularly while the fellow eye was patched (n = 15; ‘movies’ group) for a total of 40 hours.

○ Improved two-three bars on the visual acuity scale○ Lasted even after a 2 month no-contact period

● Binocular iPad treatment for amblyopia in preschool children by Dr. Stager, released in JAAPOS

○ Preschool children were assigned to either play a sham iPad game or a binocular iPad game.○ Visual stimulus was controlled for each eye using red-blue glasses

■ Not full VR○ Children’s vision improvement was 1 to 2 bars over 32 hours of treatment

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Case Study: Amblyopia - VR & How● These methods are based on a principle of selective occlusion and input

depression for the stronger eye, forcing the weaker eye to work harder○ In a VR sense, this is obtained by reducing the contrast of the screen feeding the stronger eye

○ A fast gpu-blurring can also be applied to the image in order to perform a similar, less intrusive, form of occlusion

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Case Study: Amblyopia - Concerns● Q: Is long term usage of LED screens damaging?

○ Scientific Review Boards approved the usage of these treatment methods for up to an

unspecified amount of time. No negative side effects have been noticed in any of the participants

● Q: How are accommodations made for various interpupillary distances?○ IPD is the distance between a person’s pupils. Most cheap solutions don’t accommodate this,

but once you get headsets above $30 in cost, they usually have methods of adjusting the lenses

● Q: How are people who need glasses accommodated?○ Once again, most headsets don’t accommodate this, but new ones are coming out with

support. Despite this, many people who normally need glasses may not when using VR because the VR lenses have an infinite focal length

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How can VR be used to treat medical disorders?

How can a startup economically and efficiently approach VR?

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Considerations in Medical VRand other concerns for healthcare startups

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1. Cost

2. Ease of Use

3. Education

4. Proof of Effectiveness

5. Analytics

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1. Cost● Medical treatments ideally are accessible

○ If prices are too high then only countries like the US and Western Europe will have broad access to them, this limits potential market size

○ Best solution is to create a range of products that target developed nations as well as developing ones

● How to keep costs low?○ Target a range of VR devices, HTC Vive down to Google Cardboard

■ New SDKs are coming out allowing this multi platform support■ Unity has Google Cardboard SDK and SteamVR

○ Iterate frequently in development

■ Unlike games that need to be released in a perfect final state, VR apps are just like any other app and can receive frequent updates

○ Use the simplest technologies to build the MVP23

1. Cost: Demo Application● Demo MVP required in September to show to to potential Advisors for

recruitment● Built on Web Platform to be accessible on any device

○ Modern Web Technologies are very powerful■ WebGL (Three.js)■ ondeviceorientation■ CSS3 for GPU based transforms

○ Our demo was a basic Cube Runner game that demonstrated our treatment method■ It targeted Google Cardboard compatible devices■ Less than 1000 lines of code■ Took less than 10 hours to write

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1. Cost: Demo Application - Screenshot

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2. Ease of Use● VR presents a whole new environment for stimulating a user

○ Care must be taken to make this environment approachable to users

● Important design considerations○ Head Tracking

■ If the app doesn’t properly track the user’s head, then it can cause nausea and discomfort

○ Hover to Click■ Many VR devices don’t have mechanical click functionality■ A fully cross platform app will implement “hover to click” within the app

○ Return to Home■ VR in its current form is restricting to users

■ Must provide a way for them to quickly return to the home screen/menu from any part of the app

● Looking straight up or straight down may trigger a Return to Home overlay26

3. Education● VR is new, so it’s usage hasn’t entered the public’s innate understanding yet

○ Similar to how smartphones (even original telephones) were novel when they first came out, but eventually were massively adopted and understood

● Good VR applications will implement two forms of education:1. Videos outside the VR environment for prefacing the user with what the experience will be like2. In-VR walkthrough tutorials

● This should be tested extensively, and not slapped on last minute● This can make or break the product, because if the user doesn’t understand how to use

the VR game, then they will return it/give it bad reviews

● Follow standard practices in the VR space○ Knowledge is then transferable between applications and therefore the barrier to entry is

lowered

○ However, don’t feel constrained, if a new, non-standard, feature is necessary then implement it, but make sure to properly educate the users about it 27

4. Proof of Effectiveness: Two Methods● Clinical Trials

○ Like all medical devices, rigorous proof is necessary○ What are clinical trials?

■ Controlled studies that have been approved by a Scientific Review Board■ They must follow rigorous scientific and ethical standards

○ Difference from an observational study?■ Data isn’t passively collected and then analyzed for correlation

■ A specific treatment is applied to some groups and not others, and the resulting symptoms are then actively observed and analyzed

● Beta Testing○ A cheaper, though less rigorous, avenue to get product validation and feedback○ Can easily be expanded to 1000x the sample size of a clinical trial○ Easier to try new variations of features

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4. PoE: How to Prepare a Clinical Trial - P1/31. Draft a proposal

a. Needs to detail the:i. Hypothesis & purposeii. Procedureiii. Safety precautions being taken

2. Contact a clinician/doctora. Reach out to doctors and professors to find someone who is interested and can run the trialb. They have access to the facilities and necessary equipmentc. The institution should have an SRB for reviewing the applicationd. Keep cost in mind, trials can range from $100k to $1M+ in the USA

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30Example proposal taken from the Levi 2015 study

4. PoE: How to Prepare a Clinical Trial - P2/33. Recruit participants

a. Potentially the hardest partb. Two part, getting people to sign up & getting them to stayc. All about marketing

i. Targeted facebook ads, advertisements at the institution conducting the trial, television and radio broadcasts, website SEO

ii. Geographical location is important because patients need to come in for evaluation

4. Conduct the triald. Easiest part

e. Execute the procedure that you drafted, and keep the participants engaged and accommodated

f. Requires certified clinicians, the facility you partner with will have those/have a certification process

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4. PoE: How to Prepare a Clinical Trial - P3/35. Analyze the results

a. Statisticians should analyze the results and a report should be drafted up and submitted by the head doctor/professor/clinician/researcher

b. Good/Bad News?i. Stats can usually be analyzed in a way as to support most conclusions

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5. Analytics● Critical for both clinical trials and beta testing● Provides invaluable data points about all aspects of product-consumer

interaction● We are tracking:

○ User opening/closing the app○ Which device they have○ How long it takes them to traverse each screen○ How much motion they are doing○ Which movements they do the most○ Which menu items they select the most○ How they adapt to changing environments○ How they perform in the diagnostic tests

○ Basically, every input they do gets tracked

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5. Analytics - Frugal Approach● Either use an existing service if the price is right, or easily roll your own which

we are doing● Two step

○ Record analytics events on the user's device■ Batch them and then do a bulk submit

○ Have a simple server (ie. Python/Flask or Java/Spring) backed by a SQL database■ Server mostly acts as a CRUD interface for the DB

○ Run analysis on copies of the live DB (to remove impact of analysis on live server)

● Luminopia runs ours in the AWS cloud for ~$10 / month○ With cloud providers + modular build system, analytics can easily scale with size at low cost

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Conclusion

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VR is getting most attention right now for it’s gaming and other media usage

However, these uses are much less important than the huge potential for medical treatment

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VR is a great avenue to promote neuroplasticity by controlling the majority

of a user’s environmental stimulus almost completely

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Future of Medical VR

● Physical Therapy augmentation● Ocular Disorders● Mental Health

○ ADHD○ PTSD○ Depression○ Various other disorder

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alexw@luminopia.orglet’s stay in touch :)

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