Realitatea virtuală imersivă în psihoterapia anxietăţii şi reabilitarea oculară. O abordare transdisciplinară

Introduction

Immersive virtual reality’s (iVR’s) role in anxiety disorders is extensively researched, showing promising results; current state-of-the-art research reveals an uptrend regarding iVR use in ophthalmology⁽¹⁾, in treating or diagnosing amblyopia⁽²⁾, or in remote measuring the severity of visual impairment of specific conditions through automated eye perimetry. By controlling the world, the patient vividly experiences the concept of gamification, therefore revealing a new perspective on a method of treatment that raises therapeutic potential and neuroplasticity within an enjoyable interface, increasing the patient’s motiva­tion^(3,4). Due to the interdependence between progressive eyesight loss and associated anxiety, our proposed management approach used iVR relaxation followed by add-on ocular rehabilitation through dedicated software. To our knowledge, this is the first reported case of using this type of consecutive dual approach.

Case report

Mr. L.A. is a 69-year-old man, retired from a political, academic and research career, but currently still performing as a successful writer.

He addressed the service of the Ophthalmology Ward within the “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, Iaşi, Romania, for a right eye open-angle glaucoma and posterior chamber pseudophakia, and an evolving left eye senile and evolutive cataract. The patient’s glaucoma was initially controlled with the recommended postoperative treatment, which consisted of Maxitrol Indocollyre® and Trium® 1 drop four times a week for six weeks and a therapeutic contact lens. After three months, although the patient continued the hypotensive treatment, the ocular hypertension was uncontrollable, resulting in a downgrade of the visual acuity of the right eye to 0.16 and of the left eye to 0.33. The only mentionable comorbidity of the patient is type 2 diabetes, treated with oral antidiabetics.

The optical coherence tomography (OCT) revealed significant optical disk atrophy (Figure 1). The left eye’s OCT detected the cataract that opacified the crystalline lens. On the right eye, there were revealed the impact of glaucoma (objectified by the thin black line) and also the loss of nerve fibers and cells (depicted in red), therefore translating into a limited amount of information received and also a lesser level of transmission. The combined results explain the high level of impairment of binocular vision. The received stimuli were fragmented and differently perceived by each eye due to improper conduct, forcing the brain to reconstruct binocular vision in a manner that would ensure the patient’s functionality. A Neurovert® pill was administered daily to ease the aforementioned burden on the patient’s cognitive function.

Even though all the ordinary means of treatment were used, the visual acuity deficit impaired the patient’s reading and writing tasks needed to perform the daily activity tasks and to perform in his current profession. Furthermore, he suffered from a concurrent anxiety disorder due to his ophthalmological condition and therefore he was directed towards psychotherapy.

Transdisciplinary case management: at the time of the first session, the patient was accompanied for guidance by his former wife as his eyesight impaired orientation. A high degree of anxiety was reported regarding the aforementioned symptoms, especially subjectively exposed as to origin from the lack of autonomy derived from an inability for proper orientation. Episodes of paroxysmal exacerbations were reported, especially regarding the inability to perform academic and editorial daily tasks. After gathering a brief history, iVR therapy exposure contraindications were evaluated, and no declared seizures or light photophobia were reported. The cybersickness was evaluated using the Cybersickness questionnaire and a virtual reality app, VRQ Test, developed by Tim Xu from Vectorush Studio. The test involved five different forms of dizziness tests that become harder (from 1 to 5) and are scored with 1 to 3 stars; a higher score reflects a better tolerance for VR exposure. The virtual reality equipment used consisted of a dedicated Oculus Rift S HMD, paired to a Dell Alienware 17 R4 laptop (Intel i7 processor and GTX 1080 dedicated graphics card); we underline the necessity of using a proper graphical processing unit to ensure the necessary frames per second needed to reduce the technological bias involving exposure, represented by frame loss and stutter.

The patient VRQ test and Cybersickness Questionnaire results were above expectations, therefore he represented a valid candidate with a good tolerance to iVR interventions.

The second and third sessions consisted of guided meditation techniques aimed at improving tolerance to the VR environment. An individualized implementation was offered by letting the patient choose any place on Earth he would like to visit and explore via the controllers, while no specific timed breathing technique was suggested. As the patient, a former professor of psychology and psychotherapist, already had a background of yoga, the pranayama seemed like the best-tolerated alternative for the personalized approach to the patient. The relaxation was facilitated by add-on therapeutic massage using alternative pressure points that were triggered similarly to the sequence of a Jacobson progressive muscular relaxation for a further distraction of the patient (Figure 2).

After a preliminary meeting with his ophthalmologist, the team decided that, beginning with the fourth psychotherapy session, eye rehabilitation techniques be included in the second part of each following session. From the fourth to the 16^th session, we used multiple licensed virtual reality software for relaxation in various environments, always different to enhance patient distractibility, resembling different exotic places of the world. The relaxation stage ranged from 10 to 25 minutes, considering the arterial pressure of the patient, the oxygen saturation above 95%, and the subjectively altered consciousness state reported as the moment to progress toward eye rehabilitation. The second part of the psychotherapy session consisted of ocular rehabilitation using dedicated software such as Vision Therapy, developed by Cerevrum INC (Figure 3), which consisted of five different sets of exercises per session, meant to relax eye muscles and improve focal power. In the fourth and fifth sessions, the patient only completed two, as he became tired from concentrating.

Starting from the sixth session, the tolerance of the patient became better, and he managed to complete fully concentrated from five to even eight individual 5-minute sessions of ocular rehabilitation following the relaxation techniques. The tolerance was associated with a massive improvement in eyesight of the left eye, from a visual acuity of 0.2 towards a visual acuity of 0.6 after the 16^th psychotherapeutic session. The patient was able to conduct daily tasks and even read starting from the nineth session, but we suggested blocking blue light using monitor-added filters and through the software on the smartphone.

Discussion

The particularity of this case is represented by a personalized transdisciplinary approach to progressive eye-sight loss beyond current gold standard ophthalmology treatment. Psychotherapy take-home messages consisted of ensuring a healthy night sleep between 10:00 P.M. and 06.00 A.M., no smoking at least 30 minutes before engaging in virtual reality rehabilitation, and no prolonged eye accommodation forcing through reading at low-level light levels or more than one hour per day. We mention that, within the breaks between ocular exercises during each session, we offered the patient fresh forest blueberries (250 g/day), known to contain anthocyanins that may have an add-on effect on lowering high ocular blood pressure.

The subjectively reported anxiety was associated with lower eyesight, and the improvement of eyesight determined a lowering of anxiety and hopelessness feelings⁽⁵⁾.

Currently, the eyesight improvement from 30 cm to 5 meters couldn’t be directly attributed to any of the iVR psychotherapy techniques or to ocular rehabilitation, but we believe that the patient’s high cognitive reserve represented by his academic, social, civic and editorial interests had an important role in the recovery through enhancing retinal neuroplasticity.

Although the current results are promising, we could not identify any specific reason for the currently reported improvement; therefore, we will report further follow-up results regarding the sustainability of the current progress and the evolution of the patient six months and twelve months from now, respectively.

Acknowledgements

To the highly relevant feedback of the patient regarding an accurate description of the subjective feelings of anxiety encountered because of the progressive eyesight loss, which guided our steps towards an efficient personalized approach. Also, the authors are grateful not only for his consent for the publishing of this article, but also for the presentation of the management of his case within academic conferences and to the organizers of the 4^th and 5^th editions of the Romanian Ophthalmology Summer School, that represented a true brainstorm and consulting forum for iVR transdisciplinary application, and also for granting the first author an acknowledgment prize, coining the transdisciplinary collaboration between the group of authors.

Conflict of interest statement.

The authors have no conflicts of interest to disclose.

Funding

This study received no external funding.

Consent

The authors received the consent of the aforementioned patient for publishing this case, with a blessing regarding the enhancement of further research aimed at developing standardized tools to help other persons that find themselves out of the reach of current state-of-the-art guidelines meant to improve their vision.