Metaverse and Virtual Health Care in Ophthalmology: Opportunities and Challenges : The Asia-Pacific Journal of Ophthalmology

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Metaverse and Virtual Health Care in Ophthalmology: Opportunities and Challenges

Tan, Ting Fang MBBS; Li, Yong MD∗,†; Lim, Jane Sujuan FRCOphth; Gunasekeran, Dinesh Visva MBBS; Teo, Zhen Ling MBBS; Ng, Wei Yan FRCOphth; Ting, Daniel SW. MD, PhD∗,†

Author Information
Asia-Pacific Journal of Ophthalmology: May-June 2022 - Volume 11 - Issue 3 - p 237-246
doi: 10.1097/APO.0000000000000537
  • Open


Virtual health has revolutionized the delivery of health care services using technology to overcome geographical barriers. The ever-evolving coronavirus disease 2019 (COVID-19) pandemic,1 with prolonged social restrictions to minimize transmission, has fundamentally changed the way of life. This has reinforced the role of virtual health more than ever for greater health care accessibility and reduction in exposure risk associated with in-person consultations.2 Within ophthalmology, clinical workflows had to be re-examined and digitized to minimize physical interactions.3 The recent advent of the Metaverse—an interconnected online universe with the synergistic combination of virtual reality (VR), augmented reality (AR), and mixed reality (MR)—supports a new era of immersive experiences and interoperable data exchange on a decentralized and secured network. Health care, and ophthalmology in particular, could benefit from the functionalities offered by the Metaverse. This necessitates an early evaluation of the potential benefits and challenges of the Metaverse in the field of ophthalmology before clinical adoption can be actualized.


The COVID-19 pandemic has galvanized substantial changes in the lifestyles of people all over the world. As a result, health care systems needed to reorganize care for current patients to reduce face-to-face consultations, triage cases requiring urgent medical care, postpone nonurgent appointments, and carry out new infection control measures.4 These challenges propelled the need and opportunity for digital transformation, with the aims of improving the efficiency of health care systems, reduce the time spent in health care premises, and decentralize care with reduced physical touchpoints.5

Digital transformation is defined as a process to improve an entity through combinations of information, computing, communication, and connectivity technologies.6 In health care, digital technologies can increase access to health care services for individuals, improve public health, and optimize the experience of receiving or delivering care.7 As such, COVID-19 had forced government and organizations worldwide to rapidly synergize, increase, and expand upon the applications of digital transformation.4

The core technological domains involved in digital health care transformation include artificial intelligence (AI), machine learning, deep learning, VR, AR, MR, fifth-generation (5G) telecommunication networks, blockchain, and digital twins, etc.8 These domains are complementary and can potentially be deployed synergistically as a “Metaverse” to meet the clinical needs of patients.


Demand for telemedicine has accelerated during this pandemic due to the need for greater health care accessibility and reduction in exposure risk associated with in-person consultations. Worldwide, there has been rapid upscaling of telehealth services by multiple specialties, including ophthalmology. For example, during the COVID-19—induced lockdown in 2020, up to 77.5% of ophthalmologists in India resorted to teleophthalmology to provide eye care,9 and American neuro-ophthalmologists reported a 64.4% increase in utilization of telehealth modalities.10 Ophthalmologists in China used digital systems for virtual consultations and even reported that 10,000 eye-related visits were mediated by an AI chat bot.11

Benefits of Virtual Health

Aside from its role in the COVID-19 pandemic, telehealth provides several advantages. Firstly, the ability to remotely evaluate patients has enabled improved health care access by broadening the geographical reach of health care services. This would especially benefit patients who are home-bound, or face logistical challenges to attend in-person consults.12 Secondly, telemedicine is an effective tool to reduce burden on the health care system by helping to screen and triage patients, that can be coupled with automated AI analysis, which in turn may reduce unnecessary referrals to tertiary care settings.13 Furthermore, telemedicine is an alternative modality to monitor stable patients who do not require management in tertiary care, and this potentially reduces cost of attending hospital or clinic-based appointments.14 Lastly, waiting times can be reduced through increased capacity and access to care by overcoming physical barriers.

Types of Virtual Health

Telemedicine can be broadly divided into 2 types—synchronous and asynchronous models.15 Synchronous models allow for real-time consultations and communication between patients and doctors via a telemedicine platform, whereas asynchronous models often utilize the “store-and-forward” approach where medical history, examination findings, or investigations are captured and uploaded onto cloud servers, and are subsequently reviewed by the specialist person-in-charge, or can be analyzed by AI algorithms, to determine diagnosis and management.

Telehealth Interface Platforms

Reliable internet connectivity and a secure, non–public-facing telemedicine platform are required for the implementation of synchronous telemedicine. In America, platforms should be Health Insurance Portability and Accountability Act (HIPAA) compliant. Certain Electronic Medical Record systems have an integrated HIPAA compliant video platform such as Epic.16 Other HIPAA compliant platforms include Skype for Business, Zoom for Healthcare, Google G Suite Hangouts Meet, and Webex Teams.17 Other countries have since followed suit to publish guidelines to protect health care data, with some incorporating protections within general data privacy regulations such as the General Data Protection Regulation in Europe and the Personal Data Protection Act in Singapore.

Synchronous Teleophthalmology

Screening, Diagnosis, and Management

Synchronous telemedicine has proven useful for emergency department consultations in triaging urgency of referrals or providing ophthalmic first-aid remotely, especially during the COVID-19 pandemic or in rural regions where ophthalmology services are limited. For example, in London, Moorfields Eye Hospital launched an emergency video consultation service to relieve the ophthalmic casualty load on physical premises during the COVID-19 pandemic and was shown to avoid more than 70% of potential in-person encounters.18 Likewise in Paris, emergency ophthalmic teleconsultation was adopted during the COVID-19 lockdown in 2020 and reduced unnecessary physical consultations by 73%.19

Similarly, real-time video consultations can also be applied to outpatient ophthalmology visits. Using an inflow funnel model, whereby a remote provider (ie, an ophthalmic technician or optometrist) would transmit clinical parameters and photos through a secured network to the clinician for teleconsultation, general ophthalmology clinics in Hong Kong were able to maintain 80% of their outpatient load through the pandemic,20 and a tertiary eye care hospital in Singapore reported high specificity and sensitivity using this method for evaluating chronic blurred vision.21 Subspecialties such as oculoplastics,22 pediatric ophthalmology and strabismus,23 have also employed video-based teleconsultations with good feedback from clinicians and patients. Studies have also concluded that most nonurgent cases could be managed solely through teleconsultation itself or serve as an effective triaging tool for a hospital review.22 In addition, 62% of oculoplastic patients preferred a video consultation over a physical visit due to safety and convenience provided by online platforms.22

As such, virtual consults have the potential to be widely adopted as an alternative model of care to deliver highly accurate diagnostic eye care, supported by public acceptance, even when traditional health services resume.


Besides video consultations, synchronous telemedicine may be applied to the provision of real-time surgical instruction and guidance to a surgeon from an expert residing in a different geographical location, which is termed “telementoring.”24 Telementoring has the potential to allow access of specialist teaching to trainees and generalists comparable to onsite training.25 Currently, there are limited examples to demonstrate the effectiveness of telementoring in ophthalmology. A case report published in 2000 reported the safe removal of an orbital tumor by a general ophthalmologist assisted through telementoring by an orbital specialist 210 miles away.26 Another example showed the transfer of expertise from ophthalmologists to general practitioners in a rural hospital to facilitate the removal of a corneal foreign body under real-time transmission of images from the slitlamp.27 More recently, successful teleproctoring of 2 vitreoretinal surgical cases was reported using real-time three-dimensional (3D) video transfer over a 5G network.28 As such, telementoring can address the disparity of health care access both nationally and globally.


Telesurgery, on the other hand, is when surgery is performed on a patient by a surgeon from a remote site.29 Due to the synchronous nature, it requires a reliable network that delivers low latency and high rates of data transfer (eg, 5G network).30 To date, most of the examples of telesurgery are done on animal models or in simulation. Two ophthalmological studies on telesurgery have shown feasibility in repairing corneal lacerations on rabbit eyes,31 and in performing transscleral cyclophotocoagulation on enucleated human eyes using telerobotic surgery.32 Separately, other surgical specialties such as urology33 and orthopedics34 have achieved early success in this realm. For example, an orthopedics team in China successfully performed telerobotic spinal surgery across different cities via a 5G network system with no intraoperative adverse events.34 Thus, the ability to perform remote surgery, which transcends geographical boundaries, offers the possibility to revolutionize health care delivery and access to specialist care. However, telesurgery is still in its infancy stage and greater research and development would be required before clinical adoption can be achieved. It should also be acknowledged that the cost of equipment might still be a barrier to adoption.

Asynchronous Teleophthalmology Examples

Asynchronous models have the benefit of efficiency through flexibility. Patients’ data are already captured and stored, to be reviewed at a separate, convenient time by the provider. This system bypasses the linear workflow of scheduled appointments in which bottlenecks are inevitable. Secondly, AI can be used to support triaging of cases through automated classification of medical images sent asynchronously,35 expanding health care capacity significantly. This can potentially reduce burden of care, where around half of specialist referrals may be avoided, and is more cost-effective.

In ophthalmology, this model of care has been classically used for screening of diabetic retinopathy based on a store-and-forward approach where mydriatic fundal photographs captured at a community clinic are graded remotely at a later time, and has been shown to be cost-effective and clinically applicable.36

Other conditions that have successfully implemented asynchronous telemedicine programs include glaucoma and retinopathy of prematurity monitoring.37 For glaucoma, countries such as the UK and Singapore have adopted a “virtual glaucoma clinic” system for glaucoma suspects and those with mild-moderate glaucoma.38 For example, clinical parameters such as intraocular pressure, and investigations such as visual field, optical coherence tomography (OCT) of retinal nerve fiber layer, and optic disc images taken at the hospital by a trained technician or nurse, are captured to the hospital's electronic patient record, and subsequently reviewed by a glaucoma specialist at a different time, with disposition outcomes thereafter being sent to patients. Studies have reported improved patient journey times and high patient satisfaction.38 Forthcoming developments in this area have been explored for age-related macular degeneration screening and management,39 diagnosing surgically-indicated blepharoptosis in oculoplastics,40 and cataract screening for senile41 and congenital cataracts.42 Furthermore, with the advancement of AI as an automated triaging tool with robust performance, harnessing AI would boost the capacity of asynchronous telemedicine to deliver health care services with a greater reach.

Limitations of Virtual Health

Technical challenges pose 1 of the biggest obstacles, including hardware and software problems relating to internet connectivity, digital equipment, and interface usability.43 The role of virtual health in education is also limited with the lack of in-person interactions, which compromises the development of communication skills and bedside manners, which are essential aspects of clinical medicine. In addition, virtual teaching platforms lacked individualized teaching and feedback. The accuracy of assessment of clinical findings via virtual platforms is another potential limitation. For example, photographic evaluation of wound care may be limited in the assessment of palpation, 3D views of the wound, and less accessible body areas,44 as compared to in-person consultations.


The term “Metaverse” was first conceived in a science fiction novel “Snow Crash” in 1992. It is envisioned as a parallel VR universe where users can interact as digital avatars, deliver connected, immersive, and real-time experiences, and power a creator economy by providing creator-friendly digital platforms and a decentralized economy.45 Innovative technologies center around the Metaverse value-chain namely to bring about: Experience, Discovery, Creator Economy, Spatial Commuting, Decentralization, Human Interface and Infrastructure,46 and big technology companies are currently leveraging on a combination of AR, VR, and MR to construct the Metaverse across different industries.

Utilizing Different Mobile Applications

Advances in mobile technology and network speeds have enabled the overcoming of distance and time barriers. Virtual work collaborations and social networking platforms are accessible on mobile phones, computers, and gaming consoles. Aside from enabling social connectivity, newer technologies like AR and VR have reshaped traditional industries like traveling and retail (eg, virtual viewing tours of attractions or real-estate apartments).

Immersive Experiences

The Metaverse strives to create an immersive 3D experience for the user to retain a sense of self, whereas fusing the physical and virtual worlds together. The Microsoft HoloLens 2 enhances the existing physical environment with superimposed 3D holographic visuals, spatial sound and noise cancellation (Fig. 1A). For example, Boeing and Royal Australian Air Force avionics technicians utilized HoloLens 2 to overlay holographic augmentation during maintenance of C-17 aircrafts in Australia while receiving remote real-time guidance from the US-based team.47 To further elevate the sense of realism in the virtual world, the Oculus Quest 2 by Facebook (now rebranded “Meta”) VR headset includes added features like finger dexterity tracking and haptic feedback (Fig. 1B).48 Metahuman by Epic Games replicates fine details of human facial features and expressions on digital avatars.

Figure 1:
A, Microsoft HoloLens 2. (Image from Microsoft HoloLens 2 is a mixed reality (MR) headset developed and manufactured by Microsoft. It is the successor to the pioneering Microsoft HoloLens. It is an untethered, self-contained holographic headset that allows users to leverage enterprise-ready MR applications while working “heads-up” and “hands-free.” B, Meta Quest 2. (Image from Oculus Quest 2 (marketed since November 2021 as Meta Quest 2) is a virtual reality (VR) headset created by Facebook Technologies (now Meta Platform). It is the successor to the company's previous headset, the Oculus Quest.

Decentralization and Interoperability

Another potential feature of the Metaverse is the use of blockchains with a distributed ledger technology, which is essentially a record of transactions of digital assets that are distributed amongst the network of computers allowing transactions to be stored in a decentralized manner while being cryptographically secured; and open systems that enable interoperable means of storing, exchanging, and programing digital assets across platforms.49

Content Creation

The Metaverse is also set to fuel the creator economy where users are no longer just consumers of content, but are also able to generate and contribute content. Emerging driving forces of content creation such as nonfungible tokens (NFTs), which are unique and immutable digital assets, not only encourage innovation but also open up a new source of revenue for the creator economy. These transactions can be monetized in the form of cryptocurrency. NFTs can take on any form from digital art, music, collectible items, and video highlights of historical sporting moments, to potentially ownership of virtual spaces and objects in the Metaverse. Blockchain adoption further reinforces the value of NFTs by assuring its permanence, ownership, and authenticity within a decentralized and secure network.50

Real Gamification

Gamification is defined as the incorporation of conditional rewards for completion of specified tasks, leveraging concepts from behavioral health such as loss aversion and endowment effect.51 Given the high levels of engagement, gaming platforms are increasingly tapped on as opportunities for marketing and product placement, in particular for the fashion industry. Beyond simply using point systems or leaderboards, gamification in the Metaverse can incorporate added elements of emotion, interaction, and motivation to elevate the sense of engagement to capture users.52

Simplified Providers

Simplified providers refer to multiple providers offering virtual goods or services to build a cohesive Metaverse. The platform has been adapted across several industries, including engineering and architecture, manufacturing, media and entertainment, creating a solid foundation to leap into the health care industry. For example, multiple service providers are involved in a live-streaming virtual concert, where music artists join as digital avatars and collaborate with record label companies (eg, Warner Music Group) on a metaverse streaming platform (eg, The Sandbox), to generate different digital goods and services that users can purchase. These transactions can be traded and secured on a blockchain by partnering with a particular cryptocurrency exchange (Fig. 2).53

Figure 2:
An example of multiple service providers involved in a live-streaming virtual concert. Music artists (represented as digital avatars) can work with a record label company (eg, Warner Music Group) to host the virtual concert on a VR streaming platform (eg, The Sandbox). These can generate tickets that are live-stream or on-demand (recording released on a later date), merchandise like in-game skins or accessories for digital avatars. These goods can be authenticated by nonfungible tokens (NFTs), and transactions can be traded and secured on a blockchain provided for by a particular cryptocurrency exchange. VR indicates virtual reality.

Use of Digital Twins

To establish the convergence between the physical and virtual world, it would be useful to create digital twins of real objects, environments, and assets. A digital twin is a digital representation of a physical asset of which its data model reproduces its behavior and interaction with other physical assets.54 It acts as a digital replica for the physical object or process they represent, providing nearly real-time monitoring and evaluation without being in close proximity.54 The use of digital twins in health care can revolutionize clinical processes and hospital management by improving medical care with digital tracking, simulations, and enhanced modelling of the human body.

By creating a digital twin of a hospital, operational strategies, or medical processes, it is possible for a health care provider to assess its facilities’ capacities, staffing power, and care models to decide what measures to take and devise strategies for future challenges. Moreover, the technology can also be used in personalized medicine by modelling an individual's biological characteristics, genetic makeup, and lifestyle, creating a digital twin of the human body. The purpose of digitizing the human body and building a fully functioning replica of its internal system is to build upon the “virtual patient” concept, and allow the delivery of individualized, precise medical care and treatment.


As we take huge steps towards making the Metaverse a reality, we will also explore in this article the potential uses of the Metaverse in health care, particularly in the field of ophthalmology. Ophthalmology is a medical specialty that is uniquely positioned for a spectrum of applications involving the Metaverse due to the visual nature of this new virtual technology that provides opportunities for novel applications. Potential applications include the creation of avatars for realistic consultations, personalized care through data interconnectivity, and potential clinical applications.

Creation of Avatars for Realistic Consultations

In the Metaverse, users own their avatars and individual assets, and can collaborate and interact with virtual objects and other participants (Fig. 3A). Recent behavioral studies have explored different forms of avatars with combinations of habitual facial expression and/or appearance, and concluded that individuals identify better with avatars that mirror their behaviors (“behaviors realism,” eg, facial habits) regardless of whether the avatars had a similar experience (“visual realism”).55 As Metaverse brings together all kinds of apps and multiple virtual worlds, the avatar can act as the single point of entry and unique identity, whereas we explore, interact, and engage. Using digital avatars as representations of themselves, they can interact with each other and the virtual environment, as compared to the rigid two-dimensional (2D) interface of video consultations. Ongoing innovations in this field, such as the hand and finger dexterity tracking and haptic feedback while interacting in the virtual space, shows potential in further elevating the immersive experience and enhancing the doctor-patient interaction. In addition, virtual diagnostic methods with VR and AR are becoming more tangible through avatars,56 improving the realism and “personal-touch” of remote consultations.

Figure 3:
Examples of the application of metaverse in surgical education and clinical meetings. A, Digital avatars in the metaverse (image from B, Use of metaverse for surgical education (image from

Personalized Care Through Data Interconnectivity

Personalized care means that patients have the choice and control over the way their care is planned and delivered, based on “what matters” to them and their individual strengths, needs, and preferences. The development of molecular readout technologies and computational power makes it possible to build such personalized models, and to complement patient care with continuously tracked health and lifestyle data, which could eventually lead to a digital representation of an individual patient—a “virtual patient.”57 “Virtual patients” refer to data-driven models of patients that allow for more precise and effective medical interventions,57 leveraging on the availability of biological data and data interconnectivity. To facilitate the development of this model, several initiatives such as Genomics England and US Precision Medicine have been taken to generate detailed biological data of patients, aimed to create a digital model of patients’ health.58 In ophthalmology, for example, the application of genetic technology is aimed to create such virtual patients, heralding the development of individualized treatments for some inherited eye diseases, and promises to alter prediction, diagnosis, and management of age-related macular degeneration.59

In addition, data center interconnectivity allows providers to use their patient resources collectively and access the physical and virtual resources of other data centers they are interconnected with. To achieve data interconnectivity, interoperability standards would be required. The new Health Level 7 standard, Fast Healthcare Interoperability Resources standard, has been proposed to help achieve health care systems interoperability.60 However, the issues of how and where such patient models should exist, and ethical issues regarding data confidentiality and ownership will need to be addressed in the future as the emerging technology evolves. This could potentially have a great impact on health care–related domains including data privacy and patient autonomy if appropriate solutions to manage these considerations are not incorporated within these tools.

Potential Clinical Applications


For the general population, studies have indicated that VR and AR can be effective for education on eye health. Patients had significantly improved their understanding about glaucoma and the importance of eye screening after using these immersive tools in EyeCU, which further enables scalable remote health education.61 These applications can have a range of applications ranging from helping patients understand disease progression and visual aberrations or symptoms that should prompt clinical review. The latter may be a particularly useful application for the Metaverse whereby patients newly diagnosed with eye diseases in a virtual consultation or community screening during the pandemic can be educated remotely.

For medical professionals, applications of VR and AR in education include surgical, ophthalmoscopy, and optometry training simulators for medical students, residents, and ophthalmologists (Fig. 3B). Commonly used surgical simulators include the EyeSi simulator (VR Magic),62 MicroVisTouch (Immersive Touch),63 and the PixEye Ophthalmic Simulator (SimEdge SA),64 to name a few. The most common surgical procedure simulated was cataract surgery followed by vitreoretinal procedures,62,65 along with other glaucoma and corneal surgeries.66 Several studies evaluated the use of extended reality as a tool for education in ophthalmoscopy67 and optometry training,68 and found that simulators demonstrated efficacy and validity in improving surgical and ophthalmoscopy skills.69


Extended reality can be used for the production of immersive and interactive content for diagnostics, and the display of ocular imaging data, visual function assessment, and visual field testing.

Both AR and VR can help patients understand how vision loss affects function,70 including assessing the effect of glaucoma on daily living,71 identifying vision-related disability,72 and evaluating the effect of visual field loss on functional vision.73 The AR head-mounted 3D display has shown to be useful for testing visual acuity with the advantage of portability and automated nature.74 However, future studies are warranted to improve its accuracy and completion rate for widespread clinical use.

In addition, VR technology has been used to help detect visual field deficits in glaucoma patients in correlation with the Humphrey perimeter,75 and to help evaluate visual functions in strabismus and amblyopic patients.76,77 However, the need for trained operators, lack of interoperability, and reliance on customized platforms to operate these solutions can limit their scalability. Separately, researchers have also examined the feasibility of displaying OCT images in a VR environment with a head-mounted display,78 which may provide the next generation of OCT image display mode with a platform for patient engagement, medical education, professional training, and telecommunications.


The application of AR and VR in the therapeutics domain includes surgical planning and performance, low vision therapy, amblyopia therapy, and possibly, childhood myopia control.

Using VR simulators, surgeons can perform remote telesurgery, minimally invasive surgery, surgical preplanning, imaged-guided surgery, and simulation using a surgery console. With the recent launch of 5G networks, network speeds have greatly improved, supporting the advancement of telesurgery, which in turn reduces health care costs, increases accessibility, and realizes its potential for acute care.79 Heads-up surgery is another application of extended reality technology using a 3D camera to capture images from a stereomicroscope for presentation on a 3D display for greater surgeon maneuverability and comfort.69 At present, studies have demonstrated noninferiority of heads-up surgery in comparison with conventional microscope surgery in postoperative outcomes and complications.80,81 In particular, researchers compared the use of 3D heads-up microscope with traditional ophthalmic microscope for pars-plana vitrectomy in 50 eyes, and found heads-up surgery demonstrated greater ergonomics and comfort for the surgeon, without compromising on safety, with no major complications and similar operating times.81 However, clear superiority in results would be required before the ophthalmic fraternity could be convinced to adopt it in favor of traditional operative models.

Several studies have also evaluated the use of AR-based therapy of low vision and visual field loss, and demonstrated that AR can improve the functional vision of these patients in real-world settings.82 VR on the other hand, can be used to supplement low-vision therapy through functional vision training,83 remapping,84 and magnification.85 In addition, several studies have shown the effect of VR-based interactive and immersive binocular treatment for amblyopia.86 For example, the Interactive Binocular Treatment system works by employing dynamic stimuli with preferential stimulation of an amblyopic eye, and shows modest vision improvement in children with amblyopia.86 Finally, researchers have also found that choroidal thickness markedly increased after wearing a VR headset in young adults aged between 18 and 35 years, which may due to the consequence of the fixed viewing distance combined with convergence-induced accommodation in the virtual environment.87 Further studies are warranted to determine whether this change could influence myopia progression.


However, there are still several challenges for implementation of Metaverse, which include realistic consultations, personalized care, and clinical applications. Besides the resistance by conservative health care community from adopting technologies which provide an abstract concept of what is beneficial and achievable, other challenges include cybersecurity risks, suitable internet access, lack of technology literacy, and challenges with usability among visually impaired populations.

Cybersecurity Risks

First, as with any digital application, Metaverse applications on 2D or immersive 3D domains carry cybersecurity risks from hacking and exposure of patient data. Applications that require additional new networked hardware for clinical implementation increase endpoint complexity and potential inbound portals for penetration, data instrumentation, and or surveillance by bad actors.88 However, with the development of hospital and health care organizational cybersecurity protocols, measures to mitigate against these risks have emerged. For instance, network slicing with ring-fencing of networked hardware endpoints are potential measures.89 Furthermore, strictly defining rules for communication across the network slices with omission of patient identifiers or use of anonymized identifiers to tag patients’ accounts within the hardware devices can also help manage risks.89 Furthermore, the growing adoption of blockchain and cryptocurrency solutions for practical applications provides a potential novel avenue to protect, custody, and share individual health data.90 Many health care applications of this technology have already been reported, with health record management and bolstering security within mobile and hardware solutions being leading applications described in the literature.91 That said, the same review noted most studies were in the early technical prototyping stages. Similar to AI technology at the beginning of this decade,92 real-world application of blockchain technology is relatively nascent, and further pragmatic research at the clinical microsystem, mesosystem, and macrosystem will be required to enable successful implementation at scale.4

Sparse Internet Connectivity Especially in Rural Regions

Second, the increased bandwidth requirements of immersive experiences in the 3D or even 2D environments may pose a challenge for implementation of these solutions in rural regions.30 The intermittent or sparse internet connectivity is a constant challenge in the recent implementation efforts of AI in ophthalmology,92 whereby latency has been reported to cause prohibitive disruptions to applications in busy clinical settings.93 Solutions for improved connectivity are emerging in the field of 5G telecommunications with recent research laying the foundation for a practical road map to facilitate implementation.94 However, the 5G networks require multiple small cells as base stations to be located closer together to facilitate consistent transmission of signals.95 Hence, the high demand of infrastructure may pose another challenge for 5G implementation in rural areas.8

Lack of Technology Literacy About the Metaverse Domain

Third, a lack of understanding about any new technology is a key potential barrier to adoption for a given solution.96 This can have various facets for a given solution, such as difficulty in interpreting user interface that may result in errors or misunderstandings of the output from a given device.97 There can also be concerns about privacy and misperceptions about corporate over-reach with commercialization of personal health or behavioral data. These are significant barriers to implementation that can be addressed with early qualitative studies investigating stakeholders’ ability to apply these technologies in practice and stakeholders’ willingness to adopt these solutions.98 Fortunately, early research has begun to investigate this for applications of immersive technology such as AR or VR in ophthalmology, whereby a majority of patients in 1 such study even indicated a willingness to pay for access to relevant solutions.

Usability Among the Visually Impaired Population

Finally, despite the deluge of potential applications of immersive technology in ophthalmology,69 use of these applications in an immersive application for patients with eye disease may remain challenging for those with low vision. Patients that have certain illnesses such as glaucoma and associated defects in segments of the visual field may be unable to appreciate the full content in a 3D or VR simulation due to their patchy vision.99 Fortunately, new methods to customize simulations for patients that require magnification of images due to low visual acuity or even stitching of simulations across known visual field defects have emerged that can be applied to facilitate the use of Metaverse applications for patients with existing visual impairments.100


Virtual health care services have gained significant attention and acceptance due to the evolving COVID-19 pandemic. Through reduction of logistical barriers, these digital innovations have offered a viable alternative model of care. The Metaverse could represent a new frontier of health care delivery and provide the opportunity to catalyze further innovation and technological advancement. The applications of the Metaverse in ophthalmology include the creation of avatars for realistic consultations, personalized care through data interconnectivity, use of digital twins, and potential clinical applications in education, diagnostics, and therapeutics. Although the current interest is to develop Metaverse-related technology, efforts have to also be targeted at addressing the potential challenges of cybersecurity risks, data custody and privacy, and potential barriers to access including rural areas with lack of internet connectivity and users with low vision.


1. Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). Covid-19 dashboard. Available from: Accessed January 11, 2022.
2. Wong MYZ, Gunasekeran DV, Nusinovici S, et al. Telehealth demand trends during the COVID-19 pandemic in the top 50 most affected countries: infodemiological evaluation. JMIR Public Health Surveill 2021; 7:e24445.
3. Khor WB, Yip L, Zhao P, et al. Evolving practice patterns in Singapore's public sector ophthalmology centers during the COVID-19 pandemic. Asia Pac J Ophthalmol (Phila) 2020; 9:285.
4. Gunasekeran DV, Tham YC, Ting DS, et al. Digital health during COVID-19: lessons from operationalising new models of care in ophthalmology. Lancet Digit Health 2021; 3:e124–e134.
5. Li JPO, Shantha J, Wong TY, et al. Preparedness among ophthalmologists: during and beyond the COVID-19 pandemic. Ophthalmology 2020; 127:569–572.
6. Vial G. Understanding digital transformation: a review and a research agenda. J Strateg Inf Syst 2019; 28:118–144.
7. Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med 2017; 377:1585–1592.
8. Li JPO, Liu H, Ting DS, et al. Digital technology, tele-medicine and artificial intelligence in ophthalmology: a global perspective. Prog Retin Eye Res 2021; 82:100900.
9. Nair AG, Gandhi RA, Natarajan S. Effect of COVID-19 related lockdown on ophthalmic practice and patient care in India: results of a survey. Indian J Ophthalmol 2020; 68:725–730.
10. Moss HE, Lai KE, Ko MW. Survey of telehealth adoption by neuro-ophthalmologists during the COVID-19 pandemic: benefits, barriers, and utility. J Neuroophthalmol 2020; 40:346–355.
11. Wu X, Chen J, Yun D, et al. Effectiveness of an ophthalmic hospital-based virtual service during the COVID-19 pandemic. Ophthalmology 2021; 128:942–945.
12. Gunasekeran DV, Liu Z, Tan WJ, et al. Evaluating safety and efficacy of follow-up for patients with abdominal pain using video consultation (SAVED study): randomized controlled trial. J Med Internet Res 2020; 22:e17417.
13. Gunasekeran DV, Ting DS, Tan GS, et al. Artificial intelligence for diabetic retinopathy screening, prediction and management. Curr Opin Ophthalmol 2020; 31:357–365.
14. Salsabilla A, Azzahra AB, Syafitri RI, et al. Cost-effectiveness of telemedicine in Asia: a scoping review. J Multidiscip Healthc 2021; 14:3587–3596.
15. Ting DS, Gunasekeran DV, Wickham L, et al. Next generation telemedicine platforms to screen and triage. Br J Ophthalmol 2020; 104:299.
16. Lin JC, Humphries MD, Shutze WP, et al. Telemedicine platforms and their use in the coronavirus disease-19 era to deliver comprehensive vascular care. J Vasc Surg 2021; 73:392–398.
17. Cowan A, Johnson R, Close H. Telepsychiatry in psychotherapy practice. Innov Clin Neurosci 2020; 17:23–26.
18. Kilduff CL, Thomas AA, Dugdill J, et al. Creating the Moorfields’ virtual eye casualty: video consultations to provide emergency teleophthalmology care during and beyond the COVID-19 pandemic. BMJ Health Care Inform 2020; 27:e100179.
19. Bourdon H, Jaillant R, Ballino A, et al. Teleconsultation in primary ophthalmic emergencies during the COVID-19 lockdown in Paris: experience with 500 patients in March and April 2020. J Fr Ophtalmol 2020; 43:577–585.
20. Wong JKW, Shih KC, Chan JCH, et al. Tele-ophthalmology amid COVID-19 pandemic-Hong Kong experience. Graefes Arch Clin Exp Ophthalmol 2021; 259:1663.
21. Tan JC, Poh EW, Srinivasan S, et al. A pilot trial of tele-ophthalmology for diagnosis of chronic blurred vision. J Telemed Telecare 2013; 19:65–69.
22. Kang S, Thomas PBM, Sim DA, et al. Oculoplastic video-based telemedicine consultations: Covid-19 and beyond. Eye (Lond) 2020; 34:1193–1195.
23. Deshmukh AV, Badakere A, Sheth J, et al. Pivoting to teleconsultation for paediatric ophthalmology and strabismus: our experience during COVID-19 times. Indian J Ophthalmol 2020; 68:1387.
24. Huang EY, Knight S, Guetter CR, et al. Telemedicine and telementoring in the surgical specialties: a narrative review. Am J Surg 2019; 218:760–766.
25. Erridge S, Yeung DKT, Patel HRH, et al. Telementoring of surgeons: a systematic review. Surg Innov 2019; 26:95–111.
26. Camara JG, Zabala RR, Henson RD, et al. Teleophthalmology: the use of real-time telementoring to remove an orbital tumor. Ophthalmology 2000; 107:1468–1471.
27. Hall G, Hennessy M, Barton J, et al. Teleophthalmology-assisted corneal foreign body removal in a rural hospital. Telemed J E Health 2005; 11:79–83.
28. Lu ES, Reppucci VS, Houston SKS, et al. Three-dimensional telesurgery and remote proctoring over a 5G network. Digit J Ophthalmol 2021; 27:38–43.
29. Hung AJ, Chen J, Shah A, et al. Telementoring and telesurgery for minimally invasive procedures. J Urol 2018; 199:355–369.
30. Singh G, Casson R, Chan W. The potential impact of 5G telecommunication technology on ophthalmology. Eye (Lond) 2021; 35:1859–1868.
31. Mines MJ, Bower KS, Nelson B, et al. Feasibility of telerobotic microsurgical repair of corneal lacerations in an animal eye model. J Telemed Telecare 2007; 13:95–99.
32. Belyea DA, Mines MJ, Yao WJ, et al. Telerobotic contact transscleral cyclophotocoagulation of the ciliary body with the diode laser. J Robot Surg 2014; 8:49–55.
33. Bove P, Stoianovici D, Micali S, et al. Is telesurgery a new reality? Our experience with laparoscopic and percutaneous procedures. J Endourol 2003; 17:137–142.
34. Tian W, Fan M, Zeng C, et al. Telerobotic spinal surgery based on 5G network: the first 12 cases. Neurospine 2020; 17:114–120.
35. Gunasekeran DV, Wong TY. Artificial intelligence in ophthalmology in 2020: a technology on the cusp for translation and implementation. Asia Pac J Ophthalmol (Phila) 2020; 9:61–66.
36. Nguyen HV, Tan GS, Tapp RJ, et al. Cost-effectiveness of a national telemedicine diabetic retinopathy screening program in Singapore. Ophthalmology 2016; 123:2571–2580.
37. Vinekar A, Jayadev C, Mangalesh S, et al. Role of tele-medicine in retinopathy of prematurity screening in rural outreach centers in India - a report of 20,214 imaging sessions in the KIDROP program. Semin Fetal Neonatal Med 2015; 20:335–345.
38. Huang OS, Chew ACY, Finkelstein EA, et al. Outcomes of an asynchronous virtual glaucoma clinic in monitoring patients at low risk of glaucoma progression in Singapore. Asia Pac J Ophthalmol (Phila) 2021; 10:328–334.
39. Li B, Powell AM, Hooper PL, et al. Prospective evaluation of teleophthalmology in screening and recurrence monitoring of neovascular age-related macular degeneration: a randomized clinical trial. JAMA Ophthalmol 2015; 133:276–282.
40. Souverein EA, Kim JW, Loudin NN, et al. Feasibility of asynchronous video-based telemedicine in the diagnosis and management of paediatric blepharoptosis. J Telemed Telecare 2021. 1357633x20985394 doi: 10.1177/1357633X20985394. Epub ahead of print.
41. Wu X, Huang Y, Liu Z, et al. Universal artificial intelligence platform for collaborative management of cataracts. Br J Ophthalmol 2019; 103:1553–1560.
42. Long E, Lin H, Liu Z, et al. An artificial intelligence platform for the multihospital collaborative management of congenital cataracts. Nat Biomed Eng 2017; 1:0024.
43. Sahi PK, Mishra D, Singh T. Medical education amid the COVID-19 pandemic. Indian Pediatr 2020; 57:652–657.
44. Mills EC, Savage E, Lieder J, et al. Telemedicine and the COVID-19 pandemic: are we ready to go live? Adv Skin Wound Care 2020; 33:410–417.
45. Zhang T, Gao L, He C, Zhang M, Krishnamachari B, Avestimehr AS. Federated Learning for the Internet of Things: Applications, Challenges, and Opportunities. IEEE Internet of Things Magazine 2022; 5:24–29.
46. Radoff. J. The metaverse value-chain. Building the Metaverse. Published April 7, 2021. Available from: Accessed Feburary 27, 2022
47. McLaughlin A. Boeing & RAAF use interactive and mixed-reality technology for C-17 maintenance. Australian Defence Business Review. Published September 8, 2020. Available from: Accessed Feburary 27, 2022
48. Tech at Meta. Inside reality labs research: meet the team that's working to bring touch to the digital world. Tech at Meta. Published November 16, 2021. Available from: Accessed Feburary 27, 2022
49. Yang R. Blockchain technology explained. The Startup. Published July 24, 2019. Available from: Accessed Feburary 27, 2022
50. Jaitly S. What are NFTs and why are they becoming popular? TribalScale. Published March 9, 2021. Available from: Accessed Feburary 27, 2022
51. King D, Greaves F, Exeter C, et al. ‘Gamification’: Influencing Health Behaviours With Games. 2013; London, England: Sage UK, 76–78.
52. Beerda. J. Empowering the metaverse with real gamification. The Octalysis Group. Published in 2021. Available from: Accessed Feburary 27, 2022
53. ReedSmith. Reed smith guide to the metaverse. ReedSmith. Published May 2021. Available from: Accessed Feburary 27, 2022
54. Croatti A, Gabellini M, Montagna S, et al. On the integration of agents and digital twins in healthcare. J Med Syst 2020; 44:161.
55. Park S, Kim SP, Whang M. Individual's social perception of virtual avatars embodied with their habitual facial expressions and facial appearance. Sensors (Basel) 2021; 21:5986.
56. Iskander M, Ogunsola T, Ramachandran R, et al. Virtual reality and augmented reality in ophthalmology: a contemporary prospective. Asia Pac J Ophthalmol (Phila) 2021; 10:244–252.
57. Bruynseels K, Santoni de Sio F, van den Hoven J. Digital twins in health care: ethical implications of an emerging engineering paradigm. Front Genet 2018; 9:31.
58. Ginsburg GS, Phillips KA. Precision medicine: from science to value. Health Aff (Millwood) 2018; 37:694–701.
59. Porter L, Black G. Personalized ophthalmology. Clin Genet 2014; 86:1–11.
60. Bender D, Sartipi K. HL7 FHIR: An Agile and RESTful approach to healthcare information exchange. Proceedings of the 26th IEEE International Symposium on Computer-Based Medical Systems; 2013 20-22 June 2013; 2013. p. 326-31.
61. Gunasekeran DV, Low R, Gunasekeran R, et al. Population eye health education using augmented reality and virtual reality: scalable tools during and beyond COVID-19. BMJ Innov 2021; 7:278–283.
62. Ferris JD, Donachie PH, Johnston RL, et al. ‘Royal College of Ophthalmologists’ National Ophthalmology Database study of cataract surgery: report 6. The impact of EyeSi virtual reality training on complications rates of cataract surgery performed by first and second year trainees. Br J Ophthalmol 2020; 104:324–329.
63. Sikder S, Luo J, Banerjee PP, et al. The use of a virtual reality surgical simulator for cataract surgical skill assessment with 6 months of intervening operating room experience. Clin Ophthalmol 2015; 9:141–149.
64. Alwadani F, Morsi MS. Pixeye virtual reality training has the potential of enhancing proficiency of laser trabeculoplasty performed by medical students: a pilot study. Middle East Afr J Ophthalmol 2012; 19:120.
65. Cisse C, Angioi K, Luc A, et al. EYESI surgical simulator: validity evidence of the vitreoretinal modules. Acta Ophthalmol 2019; 97:e277–e282.
66. Alwadani F, Morsi MS. PixEye virtual reality training has the potential of enhancing proficiency of laser trabeculoplasty performed by medical students: a pilot study. Middle East Afr J Ophthalmol 2012; 19:120–122.
67. Rai AS, Rai AS, Mavrikakis E, et al. Teaching binocular indirect ophthalmoscopy to novice residents using an augmented reality simulator. Can J Ophthalmol 2017; 52:430–434.
68. Wei L, Najdovski Z, Nahavandi S, et al. Towards a haptically enabled optometry training simulator. Netw Model Anal Health Inform Bioinform 2014; 3:1–8.
69. Ong CW, Tan MCJ, Lam M, et al. Applications of extended reality in ophthalmology: systematic review. J Med Internet Res 2021; 23:e24152.
70. Jones PR, Somoskeoy T, Chow WBH, et al. Seeing other perspectives: evaluating the use of virtual and augmented reality to simulate visual impairments (OpenVisSim). NPJ Digit Med 2020; 3:1–9.
71. Goh RL, Kong YXG, McAlinden C, et al. Objective assessment of activity limitation in glaucoma with smartphone virtual reality goggles: a pilot study. Transl Vis Sci Technol 2018; 7:10.
72. Lam AK, To E, Weinreb RN, et al. Use of virtual reality simulation to identify vision-related disability in patients with glaucoma. JAMA Ophthalmol 2020; 138:490–498.
73. Gopalakrishnan S, Jacob CES, Kumar M, et al. Comparison of visual parameters between normal individuals and people with low vision in a virtual environment. Cyberpsychol Behav Soc Netw 2020; 23:171–178.
74. Ong SC, Pek LCI, Chiang TLC, et al. A novel automated visual acuity test using a portable head-mounted display. Optom Vis Sci 2020; 97:591–597.
75. Alawa KA, Nolan RP, Han E, et al. Low-cost, smartphone-based frequency doubling technology visual field testing using a head-mounted display. Br J Ophthalmol 2021; 105:440–444.
76. Miao Y, Jeon JY, Park G, et al. Virtual reality-based measurement of ocular deviation in strabismus. Comput Methods Programs Biomed 2020; 185:105132.
77. Panachakel JT, Ramakrishnan AG, Manjunath KP. VR Glasses based Measurement of Responses to Dichoptic Stimuli: A Potential Tool for Quantifying Amblyopia? 2020 42nd Annual International Conference of the IEEE Engineering in Medicine & Biology Society (EMBC); 2020 20-24 July 2020; 2020. p. 5106-10.
78. Maloca PM, de Carvalho JER, Heeren T, et al. High-performance virtual reality volume rendering of original optical coherence tomography point-cloud data enhanced with real-time ray casting. Transl Vis Sci Technol 2018; 7:2.
79. Abujassar RS, Yaseen H, Al-Adwan AS. A highly effective route for real-time traffic using an IoT smart algorithm for tele-surgery using 5G networks. J Sens Actuat Netw 2021; 10:30.
80. Talcott KE, Adam MK, Sioufi K, et al. Comparison of a three-dimensional heads-up display surgical platform with a standard operating microscope for macular surgery. Ophthalmol Retina 2019; 3:244–251.
81. Romano MR, Cennamo G, Comune C, et al. Evaluation of 3D heads-up vitrectomy: outcomes of psychometric skills testing and surgeon satisfaction. Eye (Lond) 2018; 32:1093–1098.
82. Huang J, Kinateder M, Dunn MJ, et al. An augmented reality sign-reading assistant for users with reduced vision. PLoS One 2019; 14:e0210630.
83. Jung JH, Castle R, Kurukuti NM, et al. Field expansion with multiplexing prism glasses improves pedestrian detection for acquired monocular vision. Transl Vis Sci Technol 2020; 9:35.
84. Sayed AM, Abdel-Mottaleb M, Kashem R, et al. Expansion of peripheral visual field with novel virtual reality digital spectacles. Am J Ophthalmol 2020; 210:125–135.
85. Deemer AD, Swenor BK, Fujiwara K, et al. Preliminary evaluation of two digital image processing strategies for head-mounted magnification for low vision patients. Transl Vis Sci Technol 2019; 8:23.
86. Herbison N, MacKeith D, Vivian A, et al. Randomised controlled trial of video clips and interactive games to improve vision in children with amblyopia using the I-BiT system. Br J Ophthalmol 2016; 100:1511–1516.
87. Turnbull PRK, Phillips JR. Ocular effects of virtual reality headset wear in young adults. Sci Rep 2017; 7:16172.
88. Jalali MS, Kaiser JP. Cybersecurity in hospitals: a systematic, organizational perspective. J Med Internet Res 2018; 20:e10059.
89. Kotulski Z, Nowak TW, Sepczuk M, et al. Towards constructive approach to end-to-end slice isolation in 5G networks. EURASIP J Inf Secur 2018; 2018:1–23.
90. Ng WY, Tan TE, Xiao Z, et al. Blockchain technology for ophthalmology: coming of age? Asia Pac J Ophthalmol (Phila) 2021; 10:343–347.
91. Ng WY, Tan TE, Movva PV, et al. Blockchain applications in health care for COVID-19 and beyond: a systematic review. Lancet Digit Health 2021; 3:e819–e829.
92. Gunasekeran DV, Wong TY. Artificial intelligence in ophthalmology in 2020: a technology on the Cusp for translation and implementation. Asia Pac J Ophthalmol (Phila) 2020; 9:61–66.
93. Beede E, Baylor E, Hersch F, et al. A Human-Centered Evaluation of a Deep Learning System Deployed in Clinics for the Detection of Diabetic Retinopathy. Proceedings of the 2020 CHI Conference on Human Factors in Computing Systems: Association for Computing Machinery;2020:1–12.
94. Chavez-Santiago R, Szydelko M, Kliks A, et al. 5G: the convergence of wireless communications. Wirel Pers Commun 2015; 83:1617–1642.
95. Saunders J. The Transformational Impact of 5G: Proceedings of a Workshop—In Brief. National Academies of Sciences, Engineering, and Medicine; Policy and Global Affairs; Government-University-Industry Research Roundtable. Washington (DC), United States: National Academies Press; 2019.
96. Rahimi B, Nadri H, Lotfnezhad Afshar H, et al. A systematic review of the technology acceptance model in health informatics. Appl Clin Inform 2018; 9:604–634.
97. Gunasekeran DV. Technology and chronic disease management. Lancet Diabetes Endocrinol 2018; 6:91.
98. Gunasekeran DV, Tseng RMWW, Tham YC, et al. Applications of digital health for public health responses to COVID-19: a systematic scoping review of artificial intelligence, telehealth and related technologies. NPJ Digit Med 2021; 4:1–6.
99. Deemer AD, Bradley CK, Ross NC, et al. Low vision enhancement with head-mounted video display systems: are we there yet? Optom Vis Sci 2018; 95:694–703.
100. Sayed AM, Kashem R, Abdel-Mottaleb M, et al. Toward improving the mobility of patients with peripheral visual field defects with novel digital spectacles. Am J Ophthalmol 2020; 210:136–145.

augmented reality; metaverse; mixed reality; ophthalmology; virtual reality

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