Commentary: Virtual reality counseling in cataract surgery – Using a smartphone-based tool "InSight"

Modern cataract surgery has evolved to offer not just restoration of vision but optimized refractive outcomes and a lifestyle-focused approach to visual rehabilitation. Premium intraocular lenses (IOLs), including multifocal, toric, and extended depth of focus (EDOF) lenses, are central to this advancement. These IOLs address refractive errors while enhancing patient satisfaction by reducing dependence on spectacles. As cataract surgery transitions into a refractive procedure, appropriate IOL selection becomes critical to achieving patient-centered outcomes. Several studies have emphasized that high-quality preoperative counseling plays a pivotal role in improving patient understanding, confidence, and satisfaction with surgical outcomes.[1] The Need for Tailored Counseling Cataract surgery requires patients to choose among multiple IOLs, each with unique benefits and limitations. For example, monofocal lenses provide clear distance vision but limited near focus, while multifocal lenses offer vision at various distances but may introduce visual disturbances like glare or halos. EDOF lenses provide a compromise with enhanced intermediate vision and fewer side effects. However, these nuances are often difficult for patients to comprehend through conventional counseling methods. Individuals with high expectations, particularly those with perfectionist personality traits, may be predisposed to dissatisfaction if their postoperative outcomes do not align with poorly understood preoperative expectations.[2] This underscores the importance of personalized, clear, and accessible communication tools to guide decision-making. Evidence Supporting Enhanced Counseling Empirical evidence underscores the value of structured, individualized counseling in cataract surgery. One study demonstrated an 18% improvement in patient knowledge scores (mean difference +2.0, P = 0.004) and a 14% reduction in decisional conflict (mean difference +8.4, P < 0.0001), indicating both statistically and clinically significant improvements in decision-making clarity and confidence.[1] Furthermore, systematic reviews and meta-analyses consistently support the superiority of tailored health communication over generic educational approaches in influencing behavior and improving patient engagement.[3,4] A recent systematic review further highlighted the unique advantages of virtual reality (VR) in patient education, reporting enhanced comprehension of medical procedures, reduced preoperative fear and stress, and high user satisfaction with the technology itself. These findings suggest that VR can serve as an effective adjunct to conventional counseling, improving the quality of informed consent and supporting better-aligned healthcare decisions.[5] Innovation The InSight VR tool combines advanced software development with practical accessibility [Fig. 1]. Built on Unity, it features a user-friendly smartphone application that integrates with standard VR goggles, such as Google Cardboard. The tool offers dynamic simulations of vision with different IOL types [Figs. 2 and 3]:Figure 1: (a) Smartphone placement in generic VR goggles for the InSight app. (b) A counseling department employee administering the InSight VR device to the patient. VR: Virtual realityFigure 2: Fixation points in outdoor (a) and indoor (b) scenarios- near, intermediate, and farFigure 3: Simulated visual outcomes with different IOLs in indoor [a–c] and outdoor [d–f] settings. Monofocal [a, d] provides clear distance vision [green arrows] but blurred intermediate/near vision [red arrows]. EDOF [b, e] offers clear distance and intermediate vision [green arrows] with readability of larger but not finer near print [blue arrows]. Multifocal [c, f] delivers clear vision at all ranges [green arrows] but may cause halos [star] and reduced contrast compared to monofocal, evident in indoor images [c vs. a] Monofocal: Clear distance vision, blurred near vision. Multifocal: Clarity at multiple distances but potential for halos and reduced contrast. EDOF: Intermediate vision with minimized visual artifacts [Video 1]. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_v6tnehhq"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} By allowing patients to visualize both the benefits and drawbacks, InSight sets realistic expectations, fostering better-informed decisions. Its affordability ensures broad accessibility, even in resource-limited settings. Simulation Design and Technical Specifications The InSight application was developed using Unity software with baked lighting and shadow techniques, optimized for Android smartphones to ensure smooth performance on consumer-grade VR headsets (e.g., Google Cardboard). While this approach prioritizes practical implementation over photorealistic rendering, the baked lighting system provides consistent illumination conditions across all testing scenarios, eliminating variables that could affect visual assessment outcomes. Virtual environments were modeled at a 1:1 scale to preserve spatial accuracy, with test objects placed according to standard clinical vision testing distances—approximately 33–40 cm for near and 6 meters equivalent for distance targets. The simulations were rendered at 60 frames per second to maintain visual stability. While not based on ray tracing or clinical imaging data, the design incorporated established optical and spatial principles to emulate key features of visual performance with monofocal, EDOF, and multifocal IOLs. Methods Patient feedback on the InSight VR tool was obtained through structured verbal assessments. Following the VR-based counseling session, patients were asked whether the simulation improved their understanding of the IOL they were selecting and whether it helped with the decision-making. These responses provided a subjective measure of the perceived usefulness and impact of the tool on understanding and decision-making preoperatively. This pilot implementation did not include a control group, as the primary aim was to assess feasibility and initial patient response. Results In a pilot study involving 67 cataract patients, the InSight VR tool demonstrated its effectiveness: Improved understanding: 94% of participants reported enhanced clarity regarding IOL options. Ease of decision-making: 98.5% found it easier to choose an IOL after using the tool. Adoption rates: Presbyopia-correcting lenses saw a significant increase in uptake post-intervention. These results underscore the potential of InSight to revolutionize preoperative counseling in ophthalmology. Conclusion The integration of VR into preoperative counseling represents a promising advancement in cataract care. By offering immersive simulations of postoperative vision with various IOLs, tools like InSight address a longstanding gap in patient education, bridging the disconnect between clinical explanations and patient comprehension. Enhanced understanding of visual outcomes has been shown to improve decisional certainty and satisfaction, both of which are critical to the overall success of cataract surgery.[1,6] The simplicity, affordability, and compatibility of smartphone-based VR platforms like InSight make them highly scalable, particularly in high-volume or resource-limited clinical settings. As patient-centered care continues to gain emphasis, such innovations offer a practical means of aligning surgical planning with individual preferences. Future research should focus on the longitudinal impact of VR-assisted counseling on postoperative satisfaction, expectation management, and informed consent quality, as well as its seamless integration into routine clinical workflows.