case report
Immersive virtual reality
Marcel-Alexandru
Găină1,
Andreea Moraru2,3,
Bogdan‑Victor
Ștefănescu4,
Alexandra‑Maria
Găină5,
Andreea‑Silvana
Szalontay1,6,
Dănuț Costin2,3
1. Psychiatry,
Department of Medicine III,
Faculty of Medicine,
“Grigore T. Popa” University
of Medicine and Pharmacy,
Iaşi, Romania
2. Ophthalmology Ward,
“Prof. Dr. Nicolae Oblu”
Emergency Clinical Hospital,
Iaşi, Romania
3. Faculty of Medicine,
“Grigore T. Popa” University
of Medicine and Pharmacy,
Iaşi, Romania
4. Sixth year Student,
Faculty of Medicine,
“Grigore T. Popa” University
of Medicine and Pharmacy,
Iaşi, Romania
5. First Neurology Ward,
“Prof. Dr. Nicolae Oblu”
Emergency Clinical Hospital,
Iaşi, Romania
6. Socola Institute of Psychiatry,
Iași, Romania
Corresponding author:
Marcel-Alexandru Găină
E-mail: gaina_alex@yahoo.com
Conflict of interests:
The authors declare
no con­flict of interests.
38
in anxiety psychotherapy
and ocular rehabilitation.
A transdisciplinary approach
Abstract
Immersive virtual reality (iVR) can be used not only as a
guideline intervention in certain anxiety disorders but also
as a brain stimulating interface, triggering neuroplasticity
mechanisms and facilitating the rehabilitation of
sensorimotor disorders. iVR’s potential was recently
harnessed in treating or diagnosing amblyopia or in
remote measuring of patient-related outcomes. We
present the case of Mr. L.A., a 69-year-old man, a former
academic, political and civic movement figure, currently
performing successful writing. His right eye had posterior
chamber pseudophakia and was treated for glaucoma,
and his left eye had an evolving cataract. The right eye’s
optical coherence tomography (OCT) revealed the impact
of glaucoma and also the loss of nerve fibers and cells
impairing signal conduction, while the combined results
explained the high level of impairment of binocular vision.
The impaired vision caused a very high level of concurring
anxiety derived from the inability to perform daily tasks,
directing him toward psychotherapy. The personalized
iVR approach was preceded by cybersickness evaluation
using VRQTest (Vectorush Studio). For relaxation, we
used an artificial intelligence massage chair with body
scanning mimicking Jacobson progressive relaxation and
a specific pranayama yoga already familiar to the patient.
Every session used a different iVR software for further
distractibility and immersivity. The best-tolerated visual
rehabilitation software was Vision Therapy, developed
by Cerverum INC. The hardware used consisted of an
Oculus Rift virtual reality headset and a Dell Alienware
17 R4 laptop. The patient was able to conduct daily tasks
after the nineth session. The tolerance was associated
with a massive improvement in eyesight of the left eye,
from a visual acuity of 0.2 to 0.6 measured after the 20th
psychotherapeutic session. To our knowledge, this is
the first reported case of using this type of consecutive
dual approach to anxiety and ocular rehabilitation.
Keywords: immersive virtual reality, impaired vision,
anxiety, ocular rehabilitation
Recieved:
28.10.2022 Realitatea virtuală imersivă în psihoterapia anxietății și reabilitarea oculară.
Accepted:
10.11.2022 O abordare transdisciplinară
Suggested citation for this article: Găină MA, Moraru A, Ștefănescu BV, Găină AM, Szalontay AS, Costin D. Immersive virtual reality in anxiety psychotherapy and ocular
rehabilitation. A transdisciplinary approach. Psihiatru.ro. 2022;71(4):38-41
Rezumat
Realitatea virtuală imersivă (iVR) reprezintă nu numai o
intervenție indicată de ghidurile terapeutice în anumite
tulburări de anxietate, ci și o interfață de stimulare a creierului,
declanșând mecanisme de neuroplasticitate și facilitând
reabilitarea tulburărilor senzoriomotorii. Potențialul iVR a fost
recent valorificat în tratarea sau diagnosticarea ambliopiei
sau în măsurarea de la distanță a parametrilor progresiei
afecțiunilor. Prezentăm cazul domnului L.A., un bărbat în
vârstă de 69 de ani, o personalitate academică, politică și
civică, ce activează în prezent cu succes ca scriitor. Ochiul
său drept are pseudofachie de cameră posterioară și a fost
tratat pentru glaucom, iar ochiul stâng suferă de cataractă
în evoluție. Tomografia cu coerență optică (OCT) a ochiului
drept relevă impactul glaucomului, pierderea fibrelor nervoase
și a celulelor care afectează conducerea semnalului, în timp
ce rezultatele combinate explică nivelul ridicat de afectare a
vederii binoculare. Pierderea vederii a provocat un nivel foarte
ridicat de anxietate corelată, derivată din incapacitatea de a
îndeplini sarcinile zilnice, fapt ce îl redirijează pe pacient către
psihoterapie. Abordarea iVR personalizată a fost precedată
de evaluarea răului de simulator folosind VRQTest (Vectorush
Studio). Pentru relaxare, am folosit un scaun de masaj cu
inteligență artificială prin scanare corporală care imită
relaxarea progresivă Jacobson și o tehnică de pranayama yoga,
ce era deja familiară pacientului. Fiecare sesiune a folosit un
software iVR diferit, potențând distractibilitatea și imersivitatea.
Cel mai bine tolerat software de reabilitare vizuală a fost
Vision Therapy (Cerverum INC). Hardware-ul folosit a constat
dintr-o cască de realitate virtuală Oculus Rift și un laptop
Dell Alienware 17 R4. Pacientul a redobândit autonomia
desfășurării sarcinilor zilnice după a noua ședință. Toleranța
a fost asociată cu o îmbunătățire masivă a vederii ochiului
stâng, de la o acuitate vizuală de 0,2 la 0,6 după a 20-a ședință
psihoterapeutică. După cunoștințele noastre, acesta este
primul caz raportat care utilizează acest tip de abordare duală
concomitentă pentru anxietate și reabilitare vizuală.
Cuvinte-cheie: realitate virtuală imersivă, acuitate vizuală
scăzută, anxietate, reabilitare oculară
Anul XVIII • Nr. 71 (4/2022)

Introduction
Immersive virtual reality’s (iVR’s) role in anxiety
disorders is extensively researched, showing promi-
sing 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 spe-
cific conditions through automated eye perimetry.
By controlling the world, the patient vividly experi-
ences the concept of gamification, therefore revealing
a new perspective on a method of treatment that
raises therapeutic potential and neuroplasticity wi-
thin an enjoyable interface, increasing the patient’s
motiva­t ion (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 politi-
cal, 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 re-
commended 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 pati-
ent 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
Figure 1. Optical coherence tomography results in revealing optical disk atrophy
Anul XVIII • Nr. 71 (4/2022)
psihiatru
crystalline lens. On the right eye, there were revea-
led 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 ori-
entation. 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 vir-
tual 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
39
case report
Figure 2. Personalized iVR relaxation approach using a pranayama yoga breathing technique and Jacobson progressive
relaxation through an artificial intelligence massage chair
Figure 3. Ocular rehabilitation using Vision Therapy Software
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 Question-
naire 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 implemen-
tation 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 facilita-
ted by add-on therapeutic massage using alternative
pressure points that were triggered similarly to the
sequence of a Jacobson progressive muscular relaxa-
tion for a further distraction of the patient (Figure 2).
After a preliminary meeting with his ophthalmolo-
gist, 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 16th session, we used
40
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 associ-
ated 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 16th 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.
Anul XVIII • Nr. 71 (4/2022)

Discussion
The particularity of this case is represented by a per-
sonalized 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 pro-
longed 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 deter-
mined 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. n
1. Impactul realității virtuale în oftalmologie. Summer School „Provocări și
References
controverse în pandemie”, 22-26 iunie 2021. In: Costin D. Curs de oftalmologie
clinică, vol. IV, ISBN 978-606-13-6320-9, pg. 370-378.
2. Gaină MA, Ștefănescu C, Costin D. Facilitating neuroplasticity and reducing
anxiety related to the therapeutic management of amblyopia through virtual
reality techniques. Sănătate publică, economie şi management în medicină.
2022;1(92):45-46.
3. Costin D, Moraru A, Lucian E, Iorga R, Untu R, Don R, Gaină MA.
Neuroplasticitatea cortexului vizual vs. Bolile oculare [Neuroplasticity of the
Anul XVIII • Nr. 71 (4/2022)
psihiatru
Acknowledgements
To the highly relevant feedback of the patient regar-
ding an accurate description of the subjective feelings of
anxiety encountered because of the progressive eyesight
loss, which guided our steps towards an efficient per-
sonalized 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 5th 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 acknowledg-
ment 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 develo-
ping 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.
visual cortex vs. Eye diseases]. Sănătate publică, economie şi management în
medicină. 2022;1(92):39-40. ISSN 1729-8687.
4. Coco-Martin MB, Piñero DP, Leal-Vega L, et al. The Potential of Virtual Reality
for Inducing Neuroplasticity in Children with Amblyopia. J Ophthalmol.
2020;2020:7067846. doi:10.1155/2020/7067846.
5. Bez Y, Coşkun E, Erol K, Cingu AK, Eren Z, Topçuoğlu V, Ozertürk Y. Adult
strabismus and social phobia: a case-controlled study. J AAPOS. 2009
Jun;13(3):249-52. doi: 10.1016/j.jaapos.2009.02.010.
41
Copyright of Psihiatru.ro is the property of MEDICHUB MEDIA, S.R.L. and its content may
not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for
individual use.