VIRTUAL REALITY IN MEDICINE

INTRODUCTION: In a decade of technological wonders, virtual reality (VR) has captured the public's imagination. Great deals of attention and resources have been devoted to finding practical applications for this fantastical technology. Virtual reality is best described as a collection of technologies that allow people to interact efficiently with 3D computerized databases in real time using their natural senses and skills. The principal aim of this technology is to present virtual objects or complete scenes to all human senses in a way identical to their natural counterpart. Three dimensional computer graphics initiated the development of virtual reality technology several decades ago. Two major components are needed in this perspective: appropriate algorithms to calculate the visual appearance of the virtual scene to be visualized and physical devices to present the resulting images to the user. Vast collections of methods have been developed that basically simulate the interaction of light with the geometry of the virtual objects, which can be represented as a collection of surfaces (surface rendering) or as volumetric models (volume rendering). In order to achieve real time performance for large objects different specialized accelerator units have been developed, which are readily available today monitor. VR is particularly suited to medicine, which can require the communication of complex, interrelated information to physicians in remote locations. Most of the advances in medical VR have been in developing realistic simulations of medical procedures for training physicians or for helping them plan and carry out difficult operations. These VR simulations can benefit the medical community in many ways. For example, they can lower the cost of training doctors by providing reusable patients that can be operated on repeatedly. They can provide assistance to doctors in performing difficult or complex procedures. They can reduce the need for animal experimentation. They can make medical information more accessible for remote consultations. even for personal computers. The results of these rendering algorithms are usually presented on a video

In the field of medicine, virtual reality technology brought a revolution in many categories namely anatomy, radiation therapy, neurosurgery, mental health therapy etc. HAPTIC INTERFACES: Haptics is the study of human touch and interaction with the external environment via touch. Haptic interfaces are a class of human computer interaction (HCI) devices that predominantly appeal to this particular sensory modality. One of the most promising new VR technologies involves the use of these haptic interfaces. Touch is one of the most important cues for a physician; in fact, surgery is often conducted more by touch than by sight. In training, then, it is very important for a doctor to learn how an operation will feel. One haptic interface that is gaining the attention of many in the medical industry is the Phantom, which allows users to feel the physical properties of virtual objects while manipulating them to perform typical surgical operations, such as suturing (i.e., stiching) broken tube structures in the body. To use this device, a physician inserts his or her fingers into thimbles (metal rings with concave outer edges) that are attached to a robotic arm, and then interacts with a virtual anatomy that is displayed on a computer monitor. The computer interprets the finger positions in 3-D space and returns the appropriate resisting force based on the physical properties of the virtual anatomy. Finger position is updated approximately 1000 times per second. The device provides feedback on the user's performance, measuring such variables as the amount of force applied or amount of contact between the physician's fingers and the patient's tissue. VIRTUAL RETINAL DISPLAY: The 3-D display technology used in virtual reality is also constantly being improved, as is the processing capability of the computers used to render the VR data. Headmounted displays are making it easier for a physician to observe VR while conducting operations. An even more cutting-edge VR display is under development at Microvision. In this technology, called virtual retinal display (VRD), images are scanned directly onto the back of the eye with red, green, and blue streams of light. The user sees a 3-D image

that appears to float a few feet away. The goal of the project is to develop a VRD that can be incorporated into a pair of eyeglasses as the following figure demonstrates.

This new display, according to researchers, is brighter than images created with other displays. It can even be seen by patients with some forms of partial vision loss. SURGICAL SIMULATION: Its obvious that in training, there is no alternative to hands-on practice. However, students wishing to learn laproscopic procedures, usually train themselves on inanimate or artificial tissues because of high cost and low availability of real bodies for practice. But, there will be a substantial difference between training on artificial tissues and supervised procedures on real patients. Due to this reason, the VR simulators came into picture, which provide an entirely new opportunity in the area of simulation of surgical skills using computers for training and evaluation. In the last few years, new generation of simulators have appeared that have shown improved training efficiency over traditional methods. An example is the Minimally Invasive Surgery Training-Virtual Reality (MIST-VR) trainer, which is effective for training in basic laproscopic skills. The MIST system's training interface, based on modified laparoscopic instruments, is translated into quite simple real time 3D computer graphics that accurately track and represent the movements of the instruments within a virtual operating volume.

In this volume, geometric shapes that approximate to those faced during actual operations on organs are generated for display on the computer screen and subsequently manipulated by a surgical trainee. The following figure demonstrates it.

Each task can be programmed to deliver varying degrees of difficulty to the surgical trainee, and his or her performance can be recorded and saved for later replay by the supervisor or for statistical analysis. VIRTUAL ENDOSCOPY: All endosopic procedures that are being followed presently are invasive where in the patients are subjected to complications like perforation, bleeding etc. To overcome this intricacy, researchers are focusing on the possibility of virtual endoscopy. This is a new procedure, which renders three-dimensional images producing views of the organs, analogous to those obtained during real endoscopy. Virtual endoscopy is performed by a

standard CT scan or MRI scan, reconstructing the particular organ into a 3D model and then observing it. This procedure is particularly invasive and does not produce any known complications as the traditional endoscopy. VR IN PSYCHOLOGICAL ASSESSMENT: In clinical psychology, virtual reality is used to simulate the real world and it assures the researcher full control of all the implied parameters. It constitutes a highly flexible tool, which makes it possible to program an enormous variety of procedures of intervention on psychological distress. The key advantage provided by virtual reality in this context is, the possibility for the patient to manage successfully a problematic situation related to his/her disturbance. The patient is more likely not only to gain an awareness of his/her need to do something to create a change but also to experience a greater sense of personal efficacy. VR WITH HYPNOSIS: Pain from a burn is the most challenging pain to treat. The nature of burn wounds often leads patients to take the maximum-allowable dose of pain-reducing drugs, such as morphine, to help them cope during the greatest pain-inducing treatments: dressing changes and physical therapy sessions. Taking extreme levels of opiates can leave patients nauseous, drowsy and even unconscious, making treatment more difficult for hospital staff. A significant benefit of both virtual reality and hypnosis is that these treatments leave nothing in the blood stream and research has shown no side effects. Furthermore, in combination with pain medicine, virtual reality and hypnosis help patients become more cooperative during the most stressful and painful treatments. Researchers customized a virtual reality game that simulated the actions required in physical therapy sessions. Software was created that simulated the patient flying a jet plane and pulling back on a throttle to make the jet go faster. In reality, however, when the patient pulls back on the jet's throttle, the patient would really be pulling back on a real object or squeezing a ball -- actively taking part in their therapy session that would otherwise be too painful to endure.

At present researches are being made to develop what is known as the fiber optic virtual reality helmet, that can be used during dressing changes in the most painful stage of recovery -- when the patient is submerged in a bathtub to help loosen the bandages This development would help doctors access patients in the earlier stages of the recovery process. VR IN CARDIOLOGY: To operate a heart, the cardiac surgeon establishes the diagnose and plans the operation on the basis of ultrasound scanning. Infants heart cases provide a lot of difficulties, which can be reduced considerably by using virtual reality techniques. On the basis of MR scanning of a patient with a serious organic heart disease, a model of the deficient heart is built. This model is presented for the cardiac surgeon as a 3D image of the heart by means of advanced Virtual Reality equipment. The 3D image is coloured using image processing, which helps to distinguish the different part of the heart

Even though, the infant's heart is tiny, the doctor can magnify the image many times in order to view all details. The image can rotate arbitrarily to view the heart from the best angle. Many complications can be avoided if you know how the heart and its surroundings look from "the other side". It is even possible to view details from the inner of the heart. Virtual reality that allows doctors to visualise the heart in three dimensions could help in the diagnosis of heart conditions

VR IN TREATING CANCER: Virtual Reality helps Cancer patients cope with Chemotherapy. Patients with cancer have fewer adverse effects from chemotherapy and less fatigue when using virtual reality as a distraction intervention during treatments. Virtual reality enables people to immerse themselves in a computer-generated visual and aural environment by wearing a headmounted display device. Chemotherapy patients often spend hours in the clinic. Recent studies found virtual reality helped make time pass more quickly and reduced the side effects. Virtual reality makes for an excellent distraction intervention because it is interactive, engages several senses simultaneously, and immerses patients in a new world, thereby blocking out their current and often stressful environment. While using virtual reality, patients could choose between a variety of commercially available programs, such as walking on a beach, touring an art gallery or deep-sea diving. The goal of the intervention was to ease anxiety, fatigue and symptom distress. Symptom distress encompasses the discomfort the patients experienced from receiving chemotherapy. Such symptoms include nausea and vomiting, inability to concentrate, and fatigue. Nearly 60 percent of chemotherapy patients report some form of symptom distress. The results of a trial showed patients who used virtual reality during chemotherapy treatments reported significant decreases in symptom distress. Planning for radiation treatment of irregular cancer tumours requires a complete understanding of the geometry of the tumour and the anatomy of the individual patient. The goal is to apply the highest possible amount of radiation to the tumour, while limiting the amount of radiation affecting the surrounding tissue in order to reduce the side effects and long-time damages from the treatment. Modern radiation technology makes it possible to deliver the radiation within a well-defined three-dimensional area, and this generates the need for knowing the exact size and shape of the tumour and the surrounding tissue. All information regarding the tumour must be available to the experts who define these radiation volumes, in order to make the best treatment plan for the patient. In order to address this need for knowledge, researchers have developed a

prototype application for examining all relevant patient data in a virtual reality environment. VR IN LIVER SURGERY: In liver surgery, tumor resection is often the only curative treatment for patients suffering from liver cancer. A detailed planning must precede the actual intervention, because information about liver shape, tumor location, and the arrangement of the vascular structure is required. Currently, in clinical routine, an intervention plan is usually elaborated using the information retrieved from a tomographic imaging modality such as X-ray computed tomography. By inspecting a stack of gray-valued twodimensional images, a three-dimensional model must be established mentally. While radiologists are trained for this type of analysis, surgeons often have problems because they are naturally oriented towards 3D due to the nature of their clinical work. The virtual liver surgery planning system developed at the Institute for Computer Graphics and Vision combines the fields of medical image analysis and computer graphics, in order to simplify the clinical process of planning liver tumor resections. This system covers important aspects such as robust liver, tumor, and vessel segmentation, interactive segmentation refinement and includes a surgical planning environment. By using Virtual Reality techniques, a resection planning environment was developed. The presented planning tools are based on a consistent data model, which operates on top of a tetrahedral mesh and can be modified consistently by applying several partitioning operations. This enables surgeons to partition the liver into tissue target for resection and remaining liver tissue. The partitioning result can therefore deliver an elaborated resection plan individually for each patient. MOST RECENT DEVELOPMENT: The surgeons of the future could soon be learning their skills with the help of a new virtual reality simulator, Kylie, invented by a team at Monash University. It will enable surgeons to master keyhole techniques, which are being used for an increasing number of operations like hysterectomies, tumour removal and the removal of ectopic pregnancies, which previously required major surgical intervention. The technology of the simulator is being claimed as the most advanced of its type in the world.

Unlike earlier devices, which required the surgeon to put on a headset and gloves, the new model works like the simulators used to train airline pilots or to aid top golfers practicing before a major tournament. It will allow surgeons to practise by standing in front of a simulated patient's abdomen and working at a computer screen in real time. Just like a real operation, the surgeons insert a tiny video camera into the body and then study graphics on a computer screen representing the anatomy. The technology allows surgeons to virtually conduct a range of procedures, such as cutting out tumours. ISSUES TO BE CONSIDERED: Patients exposed to virtual reality environments may have disabilities that increase their susceptibility to side effects. Strategies are needed to detect any adverse effects of exposure, some of which may be difficult to anticipate, at an early stage. To date most of the VR devices available are not inter-operable i.e; they cannot be used for tasks other than for which they are developed. There are no standardized protocols for the designing of the VR systems that can be shared by the researchers. Because of lack of standard protocols and inter-operable VR devices, most of the researches need to develop their own VR devices, which ultimately consume a considerable amount of money and time. THE FUTURE: Apart from the development of current applications, virtual reality also probably has a role in such exciting developments as microsurgery and nanosurgery. As researchers keep finding practical applications for VR in medicine, it is becoming clear that this technology will be a major part of the hospitals of the future. In fact, some hospitals of the future may exist only in VR. Researchers at the HIT Lab, for example, are developing a virtual emergency room that will be used for training physicians . At Children's Hospital in Boston, researchers are developing a virtual environment in which young patients can lessen their fears by taking virtual tours of the hospital or even the

human body. These projects are in relatively early stages of development, and completion will require a great deal of work. Although these virtual hospitals are not yet a reality, the popularity of medical VR as a research subject promises that advances in the technology will continue, and such futuristic applications may soon be realized. CONCLUSION: Virtual Reality had brought about a remarkable development in the field of medicine. Many researchers, all over the world are striving hard to develop still outstanding VR devices that would improve the standards in medicine and ease the work of the clinicians. These devices, when made real, would certainly take the field of medicine to its zenith. BIBLIOGRAPHY: bmj.bmjjournals.com www.iospress.nl www.hoise.com www.cis.ufl.edu www.emedicine.com www.cybertherapy.info www.systematic.dk www.cardiovascularultrasound.com