Macular Mailbox|A Gamified MR Training Design for Age-Related Macular Degeneration

Overview

Macular Mailbox is a mixed-reality (MR) training application designed to improve accessibility and support patients with age-related macular degeneration (AMD). By combining gamification principles with MR technology, the project provides an engaging and interactive platform to aid in managing daily tasks and improving quality of life for individuals with visual impairments.

Research

To design an effective and user-centered solution, our research encompassed both fieldwork and desktop studies.

Field Research
We conducted an on-site visit to the Emory Eye Center to learn directly from Dr. Susan Primo, a leading expert in vision rehabilitation. During the visit, we observed how age-related macular degeneration (AMD) is diagnosed and explored treatment methodologies, particularly Preferred Retinal Locus (PRL) training. PRL training aims to help low-vision patients improve their fixation stability by training them to use specific retinal locations with better functional characteristics. The insights gained from Dr. Primo informed our understanding of AMD patients' challenges and the clinical objectives of PRL training.

Desktop Research

• AMD and PRL Training: We delved into clinical guidelines and case studies detailed in the MAIA handbook, which provided foundational knowledge about eccentric viewing rehabilitation. We studied the fixation stability test methodology, which measures patients' ability to maintain stable visual focus during PRL training.
• Gamification and Mixed Reality for Elderly Users: Our investigation extended to the application of gamification techniques in mixed reality (MR). We examined existing research on designing engaging and intuitive MR environments tailored to elderly users, focusing on accessibility and usability.
• MR Technology Research: To explore the feasibility of incorporating advanced MR technology, we evaluated the potential of eye-tracking devices, such as the Quest Pro, which captures positional eye movement data with a high sampling rate. This exploration highlighted the possibilities of implementing fixation stability tests in virtual reality settings, enabling innovative approaches to patient engagement and training.

Together, these research efforts provided a robust foundation for designing a gamified MR training solution that aligns with clinical needs and offers an accessible, user-friendly experience for AMD patients.

Design

The design process evolved through iterative development, informed by research insights and user needs.

Initial Design: The Clock Method
Our initial design adopted the "clock method," a traditional technique used in Preferred Retinal Locus (PRL) training. This method required patients to shift their gaze to specific positions on an imagined clock face to train their peripheral vision. While effective in its simplicity, the method relied heavily on manual patient input and lacked precision in identifying the optimal gaze point for each individual.

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Refined Design: Eye-Tracking Integration
To address these limitations, we integrated the eye-tracking functionality of VR headsets - Quest Pro, into the design. This allowed for the automatic detection and measurement of the patient's best gaze point. Using high-frequency eye movement data, the system identified the optimal retinal location for training and adjusted the exercises accordingly. This enhancement not only improved precision but also reduced the cognitive burden on patients, enabling a more seamless and effective training experience.

Gamified Training Sessions

To ensure an engaging and effective user experience, the gamification elements of our training program were informed by research into the preferences and behaviors of elderly users. Drawing on key insights, we integrated elements of nostalgia, social connection, and user control into the training system.

Nostalgia-Driven Engagement
Nostalgia has been shown to evoke positive emotions and enhance user engagement in elderly individuals. We designed the training sessions around a virtual mailbox concept, allowing users to perform tasks such as creating and sending postcards. This nostalgic activity resonates with older users by replicating familiar experiences, creating an emotionally enriching training environment (Loos et al., 2018).

Social Interactions
Social connections are critical motivators for elderly users. Inspired by this, we incorporated a feature allowing users to send virtual postcards to family members and loved ones during training. This addition created a meaningful social dimension to the training sessions, fostering motivation and adherence while addressing the emotional needs of the users (De Schutter & Vanden Abeele, 2010).

Gamification in Mixed Reality
Using mixed reality (MR) technology, we seamlessly integrated these gamified features into the training environment. For example, eye-tracking technology allowed for real-time feedback on fixation stability, enabling users to visualize their progress dynamically. Gamification elements such as rewards, achievements, and progressive challenges kept users engaged while reinforcing the training's clinical goals (Bogost, 2007).

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‍XR Prototype

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To bring the concept to life, we developed an extended reality (XR) prototype. The prototype simulated the training environment, incorporating elements such as:

• Fixation Stability Testing: Users interacted with visual tasks designed to measure and improve their fixation stability through eye-tracking technology.
• PRL Training: Exercises tailored to train patients to use specific retinal locations with better functional characteristics.
• Gamified Features: The prototype included nostalgic tasks, such as postcard creation and sending, to maintain user engagement and motivation.

The XR prototype allowed us to test and refine key design elements, ensuring an intuitive and accessible experience for elderly users.

Challenges & Solutions

• Challenge: Designing interfaces that cater to varying degrees of visual impairment.
  Solution: Implemented bold, high-contrast visuals, large text, and voice-guided interactions.
• Challenge: Ensuring intuitive gesture-based controls for elderly users.
  Solution: Simplified gestures and provided step-by-step tutorials within the application.

Next Steps

To further advance the project and refine its design, we have identified the following key steps:

1. Build the XR Application
   The next phase involves transitioning the XR prototype into a fully functional application. This will include:
   • Developing the interactive features, such as fixation stability testing, PRL training, and gamified postcard exchange.
   • Integrating eye-tracking functionality to enhance precision and feedback during training sessions.
   • Ensuring accessibility and usability for elderly users by incorporating large visuals, clear instructions, and intuitive interactions.
     The XR app will be rigorously tested for technical stability and user experience to ensure it meets clinical and practical goals.
2. Co-Design Workshops
   To gather valuable user insights and further refine the application, we will hold co-design workshops with key stakeholders, including:
   • AMD patients and their families, to understand their needs, preferences, and challenges.
   • Healthcare professionals, to validate the app’s clinical relevance and effectiveness.
   • Design and accessibility experts, to ensure the app meets industry standards for inclusivity.
     These workshops will provide hands-on experience with the application and collect feedback on usability, engagement, and feature effectiveness.
3. Iterative Development
   Based on the insights from the co-design workshops, we will iterate on the application to address user needs and improve functionality. This iterative process will include:
   • Enhancing features based on user feedback, such as adjusting difficulty levels or refining gamification elements.
   • Addressing technical challenges and improving the app’s stability.
   • Testing the updated version with a broader user base to ensure scalability and effectiveness.

Through these next steps, we aim to deliver an impactful XR training solution that meets both clinical objectives and user-centered design standards.

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References

• Bogost, I. (2007). Persuasive games: The expressive power of videogames. MIT Press.
• De Schutter, B., & Vanden Abeele, V. (2010). Meaningful play in elderly life. Proceedings of the International Conference on Fun and Games, 84-93.
• Loos, E., Ivan, L., & Leu, D. (2018). Nostalgia as a persuasive strategy in design for older users. Gerontechnology Journal, 17(2), 124-134.

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