F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.169156.1 Research Article Articles Game-based Learning in Eye Health Education - The Developmental Challenges of E-learning Games

[version 1; peer review: 1 approved, 1 approved with reservations]

 Maseedupalli Srikanth Conceptualization Data Curation Formal Analysis Investigation Methodology Project Administration Resources Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-3739-5873 1 Snigdha Snigdha Conceptualization Data Curation Formal Analysis Funding Acquisition Investigation Methodology Project Administration Resources Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0009-0007-3862-3958 1 Vaidyanathan Kartic Conceptualization Investigation Methodology Resources Software Validation Visualization Writing – Review & Editing 2 Madhukuri Sitaramanjaneyulu Methodology Project Administration Resources Validation 1 Varada Sreelakshmi Methodology Project Administration Resources Validation 1 Bollam Yamuna Methodology Project Administration Resources Validation 1 Mocherla Shobha Resources Validation Visualization Writing – Review & Editing 1 Pathengay Avinash Conceptualization Funding Acquisition Project Administration Resources Supervision Validation Writing – Review & Editing 1 Prakasam Ruby Kala Conceptualization Data Curation Formal Analysis Investigation Methodology Project Administration Resources Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-5433-4546 a 1 L V Prasad Eye Institute, Hyderabad, India Lets Play to Learn Company, Chennai, India ruby@lvpei.org

No competing interests were disclosed.

 10 12 2025 2025 14 1390 24 11 2025 Copyright: © 2025 Maseedupalli S et al. 2025 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose

Game-based learning enhances eye health education and skill acquisition but poses distinct challenges in developing effective educational games. The present study aims to demonstrate the developmental challenges encountered at various stages of creating e-learning game prototypes for training eye health professionals.

 Methods

Structured focus group discussions (FGDs) were conducted involving all the stakeholders involved in game development, the subject experts, and the technical experts. The four phases of FGDs were as follows: i) Ideation and team development; ii) Identifying the competencies and mapping these with cognition; iii) Concept to prototype development; a) Defining questions and data points; b) Accumulating content; and iv) Prototype testing and feedback. The FGDs were audio recorded, the descriptive data were transcribed verbatim, and the data were thematically analysed.

 Results

The challenges differed in every phase of the game development. Data on the strengths and weaknesses of the game development were collected via participant recall. Throughout the project, the technical team had to understand the requirements of the subject experts and vice versa. Participants’ understanding of e-learning games varied across the teams. Choosing appropriate topics for game development, identifying and mapping underlying cognition to exit competency, generating data, translating concepts into games, determining the role of communication in maintaining team dynamics, and seeking early feedback from end-users were some of the challenges encountered.

 Conclusion

The lessons learned from overcoming procedural challenges in this study may be applied by others who are developing game-based educational tools for eye health education.

 Game-based learning game development gamification eye health education medical education. Hyderabad Eye Research Foundation Authors acknowledge the support of the Hyderabad Eye Research Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Introduction

Game-based education 1, 2 involves crafting products and services through the application of new technology to theoretical learning. Thus, fusing the two fields, technology and education, has given us what is popularly called game-based learning (GBL), which is popular for its high educational value. The blend of game, technology, and learning creates an engaging and immersive educational experience that can enhance cognitive processes, such as memory, attention, and spatial abilities. 3

In response to the evolving landscape of technology and educational paradigms, educators are increasingly adopting innovative pedagogical approaches, including the systematic integration of active learning strategies into mainstream curricula. Although GBL, as one of the active learning tools, seems promising for its educational value, the development of effective e-learning games for eye health education poses significant challenges. The design of such games requires a careful balance of educational content and engaging game elements. 4 Tan et al identified lacunae with most game models in incorporating learning behaviour into game design and proposed that game designers could leverage pedagogical components such as the story, challenge, goals, and objectives in designing GBL. Addressing this gap, studies 2, 5– 8 have proposed guidelines and principles for designing effective educational computer games. These include incorporating clear learning objectives, aligning game mechanics with educational goals, providing adaptive and personalized learning experiences, and leveraging the principles of game design.

The incorporation of game-based learning into eye health education has garnered significant attention in recent years. 9– 12 This emerging discipline has been extensively studied for its benefits and pitfalls. 2, 5, 13 Researchers have emphasized the potential of educational digital games in contributing to an interactive and dynamic learning process, leading to a clearer and more functional understanding of various scientific concepts and phenomena.

Driven by a commitment to optimize learning outcomes through active learning strategies, a team at a leading eye care centre embarked on developing gamified e-learning modules for their course curriculum. This multi-disciplinary team comprised subject matter experts, educators, administrators, game developers, and design specialists. The team adopted a multidisciplinary approach to develop game prototypes suitable for a course design and a set of learners. The key aspects of the gamification process included our thorough review of the curriculum, mapping learner competencies, data collection for designing e-learning games, the scope of resources, and team collaboration. In this paper, we aim to explore the developmental challenges of creating e-learning games for eye health education and propose strategies to overcome them

 Methods

Ethical approval for this qualitative study was obtained from the Institutional Review Board of L V Prasad Eye Institute Ethics Committee (IRB Approval No. LEC-BHR-P-05-22-847). Verbal informed consent was obtained from all participants prior to participation, and the study was conducted in accordance with the principles of the Declaration of Helsinki.

Focus group discussions

Qualitative data were collected from three focus group discussions 14 involving all the collaborators and the technical and instructor teams. A total of 3 FGDs were conducted, and the mean age of participants was 33 ± 5.24 years.

The objective of the FGDs was to consolidate different challenges encountered by team members at different stages of game development. Prior to conducting the FGDs, the educator, the technical team representative, and a study moderator connected through a virtual meeting to structure the discussions. The different phases of game development were identified and labelled. 15 Further field work for each phase included the formulation of open-ended questions 15 by involving the study moderator and game-developer team. Inputs were collected, and further iterations were performed.

The duration of each focus group discussion was approximately one to two hours. The FGDs were designed and moderated by a third person, the study moderator (RKP), who was not a direct participant in game development. The Zoom Platform for videoconferencing was used to conduct and record the FGDs. Given that the FGDs were conducted and recorded online, a research assistant was not required for notetaking. The study moderator initiated the discussion by asking phase-specific open-ended questions to capture participants’ experience in the selected topic of game development. The audio version was transcribed by the study moderator, and the data were analysed with reference to the phase of the game development identified. We used a deductive thematic analysis approach 16 to analyse qualitative data from the focus group discussions. A priori themes were developed based on the study objectives and used to guide the FGD questions. Data were collected under each predefined theme and subsequently analysed to identify key reflections on the challenges encountered at different stages of game development. 15 This structured, theme-based approach facilitated systematic comparisons across focus groups. Figure 1 captures the adopted framework and summarizes the developmental challenges.

Summary of developmental challenges in game development.

Comprehensive list of challenges encountered during each phase of the game development process.

 Results FGD 1 (Phase I) Ideation and team development

Building a successful team requires a strategic blend of passion and expertise. The participants assembled a diverse team comprising internal educators, the subject matter experts with in-depth knowledge of the curriculum and learning objectives, and external technical experts, specifically game developers with the skills essential for e-learning game development. Educators and game developers engaged in team development through collaborative sessions to achieve the following goals:

Idea Exchange: Brainstorming and refining game concepts to ensure alignment with learning goals.

Expectation Setting: Establishing clear communication channels and defining roles for each team member.

Process Rollout: Developing a shared understanding of the development workflow and key milestones.

The formation of a cross-functional team with complementary expertise facilitated effective ideation and laid the foundation for the next project phases. The five challenges encountered during ideation and team development are listed in Figure 1.

 FGD 2 (Phase II) – Identifying and mapping the competencies with the cognition

Traditional teaching involves a set curriculum with lectures, practice, and assessments. This FGD highlighted the potential of game-based learning to improve the educational experience. It emphasised the importance of considering learner motivation, engagement, and knowledge retention in game design. The process of defining learning objectives and matching them with the optimal cognitive process was reflected as a constant endeavour throughout the game development. This allowed team members to identify potential gaps and accordingly adjust the game design.

The collaboration between educators with limited digital experience and the developers was crucial for creating effective game prototypes. Due to limited resources, the team strategically identified specific topics within the curriculum that would benefit students the most from gamification. Furthermore, game objectives were aligned with educational learning goals by mapping trainee exit competencies to relevant cognitive abilities, as illustrated by a sample topic from the Ophthalmic Nursing Assistants course shown in Table 1.

Identification and mapping of competencies to cognitive skills.
Example topic from the ONA * course: Preparing patients for general and specific eye surgery
1 Exit competency: Ability to prepare a patient for surgery
2 Required Knowledge: Understanding of the step-by-step procedure, including associated dos and dont’s
3 Cognitive skills required: Order memory and decision-making skills
4 Game objective: To impart technical knowledge while concurrently enhancing order memory and decision-making skills

Steps involved in identifying and mapping the competencies to the cognitive skills required for learning a topic, illustrated using an example topic.

Ophthalmic Nursing Assistants.

 FGD 3 (Phases III & IV): Concept & prototype development

Educators and facilitators initially had limited experience with 2D and text-based teaching tools. The concept of a game-based learning tool on a digital platform was entirely new, requiring collaboration with developers. The team strategically began with simple concepts to build experience and gradually progressed to creating more engaging 3D game prototypes.

This FGD highlighted the importance of creating a balance between educational value and engaging gameplay. It underscored the need for collaboration between educators with limited digital expertise and developers during the game design and development process. This iterative approach, starting with simpler concepts, allowed the team to build their experience and develop more sophisticated 3D prototypes.

Game concept development: This phase involved brainstorming and refining game concepts that incorporate fun elements to enhance educational value. Based on the chosen concept, this phase focused on accumulating relevant content (text, images, etc.) to populate the game.

Prototype development: This iterative process involved:

Creating a basic prototype that focuses on core mechanics and functionality.

Refining the prototype based on testing and feedback.

Gradually increasing complexity as experience grows, potentially leading to 3D elements.

Prototype testing and feedback process: This phase involved conducting user testing with the target audience to gather feedback and ongoingly identify areas for improvement.

Reflections on challenges

A minimal understanding of the subjects was essential for building and acquiring data for game development. As a technical team member stated, “The ophthalmic terms were new. For example, ‘sterility’ I understand, but deeper levels of the sterilization process were new.”

A member of the education team said, “It took us considerable time to understand and attain the threshold level of knowledge about every subject and then build on that.”

The fusion of fun elements with the content earmarked for learning mandated collaboration between the technical and educator teams.

Time was initially invested in helping the team of educators learn the technical details and helping the technical team grasp the subject in its entirety. In the process of game development, team collaboration was critical to both data collection and data integration.

Data collection relevant to a broad topic demanded frequent interactive meetings and follow-up. This called for the creation and sharing of subject-related content and high-quality clinical pictures in structured and special game-specific formats.

The initial prototypes were subjected to closed feedback, the suggestions were shared with the team of developers, and corrections were implemented.

Team dynamics and talent attrition in technical teams: The exit of developers from the technical team just when we had attained project efficiency significantly delayed the project. Given the boom in the technology market, engineer retention was a challenge in our short-duration project for developing e-learning games. When an engineer resigned and left the team, it was observed that there was no return on investment because of the high cost of knowledge transfer (KT) made during the training and development of the team.

Discussion

Our experiences in developing e-games echoed the common challenges 17 reported in the literature, including limited technical skills, time constraints, inadequate infrastructure, poor communication, and negative educator attitudes. Several studies have proposed strategic approaches to address these barriers and support effective gamification implementation. 17– 20 This section presents our strategic approach to addressing the challenges encountered, along with a proposed framework to guide game developers and educators in effective implementation.

Our journey revealed crucial insights throughout the game development process. Notably, the establishment of a robust user feedback loop emerged as a critical step before finalizing the game. Stakeholders, including content creators who identified key information, educators who defined functional needs, and learners who provided user-centric perspectives, all played vital roles in shaping the game. However, user requirements pertaining to the desired level of complexity, implementation strategies, and feedback mechanisms often remained ambiguous. The development team sometimes gravitated towards advanced functionalities, and initially, readily available game platform templates with “plug-and-play” features were viewed favourably. However, custom-built games that demanded coding expertise presented significant cost and development hurdles. Faculty and educators needed to prioritize concepts requiring gamification and carefully map learning objectives to corresponding cognitive skills.

Gamification impacts the motivation, cognition, emotion, and sociality of players. 21, 22 To cultivate an engaging learning experience, we incorporated visible game mechanics like scoring and progress indicators, along with the ability to track player metrics. Notably, we consciously avoided implementing punitive measures such as negative grading for incorrect choices. In retrospect, a more structured approach would have been beneficial. Scoping the project upfront, ensuring alignment between requirements and available resources, and setting realistic goals could have streamlined the development process. Our experience emphasizes the importance of iterative course correction, leading to successful project completion. The early recognition of the value of project scoping and the visualization of final deliverables were key takeaways from this endeavour.

Strengths of the study

This study represents a carefully revised and peer-reviewed version of our earlier preprint, 23 with enhanced clarity, updated analyses, and improved presentation of data. To the best of our knowledge, this research offers a novel exploration of the challenges associated with developing gamified e-learning programs in eye health education. Our findings can serve as a foundation for future research in this domain. As a concluding contribution, we propose a checklist to guide the development journey of gamified learning experiences:

Module Selection: Identifying specific modules within the curriculum best suited for gamification.

Content Curation: Defining the essential knowledge required for game development.

Media Integration: Selecting appropriate images and educational artifacts to enhance the game.

Platform Choice: Deciding between custom-built platforms or existing game templates.

Custom Development Challenges: Assessing the complexities involved in building bespoke games.

Resource Evaluation: Investigating the availability of technical expertise and addressing potential market challenges.

By implementing this framework, educators and developers can embark on a more efficient and well-defined path when creating engaging and effective gamified e-learning experiences.

 Limitations of the study

Although online FGDs present inherent limitations, including reduced non-verbal cues, weaker group dynamics, and potential distractions, these were partially mitigated in this study. Participants were provided with stable internet access, instructed to keep cameras on, and briefed on the use of the platform. Pre-designed discussion themes were employed to maintain focus and minimise topic deviation. The online format also facilitated the inclusion of participants from diverse locations, eliminating the need for travel.

 Conclusion

Gamification facilitates cognitive learning, serving the broader purpose of conventional teaching and assessment methods. Setting expectations about the use of the final product could help teams make the e-learning game user-friendly. Given that gaming is an active learning tool, gamification can only supplement the traditional modes of instruction and learning. We fulfilled the objective of our project by bringing in fun, making it interactive, and developing a failsafe learning approach to creating games. Given the variety of games available, realistic selection from a predesigned game platform may prevent over engineering to match various levels of user learning. Finally, in medical education, sophistication in digital gaming is best avoided in the interest of learning per se. The two aims of participating in games, achieving players’ focused attention and their playing with great team spirit, must be served well in gamification and game-based learning.

 Data availability statement

The study contains the following data:

The underlying data (supplementary material 1; https://doi.org/10.6084/m9.figshare.29880998.v2 15 ) has been deposited in Figshare: Deductive thematic analysis approach: Pre-defined themes, Guiding questions for FGDs, and Key reflections on the challenges encountered at different stages of game development. The extended data (supplementary material 2; https://doi.org/10.6084/m9.figshare.29880686.v2 14 ) has been deposited in Figshare: Focus Group Discussions Transcripts.

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

 Acknowledgments

The authors wish to thank faculty members for their participation in the focus group discussions. We gratefully acknowledge the strong collaboration between L V Prasad Eye Institute, Hyderabad, India, and the Let’s Play to Learn company, Chennai, India.

References Xu M Luo Y Zhang Y : Game-based learning in medical education. Front. Public Health. 2023;11:1113682. 36935696 10.3389/fpubh.2023.1113682 PMC10020233 Sardi L Idri A Fernández-Alemán JL : A systematic review of gamification in e-Health. J. Biomed. Inform. 2017;71:31–48. 28536062 10.1016/j.jbi.2017.05.011 Pk P Mittal A Aggarwal DA : Literature Review: Learning Through Game-Based Technology Enhances Cognitive Skills. International Journal of Professional Business Review. 2023;8:e01415. 10.26668/businessreview/2023.v8i4.1415 Huber SE Cortez R Kiili K : Game elements enhance engagement and mitigate attrition in online learning tasks. Comput. Hum. Behav. 2023;149:107948. 10.1016/j.chb.2023.107948 Kucher T : Principles and Best Practices of Designing Digital Game-Based Learning Environments. International Journal of Technology in Education and Science. 2021;5:213–223. 10.46328/ijtes.190 Tori A Tori R Nunes F : Serious Game Design in Health Education: A Systematic Review. IEEE Trans. Learn. Technol. 2022;15:827–846. 10.1109/TLT.2022.3200583 Aster A Laupichler MC Zimmer S : Game design elements of serious games in the education of medical and healthcare professions: a mixed-methods systematic review of underlying theories and teaching effectiveness. Adv. Health Sci. Educ. Theory Pract. 2024;29:1825–1848. 38563873 10.1007/s10459-024-10327-1 PMC11549195 Rapeepisarn K Wong K Fung C : Creating Effective Educational Computer Games For Undergraduate Classroom Learning: A Conceptual Model. i-manager’s Journal of Educational Technology (JET). 2008;5:22–31. 10.26634/jet.5.2.523 Argilés M Jurado LA Junyent LQ : Gamification, serious games and action video games in optometry practice. J. Opt. 2020;13:210–211. 31917137 10.1016/j.optom.2019.10.003 PMC7533625 Mansoory MS Yousefi D Azizi SM : Effectiveness of gamification-based teaching in approach to eye trauma: a randomized educational intervention trial. BMC Ophthalmol. 2024;24:457. 39420268 10.1186/s12886-024-03726-w PMC11488274 Trevino R Majcher C Rabin J : The Effectiveness of an Educational Game for Teaching Optometry Students Basic and Applied Science. PloS one. 2016;11:e0156389. 27233041 10.1371/journal.pone.0156389 PMC4883760 Khimani K Koshevarova V Mathew AA : Video Game Warm-Up May Suggest Improvement in Ophthalmic Surgical Simulator Performance in Surgically Naïve Students. Clin. Ophthalmol. 2022;16:2561–2568. 35978609 10.2147/OPTH.S369697 PMC9377345 Egenfeldt-Nielsen S : The challenges to diffusion of educational computer games. Leading issues in games based learning. 2010;141:145–158. Reference Source Maseedupalli S Snigdha S Vaidyanathan K : Focus Group Discussions Transcripts. figshare. 2025 [cited 2025Aug13]. 10.6084/m9.figshare.29880686.v2 Reference Source Maseedupalli S Snigdha S Vaidyanathan K : Deductive thematic analysis approach: Pre-defined themes, Guiding questions for FGDs, and Key reflections on the challenges encountered at different stages of game development. figshare. 2025 [cited 2025Aug13]. 10.6084/m9.figshare.29880998.v2 Reference Source Braun V Clarke V : Using thematic analysis in psychology. Qual. Res. Psychol. 2006;3:77–101. 10.1191/1478088706qp063oa Anitha P Krishnappa N Dhar R : Challenges of incorporating e-learning in medical education-a review. International Journal of Basic & Clinical Pharmacology. 2022;11:511–514. 10.18203/2319-2003.ijbcp20222153 Joy S Rumsey K Ford M : Gamification: Development, challenges, and implications for undergraduate nursing education. Teach. Learn. Nurs. 2023;18:423–425. 10.1016/j.teln.2023.04.004 Dimitriadou A Djafarova N Turetken O : Challenges in Serious Game Design and Development: Educators’ Experiences. Simul. Gaming. 2020;52:132–152. 10.1177/1046878120944197 Tabassum A : Challenges of Implementing Gamification in Medical Education: A Scoping Review. Journal of Bahria University Medical and Dental College. 2024;14:155–160. 10.51985/JBUMDC2023260 Annetta LA Minogue J Holmes SY : Investigating the impact of video games on high school students’ engagement and learning about genetics. Comput. Educ. 2009;53:74–85. 10.1016/j.compedu.2008.12.020 Lee J Hammer J : Gamification in Education: What, How, Why Bother? Acad. Exch. Q. 2011;15:1–5. Reference Source Game-based learning in eye health education – the developmental challenges of e-learning games [preprint]. Research Square. October 2023. 10.21203/rs.3.rs-3423921/v1 10.5256/f1000research.186443.r445590 Reviewer response for version 1 Kadri Mohammed 1 Referee https://orcid.org/0000-0002-8954-5933 Sidi Mohamed Ben Abdellah University, El Mehraz, Fez, Morocco

Competing interests: No competing interests were disclosed.

 23 1 2026 Copyright: © 2026 Kadri M 2026 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

This manuscript presents a qualitative study documenting the challenges encountered during the development of gamified e-learning modules for eye health education at L V Prasad Eye Institute, India. The multidisciplinary team of educators, subject matter experts, game developers, and administrators conducted three focus group discussions to systematically capture challenges across four phases: (1) ideation and team development, (2) competency mapping with cognition, (3) concept to prototype development, and (4) prototype testing and feedback.

Key challenges identified include: cross-disciplinary communication barriers between technical and domain experts, topic selection for gamification, mapping learning competencies to cognitive skills, content generation in game-specific formats, and talent attrition in technical teams. The authors propose a six-item checklist to guide future developers of gamified learning experiences.

Strengths

Addresses an underexplored area: Game-based learning specifically for eye health education is rarely documented in the literature.

Multidisciplinary perspective: The inclusion of both educators and developers provides balanced insights into the challenges from multiple viewpoints.

Open data availability: The authors exemplify good research practice by making FGD transcripts and analysis frameworks publicly available via Figshare.

Practical framework: The proposed six-item checklist provides actionable guidance for future developers.

Ethical rigor: Ethics approval was obtained, and the study followed the Declaration of Helsinki.

Transparent methodology: The use of deductive thematic analysis with clearly stated a priori themes enhances reproducibility.

Major Issues to Address

Lack of learner perspective: The study captures developer and educator challenges but does not include the end-user (learner) perspective. Consider conducting additional FGDs or surveys with students who used the developed games to provide a complete picture.

Framework validation: The proposed six-item checklist is based on a single development experience. The authors should either:

Acknowledge this as a preliminary framework requiring validation, OR

Test the checklist prospectively in a subsequent development project

Generalizability limitations: The findings are from one institution in one country. The authors should explicitly discuss how cultural, institutional, and resource contexts may affect transferability of findings.

Learning outcomes: There is no assessment of whether the developed games actually achieved their educational objectives. At minimum, preliminary evaluation data would strengthen the manuscript.

Minor Issues

Game prototype descriptions: Please provide more detail about the actual games developed (genre, mechanics, platforms, topics covered).

Participant demographics: Consider reporting additional relevant characteristics (e.g., years of experience, roles in more detail).

Inter-rater reliability: If multiple coders analyzed the transcripts, please report reliability metrics. If single coder, please acknowledge this limitation.

Figure 1 quality: The figure summarizing developmental challenges is referenced but ensure it is clearly legible in the published version.

Table 1: The example of competency mapping is helpful; consider expanding this with additional examples from different course topics.

Future Research Directions and Advisory Suggestions

The manuscript opens important avenues for future research that the authors should consider addressing in the Discussion section. Based on the challenges identified, particularly around prototype testing, team collaboration, and knowledge transfer, the following research directions would significantly advance this field:

1. Comparison with Immersive Technologies (VR/AR)

The current study focuses on 2D and text-based game prototypes, progressing to 3D elements. A natural extension would be to  compare the effectiveness of traditional e-learning games with immersive Virtual Reality (VR) and Augmented Reality (AR) alternatives for eye health education.

Why this matters:

VR/AR can provide spatial understanding of anatomical structures (e.g., the eye's 3D anatomy) that 2D games cannot replicate

Immersive technologies have demonstrated enhanced engagement and presence in medical education contexts

The challenges documented in this study (content translation, prototype testing) may differ significantly for VR/AR development

2. Integration of Artificial Intelligence (AI)

The authors discuss challenges in content translation and personalized learning experiences.  Integrating AI-based guidance and adaptive learning systems could address several challenges identified in Phase III (concept to prototype development).

Why this matters:

AI can provide personalized learning pathways based on individual learner performance

Generative AI assistants can reduce cognitive load during complex medical content exploration

AI can automate aspects of content generation and adaptation, addressing team workload issues

3. Collaborative and Social Learning Features

The manuscript emphasizes team collaboration challenges between developers and educators. Future game prototypes should explore  collaborative learning features that enable social presence and peer interaction, which are particularly important for professional training.

Why this matters:

Healthcare education often benefits from social learning and peer discussion

Collaborative features can enhance knowledge construction through dialogue

Social presence has been shown to improve engagement and motivation in distance learning

4. Longitudinal Knowledge Retention Assessment

The study acknowledges the lack of learning outcome assessment. Future research should incorporate  longitudinal retention testing with delayed post-tests to evaluate whether game-based learning produces durable knowledge gains.

Why this matters:

Short-term learning gains may not translate to long-term retention

Medical professionals need sustained knowledge for clinical practice

Understanding retention patterns can inform game design decisions about repetition and reinforcement.

1- The manuscript presents a well-structured qualitative study documenting the developmental challenges of e-learning games for eye health education. The four-phase framework (ideation, competency mapping, prototype development, testing) provides a clear organizational structure. The literature review adequately covers game-based learning, gamification principles, and existing applications in medical education. The references are current and relevant, with most citations from 2020-2024.

2- The qualitative research design using focus group discussions (FGDs) is appropriate for the exploratory nature of this research. The deductive thematic analysis approach with a priori themes is suitable for investigating predefined developmental phases.

Areas for improvement:

- The study would benefit from inter-rater reliability assessment for the thematic coding process

- Member checking with participants to validate findings would strengthen credibility

- The study lacks learner/end-user perspective - only developers and educators were included

- No triangulation with other data sources (e.g., project documents, observation notes)

3- The authors have commendably made raw data available through Figshare (FGD transcripts and thematic analysis frameworks), which supports reproducibility.

Missing details for full replication:

- Specific characteristics of the developed game prototypes are not described

- The topics selected for gamification are mentioned in Table 1 but not fully elaborated

- The exact decision-making process for theme identification could be more explicit

- Participant selection criteria beyond team membership are unclear

4- This is a qualitative study. The only quantitative data reported is participant demographics (mean age 33 ± 5.24 years), which is appropriately presented.

5- The authors have made underlying data available through Figshare:

- Supplementary Material 1: Deductive thematic analysis approach, pre-defined themes, guiding questions, and key reflections

- Supplementary Material 2: Focus Group Discussion transcripts

Data are available under Creative Commons Attribution 4.0 International license (CC-BY 4.0). This adherence to FAIR data principles is commendable.

6- The conclusions about developmental challenges are well-supported by the qualitative findings from FGDs. The proposed six-item checklist is a practical contribution.

However:

- The generalizability of findings from a single institution is limited

- The proposed checklist has not been empirically validated

- The claim that "lessons learned... may be applied by others" would be strengthened by testing the framework in different contexts

- No assessment of whether the developed games actually improved learning outcomes

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Educational Technology, Immersive Learning (VR/AR), Game-based Learning, Medical Education Technology, HCI, AI-Enhanced Pedagogy

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

References : IVAL: Immersive Virtual Anatomy Laboratory for enhancing medical education based on virtual reality and serious games, design, implementation, and evaluation. Entertainment Computing .2024;49: 10.1016/j.entcom.2023.100624 10.1016/j.entcom.2023.100624 : C-IVAL: A Longitudinal Study of Knowledge Retention and Technology Acceptance in Collaborative Virtual Reality-Based Medical Education. IEEE Access .2025;13: 10.1109/ACCESS.2024.3523860 16055-16071 10.1109/ACCESS.2024.3523860 Prakasam Ruby Kala L V Prasad Eye Institute, India

Competing interests: No competing interests were disclosed.

 10 3 2026

Major Issues to Address

Lack of learner perspective: The study captures developer and educator challenges but does not include the end-user (learner) perspective. Consider conducting additional FGDs or surveys with students who used the developed games to provide a complete picture.

Authors' Response: Thank you for this important comment. The authors believe the end-user perspective is an important aspect to be studied, which was beyond the scope of the present study.  We will incorporate the end-user perspective in our follow-up study on game-based learning. 

Framework validation: The proposed six-item checklist is based on a single development experience. The authors should either:

Acknowledge this as a preliminary framework requiring validation, OR

Test the checklist prospectively in a subsequent development project

Authors' Response: Thank you for your valuable comments. Authors also acknowledge that the proposed six-item checklist is a preliminary framework that requires prospective validation as part of our subsequent game development project. This statement has now been included in the manuscript under the section ‘limitations of the study’.

 

Generalizability limitations: The findings are from one institution in one country. The authors should explicitly discuss how cultural, institutional, and resource contexts may affect the transferability of findings.

Authors' Response: Thank you for this important suggestion. We have now included this information on the generalizability of the study from a single institute as a potential limitation of the study  

Learning outcomes: There is no assessment of whether the developed games actually achieved their educational objectives. At a minimum, preliminary evaluation data would strengthen the manuscript.

 Authors' Response: Thank you for your valuable suggestion. This study was primarily designed to capture educators' perceived challenges during different stages of the game development process. However, we fully agree with your point. As a follow-up, we are planning a study to assess the end-user perspective of the game and evaluate its educational outcomes. This has now been acknowledged in the manuscript under the ‘Limitations of the Study’ section.

Minor Issues

Game prototype descriptions: Please provide more detail about the actual games developed (genre, mechanics, platforms, topics covered).

Response: We appreciate this important suggestion. We have now added a detailed description of the developed game prototypes in the Results. Specifically, we have clarified:

The genre of the games (2D and 3D interactive modules).

The core mechanics, including scoring systems, order-based sequencing tasks, decision-making pathways, and timed responses.

The platform approach, including the use of structured digital templates in early stages and gradual progression to custom-built prototypes.

The topics covered include patient preparation for surgery, sterilization protocols, and procedural workflow in ophthalmic settings.

  

Participant demographics: Consider reporting additional relevant characteristics (e.g., years of experience, roles in more detail).

 Thank you for your valuable comment. We have included relevant characteristics in the methods section of the manuscript

All participants in this study were involved in game development and represented several domains of eye health education on a full-time basis. This group is a comprehensive representation of several cadres of eye health professionals, Ophthalmologists, Optometrists, and Nurses with an average of 10 years of experience in learning and development. The technical collaborator is a pioneer in game-based learning and a specialist in gamified interactive pedagogy.

 

Inter-rater reliability: If multiple coders analyzed the transcripts, please report reliability metrics. If single coder, please acknowledge this limitation.

Authors' Response: Thank you for this important comment. The FGD transcripts were analysed by a single coder. As suggested, we have now added this information to the limitations section of the manuscript

Figure 1 quality: The figure summarizing developmental challenges is referenced but ensure it is clearly legible in the published version.

 Authors' Response: Thank you. As suggested, we have replaced Figure 1 with a legible text.

Table 1: The example of competency mapping is helpful; consider expanding this with additional examples from different course topics.

 Authors' Response: We thank the reviewer for this thoughtful suggestion. Table 1 was intentionally designed to provide a single, clear illustrative example from the Ophthalmic Nursing Assistant (ONA) course to demonstrate the structured process of mapping exit competencies to cognitive skills and corresponding game objectives. The purpose of the table is to exemplify the methodological approach rather than to present topic-wise results. In methodological manuscripts, presenting one representative example is often preferred to maintain conceptual clarity and readability. Including multiple examples across topics could increase complexity and potentially reduce the ease with which readers understand the mapping framework.

However, to improve transparency, we have now clarified in the manuscript that "the same structured mapping process was systematically applied across other selected course topics during development." We appreciate the reviewer’s insight, which has helped us make this methodological intent more explicit".

Future Research Directions and Advisory Suggestions

The manuscript opens important avenues for future research that the authors should consider addressing in the Discussion section. Based on the challenges identified, particularly around prototype testing, team collaboration, and knowledge transfer, the following research directions would significantly advance this field:

Authors' Response: We thank you for your suggestion regarding future research directions. The points mentioned are well taken, and we will consider them in our future work.

 10.5256/f1000research.186443.r441450 Reviewer response for version 1 Xiong Chen Zhi 1 Referee https://orcid.org/0000-0002-7796-2115 National University of Singapore, Singapore, Singapore

Competing interests: No competing interests were disclosed.

 2 1 2026 Copyright: © 2026 Xiong CZ 2026 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

The methodologies are sound. While the lessons learned are not entirely novel, they are sufficiently detailed and remain useful to eye health professionals' context. The article documents real-world development challenges. This aligns well with F1000's scope. The article is also clearly written. A suggestion for improvement may be to include learners/players of the game in the FGDs, so that the end users' perspectives can be captured to enhance future development process.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Pediatric solid tumors, health professions education

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Prakasam Ruby Kala L V Prasad Eye Institute, India

Competing interests: No competing interests were disclosed.

 6 1 2026

Dr.Zhi, Thank you for your valuable suggestion. We will incorporate the end-user perspective in our follow-up study on game-based learning.