Valerie Neff Newitt
September 2026—As transitions to a digital pathology workflow grow in number, the question may become less about the extent to which digital slide assessment will be used in practice and more about how to work with those slides.
While scanners, image management systems, and storage are most talked about, among other things, researchers at Western University in London, Ontario, turned their attention to the interface itself. They studied whether eye- and head-tracking technologies can serve as alternative input devices to hand-based input devices for digital pathology tasks (Lopes A, et al. Arch Pathol Lab Med. Published online June 12, 2026. doi:10.5858/arpa.2025-0628-OA).
Ergonomics will become more important as the use of digital pathology expands, says Matthew J. Cecchini, MD, PhD, associate professor in the Department of Pathology and Laboratory Medicine at Western University’s Schulich School of Medicine and Dentistry and a coauthor of the study. “We’re just starting to go digital in pathology, so this is a new problem for us. With traditional input devices, there is a lot of clicking and dragging, and if you do that for an entire day, that can be ergonomically challenging.”
Coauthor Alana Lopes, PhD, BSc, researcher at Baines imaging research laboratory, Victoria Hospital, Schulich School of Medicine and Dentistry, Western University, says the study grew from concerns that digital pathology could amplify repetitive strain injuries already documented among pathologists who use microscopes and among heavy computer users generally.
“Because the transition to digital pathology is so new, there’s not a lot of data on the digital pathology interface. But on the optical microscope or the analog workflow, there have been studies that have shown repetitive hand strain of the fine muscles of the hand, the neck, and upper back.” Studies of those who work extensively with computers show reports of upper arm strain, she says. “There are projections of these injuries being exacerbated when people move to a digital pathology workflow, so we’re trying to circumvent those injuries at the starting gate.”
Although the computer mouse and keyboard are a classic combination for many, it puts pathologists at a high risk of debilitating repetitive strain injuries, Dr. Lopes says. “These injuries could then slow down pathology assessments and even lead to early career termination.”
For the Western University team, limiting hand use “was a critical issue,” Dr. Lopes says. While other hand-based devices (such as trackballs, specialized mice, and other peripherals) may reduce strain for some users, they do not address the needs of those who cannot comfortably use their hands or develop injuries over the course of their careers. “Essentially, we were trying to think outside the box of traditional input devices. We wanted to push the boundaries of the digital pathology user experience and to search for an input device that is not only accessible but also ergonomically sustainable, and maintains the pathologist’s performance and possibly enhances it,” she says.
To evaluate the concept, the investigators recruited eight pathologists who primarily practice conventional microscopy and who volunteered to perform five representative digital pathology tasks: measuring, counting, zooming, panning, and target identification. Rather than reproduce routine diagnostic cases, Dr. Cecchini says, “we devised contrived tasks that replicate real things we do in our daily practice when looking at slides.” The standardized tasks allowed for direct comparison between devices.
For measurement tasks, participants used their gaze to identify measurement endpoints instead of positioning a mouse cursor. “The pathologists measured eight lines drawn on the tissue at different lengths and angles. We recorded how accurate their measurements were, and we recorded the amount of hand movement required to complete this task using the mouse,” Dr. Lopes explains. They then repeated the task using an eye tracker as the input device. They would look at the endpoints of the line they wanted to measure instead of using the mouse cursor to localize the endpoints. Their eyes guided the cursor instead of the hand doing so.
Counting exercises, designed to simulate mitotic figure assessment, required pathologists to look directly at targets and activate counts with a simple key press. They had to count 40 targets drawn on the tissue in a 1×1 mm2 square region. The investigators recorded the accuracy of their counts, the spatial location of their counts, and the amount of hand movement, using both the mouse and eye tracker input devices to localize what they wanted to count.
Zooming, another task, “was pretty interesting. Pathologists had a lot of fun with this one,” Dr. Lopes says. “Instead of using the mouse cursor to drag to a region on the tissue they wanted to zoom into, they would look to the region in the tissue they wanted to zoom into and then use the scroll wheel to zoom in. It was essentially look, spin the scroll wheel of the mouse, and zoom in to exactly where they were looking.” There was no need to drag the cursor.
The panning and target identification tasks were done simultaneously using head tracking. A predefined path was drawn on the tissue that the pathologist had to follow, “like a maze,” Dr. Lopes says. “Tilting a head left, right, up, and down directed the direction in which the image would pan.” As they were panning, they had to identify targets drawn along the path. The pathologists were given two and a half minutes to get as far as they could with both input devices. “We compared how far they got in both settings as well as how accurate they were at identifying targets.”
The technology itself impressed even experienced observers. “I’ve done a bunch of these observer studies,” says Dr. Cecchini, a study participant, “and I’m always shocked at how good the technology is and how seamlessly it works.”
For Dr. Cecchini, counting emerged as the standout application. “It’s annoying to annotate what you’re counting as you’re going,” he explains. “It was quite nice to just look at something and press a key to count the different aspects. I found that quite natural and helpful. That was my favorite.”
Zooming also felt surprisingly natural to participants. “When you’re zooming into an image,” Dr. Lopes says, “you’re already looking at the area you want to zoom into. The pathologists didn’t have to do anything extra to complete the task.”
The investigators found that eye tracking as an input device could be used for measuring, counting, and zooming tasks without compromising the accuracy of the task itself when compared with the standard computer mouse. For the measurement endpoint localization, they found accuracy was only slightly higher in numeric value for the mouse compared with eye tracking; the difference between the two input devices was less than 10 μm.
“We found there are some useful applications here,” Dr. Cecchini says. “Some are better than others. Whereas integrating eye gaze can be very good for counting and zooming into areas, it may not be as great for fine measurements. And then actively moving the head is a bit of a polarizing thing—some people really like it, some find it nauseating.” But he says it warrants further exploration for clinical practice because “there may be real benefit for a lot of pathologists.”
Dr. Lopes adds, “We also discovered there was a substantial reduction in the hand motion recorded to perform tasks when using non-hand-based input devices compared to the mouse.” Across all tasks, she says, they found a median threefold reduction in hand movement.
Perhaps the most intriguing finding was related to target identification. During panning exercises, pathologists using head tracking did not miss any targets. In contrast, eight targets were missed by four participants when using a mouse. The result surprised the investigators. “We were not expecting that at all,” Dr. Lopes says.
Their surprise led them to analyze the eye gaze in both settings to try to understand the finding. Mouse navigation requires repeated click-and-drag movements, creating a stop-and-start viewing pattern. Head tracking produces smooth, continuous image movement. Investigators observed more uniform visual coverage of the image path during head-controlled navigation. “Normally you have a jerky, discontinuous movement as you’re dragging something or moving a mouse,” Dr. Cecchini says. “But for this, it’s a nice smooth, continuous movement, which I quite liked. It was like riding a roller coaster. I found I could go quite quickly and yet control the speed—slower or faster—with the middle scroll wheel on a mouse. I could speed up on the straightaways and slow down going around corners.” But the experience was user dependent, he says. “Some people found it made them carsick.”
In the early stage when a user is getting used to it, the head movement is large, Dr. Lopes explains. Later, when they are more comfortable with the system, “it’s sensitive enough that the head can be moved very little” to start the panning. Still, the reaction to it led investigators to conclude that such a feature would work best as an optional tool rather than a universal replacement.
The least popular application was eye-tracked measuring. Investigators determined that an interface overlay designed to help users actually distracted them, suggesting that the design will have to be refined to improve acceptance in future versions.
At the study’s conclusion, participants emerged with an overall positive outlook on the alternative input devices.
“All of our pathologists in this study expressed excitement toward these input devices for their future digital pathology workflow,” Dr. Lopes says. “They said they were surprisingly easy or intuitive to use for some tasks, and that they increased the speed of task completion as well as a feeling of confidence in the task completion.”
The pathologists who used the devices were asked if they would be willing to pay a nominal fee on their own to use features like eye and head tracking for their work. “Multiple pathologists expressed that they would,” Dr. Lopes says.
When Dr. Cecchini presented the study at the Pulmonary Pathology Society Biennial Meeting in Quebec in June, “There was a lot of interest around this,” he says. “People wanted to know how to do this and how to get this into practice. A lot of pathologists are interested because it’s a natural way of doing things.”
Neither eye- nor head-tracking technology is used at Western University, which is in the early phases of a transition to a digital workflow. However, because pathologist interest is strong, Dr. Lopes’ team is modifying the interfaces based on lessons learned in the study and is working with others to integrate the technologies into the university’s developing digital pathology platform.
Although reducing repetitive strain injury was the aim of the study, both authors now view the technology’s potential more broadly. Dr. Cecchini believes eye- and head-tracking systems may ultimately become part of multimodal pathology workstations that combine head, gaze, voice, and other inputs to reduce workflow interruptions.
“One of our biggest problems in pathology is task switching,” Dr. Cecchini says. “With eye, head, and voice interfaces, we can make it easier to do a lot of tasks and reduce the amount of task switching pathologists need to do currently. This could make us more efficient in our work.”
Dr. Lopes hopes the findings help support the centers that are transitioning to digital pathology or thinking about a transition. “The objective was not to show superiority but to show the feasibility of using eye or head tracking without compromising the pathologist’s accuracy and potentially saving them time and physical effort and increasing accuracy.”
Clinical pathology workflows do not use eye- or head-tracking now, to Dr. Lopes’ knowledge, though she says there have been interesting applications in research and calls it an emerging field to explore.
Valerie Neff Newitt is a writer in Audubon, Pa.