Intraoperative Interface Fluid Dynamics and Clinical Outcomes for Intraoperative Optical Coherence Tomography-Assisted Descemet Stripping Automated Endothelial Keratoplasty From the PIONEER Study.

PURPOSE: To correlate intraoperative interface fluid dynamics during Descemet stripping automated endothelial keratoplasty (DSAEK) using intraoperative optical coherence tomography (iOCT) in the Prospective Intraoperative and Perioperative Ophthalmic Imaging with Optical Coherence Tomography (PIONEER) study with postoperative outcomes. DESIGN: Prospective consecutive, interventional, comparative case series. PARTICIPANTS: One hundred seventy-eight eyes of 173 patients undergoing DSAEK from the Cole Eye Institute, Cleveland, Ohio. METHODS: Eyes that underwent DSAEK between October 2011 and March 2014 from the PIONEER intraoperative and perioperative OCT study were included. An automated interface fluid segmentation algorithm evaluated intraoperative dynamics of interface fluid before and after surgical manipulations. iOCT images were also captured at multiple intraoperative time points for 2 different DSAEK techniques, 1 that used an active air infusion system and 1 that did not. MAIN OUTCOME MEASURES: Interface fluid metrics, graft nonadherence. RESULTS: iOCT measurements of interface fluid after final surgical manipulations and immediately before leaving the operating room identified that total fluid volume (P = .002), largest fluid volume pocket (P = .002), max fluid area (P = .006), mean fluid thickness (P = .03), and max fluid thickness (P = .01) significantly correlated with graft nonadherence rates within the first postoperative week. After placement and optimization of intraoperative lenticle adherence, iOCT revealed a significant difference between the area, volume, and thickness of maximum fluid pockets between the 2 surgical techniques, but both techniques resulted in significant reduction of interface fluid during the procedure. CONCLUSIONS: Larger residual interface fluid volume, area, and thickness at the end of surgery detected with iOCT are associated with early graft nonadherence and can be quantified with an automated algorithm. iOCT imaging can successfully capture technique-dependent differences in fluid dynamics during DSAEK.

Intraoperative OCT-Assisted Subretinal Perfluorocarbon Liquid Removal in the DISCOVER Study.

BACKGROUND AND OBJECTIVE: To assess the role for intraoperative optical coherence tomography (iOCT) during subretinal perfluoro-n-octane (PFO) removal and evaluate it as an assistive technique during surgical maneuvers. MATERIALS AND METHODS: DISCOVER is a prospective study examining microscope-integrated iOCT systems in ophthalmic surgery. The authors report a technique utilizing iOCT guidance and feedback for surgical removal of chronic subretinal PFO. RESULTS: In this technique, real-time iOCT feedback successfully guided surgical maneuvers to facilitate removal of PFO. Due to the chronicity of the PFO, it was loculated and resistant to multiple maneuvers. Utilizing real-time feedback, additional maneuvers were attempted with feedback to the surgeon regarding the success of removal. Postoperatively, visual acuity improved with anatomic normalization. CONCLUSION: Microscope-integrated iOCT with real-time feedback provided important information to the surgeon that helped facilitate subretinal PFO removal and guided surgical maneuvers.

Intraoperative optical coherence tomography-assisted descemet membrane endothelial keratoplasty in the DISCOVER study.

PURPOSE: To investigate the utility of intraoperative optical coherence tomography (OCT) for Descemet membrane endothelial keratoplasty (DMEK) surgery. DESIGN: Prospective consecutive interventional case series. METHODS: DISCOVER (NCT02423213) is a prospective consecutive interventional case series examining the feasibility and utility of microscope-integrated intraoperative OCT in ophthalmic surgery. This report focuses on those eyes in the DISCOVER study undergoing DMEK surgery. The 8 cases were the first DMEK cases performed by the primary surgeon (J.M.G.) with microscope-integrated intraoperative OCT feedback. Qualitative OCT analysis was performed at multiple surgeon-defined time points, including host and donor tissue preparation, graft orientation, graft apposition, and tissue interface fluid dynamics. RESULTS: Correct graft orientation was confirmed by intraoperative OCT prior to unscrolling in 100% of cases. Seven of 8 grafts were fully attached at the conclusion of surgery and on postoperative day 1. One graft had a linear paracentral fixed area of interface separation corresponding to posterior stromal irregularities that was visible during surgery and unchanged on postoperative day 1. Two eyes developed significant peripheral graft dehiscence visible by the first postoperative week. Both grafts were successfully reattached with repeat gas injection. All eyes demonstrated improvement in best-corrected visual acuity and there was a 100% graft survival rate at last follow-up (minimum 4 months). Surgeon feedback indicated that intraoperative OCT provided valuable information in all 8 cases. CONCLUSIONS: Real-time intraoperative OCT can provide useful information that may directly impact surgical decision making during DMEK surgery. Intraoperative OCT may facilitate the transition for novice DMEK surgeons by increasing surgeon confidence and reducing the risk of iatrogenic graft failure.