Original article
Intraoperative Optical Coherence Tomography–Assisted Descemet Membrane Endothelial Keratoplasty in the DISCOVER Study

https://doi.org/10.1016/j.ajo.2015.05.020Get rights and content

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.

Section snippets

Methods

The DISCOVER study is a single-site, prospective multi-surgeon investigational device consecutive interventional case series. The study was approved by the Cleveland Clinic Institutional Review Board and adhered to the tenets of the Declaration of Helsinki. Informed consent was obtained from all participants. The purpose of the DISCOVER study is to examine the feasibility and utility of a microscope-integrated intraoperative OCT system in both anterior and posterior segment surgery and identify

Clinical Results

Eight eyes of 7 patients (4 female, 3 male; mean age 74 years, range 49–88 years) that underwent DMEK in the DISCOVER study were included in this analysis. All surgeries were performed by a single surgeon (J.M.G.). Of note, these were the first DMEK cases performed by this surgeon (with or without intraoperative OCT). The median “un-scrolling time” (onset of intraocular graft manipulation until full apposition with 100% gas fill) was 6 minutes and 15 seconds (range 2:25–27:36). The median

Discussion

The field of intraoperative OCT is currently going through substantial growth and increased availability. Until recently, all systems that were commercially available in the United States were portable systems, such as the Bioptigen and Optovue systems.3, 6, 7 More recently there has been significant interest in microscope integration of this technology.4, 5, 8, 9, 10 There are 2 commercially available microscope integrated systems: the Haag-Streit integrated system and the Zeiss RESCAN 700.4, 8

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Cited by (49)

  • Intraoperative optical coherence tomography in anterior segment surgery

    2021, Survey of Ophthalmology
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    Various methods and clinical signs have been described to facilitate correct graft orientation, including “S” or “F” stamps on the stromal aspect, double-ring sign for DSAEK lenticules, “Moutsouris” and “Minuteman” sign for DM scrolls.19,22 Additional surgical manipulation is required to mark the stromal aspect of grafts with dye stamps which is time consuming and can cause inadvertent tissue injury.17 Moreover, hazy corneas may impede visibility and hamper visualization of dye stamps or the clinical signs.27

  • Intraoperative Optical Coherence Tomography–Assisted Descemet Membrane Endothelial Keratoplasty in the DISCOVER Study: First 100 Cases

    2020, American Journal of Ophthalmology
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    As of this writing, however, there have been only 3 case series specifically evaluating the utility of iOCT in DMEK surgery. These reports demonstrated that iOCT was helpful in identifying remnants of Descemet membrane left on the host cornea, localizing the endothelial side of the donor graft, and facilitating tissue orientation when visualization is poor.7–9 These studies, however, were limited by small sample size (26, 14, and 8 patients) and did not report tissue unscrolling times.

  • Lamellar keratoplasty in children

    2020, Survey of Ophthalmology
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    Correct orientation of donor lenticule can be secured by staining its endothelial side with trypan blue dye or stromal side with gentian violet dye. The use of i-OCT during EK can help in determining the need for any additional intraoperative manipulations to minimize interface fluid.23 According to our experience, it also helps in confirming graft centration, presence of interface fluid, and depth of vent incisions (Fig. 5B).

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