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Original Investigation | Clinical Sciences

Optimizing Descemet Membrane Endothelial Keratoplasty Using Intraoperative Optical Coherence Tomography

Philipp Steven, MD1; Carolin Le Blanc1; Kai Velten, PhD2; Eva Lankenau, PhD3; Marc Krug, PhD3; Stefan Oelckers, PhD4; Ludwig M. Heindl, MD1; Uta Gehlsen, PhD1; Gereon Hüttmann, PhD5; Claus Cursiefen, MD1
[+] Author Affiliations
1Department of Ophthalmology, University of Cologne, Cologne, Germany
2Process Engineering Department, Hochschule Geisenheim University, Geisenheim, Germany
3OptoMedical Technologies GmbH, Luebeck, Germany
4Moeller-Wedel GmbH, Wedel, Germany
5Institute of Biomedical Optics, University of Luebeck, Luebeck, Germany
JAMA Ophthalmol. 2013;131(9):1135-1142. doi:10.1001/jamaophthalmol.2013.4672.
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Importance  Descemet membrane endothelial keratoplasty (DMEK) is a challenging procedure for the surgeon, particularly because of deficient visibility of the delicate tissue due to the natural en face view through the operating microscope. A cross-sectional view would greatly enhance intraoperative overview and enable the surgeon to better control the procedure.

Objective  To retrospectively analyze the use of intraoperative optical coherence tomography (iOCT) for improving the safety of DMEK.

Design  Intraoperative OCT during DMEK was performed in 26 eyes of 26 patients. We retrospectively analyzed imaging and video data.

Setting  Department of Ophthalmology, University of Cologne.

Participants  Seven men and 19 women aged 39 to 93 years with corneal endothelial dysfunction undergoing DMEK.

Exposure  Descemet membrane endothelial keratoplasty.

Main Outcomes and Measures  Visibility of surgical steps, overall duration of DMEK, overall time for complete intraoperative air filling of the anterior chamber, and correlation between donor age and Descemet rolling behavior.

Results  Intraoperative OCT enables visualization of all steps of the DMEK procedure. Overall mean (SD) duration of the DMEK procedure was 25.7 (6.9) minutes when using iOCT. Overall mean (SD) complete intraoperative anterior chamber air-filling time was 236 (108) seconds in contrast to 60 to 90 minutes for standard air-filling time. Descemet membrane rolling behavior showed significant inverse correlation between donor age (range, 39-93 years) and the extent of rolling (R2 = 0.5 [P = .006]).

Conclusions and Relevance  Intraoperative OCT enhances the visibility of graft orientation and unfolding, thereby improving safety of the DMEK procedure. Overall, iOCT is a helpful device that may support surgeons in all steps of DMEK procedures.

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Figure 1.
Intraoperative Optical Coherence Tomography (OCT) Setup During Posterior Lamellar Keratoplasty

The OCT camera (asterisk) and display are directly mounted at the operating microscope, enabling the surgeon to monitor real-time OCT images without distinctive head movement.

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Figure 2.
Intraoperative Optical Coherence Tomography (OCT) Enables Real-Time Visualization of All DMEK Steps

Steps are described in order of performance. A, Graft preparation. DM indicates Descemet membrane; EP, epithelium; ST, stroma. B, Graft rolling behavior. C, DM stripping (arrows). D, Graft localization within the anterior chamber (arrows demonstrate inward rolling behavior of DM edges, with correct graft positioning). E, Graft localization and shape after initial air filling (arrows indicate graft). Virtual inversion of the cornea was caused by an OCT imaging artifact, in which the imaged tissue depth partly exceeded the range in which OCT can uniquely determine the axial position of the scattering structures. Frequency-domain OCT then folds all tissue structures above the upper image margin downwards. F, Control of graft attachment during air-filling time (arrowheads indicate complete attachment; arrow, interface fluid).

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Figure 3.
Descemet Membranes Feature Different Rolling Behaviors

Donor age less than 60 years is correlated with strong rolling activity (multilamellar shape), whereas donor age 60 years and greater is correlated with less rolling activity (open-spiral shape).

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Figure 4.
Mean Curvature c Correlation With Age

Increasing age is inversely correlated with decreasing curvature of donor graft roll (regression line, c = −0.0323 × age + 3.28; R2 = 0.5).

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Figure 5.
Real-Time Visualization of Descemet Membrane (DM) Grafts Within Anterior Chamber

A-F, Real-time visualization of DM grafts within anterior chamber in 6 representative cases. Intraoperative optical coherence tomography enables the surgeon to control graft location and unfolding even when recipient corneas exhibit reduced transparency. Arrows indicate the endothelial side of the DM.

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Figure 6.
Intraoperative Visualization of Descemet Membrane Apposition to Posterior Surface of Recipient Stroma

During air-filling time, localized graft nonattachment (arrows) is monitored and reduced by drainage maneuvers until intraoperative optical coherence tomography ensures attachment of the entire graft at the end of surgery. This monitoring helps to reduce time of complete anterior chamber air fill.

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