0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
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.
Text Size: A A A
Published online

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.

Figures in this Article

Sign in

Create a free personal account to sign up for alerts, share articles, and more.

Purchase Options

• Buy this article
• Subscribe to the journal

Figures

Place holder to copy figure label and caption
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.

Graphic Jump Location
Place holder to copy figure label and caption
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).

Graphic Jump Location
Place holder to copy figure label and caption
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).

Graphic Jump Location
Place holder to copy figure label and caption
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).

Graphic Jump Location
Place holder to copy figure label and caption
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.

Graphic Jump Location
Place holder to copy figure label and caption
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.

Graphic Jump Location

Tables

References

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 4

Sign in

Create a free personal account to sign up for alerts, share articles, and more.

Purchase Options

• Buy this article
• Subscribe to the journal

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
Jobs
brightcove.createExperiences();