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Original Investigation |

Determination of Feasibility and Utility of Microscope-Integrated Optical Coherence Tomography During Ophthalmic Surgery The DISCOVER Study RESCAN Results

Justis P. Ehlers, MD1; Jeff Goshe, MD2; William J. Dupps, MD, PhD1; Peter K. Kaiser, MD1; Rishi P. Singh, MD1; Richard Gans, MD2; Jonathan Eisengart, MD2; Sunil K. Srivastava, MD1
[+] Author Affiliations
1Ophthalmic Imaging Center, Cleveland, Ohio
2Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio
JAMA Ophthalmol. 2015;133(10):1124-1132. doi:10.1001/jamaophthalmol.2015.2376.
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Published online

Importance  Optical coherence tomography (OCT) has transformed the clinical management of a myriad of ophthalmic conditions. Applying OCT to ophthalmic surgery may have implications for surgical decision making and patient outcomes.

Objective  To assess the feasibility and effect on surgical decision making of a microscope-integrated intraoperative OCT (iOCT) system.

Design, Setting, and Participants  Report highlighting the 1-year results (March 2014–February 2015) of the RESCAN 700 portion of the DISCOVER (Determination of Feasibility of Intraoperative Spectral Domain Microscope Combined/Integrated OCT Visualization During En Face Retinal and Ophthalmic Surgery) study, a single-site, multisurgeon, prospective consecutive case series regarding this investigational device. Participants included patients undergoing ophthalmic surgery. Data on clinical characteristics were collected, and iOCT was performed during surgical milestones, as directed by the operating surgeon. A surgeon questionnaire was issued to each surgeon and was completed after each case to evaluate the role of iOCT during surgery and its particular role in select surgical procedures.

Main Outcomes and Measures  Percentage of cases with successful acquisition of iOCT (ie, feasibility). Percentage of cases in which iOCT altered surgical decision making (ie, utility).

Results  During year 1 of the DISCOVER study, a total of 227 eyes (91 anterior segment cases and 136 posterior segment cases) underwent imaging with the RESCAN 700 system. Successful imaging (eg, the ability to acquire an OCT image of the tissue of interest) was obtained for 224 of 227 eyes (99% [95% CI, 98%-100%]). During lamellar keratoplasty, the iOCT data provided information that altered the surgeon’s decision making in 38% of the cases (eg, complete graft apposition when the surgeon believed there was interface fluid). In membrane peeling procedures, iOCT information was discordant with the surgeon’s impression of membrane peel completeness in 19% of cases (eg, lack of residual membrane or presence of occult membrane), thus affecting additional surgical maneuvers.

Conclusions and Relevance  The DISCOVER study demonstrates the feasibility of real-time iOCT with a microscope-integrated iOCT system for ophthalmic surgery. The information gained from iOCT appears to allow surgeons to assess subtle details in a unique perspective from standard en face visualization, which can affect surgical decision making some of the time, although the effect of these changes in decision making on outcomes remains unknown. A prospective randomized masked trial is needed to confirm these results.

Figures in this Article

Figures

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Figure 1.
Intraoperative Optical Coherence Tomography of Descemet Stripping Automated Endothelial Keratoplasty

The arrowheads indicate interface fluid.

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Figure 2.
Intraoperative Optical Coherence Tomography (iOCT) of Lamellar Keratoplasty

A, iOCT during Descemet membrane endothelial keratoplasty (DMEK) graft placement (2 arrowheads). B, iOCT during deep anterior lamellar keratoplasty (DALK) revealing corneal striae (arrowhead) and dissection depth (double arrow). C, iOCT during DALK showing bare Descemet membrane (arrowhead) following stromal removal.

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Figure 3.
Real-Time Intraoperative Optical Coherence Tomography (iOCT) of Membrane Peeling

A, iOCT during peeling reveals membranes (white arrowheads) with shadowing from metal (yellow arrowheads). B, iOCT of membrane scraper with shadowing from diamonds (yellow arrowhead) and membrane edge (white arrowhead).

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Figure 4.
Intraoperative Optical Coherence Tomography (iOCT) for Retinal Detachment and Proliferative Diabetic Retinopathy

A, The black arrowhead points to a possible retinal detachment. B, The white arrowheads point to the traction retinal detachment, and the yellow arrowheads point to dense membranes. C, The white arrowhead points to the proliferative diabetic retinopathy with focal traction, and the asterisk indicates the visible surgical plane.

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Multimedia

Video 1.

Descemet Stripping Automated Endothelial Keratoplasty

Video shows initial portion of host Descemet membrane removal. Following removal the graft is placed in the anterior chamber and an air bubble infusion facilitates graft-host apposition. Residual interface fluid is visualized and decreases over time.

Video 2.

Vitrectomy With Membrane Peeling for Complex Myopic Schisis

Following staining with triamcinolone and indocyanine green, the membrane is engaged and readily peeled from the retinal surface using a membrane loop. Following membrane removal, intraoperative optical coherence tomography reveals a prominent residual membrane that requires additional peeling.

Video 3.

Intraoperative Optical Coherence Tomography During Vitrectomy for Proliferative Diabetic Retinopathy

During surgical repair, the surgeon directs the aiming beam throughout the posterior pole to identify areas of traction and potential areas for safe dissection.

Video 4.

Intraoperative Optical Coherence Tomography During Choroidal Biopsy

Vitreous cutter is directly placed into the choroidal lesion. Intraoperative optical coherence tomography allows visualization of the entry into the lesion, the actual motion of the vitreous cutter, and the final depth of the biopsy.

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