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Dynamic intraoperative optical coherence tomography for inverted internal limiting membrane flap technique in large macular hole surgery

  • Retinal Disorders
  • Published:
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Abstract

Background/objectives

To assess the efficacy of dynamic intraoperative spectral-domain optical coherence tomography (iSD-OCT) imaging for inverted internal limiting membrane (ILM) flap technique (IILMFT) in large macular hole (MH) surgery.

Subjects/methods

Prospective, non-randomized, observational study was conducted on 8 eyes of 7 patients with large, chronic and recurrent MHs, which were treated by pars plana vitrectomy (PPV) with IILMFT. All patients underwent standard pre- and postoperative examination. The iSD-OCT imaging was performed using microscope integrated systems before, during, and after ILM peeling. The iSD-OCT data were post-processed using graphic software and reviewed for tissue behavior and instruments position.

Results

The real-time iSD-OCT-assisted IILMFT allowed for real-time imaging of the entire surgery with visualization of the MH, vitreoretinal instruments, and all steps of inverted ILM flap formation. In spite of shadowing created by the steel instruments, it was possible to follow and control the distance between the instrument tips and retinal layers. Dynamic imaging of the surgical maneuvers including ILM peeling and mechanical apposition of MH edges revealed the iatrogenic impact on the retina (depression and appearance of hyporeflective zones). iSD-OCT imaging could confirm the proper position of the inverted ILM flap at the very end of the surgery after fluid-air exchange.

Conclusions

iSD-OCT imaging is an effective tool for learning and performing a well-controlled and safe inverted ILM flap technique in patients with large MH. Clinical significance of the structural iSD-OCT findings has to be further studied.

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Funding

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Author information

Authors and Affiliations

  1. Department of Ophthalmology, Justus Liebig University, University Hospital Giessen and Marburg GmbH, Campus Giessen, Friedrichstrasse 18, 35392, Giessen, Germany

    Lyubomyr M. Lytvynchuk & Birgit Lorenz

  2. Karl Landsteiner Institute for Retinal Research and Imaging, Juchgasse 25, 1030, Vienna, Austria

    Lyubomyr M. Lytvynchuk, Christiane I. Falkner-Radler, Katharina Krepler, Carl G. Glittenberg, Daniel Ahmed & Siamak Ansari-Shahrezaei

  3. Department of Ophthalmology, Rudolf Foundation Hospital, Juchgasse 25, 1030, Vienna, Austria

    Christiane I. Falkner-Radler, Katharina Krepler, Carl G. Glittenberg, Daniel Ahmed, Siamak Ansari-Shahrezaei & Susanne Binder

  4. Center for Eye Research, Department of Ophthalmology, Oslo University Hospital and University of Oslo, Oslo, Norway

    Goran Petrovski

  5. Department of Ophthalmology, Medical University of Graz, Graz, Austria

    Siamak Ansari-Shahrezaei

  6. Retina Center Vienna, Jacquingasse 41, 1030, Vienna, Austria

    Siamak Ansari-Shahrezaei & Susanne Binder

  7. Department of Ophthalmology, Eye Center Donaustadt, Sigmund Freud University, Zschokkegasse 140, 1220, Vienna, Austria

    Susanne Binder

Authors
  1. Lyubomyr M. Lytvynchuk
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Corresponding author

Correspondence to Lyubomyr M. Lytvynchuk.

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Conflict of interest

Author Lyubomyr M. Lytvynchuk declares that he has no conflict of interest related to this study. Author Christiane I. Falkner-Radler declares that she has no conflict of interest related to this study. Author Katharina Krepler declares that she has no conflict of interest related to this study. Author Carl G. Glittenberg declares that he has no conflict of interest related to this study. Author Daniel Ahmed declares that he has no conflict of interest related to this study. Author Goran Petrovski declares that he has no conflict of interest related to this study. Author Birgit Lorenz declares that she has no conflict of interest related to this study. Author Siamak Ansari-Shahrezaei declares that he has no conflict of interest related to this study. Author Susanne Binder is a consultant for Carl Zeiss Meditech (Oberkochen, Germany).

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

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Informed consent was obtained from all individual participants included in the study.

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Electronic supplementary material

Video 1

Surgical flow of iSD-OCT assisted classical IILMFT (case 4). (MP4 37,960 kb)

Video 2

Dynamic iSD-OCT imaging of inverted ILM flap technique at the end of the surgery in Case 8 (imaged with EnFocus™, Leica Mikrosysteme Vertrieb GmbH, Wetzlar, Germany). (MP4 2834 kb)

Video 3

iSD-OCT imaging of response of the retinal tissue on the ILM peeling: 1 - Initiation of ILM flap with depression of the retina; 2 - Appearance of hyporeflective zone during ILM peeling (case 5). (MP4 13,266 kb)

Video 4

Mechanical apposition of the MH edges performed with the closed branches of end-gripping forceps. Slow motion section demonstrates the application of pressure to the retinal surface. The distance between the forceps tip and RPE was controlled with iSD-OCT imaging. (MP4 15,616 kb)

Video 5

Centripetal direction of the peeling forces during inverted ILM flap technique prevents MH edges from elevation (case 4). (MP4 5831 kb)

Video 6

Enlargement of the MH base during conventional circumferential ILM peeling. Circumferential ILM peeling created traction forces on MH edges and outer retinal layers (Discussion). (MP4 6079 kb)

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Lytvynchuk, L.M., Falkner-Radler, C.I., Krepler, K. et al. Dynamic intraoperative optical coherence tomography for inverted internal limiting membrane flap technique in large macular hole surgery. Graefes Arch Clin Exp Ophthalmol 257, 1649–1659 (2019). https://doi.org/10.1007/s00417-019-04364-5

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  • DOI: https://doi.org/10.1007/s00417-019-04364-5

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