Abstract
Intraoperative optical coherence tomography (OCT) has been a transformative technology for corneal surgery. This chapter illustrates its use for endothelial keratoplasty (EK), deep anterior lamellar keratoplasty (DALK), and for evaluating intraocular lens and Implantable Collamer Lens (ICL) placement. We use it most often for Descemet membrane endothelial keratoplasty (DMEK), and as a result, never have to place orientation marks on the donor tissue. The most transformative change has been with DALK, where feedback from the OCT allows the surgeon to obtain visual outcomes with manual/peeling dissection that can match the visual outcomes obtained with big bubble dissection. The iOCT™ enables the surgeon to see the OCT image in real time through the oculars rather than having to look away at a screen to see the OCT details. In DMEK cases, this allows the surgeon to see the graft orientation while the tissue is being manipulated, and in DALK cases, this allows the surgeon to see the depth of the peripheral dissection plane to make sure it is deep enough prior to starting a peel.
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Type 1 and Type 2 big bubbles. This eye has many small bubbles in the anterior chamber after air escaped through the trabecular meshwork during corneal air injection to create a big bubble. A Type 1 bubble formed, but also note the slight irregularity on the left side of the anterior corneal surface as the image scans across the corneal bed. This irregularity marks the edge of a Type 2 bubble, which formed between the stroma and Descemet membrane. The Type 2 bubble can be hard to appreciate with the OCT at this low magnification, but looking closely one may observe a change in the pattern of the anterior chamber bubbles, which have been pushed aside by the type 2 bubble. Type 2 bubbles can form centrally, or peripherally. (MP4 128767 kb)
An ALK case with a thick, irregular dissection bed. Manual dissection across the cornea can produce an irregular bed, because it is difficult for the surgeon to accurately assess the depth of the dissection plane or the regularity of the bed with the coaxial microscope. Bed irregularities may lead to poor visual results, so this irregular bed should be re-dissected. Peel techniques minimize bed irregularity, especially if the peeling is initiated at a very deep level. Note the cross-sectional thickness variation of the dissection bed in the iOCT™ inset as the view is scanned across the cornea. (M4V 18355 kb)
Example of double anterior chamber formation during cataract surgery performed after DALK. This eye had a large diameter DALK for keratoconus. The sutures had all been removed and the patient later had cataract surgery. Cataract surgery was initiated with a superior incision, but the approach was difficult so that incision was sutured closed. The surgeon changed to a temporal keratome incision, which was closed with one suture at end of the cataract procedure. In the video, the stab incision is being hydrated closed. While hydrating the incision, a fluid wave could be seen going across the cornea and the iOCT™ showed separation of the recipient bed from the DALK graft. A calibrated diamond blade is used to make an incision through the DALK graft into the area with the fluid pocket, or double anterior chamber. Tying forceps were used to open the incision to drain the fluid pocket. Intermittently, as needed, fluid was injected into the anterior chamber through the superior incision to raise the intraocular pressure to push fluid out of the drainage incision. The iOCT™ shows the fluid pocket decreasing in size until it is gone and the DALK is once again in perfect apposition with the recipient cornea. The eye looked perfect the next day. (MP4 192260 kb)
Showing use of the iOCT™ to detect and aspirate a residual nuclear fragment that had caused inferior corneal decompensation after uncomplicated cataract surgery. (MP4 332301 kb)
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Price, F.W., Gang, A., Price, M.O. (2023). Intraoperative OCT in Anterior Segment Surgery. In: Alió, J.L., del Barrio, J.L.A. (eds) Modern Keratoplasty. Essentials in Ophthalmology. Springer, Cham. https://doi.org/10.1007/978-3-031-32408-6_38
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DOI: https://doi.org/10.1007/978-3-031-32408-6_38
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