VISUALIZATION FROM INTRAOPERATIVE SWEPT-SOURCE MICROSCOPE-INTEGRATED OPTICAL COHERENCE TOMOGRAPHY IN VITRECTOMY FOR COMPLICATIONS OF PROLIFERATIVE DIABETIC RETINOPATHY

Abstract

Purpose: To evaluate the use of live volumetric (4D) intraoperative swept-source microscope-integrated optical coherence tomography in vitrectomy for proliferative diabetic retinopathy complications.

Methods: In this prospective study, we analyzed a subgroup of patients with proliferative diabetic retinopathy complications who required vitrectomy and who were imaged by the research swept-source microscope-integrated optical coherence tomography system. In near real time, images were displayed in stereo heads-up display facilitating intraoperative surgeon feedback. Postoperative review included scoring image quality, identifying different diabetic retinopathy-associated pathologies and reviewing the intraoperatively documented surgeon feedback.

Results: Twenty eyes were included. Indications for vitrectomy were tractional retinal detachment (16 eyes), combined tractional-rhegmatogenous retinal detachment (2 eyes), and vitreous hemorrhage (2 eyes). Useful, good-quality 2D (B-scans) and 4D images were obtained in 16/20 eyes (80%). In these eyes, multiple diabetic retinopathy complications could be imaged. Swept-source microscope-integrated optical coherence tomography provided surgical guidance, e.g., in identifying dissection planes under fibrovascular membranes, and in determining residual membranes and traction that would benefit from additional peeling. In 4/20 eyes (20%), acceptable images were captured, but they were not useful due to high tractional retinal detachment elevation which was challenging for imaging.

Conclusion: Swept-source microscope-integrated optical coherence tomography can provide important guidance during surgery for proliferative diabetic retinopathy complications through intraoperative identification of different complications and facilitation of intraoperative decision making.

Conflict of interest statement

Conflict of Interest Disclosures: Dr. Toth reported receiving royalties through her university from Alcon. Dr. Izatt reported being chairman and chief scientific advisor for Bioptigen, Inc (since acquired by Leica Microsystems), and holding corporate, equity, and intellectual property interests (including royalties) in this company. Dr. Izatt and Dr. Toth are inventors on issued and pending patents pertaining to the technology described in this article. No other disclosures were reported.

Figures

Fig. 1

An example of a case with poor image quality. Due to complexity of pathology and high tractional retinal detachment, intraoperative swept-source microscope-integrated OCT could not distinguish the retina form the fibrovascular membranes in 2D and 3D images.

Fig. 2

Intraoperative swept-source microscope-integrated OCT shows retinoschisis. B-scan (2D) and 3D images show the subsurface columnar retinal tissues characteristic of retinoschisis.

Fig. 3

Intraoperative swept-source microscope-integrated OCT shows subretinal and intraretinal fluid in 2D (B-scan) and 3D images

Fig. 4

Intraoperative swept-source microscope-integrated OCT shows focal versus broad attachment of the fibrovascular membrane to the retina. Above row: B-scan (2D) and 3D images of focal membrane attachment. Below row: B-scan (2D) and 3D images of broad membrane attachment

Fig. 5

Intraoperative swept-source microscope-integrated OCT shows laser scars as adhesions bridging choroid to detached retina (red circles). While the B-scans (left column) look the same, the 3D images (right column) show the spatial configuration of the laser scars from 2 different angles (through volume rotation) in relation to the detached retina.

Fig. 6

B-scan from Intraoperative swept-source microscope-integrated OCT shows small full thickness hole (arrow) detected inferior to the fovea with minimal residual membranes at the edges of the hole.

Fig. 7

Intraoperative swept-source microscope-integrated OCT guidance of viscodissection of a tightly adherent fibrovascular membrane. Above row: B-scans, below row: 3D images. A1, 2) Images show the membrane overlying the retina. B1, 2) Images show an initial partial thickness hole (arrow) created in the membrane which did not allow for viscoelastic injection. C1, 2) Images show the hole (arrow) after being converted to full thickness allowing viscoelastic injection. D1, 2) Starting dissection of the membrane from the retina as the viscoelastic being injected. E1, 2) Progression of the membrane dissection from the retina with more viscoelastic injection and more space created between the retina and the membrane. F1) Vitrectomy cutter tip (circle) going through the hole in the space created by viscoelastic to interact with membrane. F2) Hole and cutter tip (circle) as visualized from the under surface of the membrane with the help of volume rotation. A2, B2, F1: Artifacts(*)

Fig. 8

B-scan from intraoperative swept-source microscope-integrated OCT shows deroofed macular cyst noted during release of vitreomacular traction.