Intra-operative optical coherence tomography in glaucoma surgery-a systematic review

Cost-effectiveness of the ADVISE trial: An intraoperative OCT protocol in DMEK surgery

The intraoperative optical coherence tomography (iOCT) is recently introduced in Descemet membrane endothelial keratoplasty (DMEK) surgery, which aims to increase clinical performance and surgery safety. However, the acquisition of this modality is a substantial investment. The objective of this paper is to report on the cost-effectiveness of an iOCT-protocol in DMEK surgery with the Advanced Visualization in Corneal Surgery Evaluation (ADVISE) trial. This cost-effectiveness analysis uses data 6 months postoperatively from the multicentre prospective randomized clinical ADVISE trial. Sixty-five patients were randomized to usual care (n = 33) or the iOCT-protocol (n = 32). Quality-Adjusted Life Years (EQ-5D-5L), Vision-related Quality of Life (NEI-VFQ-25) and self-administered resources questionnaires were administered. Main outcome is the incremental cost-effectiveness ratio (ICER) and sensitivity analyses. The iOCT protocol reports no statistical difference in ICER. For the usual care group compared with the iOCT protocol, respectively, the mean societal costs are €5027 compared with €4920 (Δ€107). The sensitivity analyses report the highest variability on time variables. This economic evaluation learned that there is no added value in quality of life or cost-effectiveness in using the iOCT protocol in DMEK surgery. The variability of cost variables depends on the characteristics of an eye clinic. The added value of iOCT could gain incrementally by increasing surgical efficiency, and aiding in surgical decision-making.

Microfluidics in the eye: a review of glaucoma implants from an engineering perspective

Glaucoma is a progressive optic neuropathy in the eye, which is a leading cause of irreversible blindness worldwide and currently affects over 70 million individuals. Clinically, intraocular pressure (IOP) reduction is the only proven treatment to halt the progression of glaucoma. Microfluidic devices such as glaucoma drainage devices (GDDs) and minimally invasive glaucoma surgery (MIGS) devices are routinely used by ophthalmologists to manage elevated IOP, by creating an artificial pathway for the over-accumulated aqueous humor (AH) in a glaucomatous eye, when the natural pathways are severely blocked. Herein, a detailed modelling and analysis of both the natural microfluidic pathways of the AH in the eye and artificial microfluidic pathways formed additionally by the various glaucoma implants are conducted to provide an insight into the causes of the IOP abnormality and the improvement schemes of current implant designs. The mechanisms of representative glaucoma implants have been critically reviewed from the perspective of microfluidics, and we have categorized the current implants into four groups according to the targeted drainage sites of the AH, namely Schlemm's canal, suprachoroidal space, subconjunctival space, and ocular surface. In addition, we propose to divide the development and evolution of glaucoma implant designs into three technological waves, which include microtube (1st), microvalve (2nd) and microsystem (3rd). With the emerging trends of minimal invasiveness and artificial intelligence in the development of medical implants, we envision that a comprehensive glaucoma treatment microsystem is on the horizon, which is featured with active and wireless control of IOP, real-time continuous monitoring of IOP and aqueous rate, etc. The current review could potentially cast light on the unmatched needs, challenges, and future directions of the microfluidic structural and functional designs of glaucoma implants, which would enable an enhanced safety profile, reduced complications, increased efficacy of lowering IOP and reduced IOP fluctuations, closed-loop and on-demand control of IOP, etc.

Intraoperative Optical Coherence Tomography for Ab Interno Trabecular Bypass Glaucoma Surgery

ABSTRACT

The purpose of this study was to demonstrate a case of a novel surgical technique utilizing intraoperative optical coherence tomography (iOCT) to aid implantation and optimal placement of 2 trabecular bypass minimally invasive glaucoma surgery devices-the iStent inject W and the Hydrus microstent. In iStent inject W implantation, where the depth of stent implantation has been correlated to postoperative outcomes. the iOCT allowed real-time appreciation of device implantation depth relative to the trabecular meshwork surface. In Hydrus microstent implantation, the iOCT allowed confirmation of successful stent placement within the Schlemm canal, and may help in cases where intraoperative gonioscopic view of the 3 microstent windows is impeded. This case demonstrated the use of the iOCT as an imaging adjunct to ensure optimal placement of trabecular bypass minimally invasive glaucoma surgery devices such as the iStent inject W and Hydrus microstent.

Recent Advancements in Glaucoma Surgery-A Review

Surgery has long been an important treatment for limiting optic nerve damage and minimising visual loss in patients with glaucoma. Numerous improvements, modifications, and innovations in glaucoma surgery over recent decades have improved surgical safety, and have led to earlier and more frequent surgical intervention in glaucoma patients at risk of vision loss. This review summarises the latest advancements in trabeculectomy surgery, glaucoma drainage device (GDD) implantation, and minimally invasive glaucoma surgery (MIGS). A comprehensive search of MEDLINE, EMBASE, and CENTRAL databases, alongside subsequent hand searches-limited to the past 10 years for trabeculectomy and GDDs, and the past 5 years for MIGS-yielded 2283 results, 58 of which were included in the final review (8 trabeculectomy, 27 GDD, and 23 MIGS). Advancements in trabeculectomy are described in terms of adjunctive incisions, Tenon's layer management, and novel suturing techniques. Advancements in GDD implantation pertain to modifications of surgical techniques and devices, novel methods to deal with postoperative complications and surgical failure, and the invention of new GDDs. Finally, the popularity of MIGS has recently promoted modifications to current surgical techniques and the development of novel MIGS devices.

Diagnostic accuracy of optical coherence tomography for margin assessment in breast-conserving surgery: A systematic review and meta-analysis

BACKGROUND

Breast cancer is the most common malignant tumor among women, and its incidence is increasing annually. At present, the results of the study on whether optical coherence tomography (OCT) can be used as an intraoperative margin assessment method for breast-conserving surgery (BCS) are inconsistent. We herein conducted this systematic review and meta-analysis to assess the diagnostic value of OCT in BCS.

METHODS

PubMed, Web of Science, Cochrane Library, and Embase were used to search relevant studies published up to September 15, 2022. We used Review Manager 5.4, Meta-Disc 1.4, and STATA 16.0 for statistical analysis.

RESULTS

The results displayed 18 studies with 782 patients included according to the inclusion and exclusion criteria. Meta-analysis showed the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and the area under the curve (AUC) of OCT in the margin assessment of BCS were 0.91 (95% CI 0.88-0.93), 0.88 (95% CI 0.83-0.92), 7.53 (95% CI 5.19-10.93), 0.11(95% CI 0.08-0.14), 70.37 (95% CI 39.78-124.47), and 0.94 (95% CI 0.92-0.96), respectively.

CONCLUSIONS

OCT is a promising technique in intraoperative margin assessment of breast cancer patients.

Evaluation of the Use of Intraoperative OCT in Routine Surgery: A Two-year Comparison

BACKGROUND

In recent years, an increasing number of surgical microscopes fitted with an OCT module (intraoperative OCT, iOCT) have become available, providing high-resolution images of the surgical site in real time. While a 2018 survey at our hospital showed that iOCT delivered an additional intraoperative benefit in only 2.4% of all operations, considering that the manufacturer had since revised the hardware and software, we conducted a second user evaluation of this technology.

MATERIAL AND METHODS

Prospective monocentric analysis of the application and user-friendliness of an EnFocus Ultra-Deep OCT (Leica Microsystems) over a period of 25 (2018) and 20 working days (2021). A standardized questionnaire was used to assess the surgeons' use of iOCT and its influence on the surgical course.

RESULTS

118 operations were performed over a 25-day period in 2018 and 92 operations were performed over a 20-day period in 2021. In 2018, iOCT was used in 24.6% and in 2021 in 48.9% of all surgeries, with iOCT proving to be "critical" to the surgical course in 2.4% and 3.3% of cases, respectively, as assessed by the surgeons in both years. These were operations in which the intraocular view was limited, e.g., with decompensated cornea, vitreous hemorrhage, or after previous surgery, e.g., after penetrating keratoplasty.

CONCLUSION

Further development of the user interface led to an improvement in usability, and the iOCT was used significantly more often. In both years, the iOCT proved to be critical for the course of the surgery in a comparably small number of operations, especially those involving complex situations.

Anterior segment imaging in minimally invasive glaucoma surgery - A systematic review

Minimally invasive glaucoma surgery (MIGS) has grown in popularity over the past decade. This systematic review explores the peri-operative and intraoperative application of anterior segment imaging to maximize the efficacy and safety of MIGS. A review of the PubMed, EMBASE and CINAHL databases was conducted, with inclusion criteria restricted to MIGS that had received United States Food and Drug Administration (FDA) premarket approval, FDA 510(K) premarket notification, or were listed as a class 1 device exempt from FDA approval or notification. 21 manuscripts from 21 unique studies were identified pertaining to MIGS devices including the XEN Gel Stent, Trabectome, iStent Inject, 1st-generation iStent and the Kahook Dual Blade (KDB). Anterior segment imaging modalities included anterior segment optical coherence tomography (AS-OCT), ultrasound biomicroscopy (UBM), aqueous angiography, OCT volumetric scans and in vivo confocal microscopy. Identification and evaluation of aqueous outflow pathways before and after MIGS have potential for improving patient preoperative patient selection and postoperative outcomes. Intraoperative imaging potentially provides the resolution needed for good visualization of angle anatomy and accurate evaluation of surgical endpoints in angle-based MIGS. Anterior segment imaging has been used to identify procedural complications, provide objective information on implant location in relation to surrounding anatomy, assess the post-implantation structural impact of MIGS devices and manage bleb failure and scarring. Technical difficulties in incorporating imaging modalities into the surgical microscope, variable quality of images and optical interference from ocular structures or surgical instruments are remaining barriers, which discourage the widespread clinical use of this technology.

Optical Coherence Tomography and Glaucoma

Early detection and monitoring are critical to the diagnosis and management of glaucoma, a progressive optic neuropathy that causes irreversible blindness. Optical coherence tomography (OCT) has become a commonly utilized imaging modality that aids in the detection and monitoring of structural glaucomatous damage. Since its inception in 1991, OCT has progressed through multiple iterations, from time-domain OCT, to spectral-domain OCT, to swept-source OCT, all of which have progressively improved the resolution and speed of scans. Even newer technological advancements and OCT applications, such as adaptive optics, visible-light OCT, and OCT-angiography, have enriched the use of OCT in the evaluation of glaucoma. This article reviews current commercial and state-of-the-art OCT technologies and analytic techniques in the context of their utility for glaucoma diagnosis and management, as well as promising future directions. Expected final online publication date for the Annual Review of Vision Science, Volume 7 is September 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Intraoperative Versus Postoperative Vault Measurement After Implantable Collamer Lens Implantation in a Large Cohort of Patients

PURPOSE

To compare intraoperative and postoperative central vault measurement after implantable Collamer lens (ICL; STAAR Surgical) implantation using optical coherence tomography (OCT).

METHODS

A total of 574 eyes of 338 consecutive patients undergoing myopic ICL implantation were evaluated (mean age of 30.8 ± 5.7 years, 117 men and 221 women). Central ICL vault was measured both intraoperatively using the microscope-integrated iOCT (Optomedical Technologies GmbH) mounted on a standard surgical microscope (HS Hi-R NEO 900A; Haag-Streit Surgical GmbH), and postoperatively using the CASIA2 swept-source OCT (Tomey GmbH) at 4 and 24 hours.

RESULTS

Mean differences between intraoperative and postoperative vault values were 11.5 ± 29.0% of the mean value 4 hours postoperatively (P < .001) and 2.7 ± 33.5% of the mean value 24 hours postoperatively (P < .001). Correlation analysis shows significant agreement between vault values obtained intraoperatively and at the two postoperative times, 4 hours (Spearman Rho = 0.850, P < .001) and 24 hours (Spearman Rho = 0.745, P < .001). In 73% of cases, postoperative vault values 4 hours after the surgery could be predicted from intraoperative vault values, and so were 56% of vault values 1 day after surgery. Significant differences in vault were found at the different times, grouping cases by ICL size (Kruskal-Wallis, P = .028 for intraoperative vault, and P < .001 for both postoperative vault times), with smaller vault values for the smaller ICL size.

CONCLUSIONS

Intraoperative determination of ICL vault using iOCT is an effective method for predicting postoperative ICL vault and minimizing postoperative vault surprises that could require surgical retouching. [J Refract Surg. 2021;37(7):477-483.].

Agreement between intraoperative anterior segment spectral-domain OCT and 2 swept-source OCT biometers

Purpose: To evaluate the agreement of different biometric parameters obtained using intraoperative spectral-domain optical coherence tomography (SD-OCT) and two swept-source optical coherence tomography (SS-OCT) based biometers.Methods: 102 eyes were assessed using the intraoperative SD-OCT integrated into the Catalys femtosecond-laser, and the IOLMaster 700 and Anterion SS-OCT-based-biometers. Central corneal thickness (CCT), anterior chamber depth (ACD), white-to-white (WTW), and lens thickness (LT) were measured.Results: There were statistically significant differences for CCT, ACD, WTW and LT between devices (p < 0.001). The mean difference for ACD ranged from -0.067 to -0.250 mm, with the largest mean difference being between the IOLMaster 700 and Catalys. CCT mean differences ranged from 7 to 32 µm, with the largest mean difference being between the Anterion and Catalys. For WTW, the comparison between the IOLMaster 700 vs Catalys showed the largest mean difference (0.38 mm). However, the mean differences for LT from all three devices were quite similar, ranging from -0.02 to -0.08 mm.Conclusions: SS-OCT biometers showed good agreement for ACD, CCT, WTW and LT. The SD-OCT showed ACD, CCT and WTW values that do not seem to be interchangeable with the SS-OCT biometers; however, this device did show excellent agreement in the case of LT.

Feasibility of microscope-integrated swept-source optical coherence tomography in canaloplasty

Background

Several researchers have used commercial microscope-integrated optical coherence tomography (OCT) systems in glaucoma surgery, including ab interno trabeculectomy and canaloplasty. However, the 840 nm wavelength light source of the OCT systems is not ideal for imaging the anterior chamber angle structures because of its limited penetration. We evaluated the potential value of a microscope-integrated swept-source OCT system with a 1,310 nm center-wavelength light in canaloplasty for glaucoma.

Methods

Sixteen porcine eyes were used to simulate canaloplasty. The critical surgical steps were monitored using a prototype microscope-integrated OCT system with a 1,310 nm light source and a high axial scan rate of 100 kHz. The images from swept-source OCT and three-dimensional images from the microscope were projected simultaneously onto a liquid crystal display three-dimensional monitor (LMD-4251TD, Sony, Japan). The changes in the collector vessel (aqueous drainage structure in the porcine eye, similar to Schlemm’s canal in humans) were measured using Image J software. Histological sections stained with hematoxylin and eosin were used to assess surgical efficacy.

Results

High-resolution real-time images of the anterior segment were acquired during canaloplasty using the microscope-integrated OCT system. With the real-time OCT images, the position of the collector vessel was identified and the scleral flap could be created at the ideal location. The expansion of the collector vessel after viscoelastic injection was also visualized in real time. Compared with baseline, there was a significant increase in the cross-sectional area (from 14,502.98±9,242.55 to 59,499.04±20,506.41 µm², P<0.001) of the collector vessel.

Conclusions

Using the microscope-integrated OCT system, real-time images of the anterior segment were successfully acquired during the operation. The microscope-integrated OCT system might be useful in future anti-glaucoma surgery.

Intraoperative optical coherence tomography in anterior segment surgery

Intraoperative optical coherence tomography (iOCT) enables real-time visualization of ocular structures during surgery and enhances our understanding of intraoperative dynamics. iOCT aids in decision-making during various anterior segment surgeries, and its efficacy and feasibility in anterior lamellar keratoplasty and endothelial keratoplasty is well established. The landmark DISCOVER study observed that iOCT altered the surgeon decision in 38% of cases undergoing lamellar keratoplasty and provided guidance regarding the need for secondary surgical intervention. iOCT also finds an application in phacoemulsification wherein it helps to assess corneal incisions, intralenticular pressure, and posterior capsule integrity during nuclear emulsification. iOCT aids in the visualization of angle structures during placement of tubes and shunts in glaucoma surgeries and allows precise creation of partial thickness scleral flaps. In addition, iOCT helps in establishing a diagnosis, as well as provide intraoperative guidance, in pediatric patients who are not cooperative for examination. The role of iOCT in refractive surgeries and ocular surface disorders is increasingly being evaluated. The limitations of present-day iOCT systems are related to instrument compatibility, automated tracking of the surgical field, and on-table volumetric analysis of the real-time images. Technological advances may facilitate complete integration of OCT in the surgical microscopes for all surgical procedures.