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Lucchino L, Visioli G, Scarinci F, Colabelli Gisoldi RAM, Komaiha C, Marenco M, Pocobelli G, Lambiase A, Pocobelli A. Tomographic and topographic predictive factors of big bubble formation during deep anterior lamellar keratoplasty in keratoconus. Br J Ophthalmol 2024:bjo-2024-325810. [PMID: 39197954 DOI: 10.1136/bjo-2024-325810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 08/13/2024] [Indexed: 09/01/2024]
Abstract
PURPOSE To identify preoperative predictors of big bubble (BB) formation during deep anterior lamellar keratoplasty (DALK) in patients with keratoconus (KC). METHODS DESIGN: Retrospective cohort study in an Italian tertiary centre. STUDY POPULATION Consecutive patients with KC undergoing DALK from January 2021 to July 2023. OBSERVATION PROCEDURE Tomographic and topographic data including K-max, K-mean, keratometric astigmatism, thinnest point, mean peripheral corneal thickness, difference between the mean peripheral corneal thickness and the thinnest point (peripheral-minimal corneal thickness), position (central/paracentral) and cone area (%), Amsler-Krumeich classification and anterior segment optical coherence tomography (AS-OCT) analysis to assess the severity stage. MAIN OUTCOME MEASURES Rate of BB formation and type; multivariate logistic regression analysis was used to analyse all preoperative parameters in patients with BB formation versus failure. RESULTS Pneumatic dissection succeeded in 98 of 140 eyes (70.0%), with 94 type 1 bubbles (67.1%) and four type 2 bubbles (2.9%). BB formation succeeded more frequently in patients with lower K-max (p=0.032), lower K-mean (p=0.010), higher thinnest point (p=0.017), lower peripheral-minimal corneal thickness (p=0.009) and lower Amsler-Krumeich stages (p=0.021). According to the AS-OCT analysis, BB formation was more frequent in the lower stages (p<0.001). After the logistic regression (pseudo-R²=0.176, constant=3.21, 95% CI 1.14 to 5.29, p=0.002), AS-OCT classification was found to be the only factor that predicted BB formation (coefficient=-0.81, 95% CI -1.18 to -0.43, p<0.001). CONCLUSIONS AS-OCT classification is a reliable predictor for BB formation. Tomographic and topographic analyses indicated that a steeper and more ectatic cornea is more prone to BB failure.
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Affiliation(s)
- Luca Lucchino
- Department of Sense Organs, Sapienza - University of Rome, Rome, Italy
| | - Giacomo Visioli
- Department of Sense Organs, Sapienza - University of Rome, Rome, Italy
| | - Fabio Scarinci
- UOC Oftalmologia - Banca degli Occhi, San Giovanni Addolorata Hospital, Rome, Italy
| | | | - Chiara Komaiha
- UOC Oftalmologia - Banca degli Occhi, San Giovanni Addolorata Hospital, Rome, Italy
| | - Marco Marenco
- Department of Sense Organs, Sapienza - University of Rome, Rome, Italy
| | - Giulio Pocobelli
- Department of Microbiology, Immunology, Infectious Diseases, and Transplants (MIMIT), University of Rome Tor Vergata, Rome, Italy
| | | | - Augusto Pocobelli
- UOC Oftalmologia - Banca degli Occhi, San Giovanni Addolorata Hospital, Rome, Italy
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Opfermann JD, Wang Y, Kaluna J, Suzuki K, Gensheimer W, Krieger A, Kang JU. Design and Evaluation of an Eye Mountable AutoDALK Robot for Deep Anterior Lamellar Keratoplasty. MICROMACHINES 2024; 15:788. [PMID: 38930758 PMCID: PMC11205909 DOI: 10.3390/mi15060788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/10/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024]
Abstract
Partial-thickness corneal transplants using a deep anterior lamellar keratoplasty (DALK) approach has demonstrated better patient outcomes than a full-thickness cornea transplant. However, despite better clinical outcomes from the DALK procedure, adoption of the technique has been limited because the accurate insertion of the needle into the deep stroma remains technically challenging. In this work, we present a novel hands-free eye mountable robot for automatic needle placement in the cornea, AutoDALK, that has the potential to simplify this critical step in the DALK procedure. The system integrates dual light-weight linear piezo motors, an OCT A-scan distance sensor, and a vacuum trephine-inspired design to enable the safe, consistent, and controllable insertion of a needle into the cornea for the pneumodissection of the anterior cornea from the deep posterior cornea and Descemet's membrane. AutoDALK was designed with feedback from expert corneal surgeons and performance was evaluated by finite element analysis simulation, benchtop testing, and ex vivo experiments to demonstrate the feasibility of the system for clinical applications. The mean open-loop positional deviation was 9.39 µm, while the system repeatability and accuracy were 39.48 µm and 43.18 µm, respectively. The maximum combined thrust of the system was found to be 1.72 N, which exceeds the clinical penetration force of the cornea. In a head-to-head ex vivo comparison against an expert surgeon using a freehand approach, AutoDALK achieved more consistent needle depth, which resulted in fewer perforations of Descemet's membrane and significantly deeper pneumodissection of the stromal tissue. The results of this study indicate that robotic needle insertion has the potential to simplify the most challenging task of the DALK procedure, enable more consistent surgical outcomes for patients, and standardize partial-thickness corneal transplants as the gold standard of care if demonstrated to be more safe and more effective than penetrating keratoplasty.
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Affiliation(s)
- Justin D. Opfermann
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD 21218, USA; (J.K.); (K.S.); (A.K.)
- Laboratory for Computational Sensing and Robotics, Johns Hopkins University, Baltimore, MD 21218, USA; (Y.W.); (J.U.K.)
| | - Yaning Wang
- Laboratory for Computational Sensing and Robotics, Johns Hopkins University, Baltimore, MD 21218, USA; (Y.W.); (J.U.K.)
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - James Kaluna
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD 21218, USA; (J.K.); (K.S.); (A.K.)
- Laboratory for Computational Sensing and Robotics, Johns Hopkins University, Baltimore, MD 21218, USA; (Y.W.); (J.U.K.)
| | - Kensei Suzuki
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD 21218, USA; (J.K.); (K.S.); (A.K.)
| | - William Gensheimer
- Ophthalmology Section, White River Junction Veterans Affairs Medical Center, White River Junction, VT 05009, USA;
- Ophthalmology Section, Dartmouth—Hitchcock Medical Center, Lebanon, NH 03766, USA
| | - Axel Krieger
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD 21218, USA; (J.K.); (K.S.); (A.K.)
- Laboratory for Computational Sensing and Robotics, Johns Hopkins University, Baltimore, MD 21218, USA; (Y.W.); (J.U.K.)
| | - Jin U. Kang
- Laboratory for Computational Sensing and Robotics, Johns Hopkins University, Baltimore, MD 21218, USA; (Y.W.); (J.U.K.)
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
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Britten A, Matten P, Nienhaus J, Masch JM, Dettelbacher K, Roodaki H, Hecker-Denschlag N, Leitgeb RA, Drexler W, Pollreisz A, Schmoll T. Visualization of Cataract Surgery Steps With 4D Microscope-Integrated Swept-Source Optical Coherence Tomography in Ex Vivo Porcine Eyes. Transl Vis Sci Technol 2024; 13:18. [PMID: 38607633 PMCID: PMC11019595 DOI: 10.1167/tvst.13.4.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/19/2024] [Indexed: 04/13/2024] Open
Abstract
Purpose To investigate the visualization capabilities of high-speed swept-source optical coherence tomography (SS-OCT) in cataract surgery. Methods Cataract surgery was simulated in wet labs with ex vivo porcine eyes. Each phase of the surgery was visualized with a novel surgical microscope-integrated SS-OCT with a variable imaging speed of over 1 million A-scans per second. It was designed to provide four-dimensional (4D) live-volumetric videos, live B-scans, and volume capture scans. Results Four-dimensional videos, B-scans, and volume capture scans of corneal incision, ophthalmic viscosurgical device injection, capsulorrhexis, phacoemulsification, intraocular lens (IOL) injection, and position of unfolded IOL in the capsular bag were recorded. The flexibility of the SS-OCT system allowed us to tailor the scanning parameters to meet the specific demands of dynamic surgical steps and static pauses. The entire length of the eye was recorded in a single scan, and unfolding of the IOL was visualized dynamically. Conclusions The presented novel visualization method for fast ophthalmic surgical microscope-integrated intraoperative OCT imaging in cataract surgery allowed the visualization of all major steps of the procedure by achieving large imaging depths covering the entire eye and high acquisition speeds enabling live volumetric 4D-OCT imaging. This promising technology may become an integral part of routine and advanced robotic-assisted cataract surgery in the future. Translational Relevance We demonstrate the visualization capabilities of a cutting edge swept-source OCT system integrated into an ophthalmic surgical microscope during cataract surgery.
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Affiliation(s)
- Anja Britten
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | | | - Jonas Nienhaus
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | | | - Katharina Dettelbacher
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | | | | | - Rainer A. Leitgeb
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Drexler
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Andreas Pollreisz
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Tilman Schmoll
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
- Carl Zeiss Meditec, Inc., Dublin, CA, USA
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Du K, Liu E, Li N, Yuan B, Peng R, Hong J. Comparison of Femtosecond Laser Assistance and Manual Trephination in Deep Anterior Lamellar Keratoplasty in the Treatment of Keratoconus: A Meta-Analysis. Am J Ophthalmol 2023; 256:126-137. [PMID: 37553035 DOI: 10.1016/j.ajo.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 08/10/2023]
Abstract
PURPOSE To compare the efficacy and safety of femtosecond laser-assisted deep anterior lamellar keratoplasty (F-DALK) with those of manual-trephination DALK (M-DALK) in treating keratoconus. DESIGN Systematic review and meta-analysis. METHODS Through November 2022, we comprehensively searched PubMed, EMBASE, the Cochrane Library, and 4 Chinese databases. Studies that involved comparisons between F-DALK and M-DALK groups and that reported on relevant efficacy and/or safety parameters were included. Primary outcomes were uncorrected- and corrected-distance visual acuity and intraoperative complication rates. Secondary outcomes were spherical equivalent, topographic astigmatism, refractive cylinder, mean keratometry, endothelial cell density, suture removal time, and postoperative complication rates. These data were analyzed using Cochrane Review Manager software version 5.3. RESULTS This meta-analysis included 9 nonrandomized controlled studies involving 1713 eyes. In eyes treated with F-DALK, corrected-distance visual acuity at 1 to 6 months (weighted mean difference = -0.07 [95% confidence interval {CI} -0.10 to -0.03]; I2 = 0%; P < .001) after surgery was better and intraoperative Descemet membrane perforation occurred less often (odds ratio = 0.53 [95% CI 0.31-0.92]; I2 = 6%; P = .02) than in eyes treated with M-DALK. No clinically significant differences in other outcomes were found among the groups. CONCLUSIONS Both F-DALK and M-DALK are safe and efficacious for patients with keratoconus. Compared with M-DALK, F-DALK can provide better early visual acuity and reduce the intraoperative perforation rate, and its likely improvements to long-term visual quality and endothelial cell preservation warrant further investigation. In addition, the 2 techniques seem to be comparable regarding refractive outcomes and other complications.
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Affiliation(s)
- Kaiyue Du
- Department of Ophthalmology (K.D., E.L., B.Y., R.P., J.H.), Peking University Third Hospital, Beijing, China; Key Laboratory of Vision Loss and Restoration (K.D., E.L., B.Y., R.P., J.H.), Ministry of Education, Beijing, China
| | - Enshuo Liu
- Department of Ophthalmology (K.D., E.L., B.Y., R.P., J.H.), Peking University Third Hospital, Beijing, China; Key Laboratory of Vision Loss and Restoration (K.D., E.L., B.Y., R.P., J.H.), Ministry of Education, Beijing, China
| | - Nan Li
- Peking University Third Hospital (N.L.), Beijing, China
| | - Bowei Yuan
- Department of Ophthalmology (K.D., E.L., B.Y., R.P., J.H.), Peking University Third Hospital, Beijing, China; Key Laboratory of Vision Loss and Restoration (K.D., E.L., B.Y., R.P., J.H.), Ministry of Education, Beijing, China
| | - Rongmei Peng
- Department of Ophthalmology (K.D., E.L., B.Y., R.P., J.H.), Peking University Third Hospital, Beijing, China; Key Laboratory of Vision Loss and Restoration (K.D., E.L., B.Y., R.P., J.H.), Ministry of Education, Beijing, China
| | - Jing Hong
- Department of Ophthalmology (K.D., E.L., B.Y., R.P., J.H.), Peking University Third Hospital, Beijing, China; Key Laboratory of Vision Loss and Restoration (K.D., E.L., B.Y., R.P., J.H.), Ministry of Education, Beijing, China.
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Zhao Y, Jablonka AM, Maierhofer NA, Roodaki H, Eslami A, Maier M, Nasseri MA, Zapp D. Comparison of Robot-Assisted and Manual Cannula Insertion in Simulated Big-Bubble Deep Anterior Lamellar Keratoplasty. MICROMACHINES 2023; 14:1261. [PMID: 37374846 DOI: 10.3390/mi14061261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023]
Abstract
This study aimed to compare the efficacy of robot-assisted and manual cannula insertion in simulated big-bubble deep anterior lamellar keratoplasty (DALK). Novice surgeons with no prior experience in performing DALK were trained to perform the procedure using manual or robot-assisted techniques. The results showed that both methods could generate an airtight tunnel in the porcine cornea, and result in successful generation of a deep stromal demarcation plane representing sufficient depth reached for big-bubble generation in most cases. However, the combination of intraoperative OCT and robotic assistance received a significant increase in the depth of achieved detachment in non-perforated cases, comprising a mean of 89% as opposed to 85% of the cornea in manual trials. This research suggests that robot-assisted DALK may offer certain advantages over manual techniques, particularly when used in conjunction with intraoperative OCT.
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Affiliation(s)
- Yinzheng Zhao
- Klinik und Poliklinik für Augenheilkunde, Technische Universität München, 81675 München, Germany
| | - Anne-Marie Jablonka
- Klinik und Poliklinik für Augenheilkunde, Technische Universität München, 81675 München, Germany
| | - Niklas A Maierhofer
- Klinik und Poliklinik für Augenheilkunde, Technische Universität München, 81675 München, Germany
| | - Hessam Roodaki
- Translational Research Lab, Carl Zeiss Meditec AG, 81379 München, Germany
| | - Abouzar Eslami
- Translational Research Lab, Carl Zeiss Meditec AG, 81379 München, Germany
| | - Mathias Maier
- Klinik und Poliklinik für Augenheilkunde, Technische Universität München, 81675 München, Germany
| | - Mohammad Ali Nasseri
- Klinik und Poliklinik für Augenheilkunde, Technische Universität München, 81675 München, Germany
| | - Daniel Zapp
- Klinik und Poliklinik für Augenheilkunde, Technische Universität München, 81675 München, Germany
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Mirzayev I, Gündüz AK, Aydın Ellialtıoğlu P, Gündüz ÖÖ. Clinical applications of anterior segment swept-source optical coherence tomography: A systematic review. Photodiagnosis Photodyn Ther 2023; 42:103334. [PMID: 36764640 DOI: 10.1016/j.pdpdt.2023.103334] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/25/2023] [Accepted: 02/07/2023] [Indexed: 02/11/2023]
Abstract
Optical coherence tomography (OCT) is a non-invasive method that provides the opportunity to examine tissues by taking cross-sectional images. OCT is increasingly being used to evaluate anterior segment (AS) pathologies. Swept-source (SS) OCT allows greater penetration and achieves better visualization of the internal configuration of AS tissues due to the longer wavelength employed and high scan speeds. We reviewed the utilization of AS SS-OCT in various conditions including glaucoma, ocular surface pathologies, iris tumors, refractive surgery, cataract surgery, and scleral diseases. A systematic literature search was carried out on PubMed, Scopus, and Web of Science databases between January 1, 2008, and September 1, 2022 using the following keywords: AS SS-OCT; dry eye and SS-OCT; ocular surface and SS-OCT; cornea and SS-OCT; dystrophy and SS-OCT; glaucoma and SS-OCT; ocular surface tumors and SS-OCT; conjunctival tumors and SS-OCT; refractive surgery and SS-OCT; cataract and SS-OCT; biometry and SS-OCT; sclera and SS-OCT; iris and SS-OCT; ciliary body and SS-OCT; artificial intelligence and SS-OCT. A total of 221 studies were included in this review. Review of the existing literature shows that SS-OCT offers several advantages in the diagnosis of AS diseases. Exclusive features of SS-OCT including rapid scanning, deeper tissue penetration, and better image quality help improve our understanding of various AS pathologies.
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Affiliation(s)
- Ibadulla Mirzayev
- Department of Ophthalmology, Ankara University Faculty of Medicine, Ankara, Turkey; Halil Şıvgın Çubuk State Hospital, Ophthalmology Clinic, Ankara, Turkey
| | - Ahmet Kaan Gündüz
- Department of Ophthalmology, Ankara University Faculty of Medicine, Ankara, Turkey; Private Eye Clinic, Ankara, Turkey.
| | | | - Ömür Özlenen Gündüz
- Department of Ophthalmology, Ankara University Faculty of Medicine, Ankara, Turkey
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Malyugin BE, Belodedova A, Antonova O, Gelyastanov A, Tuuminen R, Levinger E, Achiron A, Knyazer B. Clinical comparison of manual and laser-cut corneal tunnel for intrastromal air injection in femtosecond laser-assisted deep anterior lamellar keratoplasty (DALK). Graefes Arch Clin Exp Ophthalmol 2023; 261:185-191. [PMID: 35896678 DOI: 10.1007/s00417-022-05765-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/30/2022] [Accepted: 07/09/2022] [Indexed: 01/04/2023] Open
Abstract
PURPOSE The most crucial step in deep anterior lamellar keratoplasty (DALK) is to achieve a bare Descemet's membrane. We aimed to assess a new femtosecond laser software that allows for a precise intrastromal tunnel creation for big bubble (BB) air injection using a real-time microscope-integrated optical coherence tomography. MATERIALS AND METHODS A retrospective review of 61 eyes of 61 patients with keratoconus. Before introducing the new software update, DALK was performed using a partial-assisted femtosecond laser (partial-thickness circular cut followed by a lamellar cut) with manual intrastromal tunnel creation (partial FS-DALK group). After the software update, the femtosecond laser created the intrastromal tunnel (full FS-DALK group). RESULTS In the full FS-DALK group, the BB's formation was significantly higher (64.3% vs. 36.4%, p = 0.04), and surgery time was shorter (21.8 ± 5.1 vs. 25.6 ± 6.8 min, p = 0.025) than in the partial FS-DALK. Penetrating keratoplasty conversion rate (7.1% vs. 15.1%, p = 0.432) was similar between the groups. Both groups showed statistically significant improvement in uncorrected and corrected distance visual acuity, central corneal thickness, surface asymmetry, and regularity indices. Endothelial cell density loss at 12 and 18 months was lower in the full compared with the partial FS-DALK group (12 months:10.0% vs. 16; 18 months: 10.7 vs. 16.5%, p < 0.001 for both comparisons). CONCLUSIONS Creating the intrastromal guiding tunnel using FS laser for air injection resulted in a higher rate of BB formation, reduced long-term endothelial cell loss, and operating room time.
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Affiliation(s)
- Boris E Malyugin
- S. Fyodorov Eye Microsurgery Federal State Institution, Beskudnikovsky Blvd., 59a, 127486, Moscow, Russian Federation. .,A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russian Federation. .,Department of Ophthalmology, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Alexandra Belodedova
- S. Fyodorov Eye Microsurgery Federal State Institution, Beskudnikovsky Blvd., 59a, 127486, Moscow, Russian Federation
| | - Olga Antonova
- S. Fyodorov Eye Microsurgery Federal State Institution, Beskudnikovsky Blvd., 59a, 127486, Moscow, Russian Federation
| | - Aslan Gelyastanov
- S. Fyodorov Eye Microsurgery Federal State Institution, Beskudnikovsky Blvd., 59a, 127486, Moscow, Russian Federation
| | - Raimo Tuuminen
- Helsinki Retina Research Group, University of Helsinki, Helsinki, Finland.,Department of Ophthalmology, Kymenlaakso Central Hospital, Kotka, Finland
| | - Eliya Levinger
- Tel-Aviv Sourasky Medical Center and Sackler School of Medicine, Sackler Faculty of Medicine, Tel Aviv University, Dafna St 5, Tel Aviv-Yafo, Israel
| | - Asaf Achiron
- Tel-Aviv Sourasky Medical Center and Sackler School of Medicine, Sackler Faculty of Medicine, Tel Aviv University, Dafna St 5, Tel Aviv-Yafo, Israel.
| | - Boris Knyazer
- Department of Ophthalmology, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Iovieno A, Fontana L, Coassin M, Bovio D, Salito C. Ex Vivo Evaluation of a Pressure-Sensitive Device to Aid Big Bubble Intrastromal Dissection in Deep Anterior Lamellar Keratoplasty. Transl Vis Sci Technol 2022; 11:17. [PMID: 36580320 PMCID: PMC9804022 DOI: 10.1167/tvst.11.12.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Purpose To develop and perform ex vivo testing for a device designed for semiquantitative determination of intracorneal dissection depth during big bubble (BB) deep anterior lamellar keratoplasty. Methods A prototype device connected to a syringe and cannula was designed to determine depth of intrastromal placement based on air rebound pressure emitted by a software controlled generator. Ex vivo testing of the device was conducted on human corneas mounted on an artificial anterior chamber in three experiments: (1) cannula purposely introduced at different depths measured with anterior segment optical coherence tomography, (2) cannula introduced as per the BB technique, and (3) simulation of the BB technique guided by the device. Results A positive pressure differential and successful BB were observed only when the cannula was positioned within 150 microns from the endothelial plane. In all successful BB cases (21/40), a repeatable increase in tissue rebound pressure was detected, which was not recorded in unsuccessful cases. The device was able to signal to the surgeon correct placement of the cannula (successful BB) in 16 of 17 cases and incorrect placement of the cannula (unsuccessful BB) in 8 of 8 cases (94.1% sensitivity, 100% specificity). Conclusions In our ex vivo model, this novel medical device could reliably signal cannula positioning in the deep stroma for effective pneumatic dissection and possibly aid technical execution of BB deep anterior lamellar keratoplasty. Translational Relevance A medical device that standardizes big bubble deep anterior lamellar keratoplasty could increase the overall success rate of the surgical procedure and aid popularization of deep anterior lamellar keratoplasty.
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Affiliation(s)
- Alfonso Iovieno
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, British Columbia, Canada,IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Luigi Fontana
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Marco Coassin
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy,Department of Ophthalmology, University Campus Bio-medico, Rome, Italy
| | - Dario Bovio
- Biocubica Biomedical Engineering, Milan, Italy
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Surgical Advancements in Corneal Transplantation. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00335-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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10
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Tian Y, Draelos M, McNabb RP, Hauser K, Kuo AN, Izatt JA. Optical coherence tomography refraction and optical path length correction for image-guided corneal surgery. BIOMEDICAL OPTICS EXPRESS 2022; 13:5035-5049. [PMID: 36187253 PMCID: PMC9484446 DOI: 10.1364/boe.464762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/05/2022] [Accepted: 08/21/2022] [Indexed: 06/16/2023]
Abstract
Optical coherence tomography (OCT) may be useful for guidance of ocular microsurgeries such as deep anterior lamellar keratoplasty (DALK), a form of corneal transplantation that requires delicate insertion of a needle into the stroma to approximately 90% of the corneal thickness. However, visualization of the true shape of the cornea and the surgical tool during surgery is impaired in raw OCT volumes due to both light refraction at the corneal boundaries, as well as geometrical optical path length distortion due to the group velocity of broadband OCT light in tissue. Therefore, uncorrected B-scans or volumes may not provide an accurate visualization suitable for reliable surgical guidance. In this article, we introduce a method to correct for both refraction and optical path length distortion in 3D in order to reconstruct corrected OCT B-scans in both natural corneas and corneas deformed by needle insertion. We delineate the separate roles of phase and group index in OCT image distortion correction, and introduce a method to estimate the phase index from the group index which is readily measured in samples. Using the measured group index and estimated phase index of human corneas at 1060 nm, we demonstrate quantitatively accurate geometric reconstructions of the true cornea and inserted needle shape during simulated DALK surgeries.
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Affiliation(s)
- Yuan Tian
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA
| | - Mark Draelos
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA
| | - Ryan P. McNabb
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA
| | - Kris Hauser
- Department of Computer Science, University of Illinois Urbana-Champaign, Urbana, IL 61801, USA
| | - Anthony N. Kuo
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA
- Department of Ophthalmology, Duke University Medical Center, Durham, NC 27710, USA
| | - Joseph A. Izatt
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA
- Department of Ophthalmology, Duke University Medical Center, Durham, NC 27710, USA
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Edwards W, Tang G, Tian Y, Draelos M, Izatt J, Kuo A, Hauser K. Data-Driven Modelling and Control for Robot Needle Insertion in Deep Anterior Lamellar Keratoplasty. IEEE Robot Autom Lett 2022; 7:1526-1533. [PMID: 37090091 PMCID: PMC10117280 DOI: 10.1109/lra.2022.3140458] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Deep anterior lamellar keratoplasty (DALK) is a technique for cornea transplantation which is associated with reduced patient morbidity. DALK has been explored as a potential application of robot microsurgery because the small scales, fine control requirements, and difficulty of visualization make it very challenging for human surgeons to perform. We address the problem of modelling the small scale interactions between the surgical tool and the cornea tissue to improve the accuracy of needle insertion, since accurate placement within 5% of target depth has been associated with more reliable clinical outcomes. We develop a data-driven autoregressive dynamic model of the tool-tissue interaction and a model predictive controller to guide robot needle insertion. In an ex vivo model, our controller significantly improves the accuracy of needle positioning by more than 40% compared to prior methods.
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Affiliation(s)
- William Edwards
- Department of Computer Science, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
| | - Gao Tang
- Department of Computer Science, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
| | - Yuan Tian
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA
| | - Mark Draelos
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA
| | - Joseph Izatt
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA
| | - Anthony Kuo
- Department of Ophthalmology, Duke University, Durham, NC 27710, USA
| | - Kris Hauser
- Department of Computer Science, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
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Guo S, Opfermann J, Gemsheimer WG, Krieger A, Kang JU. Downward viewing common-path optical coherence tomography guided hydro-dissection needle for DALK. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2022; 11953:1195308. [PMID: 36277992 PMCID: PMC9583597 DOI: 10.1117/12.2607813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Deep anterior lamellar keratoplasty (DALK) is a partial-thickness cornea transplant procedure in which only the recipient's stroma is replaced, leaving the host's Descemet's membrane (DM) and endothelium intact. This highly challenging "Big Bubble" procedure requires micron accuracy to insert a hydro-dissection needle as close as possible to the DM. Here, we report the design and evaluation of a downward viewing common-path optical coherence tomography (OCT) guided hydro-dissection needle for DALK. This design offers the flexibility of using different insertion angles and needle sizes. With the fiber situated outside the needle and eye, the needle can use its' full lumen for a smoother air/fluid injection and image quality is improved. The common-path OCT probe uses a bare optical fiber with its tip cleaved at the right angle for both reference and sample arm which is encapsulated in a 25-gauge stainless still tube. The fiber was set up vertically with a half-ball epoxy lens at the end to provide an A-scan with an 11-degree downward field of view. The hydro dissection needle was set up at 70 degrees from vertical and the relative position between the fiber end and the needle tip remained constant during the insertion. The fiber and needle were aligned by a customized needle driver to allow the needle tip and tissue underneath to both be imaged within the same A-scan. Fresh porcine eyes (N = 5) were used for the studies. The needle tip position, the stroma, and DM were successfully identified from the A-scan during the whole insertion process. The results showed the downward viewing OCT distal sensor can accurately guide the needle insertion for DALK and improved the average insertion depth compared to freehand insertion.
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Affiliation(s)
- Shoujing Guo
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, USA 21218
| | - Justin Opfermann
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA, 21218
| | - William G. Gemsheimer
- Department of Ophthalmology, White River Junction VA Medical Center, VT, USA, 05009
- Department of Ophthalmology, Dartmouth-Hitchcock, NH, USA, 03766
| | - Axel Krieger
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA, 21218
| | - Jin U. Kang
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, USA 21218
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Reply: Remote corneal suturing wet lab: microsurgical education during the COVID-19 pandemic. J Cataract Refract Surg 2021; 47:556-557. [PMID: 33770427 DOI: 10.1097/j.jcrs.0000000000000619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Characterization of Endothelial Cell Loss in Pre-Descemet Endothelial Keratoplasty Graft Preparation. Cornea 2020; 40:364-369. [PMID: 33278083 DOI: 10.1097/ico.0000000000002536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 07/31/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To characterize the pattern and factors affecting endothelial cell loss (ECL) in pre-Descemet Endothelial Keratoplasty (PDEK) graft preparation. METHODS A prospective study was performed to characterize the pattern of ECL and the impact of inflation pressure in PDEK. Donor corneas were randomized to inflation with air versus Optisol GS storage media. PDEK preparation was performed under continuous pressure monitoring. Trypan blue was used to grade the tissue as acceptable (<25% ECL) or unacceptable (≥25% ECL). Rate of unacceptable ECL was correlated with injection media type and inflation pressure. A retrospective study was then performed of all attempted PDEK preparations at Lions Gift of Sight to evaluate impact of donor tissue factors on ECL. Donor age and tissue preservation time were evaluated and correlated with ECL with PDEK bubbling. RESULTS Twenty-five corneas were tested prospectively. A reticular pattern of ECL that varied in severity occurred with bubbling. There was no difference in peak inflation pressure or mean expansion pressure between air (706.0, 510.7 mm Hg) and Optisol GS (852.9, 653.0 mm Hg). Increasing peak inflation pressure and mean expansion pressure were associated with an increased risk for unacceptable ECL. On retrospective evaluation of 131 attempted PDEKs, only 44.0% of cases with successful bubbles had acceptable endothelium after processing. Increasing donor age and decreasing preservation time were associated with increased rates of acceptable endothelium. CONCLUSIONS PDEK processing can result in a reticular pattern of ECL. Higher inflation pressures are associated with greater ECL. Older donor tissues with shorter preservation times might be preferable for PDEK.
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Pasricha ND, Haq Z, Ahmad TR, Chan L, Redd TK, Seitzman GD, Parikh N, Kim TN, Schallhorn JM, Ramanathan S. Remote corneal suturing wet lab: microsurgical education during the COVID-19 pandemic. J Cataract Refract Surg 2020; 46:1667-1673. [PMID: 32769754 PMCID: PMC7446976 DOI: 10.1097/j.jcrs.0000000000000374] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
PURPOSE To study the feasibility and efficacy of a new remote wet lab for microsurgical education using a corneal suturing task. SETTING Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA. DESIGN Prospective randomized controlled study. METHODS Ten ophthalmology residents were stratified by postgraduate year and randomized to perform a corneal suturing task consisting of placing the 4 cardinal sutures for a penetrating keratoplasty in porcine eyes with or without remote ophthalmology attending feedback. Subsequently, both groups repeated the same task without remote feedback to test whether initial remote feedback affected subsequent performance. Finally, the group without feedback was crossed over to repeat the same corneal suturing task with remote feedback. The effectiveness of the remote wet lab was assessed subjectively by survey and objectively by grading each suture pass. RESULTS Resident-reported comfort with corneal suturing improved significantly after the remote wet lab for all residents. Residents and attendings rated the remote wet lab as equally or more effective compared with previous in-person wet labs and overall effective in corneal suturing. Attendings rated the remote wet lab as effective in multiple domains of microsurgical education using a modified microsurgical global rating scale. Objective corneal suturing performance was similar for both groups. CONCLUSIONS The remote wet lab was feasible and effective for training ophthalmology residents in corneal suturing. This represents a new social distancing compliant platform for microsurgical education during the COVID-19 pandemic.
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Affiliation(s)
- Neel D Pasricha
- From the Department of Ophthalmology (Pasricha, Haq, Chan, Redd, Seitzman, Parikh, Kim, Schallhorn, Ramanathan), School of Medicine (Ahmad), and Francis I. Proctor Foundation (Redd, Seitzman, Schallhorn), University of California San Francisco, San Francisco, California, USA
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Gadhvi KA, Romano V, Fernández-Vega Cueto L, Aiello F, Day AC, Gore DM, Allan BD. Femtosecond Laser-Assisted Deep Anterior Lamellar Keratoplasty for Keratoconus: Multi-surgeon Results. Am J Ophthalmol 2020; 220:191-202. [PMID: 32707206 DOI: 10.1016/j.ajo.2020.07.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/11/2020] [Accepted: 07/14/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To compare the clinical outcomes in femtosecond laser-assisted deep anterior lamellar keratoplasty (F-DALK) to manual non-laser deep anterior lamellar keratoplasty (M-DALK) for keratoconus in a multi-surgeon public healthcare setting. DESIGN Single-center, comparative, retrospective interventional case series. METHODS Population: Consecutive cases of keratoconus treated with big-bubble F-DALK from August 1, 2015, to September 1, 2018 and big-bubble M-DALK from September 1, 2012, to September 30, 2016. SETTING Moorfields Eye Hospital, London. OBSERVATIONS Data on preoperative status, operative details, intraoperative and postoperative complications, secondary interventions, and visual outcomes were archived on a customized spreadsheet for analysis. MainOutcomeMeasures: Rate of intraoperative perforation and conversion to penetrating keratoplasty (PK) and the percentage of patients, post removal of sutures (ROS), with corrected distance visual acuity (CDVA) ≥20/40. RESULTS We analyzed 58 eyes of 55 patients who underwent F-DALK and 326 eyes of 309 patients who underwent M-DALK. Intraoperative perforation of Descemet membrane occurred in 15 of 58 (25.9%) F-DALK cases compared to 148 of 326 (45.4%) M-DALK cases (P = .006). Intraoperative conversion to PK was carried out in 2 of 58 (3.4%) F-DALK cases compared to 80 of 326 (24.5%) M-DALK cases (P = .001). Post ROS, 86.5% of F-DALK eyes had a CDVA of ≥20/40 (15 ± 7.3 months after surgery) compared to 83.7% of M-DALK eyes (24.9 ± 10.6 months) (P = .825). CONCLUSION Laser automation of some steps in DALK for keratoconus may reduce the rate of intraoperative Descemet perforation and the conversion to PK in a multi-surgeon setting.
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Keller B, Draelos M, Zhou K, Qian R, Kuo A, Konidaris G, Hauser K, Izatt J. Optical Coherence Tomography-Guided Robotic Ophthalmic Microsurgery via Reinforcement Learning from Demonstration. IEEE T ROBOT 2020; 36:1207-1218. [PMID: 36168513 PMCID: PMC9511825 DOI: 10.1109/tro.2020.2980158] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
Ophthalmic microsurgery is technically difficult because the scale of required surgical tool manipulations challenge the limits of the surgeon's visual acuity, sensory perception, and physical dexterity. Intraoperative optical coherence tomography (OCT) imaging with micrometer-scale resolution is increasingly being used to monitor and provide enhanced real-time visualization of ophthalmic surgical maneuvers, but surgeons still face physical limitations when manipulating instruments inside the eye. Autonomously controlled robots are one avenue for overcoming these physical limitations. We demonstrate the feasibility of using learning from demonstration and reinforcement learning with an industrial robot to perform OCT-guided corneal needle insertions in an ex vivo model of deep anterior lamellar keratoplasty (DALK) surgery. Our reinforcement learning agent trained on ex vivo human corneas, then outperformed surgical fellows in reaching a target needle insertion depth in mock corneal surgery trials. This work shows the combination of learning from demonstration and reinforcement learning is a viable option for performing OCT guided robotic ophthalmic surgery.
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Affiliation(s)
- Brenton Keller
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Mark Draelos
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Kevin Zhou
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Ruobing Qian
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Anthony Kuo
- Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA
| | - George Konidaris
- Department of Computer Science Brown University, Providence, RI, USA
| | - Kris Hauser
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, USA
| | - Joseph Izatt
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
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Posarelli C, Sartini F, Casini G, Passani A, Toro MD, Vella G, Figus M. What Is the Impact of Intraoperative Microscope-Integrated OCT in Ophthalmic Surgery? Relevant Applications and Outcomes. A Systematic Review. J Clin Med 2020; 9:jcm9061682. [PMID: 32498222 PMCID: PMC7356858 DOI: 10.3390/jcm9061682] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/28/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Optical coherence tomography (OCT) has recently been introduced in the operating theatre. The aim of this review is to present the actual role of microscope-integrated optical coherence tomography (MI-OCT) in ophthalmology. Method: A total of 314 studies were identified, following a literature search adhering to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. After full-text evaluation, 81 studies discussing MI-OCT applications in ophthalmology were included. Results: At present, three microscope-integrated optical coherence tomography systems are commercially available. MI-OCT can help anterior and posterior segment surgeons in the decision-making process, providing direct visualization of anatomic planes before and after surgical manoeuvres, assisting in complex cases, and detecting or confirming intraoperative complications. Applications range from corneal transplant to macular surgery, including cataract surgery, glaucoma surgery, paediatric examination, proliferative diabetic retinopathy surgery, and retinal detachment surgery. Conclusion: The use of MI-OCT in ophthalmic surgery is becoming increasingly prevalent and has been applied in almost all procedures. However, there are still limitations to be overcome and the technology involved remains difficult to access and use.
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Affiliation(s)
- Chiara Posarelli
- Ophthalmology, Department of Surgical, Medical, Molecular Pathology and of the Critical Area, University of Pisa, 56126 Pisa, Italy; (C.P.); (G.C.); (A.P.); (G.V.); (M.F.)
| | - Francesco Sartini
- Ophthalmology, Department of Surgical, Medical, Molecular Pathology and of the Critical Area, University of Pisa, 56126 Pisa, Italy; (C.P.); (G.C.); (A.P.); (G.V.); (M.F.)
- Correspondence: ; Tel.: +39-050-997-675
| | - Giamberto Casini
- Ophthalmology, Department of Surgical, Medical, Molecular Pathology and of the Critical Area, University of Pisa, 56126 Pisa, Italy; (C.P.); (G.C.); (A.P.); (G.V.); (M.F.)
| | - Andrea Passani
- Ophthalmology, Department of Surgical, Medical, Molecular Pathology and of the Critical Area, University of Pisa, 56126 Pisa, Italy; (C.P.); (G.C.); (A.P.); (G.V.); (M.F.)
| | - Mario Damiano Toro
- Department of General Ophthalmology, Medical University of Lublin, 20079 Lublin, Poland;
- Faculty of Medical Sciences, Collegium Medicum Cardinal Stefan Wyszyński University, 01815 Warsaw, Poland
| | - Giovanna Vella
- Ophthalmology, Department of Surgical, Medical, Molecular Pathology and of the Critical Area, University of Pisa, 56126 Pisa, Italy; (C.P.); (G.C.); (A.P.); (G.V.); (M.F.)
| | - Michele Figus
- Ophthalmology, Department of Surgical, Medical, Molecular Pathology and of the Critical Area, University of Pisa, 56126 Pisa, Italy; (C.P.); (G.C.); (A.P.); (G.V.); (M.F.)
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Fang W, Li Q, Fan J, Tang N, Yu J, Xu H, Zong Y, Jiang C, Shi G, Sun X. Microscope-integrated Intraoperative Optical Coherence Tomography for Anterior Segment Surgical Maneuvers. Transl Vis Sci Technol 2020; 9:18. [PMID: 32832225 PMCID: PMC7414702 DOI: 10.1167/tvst.9.7.18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 04/21/2020] [Indexed: 01/26/2023] Open
Abstract
Purpose To evaluate the potential value of microscope-integrated optical coherence tomography (MI-OCT) in anterior segment surgical maneuvers. Methods Twenty-four ophthalmology residents, who were randomly and evenly divided into two groups, performed four anterior segment surgical maneuvers (corneal tunnel, scleral tunnel, simple corneal suture, and corneal laceration repair) on porcine eyes with (group B) or without (group A) real-time MI-OCT feedback. All residents performed the maneuvers again without MI-OCT. Results Compared with group A, group B (with MI-OCT) showed better accuracy in the length/depth of the corneal tunnel and the length of the scleral tunnel. However, both groups showed similar performances in the depth of both the simple corneal suture and the corneal laceration suture. When both groups performed the maneuvers again without MI-OCT, group B still showed better results than group A for the length of both the corneal and scleral tunnels. Conclusions Primary results suggest that real-time MI-OCT images are valuable for some anterior segment surgical maneuvers and could be helpful in surgical training. Translational Relevance MI-OCT systems can be valuable in improving accuracy and decision making during anterior segment surgery and will be useful in surgical training.
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Affiliation(s)
- Wangyi Fang
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Fudan University, Shanghai, 200031, People's Republic of China
- Key Laboratory of Myopia of State Health Ministry, and Key Laboratory of Visual Impairment and Restoration of Shanghai, Shanghai, 200031, People's Republic of China
| | - Qingchen Li
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Fudan University, Shanghai, 200031, People's Republic of China
- Key Laboratory of Myopia of State Health Ministry, and Key Laboratory of Visual Impairment and Restoration of Shanghai, Shanghai, 200031, People's Republic of China
| | - Jinyu Fan
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, Jiangsu Province, China
| | - Ning Tang
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, Jiangsu Province, China
| | - Jian Yu
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Fudan University, Shanghai, 200031, People's Republic of China
- Key Laboratory of Myopia of State Health Ministry, and Key Laboratory of Visual Impairment and Restoration of Shanghai, Shanghai, 200031, People's Republic of China
| | - Huan Xu
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Fudan University, Shanghai, 200031, People's Republic of China
- Key Laboratory of Myopia of State Health Ministry, and Key Laboratory of Visual Impairment and Restoration of Shanghai, Shanghai, 200031, People's Republic of China
| | - Yuan Zong
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Fudan University, Shanghai, 200031, People's Republic of China
- Key Laboratory of Myopia of State Health Ministry, and Key Laboratory of Visual Impairment and Restoration of Shanghai, Shanghai, 200031, People's Republic of China
| | - Chunhui Jiang
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Fudan University, Shanghai, 200031, People's Republic of China
- Key Laboratory of Myopia of State Health Ministry, and Key Laboratory of Visual Impairment and Restoration of Shanghai, Shanghai, 200031, People's Republic of China
| | - Guohua Shi
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, Jiangsu Province, China
| | - Xinghuai Sun
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Fudan University, Shanghai, 200031, People's Republic of China
- Key Laboratory of Myopia of State Health Ministry, and Key Laboratory of Visual Impairment and Restoration of Shanghai, Shanghai, 200031, People's Republic of China
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Guo S, Sarfaraz NR, Gensheimer WG, Krieger A, Kang JU. Demonstration of Optical Coherence Tomography Guided Big Bubble Technique for Deep Anterior Lamellar Keratoplasty (DALK). SENSORS 2020; 20:s20020428. [PMID: 31940877 PMCID: PMC7013995 DOI: 10.3390/s20020428] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 12/03/2022]
Abstract
Deep anterior lamellar keratoplasty (DALK) is a highly challenging procedure for cornea transplant that involves removing the corneal layers above Descemet’s membrane (DM). This is achieved by a “big bubble” technique where a needle is inserted into the stroma of the cornea down to DM and the injection of either air or liquid. DALK has important advantages over penetrating keratoplasty (PK) including lower rejection rate, less endothelial cell loss, and increased graft survival. In this paper, we successfully designed and evaluated the optical coherence tomography (OCT) distal sensor integrated needle for a precise big bubble technique. We successfully used this sensor for micro-control of a robotic DALK device termed AUTO-DALK for autonomous big bubble needle insertion. The OCT distal sensor was integrated inside a 25-gauge needle, which was used for pneumo-dissection. The AUTO-DALK device is built on a manual trephine platform which includes a vacuum ring to fix the device on the eye and add a needle driver at an angle of 60 degrees from vertical. During the test on five porcine eyes with a target depth of 90%, the measured insertion depth as a percentage of cornea thickness for the AUTO-DALK device was 90.05%±2.33% without any perforation compared to 79.16%±5.68% for unassisted free-hand insertion and 86.20%±5.31% for assisted free-hand insertion. The result showed a higher precision and consistency of the needle placement with AUTO-DALK, which could lead to better visual outcomes and fewer complications.
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Affiliation(s)
- Shoujing Guo
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD 21218, USA;
- Correspondence: ; Tel.: +1-443-858-6100
| | - Nicolas R. Sarfaraz
- Department of Mechanical Engineering, University of Maryland, College Park, MD 20742, USA; (N.R.S.); (A.K.)
| | - William G. Gensheimer
- Warfighter Eye Center, Malcolm Grow Medical Clinics and Surgery Center, Joint Base Andrews, MD 20762, USA;
| | - Axel Krieger
- Department of Mechanical Engineering, University of Maryland, College Park, MD 20742, USA; (N.R.S.); (A.K.)
| | - Jin U. Kang
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD 21218, USA;
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Draelos M, Tang G, Keller B, Kuo A, Hauser K, Izatt JA. Optical Coherence Tomography Guided Robotic Needle Insertion for Deep Anterior Lamellar Keratoplasty. IEEE Trans Biomed Eng 2019; 67:2073-2083. [PMID: 31751219 DOI: 10.1109/tbme.2019.2954505] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Deep anterior lamellar keratoplasty (DALK) significantly reduces the post-transplantation morbidity in patients eligible for partial-thickness cornea grafts. The popular "big bubble" technique for DALK is so challenging, however, that a significant fraction of corneal pneumodissection attempts fail for surgeons without extensive DALK-specific experience, even with previous-generation cross-sectional optical coherence tomography (OCT) guidance. We seek to develop robotic, volumetric OCT-guided technology capable of facilitating or automating the difficult needle insertion step in DALK. METHODS Our system provides for real-time volumetric corneal imaging, segmentation, and tracking of the needle insertion to display feedback for surgeons and to generate needle insertion plans for robotic execution. We include a non-automatic mode for cooperative needle control for stabilization and tremor attenuation, and an automatic mode in which needle insertion plans are generated based on OCT tracking results and executed under surgeon hold-to-run control by the robot arm. We evaluated and compared freehand, volumetric OCT-guided, cooperative, and automatic needle insertion approaches in terms of perforation rate and final needle depth in an ex vivo human cornea model. RESULTS Volumetric OCT visualization reduces cornea perforations and beneficially increases final needle depth in manual insertions by clinically significant amounts. Our automatic robotic needle insertion techniques meet or exceed surgeon performance in both needle placement and perforation rate. CONCLUSION Volumetric OCT is a key enabler for surgeons, although robotic techniques can reliably replicate their performance. SIGNIFICANCE Robotic needle control and volumetric OCT promise to improve outcomes in DALK.
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Yoo YS, Whang WJ, Kang MJ, Hwang JH, Byun YS, Yoon G, Shin S, Jung W, Moon S, Joo CK. Effect of Air Injection Depth on Big-bubble Formation in Lamellar Keratoplasty: an Ex Vivo Study. Sci Rep 2019; 9:3785. [PMID: 30846714 PMCID: PMC6405887 DOI: 10.1038/s41598-018-36522-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 11/19/2018] [Indexed: 11/09/2022] Open
Abstract
This study evaluated the effect of air injection depth in the big-bubble (BB) technique, which is used for corneal tissue preparation in lamellar keratoplasty. The BB technique was performed on ex vivo human corneoscleral buttons using a depth-sensing needle, based on optical coherence tomography (OCT) imaging technology. The needle tip, equipped with a miniaturized OCT depth-sensing probe, was inserted for air injection at a specified depth. Inside the corneal tissue, our needle obtained OCT line profiles, from which residual thickness below the needle tip was measured. Subjects were classified into Groups I, II, III, and IV based on injection depths of 75-80%, 80-85%, 85-90%, and >90% of the full corneal thickness, respectively. Both Type I and II BBs were produced when the mean residual thicknesses of air injection were 109.7 ± 38.0 µm and 52.4 ± 19.2 µm, respectively. Type II BB (4/5) was dominant in group IV. Bubble burst occurred in 1/16 cases of type I BB and 3/16 cases of type II BB, respectively. Injection depth was an important factor in determining the types of BBs produced. Deeper air injection could facilitate formation of Type II BBs, with an increased risk of bubble bursts.
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Affiliation(s)
- Young-Sik Yoo
- Department of Convergence Medical Science, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Woong-Joo Whang
- Department of Ophthalmology and Visual Science, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Min-Ji Kang
- Department of Ophthalmology and Visual Science, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Je-Hyung Hwang
- Department of Ophthalmology, Sang-gye Paik Hospital, Inje University, Seoul, South Korea
| | - Yong-Soo Byun
- Department of Ophthalmology and Visual Science, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Geunyoung Yoon
- Flaum Eye Institute, The Institute of Optics, Center for Visual Science, University of Rochester, Rochester, New York, USA
| | - Sungwon Shin
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology, Ulsan, South Korea
| | - Woonggyu Jung
- Department of Biomedical Engineering, Ulsan National Institute of Science and Technology, Ulsan, South Korea
| | - Sucbei Moon
- Department of Physics, Kookmin University, Seoul, South Korea.
| | - Choun-Ki Joo
- Department of Ophthalmology and Visual Science, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
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Keller B, Draelos M, Tang G, Farsiu S, Kuo AN, Hauser K, Izatt JA. Real-time corneal segmentation and 3D needle tracking in intrasurgical OCT. BIOMEDICAL OPTICS EXPRESS 2018; 9:2716-2732. [PMID: 30258685 PMCID: PMC6154196 DOI: 10.1364/boe.9.002716] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/08/2018] [Accepted: 05/10/2018] [Indexed: 05/09/2023]
Abstract
Ophthalmic procedures demand precise surgical instrument control in depth, yet standard operating microscopes supply limited depth perception. Current commercial microscope-integrated optical coherence tomography partially meets this need with manually-positioned cross-sectional images that offer qualitative estimates of depth. In this work, we present methods for automatic quantitative depth measurement using real-time, two-surface corneal segmentation and needle tracking in OCT volumes. We then demonstrate these methods for guidance of ex vivo deep anterior lamellar keratoplasty (DALK) needle insertions. Surgeons using the output of these methods improved their ability to reach a target depth, and decreased their incidence of corneal perforations, both with statistical significance. We believe these methods could increase the success rate of DALK and thereby improve patient outcomes.
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Affiliation(s)
- Brenton Keller
- Department of Biomedical Engineering, Duke University, Durham, NC 27708,
USA
| | - Mark Draelos
- Department of Biomedical Engineering, Duke University, Durham, NC 27708,
USA
| | - Gao Tang
- Department of Mechanical Engineering, Duke University, Durham, NC 27708,
USA
| | - Sina Farsiu
- Department of Biomedical Engineering, Duke University, Durham, NC 27708,
USA
- Department of Ophthalmology, Duke University Medical Center, Durham NC 27710,
USA
| | - Anthony N. Kuo
- Department of Biomedical Engineering, Duke University, Durham, NC 27708,
USA
- Department of Ophthalmology, Duke University Medical Center, Durham NC 27710,
USA
| | - Kris Hauser
- Department of Electrical and Computer Engineering, Duke University, Durham, NC 27701,
USA
| | - Joseph A. Izatt
- Department of Ophthalmology, Duke University Medical Center, Durham NC 27710,
USA
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24
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Shin S, Bae JK, Ahn Y, Kim H, Choi G, Yoo YS, Joo CK, Moon S, Jung W. Lamellar keratoplasty using position-guided surgical needle and M-mode optical coherence tomography. JOURNAL OF BIOMEDICAL OPTICS 2017; 22:1-7. [PMID: 29235270 DOI: 10.1117/1.jbo.22.12.125005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 11/20/2017] [Indexed: 05/12/2023]
Abstract
Deep anterior lamellar keratoplasty (DALK) is an emerging surgical technique for the restoration of corneal clarity and vision acuity. The big-bubble technique in DALK surgery is the most essential procedure that includes the air injection through a thin syringe needle to separate the dysfunctional region of the cornea. Even though DALK is a well-known transplant method, it is still challenged to manipulate the needle inside the cornea under the surgical microscope, which varies its surgical yield. Here, we introduce the DALK protocol based on the position-guided needle and M-mode optical coherence tomography (OCT). Depth-resolved 26-gage needle was specially designed, fabricated by the stepwise transitional core fiber, and integrated with the swept source OCT system. Since our device is feasible to provide both the position information inside the cornea as well as air injection, it enables the accurate management of bubble formation during DALK. Our results show that real-time feedback of needle end position was intuitionally visualized and fast enough to adjust the location of the needle. Through our research, we realized that position-guided needle combined with M-mode OCT is a very efficient and promising surgical tool, which also to enhance the accuracy and stability of DALK.
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Affiliation(s)
- Sungwon Shin
- Ulsan National Institute of Science and Technology, Department of Biomedical Engineering, Ulsan, Republic of Korea
| | - Jung Kweon Bae
- Ulsan National Institute of Science and Technology, Department of Biomedical Engineering, Ulsan, Republic of Korea
| | - Yujin Ahn
- Ulsan National Institute of Science and Technology, Department of Biomedical Engineering, Ulsan, Republic of Korea
| | - Hyeongeun Kim
- Ulsan National Institute of Science and Technology, Department of Biomedical Engineering, Ulsan, Republic of Korea
| | - Geonho Choi
- Ulsan National Institute of Science and Technology, Department of Biomedical Engineering, Ulsan, Republic of Korea
| | - Young-Sik Yoo
- Catholic University of Korea, College of Medicine, Department of Ophthalmology and Visual Science, S, Republic of Korea
| | - Choun-Ki Joo
- Catholic University of Korea, College of Medicine, Department of Ophthalmology and Visual Science, S, Republic of Korea
| | - Sucbei Moon
- Kookmin University, Department of Physics, Seoul, Republic of Korea
| | - Woonggyu Jung
- Ulsan National Institute of Science and Technology, Department of Biomedical Engineering, Ulsan, Republic of Korea
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25
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Bhullar PK, Carrasco-Zevallos OM, Dandridge A, Pasricha ND, Keller B, Shen L, Izatt JA, Toth CA, Kuo AN. Intraocular Pressure and Big Bubble Diameter in Deep Anterior Lamellar Keratoplasty: An Ex-Vivo Microscope-Integrated OCT With Heads-Up Display Study. Asia Pac J Ophthalmol (Phila) 2017; 6:412-417. [PMID: 28930381 PMCID: PMC5658009 DOI: 10.22608/apo.2017265] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 09/06/2017] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To investigate the relationship between intraocular pressure (IOP) and big bubble (BB) formation in a model of deep anterior lamellar keratoplasty (DALK). DESIGN Ex-vivo. METHODS Corneoscleral buttons from human donors were loaded onto an artificial anterior chamber connected to a column of balanced salt solution. A surgeon-in-training learned to perform DALK via the BB technique using swept-source microscope-integrated optical coherence tomography (SS-MIOCT) with heads-up display (HUD). DALK procedures were performed at 6 different IOPs (5, 10, 15, 20, 30, or 40 mm Hg; n = 6 per group) in a randomized fashion, with the surgeon-in-training masked to the pressure and guided by SS-MIOCT with HUD. For a subset of corneas within each pressure group, DALK was performed on matching donor tissue at a control IOP. BB diameter was recorded, and a diameter exceeding the trephine diameter was considered optimal. RESULTS Wilcoxon rank sum test showed a difference in BB diameter among the different pressure groups (mean ± SD of 7.75 ± 1.60, 8.33 ± 1.99, 10.9 ± 0.92, 9.08 ± 1.07, 6.67 ± 3.33, and 3.42 ± 3.77 mm in the 5, 10, 15, 20, 30, and 40 mm Hg groups, respectively; P = 0.0014). Per Tukey test, this difference was attributable to comparisons between the 40 mm Hg group and the 5, 10, 15, or 20 mm Hg groups (P = 0.04, 0.02, 0.0001, 0.004, respectively). CONCLUSIONS In this ex-vivo model of DALK, the BB technique guided by SS-MIOCT with HUD yielded bubbles of optimal diameters only at physiologic pressures (10‒20 mm Hg). Extremely high IOP (40 mm Hg) resulted in BBs of significantly smaller diameter than BBs obtained at physiologic and low (5 mm Hg) IOPs.
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Affiliation(s)
- Paramjit K Bhullar
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC
| | | | | | - Neel D Pasricha
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC
| | - Brenton Keller
- Department of Biomedical Engineering, Duke University, Durham, NC
| | - Liangbo Shen
- Department of Biomedical Engineering, Duke University, Durham, NC
| | - Joseph A Izatt
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC
- Department of Biomedical Engineering, Duke University, Durham, NC
| | - Cynthia A Toth
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC
- Department of Biomedical Engineering, Duke University, Durham, NC
| | - Anthony N Kuo
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC
- Department of Biomedical Engineering, Duke University, Durham, NC
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26
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Carrasco-Zevallos OM, Viehland C, Keller B, Draelos M, Kuo AN, Toth CA, Izatt JA. Review of intraoperative optical coherence tomography: technology and applications [Invited]. BIOMEDICAL OPTICS EXPRESS 2017; 8:1607-1637. [PMID: 28663853 PMCID: PMC5480568 DOI: 10.1364/boe.8.001607] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/09/2017] [Accepted: 02/09/2017] [Indexed: 05/19/2023]
Abstract
During microsurgery, en face imaging of the surgical field through the operating microscope limits the surgeon's depth perception and visualization of instruments and sub-surface anatomy. Surgical procedures outside microsurgery, such as breast tumor resections, may also benefit from visualization of the sub-surface tissue structures. The widespread clinical adoption of optical coherence tomography (OCT) in ophthalmology and its growing prominence in other fields, such as cancer imaging, has motivated the development of intraoperative OCT for real-time tomographic visualization of surgical interventions. This article reviews key technological developments in intraoperative OCT and their applications in human surgery. We focus on handheld OCT probes, microscope-integrated OCT systems, and OCT-guided laser treatment platforms designed for intraoperative use. Moreover, we discuss intraoperative OCT adjuncts and processing techniques currently under development to optimize the surgical feedback derivable from OCT data. Lastly, we survey salient clinical studies of intraoperative OCT for human surgery.
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Affiliation(s)
| | - Christian Viehland
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA
| | - Brenton Keller
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA
| | - Mark Draelos
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA
| | - Anthony N. Kuo
- Department of Ophthalmology, Duke University Medical Center, NC 27710, USA
| | - Cynthia A. Toth
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA
- Department of Ophthalmology, Duke University Medical Center, NC 27710, USA
| | - Joseph A. Izatt
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA
- Department of Ophthalmology, Duke University Medical Center, NC 27710, USA
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