This article is more than 5 years old. Information may no longer be current.
Visualization during surgery continues to evolve
Click Here to Manage Email Alerts
Intraoperative OCT is showing promise as a useful adjunct, especially in vitrectomy and lamellar keratoplasty. However, indications are limited, as vitrectomy only represents about 2% of ophthalmic surgical procedures in the U.S., or about 250,000 procedures per year. Endothelial and lamellar anterior keratoplasty represent only 0.25% of procedures, or about 30,000 per year.
In vitrectomy, early adopter surgeons are finding intraoperative OCT helpful when peeling epiretinal membranes and treating other vitreoretinal interface pathologies. Intraoperative OCT can help differentiate retinoschisis from retinal detachment. It is also potentially helpful in select surgical procedures to repair macular hole and retinal detachment and treat retinopathy of prematurity. In particular, those vitreoretinal surgeons who are training residents and fellows have found it to be a valuable teaching tool. For the corneal surgeon, it can help scan for interface fluid and delineate tissue planes in Descemet’s stripping endothelial keratoplasty, Descemet’s membrane endothelial keratoplasty, pre-Descemet’s endothelial keratoplasty and deep anterior lamellar keratoplasty.
Several manufacturers, including Carl Zeiss Meditec, Haag-Streit, Leica, Optovue and Heidelberg Engineering, are investing human and financial capital, hoping to make operating microscope-integrated intraoperative OCT a routine part of eye surgery. To achieve this goal, intraoperative OCT must find a routine indication in the most frequent surgical procedure in ophthalmology, cataract surgery. Our femtosecond laser-assisted cataract surgery (FLACS) procedures are OCT driven, but FLACS is currently infrequently utilized and requires a separate surgical work station.
I can easily imagine an ophthalmic surgery work station of the future in which real-time OCT is integrated into the operating microscope and therapeutic laser is also delivered through the same optics. Such an ophthalmic work station will almost certainly become available in the next decade.
There are still several technical challenges yet to overcome, including imaging the peripheral retina, some image quality deficiencies and light scattering off hand-held surgical instruments. However, in just a few years we have gone from poor two-dimensional images from an OCT not integrated into the operating microscope to real-time high-quality three-dimensional images from an intraoperative OCT integrated into the operating microscope. Future enhancements will include auto tracking and refinements in the use of adjunct contrast agents such as triamcinolone, indocyanine green and trypan blue.
There is parallel ongoing research into applying robotics to ocular surgery. As both fields advance, intraoperative OCT is to me a promising partner to robotics in eye surgery. We have seen the impact of minimally invasive robotic surgery combined with sophisticated intraoperative visualization systems in many other surgical specialties. Eye surgeons are highly dependent on magnified visualization of the tissues being operated upon. I have often told my fellows that ophthalmic surgery is a visual sport, and the better we see the target tissue, the safer and more effective our surgery.
I look forward to the innovation cycle through the investment of human and financial capital bringing us additional tools to visualize ocular tissues and perhaps even individual cells during surgery. We are steadily advancing in ophthalmology from micro-surgery to micron-surgery, potentially allowing future procedures to be performed at the cellular level. We and our patients are blessed that our specialty still supports this level of innovation.
Disclosure: Lindstrom reports no relevant financial disclosures.