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COVER STORY
Intraoperative OCT in
Headline
Pediatric Posttraumatic
Intraocular Bleeding
deck
The
following case report demonstrates the utility of this promising imaging technique in
AUTHOR
surgical decision-making.
BY MICHELE COPPOLA, MD,
and
ANTONIO CAIMI, MD
S
pectral-domain optical coherence tomography
(OCT) is a noninvasive, high-resolution imaging
technique that provides in vivo cross-sectional
views of the retina and choroid with good
reproducibility.1,2 This technology has revolutionized diagnosis, therapeutic decision-making, surgical
planning, and follow-up for patients affected by
vitreoretinal diseases.
Vitreoretinal surgery has also made outstanding
advances over the past few years,3 with the development
of small-gauge instruments,4 vital dyes,5 new illumination
systems,6 and widefield viewing systems.7 OCT has clearly
already transformed medical retina, but the application
of this imaging modality in the OR could be the next
breakthrough in ophthalmic surgery.
CASE REPORT
A 5-year-old girl was referred to our department with
a history of recent domestic trauma in her right eye
(OD). Anterior segment examination showed periorbital
At a Glance
• Ideally, intraoperative OCT should be
performed with a hands-free technique.
• Fully integrated intraoperative OCT delivers
high-resolution, cross-sectional images with
immediate feedback to surgeons during surgery.
• In the case study, a real-time integrated
high-definition OCT system confirmed that
macular integrity was achieved through surgery.
70 RETINA TODAY NOVEMBER/DECEMBER 2015
Video: Addressing Hyphema
bit.ly/1S0YuHK
hematoma with no extraocular foreign bodies visible
and no extraocular muscle deficits detectable. Massive
bleeding in the anterior chamber was evident, and no
visualization of the posterior segment was possible at the
slit-lamp examination.
BCVA OD was light perception with forced opening of
the eyelids. Digital intraocular pressure (IOP) seemed to
be higher OD than in the fellow eye. B-scan ultrasonography showed no pathologic echoes from the vitreous
cavity, macula, or peripheral retina. The patient was hospitalized, and topical therapy of 2% atropine and 0.5%
timolol twice a day was established.
The day after the trauma, periorbital edema had diminished and digital IOP seemed to be better, but massive
hyphema persisted. With the informed consent of the
patient’s parents, surgery was planned for the next day
under general anesthesia (Video).
To ensure thorough disinfection, instillation of
5% povidone-iodine solution into the conjunctival
fornix was performed, and the solution was left on for
COVER STORY
Figure. Posterior segment evaluation of the vitreoretinal
interface with intraoperative OCT.
3 minutes. Then a 25-gauge irrigation cannula was
inserted at the limbus into the anterior chamber at
7 o’clock. The main port was created at 11 o’clock with
a microvitreoretinal blade, and removal of the anterior
chamber blood clot was accomplished with 25-gauge
vitrectomy while paying attention to the integrity of
the lens and endothelium.
By means of a widefield imaging system integrated
into the microscope (Resight 700, Carl Zeiss Meditec),
a careful inspection of the posterior pole and retinal
periphery was performed with no pathologic findings.
Further confirmation of macular integrity was obtained
using a real-time integrated high-definition OCT system
(Rescan 700, Carl Zeiss Meditec).
The incisions were closed with hydro-sutures,
and a subconjunctival injection of cefazolin and
dexamethasone was administered. The postoperative
course presented no complications.
Five days after surgery, BVCA had improved to 20/20,
IOP was 16 mm Hg by applanation tonometry, and
anterior and posterior segment examination showed no
inflammation or bleeding recurrence. This status was
maintained throughout the 2-month follow-up.
DISCUSSION
Several authors have reported the advantages of
perioperative OCT in the surgical theater, including
interesting findings in many vitreoretinal diseases: epiretinal membrane,8-13 macular hole,8-12,14 retinal detachment,15-17 vitreomacular traction,10,18 optic pit–associated
maculopathy,19 and retinopathy of prematurity.20
Most of these studies were conducted using handheld or non-parfocal microscope-coupled OCT
devices. Although these machines provide prompt and
useful details about the morphologic consequences of
surgical procedures, they still do not allow real-time
surgical visualization. In addition, without the steadiness of a fixed platform, even minimal operator movements can result in unsatisfactory image quality.
Identifying the target tissue on OCT is difficult without
surgical microscope integration; in fact, patients undergoing vitreoretinal surgery are usually unable to collaborate
by fixating due to sedation and/or local or general anesthesia. Thus, it is crucial to perform OCT with a handsfree technique, allowing the surgeon to move and keep
focus on the OCT image without interrupting the surgery.
An additional issue with OCT that is not integrated
into the surgical microscope is the potential risk of contamination of the surgical field. From a practical point
of view, an OCT device incorporated into the surgical
microscope optics could minimize this risk.
We believe that fully integrated intraoperative OCT
(Figure) could have a huge impact on daily surgical
practice for several reasons:
• It provides high-resolution, cross-sectional images
with simultaneous feedback to the surgeon during
intraoperative maneuvers.
• It allows real-time imaging, facilitating surgical
decision-making and improving the understanding
of the pathophysiology of underlying diseases.
• It saves time and offers ergonomic benefits with
respect to perioperative imaging with minimal
disturbance of the surgical procedure.
• It gives the surgeon control of the OCT from the
microscope footpedal; the surgeon can simultaneously look at the surgical field in a planar and
cross-sectional view.
In addition, published studies have already addressed
the utility of parfocal OCT integrated with the surgical
microscope, both with commercial systems9,21 and laboratory prototypes.22
The incidence of patients with ocular emergencies presenting at emergency departments in the United States
has been estimated to be three per 1000 persons per
year,23 and ocular trauma is the major cause of unilateral
blindness in the United States,24 with associated relevant
social and economic implications. As seen in our case
report, intraoperative imaging can be particularly useful
during pediatric evaluations and surgery. This observation has also been reported by other authors.25,26
In our case, intraoperative OCT helped us to minimize
the length of surgery and the potential for iatrogenic
damage (ie, cataract development), which improved our
surgical management and outcome. The intraoperative
objective confirmation of macular integrity had great
value, including from a medicolegal point of view.
Fully integrated intraoperative OCT can greatly
influence surgical decision-making; however, further
studies are needed to establish the real
cost-to-benefit ratio of this novel and promising
imaging technique. n
NOVEMBER/DECEMBER 2015 RETINA TODAY 71
COVER STORY
Antonio Caimi, MD, is a consultant at
Centro Oculistico Reggiano, Reggio Emilia, Italy.
He reports no relevant financial disclosures.
Michele Coppola, MD, is director in the
department of ophthalmology at Azienda
Ospedaliera di Desio and a professor of ophthalmology at University ‘Vita e Salute’ HSR,
both in Milan, Italy. He reports no relevant
financial disclosures. Dr. Coppola may be
reached at [email protected].
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