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optimising deep anterior lamellar keratoplasty (dalk) using intraoperative online optical coherence tomography (ioct)

by:Toponetech     2020-04-12
Background/objective to describe online optical coherence tomography during surgery (iOCT)
Improve the corneal transplant of deep plate layer (DALK)surgery.
Methods a retrospective case series study was conducted in 6 eyes of 6 male corneal Bridge patients treated with DALK using preoperative optical coherence tomography and post-operative image/video analysis.
The main outcome measurements were: visibility of the surgical steps, in particular the assessment of the depth of placement of the injection needle, preparation of the bare posterior dental membrane and drainage of the interface fluid.
Results iOCT realized real-time
Time visualization of all surgical steps for DALK surgery in all patients.
The position of the air injection needle above the desemet membrane was reliably monitored, as well as the presence of the bare deset et membrane and potential interface fluid.
Conclusion in DALK surgery, iOCT helps to observe the placement of the injection needle and to evaluate the exposed desemet membrane and interface fluid.
Overall, iOCT may be a useful device to support surgeons in all steps of DALK surgery.
Background/objective to describe online optical coherence tomography during surgery (iOCT)
Improve the corneal transplant of deep plate layer (DALK)surgery.
Methods a retrospective case series study was conducted in 6 eyes of 6 male corneal Bridge patients treated with DALK using preoperative optical coherence tomography and post-operative image/video analysis.
The main outcome measurements were: visibility of the surgical steps, in particular the assessment of the depth of placement of the injection needle, preparation of the bare posterior dental membrane and drainage of the interface fluid.
Results iOCT realized real-time
Time visualization of all surgical steps for DALK surgery in all patients.
The position of the air injection needle above the desemet membrane was reliably monitored, as well as the presence of the bare deset et membrane and potential interface fluid.
Conclusion in DALK surgery, iOCT helps to observe the placement of the injection needle and to evaluate the exposed desemet membrane and interface fluid.
Overall, iOCT may be a useful device to support surgeons in all steps of DALK surgery.
Corneal transplant of deep plate layer (DALK)using the big-
Anwar and Teichmann first describe the bubble technology.
1 DALK uses matrix air-
A membrane of elastic after dissection of the injected interstitial tissue (DM)
A matrix donor button is then implanted for the treatment of corneal matrix diseases such as corneal bridges, genetic corneal degeneration, or corneal scars.
This technique has shown to be superior to a perforated corneal transplant (PKP)
If there is no rejections2-4 of endothelial transplant, postoperative complications will be reduced.
The most important limiting factor for DALK vision outcomes is incomplete matrix anatomy.
Nevertheless, the American eye society, in a recent technical assessment report, recommended that DALK be as good as PKP in terms of vision, but with better safety due to the risk of a lack of endothelial immune response.
6 DALK\'s worldwide adaptation is slow due in part to this procedure and its non-
Standardized nature
This part has to do with limited visualization of key surgical steps during surgery that are based on tissue transparency and due to en-
Observe the facial view on the cornea through an Surgical Microscope.
Therefore, the light Cross
Slices will enable surgeons to better navigate and control the operation, especially key steps such as assessing the depth of needle placement in the matrix, at the end of the operation, the implementation of pure DM preparation and lack of interface liquid.
Recently, optical coherent tomography (OCT)
It has been modified to be used during surgery.
Therefore, two main methods can be adopted :(1)using hand-
8, 9 or (2)
Integrate October into the surgical microscope.
The latter has several advantages, such as visualizing all surgical steps online without the need to interrupt surgery and adjustments in October
Image to any given zoom and focus-
The steps of the microscope.
The study was first evaluated in October (iOCT)
The technology for online visualization of DALK surgery does not need to stop the procedure for measurement in October.
Methods on-line surgical techniques in October were used for online surgical evaluation in October, microscope-
Installation, commercial spectrum-
Domain camera October (
IOCT, Lubeck Medical Technology Co. , Ltd)
Use the 840 nm center wavelength and perform 10 000 nm-
Scan/s was used.
IOCT connects to the camera port of October-
Compatible with Merle Hi-
Infrared microscope R 900 (Moeller-
Weddell, Germany).
The October image is displayed on a separate touch screen in front of the surgeon\'s field of vision to facilitate easy exchange between the microscope and the October image.
IOCT imaging includes high recording
Resolution video and images at an axial resolution of about 10 μm in the air.
The image size is 4.
Axial 2mm in the air, 3 respectively.
According to the Micro Zoom coefficient used, it is 2mm axial in the water, between 5 and 29 in the transverse direction.
Patientsict was continuously used in 6 male patients aged 25-64 who had a corneal Bridge (3 cases)
Scar matrix (2 cases)
Or genetic corneal matrix malnutrition (1 case)(table 1).
View this table: View inline View popuptable 1 patient, diagnosis 1, and surgery 2 cases DALK had to convert to penetrating cornea due to the larger DM perforation during Plate preparation
Evaluation parameters include iOCT-
Visual drilling depth, deep matrix placement of air injection needles, preparation of bare DM, interface fluid and Interface Alignment of graft.
ProcedureDALK previously12 made a description outlining what will be taken, and the recipient\'s cornea is the 8-mm-side area with the smallest corneal thickness of trephined 90% using Hessberg-
Barron trephine (
Dormyance, Hamburg)of 7. 75u2005mm.
Thickness was evaluated before operation using Pentacam. A 30-
The gauge injection needle was placed in the deep tissue directly above the DM, and the placement of the needle was observed during the operation on October.
Then, inject air until the boundaries of whitening extend to the trephation interface.
After the surface and the middle plate layer are peeled off
Matrix tissue
Large air chamber (big-bubble)
Open, dissect the remaining tissue from the DM to obtain the naked DM condition under the protection of the sticky bullet (
Injected space).
The donor tissue places the endothelial side up into the Hanna punch block (
United States, Pennsylvania, dolestown, Moriya)
Divest DM from the cornea.
Then, the DM graft can be used for the corneal transplant of the posterior tooth membrane (DMEK)
Corneal graft surgery.
A graft with a cutting diameter of 8mm (
Using Hessberg-Barron trephine)
Transfer to the recipient\'s cornea
The graft is fixed with 16 single or two double continuous stitches, draining the remaining interface fluid by gently massaging the corneal surface and opening the interface using a blunt spatula.
Donor tissue graft is an organ-
Culture in minimum basic medium (MEM)(
Biochrom, Berlin, Germany)
At 32 °c, debunk In MEM containing 5% right-spin ammonium (
Biochrom, Berlin, Germany)at 32°C.
Two transplanted organs
Culture in minimum basic medium (
European biological laboratory cornea max R, Les Ulis, France)
At 31 °c, salt is removed in the minimum essential medium containing 5-6% of the right-spin ammonium (
Corneal jet R, European Biological Laboratory, Les Ulis, France).
However, due to legal requirements, it is not possible to obtain the exact post-mortem time information from the provider Eye Bank, and the eyes of all donors are collected within 24 hours of death.
The donor age is between 18 and 72 years old ,(
4 males and 2 females)
No previous reports of eye disease.
For retrospective image analysis and depth measurement, x-
Depending on the axial optical window depth of 4, set the axis of the October image to 840 pixels. 2u2005mm.
Therefore, set the axial pixel size to 5 µm.
Corrected the refractive index 1 in the corneal tissue.
35, the pixel size is divided by this factor, and the value obtained is 3. 7u2005µm.
Using image J, the distance between corneal epithelial, endothelial and Air Center
Measure the injection needle and convert the number of pixels to real distance in m
On-line October technique during operation for on-line October evaluation during operation, microscope-
Installation, commercial spectrum-
Domain camera October (
IOCT, Lubeck Medical Technology Co. , Ltd)
Use the 840 nm center wavelength and perform 10 000 nm-
Scan/s was used.
IOCT connects to the camera port of October-
Compatible with Merle Hi-
Infrared microscope R 900 (Moeller-
Weddell, Germany).
The October image is displayed on a separate touch screen in front of the surgeon\'s field of vision to facilitate easy exchange between the microscope and the October image.
IOCT imaging includes high recording
Resolution video and images at an axial resolution of about 10 μm in the air.
The image size is 4.
Axial 2mm in the air, 3 respectively.
According to the Micro Zoom coefficient used, it is 2mm axial in the water, between 5 and 29 in the transverse direction.
Patientsict was continuously used in 6 male patients aged 25-64 who had a corneal Bridge (3 cases)
Scar matrix (2 cases)
Or genetic corneal matrix malnutrition (1 case)(table 1).
View this table: View inline View popuptable 1 patient, diagnosis 1, and surgery 2 cases DALK had to convert to penetrating cornea due to the larger DM perforation during Plate preparation
Evaluation parameters include iOCT-
Visual drilling depth, deep matrix placement of air injection needles, preparation of bare DM, interface fluid and Interface Alignment of graft.
ProcedureDALK previously12 made a description outlining what will be taken, and the recipient\'s cornea is the 8-mm-side area with the smallest corneal thickness of trephined 90% using Hessberg-
Barron trephine (
Dormyance, Hamburg)of 7. 75u2005mm.
Thickness was evaluated before operation using Pentacam. A 30-
The gauge injection needle was placed in the deep tissue directly above the DM, and the placement of the needle was observed during the operation on October.
Then, inject air until the boundaries of whitening extend to the trephation interface.
After the surface and the middle plate layer are peeled off
Matrix tissue
Large air chamber (big-bubble)
Open, dissect the remaining tissue from the DM to obtain the naked DM condition under the protection of the sticky bullet (
Injected space).
The donor tissue places the endothelial side up into the Hanna punch block (
United States, Pennsylvania, dolestown, Moriya)
Divest DM from the cornea.
Then, the DM graft can be used for the corneal transplant of the posterior tooth membrane (DMEK)
Corneal graft surgery.
A graft with a cutting diameter of 8mm (
Using Hessberg-Barron trephine)
Transfer to the recipient\'s cornea
The graft is fixed with 16 single or two double continuous stitches, draining the remaining interface fluid by gently massaging the corneal surface and opening the interface using a blunt spatula.
Donor tissue graft is an organ-
Culture in minimum basic medium (MEM)(
Biochrom, Berlin, Germany)
At 32 °c, debunk In MEM containing 5% right-spin ammonium (
Biochrom, Berlin, Germany)at 32°C.
Two transplanted organs
Culture in minimum basic medium (
European biological laboratory cornea max R, Les Ulis, France)
At 31 °c, salt is removed in the minimum essential medium containing 5-6% of the right-spin ammonium (
Corneal jet R, European Biological Laboratory, Les Ulis, France).
However, due to legal requirements, it is not possible to obtain the exact post-mortem time information from the provider Eye Bank, and the eyes of all donors are collected within 24 hours of death.
The donor age is between 18 and 72 years old ,(
4 males and 2 females)
No previous reports of eye disease.
For retrospective image analysis and depth measurement, x-
Depending on the axial optical window depth of 4, set the axis of the October image to 840 pixels. 2u2005mm.
Therefore, set the axial pixel size to 5 µm.
Corrected the refractive index 1 in the corneal tissue.
35, the pixel size is divided by this factor, and the value obtained is 3. 7u2005µm.
Using image J, the distance between corneal epithelial, endothelial and Air Center
Measure the injection needle and convert the number of pixels to real distance in m
Results the operation on October was able to monitor all surgical steps of DALK in all analyzed patients (6/6: 100%)
Accurately imaging the depth of the drill hole (Figure1A)
, And the needle insertion can be reliably monitored near the DM (Figure1B).
Air injection in the rear matrix was observed, resulting in white staining of the image in October due to increased tissue scattering by bubbles.
In two of the six cases, the formation of large bubbles can be seen (Figure1C)
In the deep matrix position.
Preparation of deep matrix tissue (Figure1D,E)
Reliable monitoring before obtaining naked DM (Figure1F).
Monitor graft insertion and stitching and control interface consistency during surgery in October (Figure1G).
These steps were reliably monitored by 6/6 patients, however, in both cases DM rupture during deep matrix preparation resulted in conversion to PKP.
In both cases, there is no initial big
The formation of bubbles is realized.
Download figureOpen in the new tabDownload powerpoint figure 1 to realize real-time online optical coherent tomography
Time visualization of all surgical steps for Deep anterior panel corneal transplant surgery, including graft drilling (A;
The arrow shows the peripheral trephation)
Needle insertion (B;
Arrow marking needle)
Into the deep substrate, the air blows into the large-
The bubble formation of this patient (C;
Illustration shows small in-matrix airbags)
Preparation of surface layer (D)
Preparation of deep plate layers (E and F;
The arrow shows the membrane of elasticity after separation)
At the end of the operation, go down to the isolated desemet membrane and the graft attachment (G).
IOCT\'s guide to microbubble-
4/6 cases without large incision
However, bubble formation was observed and small bubbles were evenly distributed throughout the corneal matrix (Figure2A).
After the substrate of the shallow plate layer is stripped (Figure2B)
According to the \"micro-bubbles\" described earlier, a single bubble is cut using a 15 ° knife to form a larger cavity
15 years (Figure2C,D). This pre-
The rear elastic cavity can be opened (Figure2E)
And can be prepared for naked DM (Figure2F).
In this way, 2/4 cases can be \"saved\" and DALK can be performed.
The other 2 cases of DM broke down and PKP was performed.
Download the new tabDownload figureOpen powerpointFigure2 full size
Bubbles formed after deep plate layer corneal transplant and gas injection.
Rescue attempts using \"micro\"
Foam cutting technology (
See ref for more information. 15). (A)
Air in the matrix (white tissue)without big-
Bubbles form.
After the plate layer is stripped (B)
, Using sharp instruments to cut the remaining pre-set bubbles in the matrix in turn (
15 ° knife, Arrow; C).
More and more bubbles repeat this (D, arrow and E)
, Then open to expose the exposed desemet membrane (F).
IOCT helps to evaluate the interface fluid and interface steps at the end of the operation, after placing the graft on the cornea recipient bed and stitching, the remaining interface fluid can be detected by October (Figure3A)
Two of the four patients
After gentle massage on the surface of the cornea and blunt opening of all four quadrant interfaces filled with air in the front room, the remaining liquid can be safely discharged (Figure3B).
Download the new tabDownload powerpointFigure3 (A)
Optical coherence tomography during operation can ensure that the graft is attached to the posterior membrane (arrows)
Corneal transplant in the deep plate layer (DALK)
And guide the drainage of the interface fluid between the donor matrix and the host desscemet membrane at the end of DALK surgery.
Note that there is no liquid after drainage on the right side (B).
In addition, consistency of the graft and donor interface can be ensured and interface steps can be corrected before the end of the operation.
The drilling depth and air injection needle perspective image analysis of representative images in October showed that the drilling depth was about 270 or 198 m and the injection needle position was 311 or 296 m (Figure4).
Corneal thickness was measured with 389 or 333 µm.
Therefore, the depth of the drill hole reaches 69% or 67% of the total thickness of the cornea, respectively.
The depth of the air injection needle is 80% or 88% of the total thickness of the cornea;
However, this value represents the central core of the injection needle.
Download figureOpen in the new form download powerpoint figure 4 quantitative measurement of corneal thickness, air injection needle depth and drilling hole depth (A)
Representative side-Center optical coherent tomography (OCT)
Image of patient 5 with corneal thickness index (1=389u2005µm)
Depth of injection needle (2=311u2005µm)
Depth (3=270u2005µm)(B)
Representative Central side image of patient 2 in October, corneal thickness index (1=333u2005µm)
Depth of injection needle (2=296u2005µm)
Depth (3=198u2005µm).
The dotted line indicates the posterior surface of the cornea.
In October, all surgical steps in DALK were able to be monitored in all patients analyzed (6/6: 100%)
Accurately imaging the depth of the drill hole (Figure1A)
, And the needle insertion can be reliably monitored near the DM (Figure1B).
Air injection in the rear matrix was observed, resulting in white staining of the image in October due to increased tissue scattering by bubbles.
In two of the six cases, the formation of large bubbles can be seen (Figure1C)
In the deep matrix position.
Preparation of deep matrix tissue (Figure1D,E)
Reliable monitoring before obtaining naked DM (Figure1F).
Monitor graft insertion and stitching and control interface consistency during surgery in October (Figure1G).
These steps were reliably monitored by 6/6 patients, however, in both cases DM rupture during deep matrix preparation resulted in conversion to PKP.
In both cases, there is no initial big
The formation of bubbles is realized.
Download figureOpen in the new tabDownload powerpoint figure 1 to realize real-time online optical coherent tomography
Time visualization of all surgical steps for Deep anterior panel corneal transplant surgery, including graft drilling (A;
The arrow shows the peripheral trephation)
Needle insertion (B;
Arrow marking needle)
Into the deep substrate, the air blows into the large-
The bubble formation of this patient (C;
Illustration shows small in-matrix airbags)
Preparation of surface layer (D)
Preparation of deep plate layers (E and F;
The arrow shows the membrane of elasticity after separation)
At the end of the operation, go down to the isolated desemet membrane and the graft attachment (G).
IOCT\'s guide to microbubble-
4/6 cases without large incision
However, bubble formation was observed and small bubbles were evenly distributed throughout the corneal matrix (Figure2A).
After the substrate of the shallow plate layer is stripped (Figure2B)
According to the \"micro-bubbles\" described earlier, a single bubble is cut using a 15 ° knife to form a larger cavity
15 years (Figure2C,D). This pre-
The rear elastic cavity can be opened (Figure2E)
And can be prepared for naked DM (Figure2F).
In this way, 2/4 cases can be \"saved\" and DALK can be performed.
The other 2 cases of DM broke down and PKP was performed.
Download the new tabDownload figureOpen powerpointFigure2 full size
Bubbles formed after deep plate layer corneal transplant and gas injection.
Rescue attempts using \"micro\"
Foam cutting technology (
See ref for more information. 15). (A)
Air in the matrix (white tissue)without big-
Bubbles form.
After the plate layer is stripped (B)
, Using sharp instruments to cut the remaining pre-set bubbles in the matrix in turn (
15 ° knife, Arrow; C).
More and more bubbles repeat this (D, arrow and E)
, Then open to expose the exposed desemet membrane (F).
IOCT helps to evaluate the interface fluid and interface steps at the end of the operation, after placing the graft on the cornea recipient bed and stitching, the remaining interface fluid can be detected by October (Figure3A)
Two of the four patients
After gentle massage on the surface of the cornea and blunt opening of all four quadrant interfaces filled with air in the front room, the remaining liquid can be safely discharged (Figure3B).
Download the new tabDownload powerpointFigure3 (A)
Optical coherence tomography during operation can ensure that the graft is attached to the posterior membrane (arrows)
Corneal transplant in the deep plate layer (DALK)
And guide the drainage of the interface fluid between the donor matrix and the host desscemet membrane at the end of DALK surgery.
Note that there is no liquid after drainage on the right side (B).
In addition, consistency of the graft and donor interface can be ensured and interface steps can be corrected before the end of the operation.
The drilling depth and air injection needle perspective image analysis of representative images in October showed that the drilling depth was about 270 or 198 m and the injection needle position was 311 or 296 m (Figure4).
Corneal thickness was measured with 389 or 333 µm.
Therefore, the depth of the drill hole reaches 69% or 67% of the total thickness of the cornea, respectively.
The depth of the air injection needle is 80% or 88% of the total thickness of the cornea;
However, this value represents the central core of the injection needle.
Download figureOpen in the new form download powerpoint figure 4 quantitative measurement of corneal thickness, air injection needle depth and drilling hole depth (A)
Representative side-Center optical coherent tomography (OCT)
Image of patient 5 with corneal thickness index (1=389u2005µm)
Depth of injection needle (2=311u2005µm)
Depth (3=270u2005µm)(B)
Representative Central side image of patient 2 in October, corneal thickness index (1=333u2005µm)
Depth of injection needle (2=296u2005µm)
Depth (3=198u2005µm).
The dotted line indicates the posterior surface of the cornea.
DiscussionDALK is a mature surgical technique for the treatment of corneal matrix diseases, such as the cornea.
Several preparation steps are challenging, such as positioning the instrument in the matrix or estimating the thickness of the remaining tissue associated with the DM because of the traditional en-Facial microscope
It is feasible to use Pentacam16 to measure matrix thickness before operation.
However, the visualization of drilling depth and needle position during surgery will be better compared to preoperative measurements, and will help surgeons during surgery.
October has been used to photograph the front section of the eye 17 before and after the deep anterior corneal transplant to plan the procedure and analyze the results of the procedure.
In contrast, optical coherence tomography (iOCT)
, Is able to visualize the organization in the virtual crossover and visualize the instrument to a certain extent
Part of the area of interest, thus being able to accurately identify different tissue structures, tissue thickness, etc. with higher accuracy without interrupting surgery.
Therefore, it is of great interest to adapt to the use during surgery in October, especially the plate-layer corneal transplant, which our group and others have recently demonstrated.
7, 8, 19, 20 although most of the methods use the customized and modified October system, so far, during surgery, before or after surgery18 or slit beam imaging 21, the patient this place
The system was the first to develop equipment specifically installed on surgical microscopy.
Especially in the fine surgical steps of DALK, this allows the tissue to be observed from another angle without interrupting the procedure itself.
In addition, by integrating iOCT into a microscope and adjusting its function to zoom, focus, and image acquisition, online imaging during surgery in October was enabled, as recently described, corneal transplant surgery in the posterior layer.
10 in the case of DALK, iOCT has proved to be a useful device that can verify the depth of the drill holes and needle insertion in DALK to accurately identify the exact depth of preparation.
Therefore, before further preparation steps, very low or very deep drilling depth will be accurately observed, for example, leading to drilling or special attention in the placement of needles.
Although the accuracy of drilling depth is reliably improved with the use of a femtosecond laser, iOCT will help with manual drilling, which is still used by most corneal surgeons performing DALK.
Due to the control of residual matrix tissue during surgery, the preparation of bare DM becomes easier, however, in all cases studied in this series of articles, DM rupture cannot be prevented.
One reason may be that in young patients, compared to older patients who require higher human productivity during anatomy, corneal matrix adhesion is increased, thereby increasing the risk of perforation.
Future technological developments such as 3D
Imaging of the entire cornea in October will enable surgeons to position instruments without constant adjustment in October
It will then allow for better navigation and reduction of complications in particularly difficult situations.
In the absence of large bubble formation, the \"microbubble cutting technology\" controlled by iOCT, due to the clear positioning of the inner cavity of the artificial matrix, helps to prepare DM more safely.
In addition, visualization and drainage of clinically invisible interface fluids will avoid delayed healing and reduce the rate of air injection for this indication.
Overall, the proposed iOCT is the first in October surgical device fully integrated into a surgical microscope, enabling real-time
Imaging examination during eye surgery in October.
Such as corneal transplant in the posterior panel (DMEK).
10 iOCT is also good for corneal transplant in the anterior panel (DALK)
In particular, it is possible to help a surgeon by adding a learning curve at the beginning of the training for a panel corneal transplant surgery.
Compared with other imaging methods, there are still some limitations in the operation in October, such as high cost, fixed angle and limited rotation of single sweep direction.
However, in challenging situations such as reduced visibility, uncertain or large organizational depth during plate-layer preparation-
Bubble formation iOCT can accurately assess the situation and possible \"rescue\"
Measures to successfully complete the procedure without the need for additional staff to handle the hand
Keep the device without the need to interrupt the program.
Future developments, such as 3D images across the surgical field and automated intra-operative depth measurements, as well as larger prospective trials, will have to assess to what extent this technology can improve greatly-
Bubble Decker surgery
The author would like to thank S. Hackbarth and G. Simons for their excellent technical work at the cornea bank, University Hospital of Cologne.
The referee of tihiman KD, Anwar M. Big-
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All authors contributed to the design or progress of the study, or performed retrospective data analysis and writing of the manuscript.
Fund the German Foundation (
German Research Council: SFB 643 (B10), STE 1928/2-1, CU 47/4-1).
Ruth and Helmut Lingen Stephen Tong
EU FP7: cost BM 1302.
Koeln Fortune Research Fund, College of Medicine, Cologne University.
Sponsors or funding organizations do not have any role in the design or conduct of this study.
EL and MK are employees of Medical Technology Co. , Ltd, and so is Moeller\'s employees
The company, EL, MK and so on are shareholders of optomical technology.
Uncommissioned moral examination and approval and peer review;
External peer review.
Data sharing statement data will be available at the request of the corresponding author.
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