Membrane Peeling-Induced Retinal Alterations on Intraoperative OCT in Vitreomacular Interface Disorders From the PIONEER Study

Abstract

PURPOSE. To assess retinal architectural alterations that occur following membrane peeling procedures and the impact of peel technique on these alterations utilizing intraoperative optical coherence tomography (iOCT).METHODS. This is a subanalysis of the prospective PIONEER iOCT study of eyes undergoing a membrane peeling for a vitreomacular interface (VMI) disorder. Intraoperative scanning was performed with a microscope-mounted OCT system. Macroarchitectural alterations (e.g., fullthickness retinal elevations) and microarchitectural alterations (e.g., relative layer thickness alterations) were analyzed. Video/iOCT correlation was performed to identify instrumenttissue manipulations resulting in macroarchitectural alterations. RESULTS.One hundred sixty-three eyes were included in the macroarchitectural analysis. Instrumentation utilized for membrane peeling included forceps alone for 73 eyes (45%), combined diamond-dusted membrane scraper (DDMS) and forceps for 87 eyes (53%), and other techniques in three eyes (2%). Focal retinal elevations were identified in 45 of 163 eyes (28%). Video/iOCT correlation identified 69% of alterations involved forceps compared to 26% due to DDMS. Sixteen percent of retinal alterations persisted 1 month following surgery. The microarchitectural analysis included 134 eyes. Immediately following membrane peeling, there was a significant increase in the ellipsoid zone to retinal pigment epithelium height (þ20%, P < 0.00001) and the cone outer segment tips to retinal pigment epithelium height (þ18%, P < 0.00001).CONCLUSIONS. Significant subclinical retinal architectural changes occur during membrane peeling for VMI conditions. Differences in surgical instruments may impact these architectural alterations.

Clinical utility of intraoperative optical coherence tomography

“…[7,9,13,14,18,28,52,53] As such, iOCT can guide surgical decision-making during a membrane peeling case, including the identification of membrane that needs further peeling. Alternatively, it can signal the end of a case by confirming attainment of surgical goals.…”

“…At the micro level of retinal architecture, some of the commonly reported changes following membrane peeling include expansion of the distance between the ellipsoid zone and the retinal pigment epithelium and alterations of the inner retinal surface. [11,18,52,53] The overall visual implications of the microarchitectural changes remain unclear. However, one study demonstrated that these intraoperative outer retinal alterations are directly correlated with rate of anatomic normalization following MH repair.…”

Review of intraoperative optical coherence tomography: technology and applications [Invited]

“…The 2-year PIONEER study [82] conducted in 2014 included 256 eyes, and the authors of the study reported that intraoperative HHOCT imaging impacted the surgeon's decision-making in 63 out of 146 procedures involving ERM peeling. A multitude of other findings stemmed from this study [177,178], including the demonstration of HHOCT for identifying persistent subretinal fluid [179] and HHOCT visualization of peeling-induced retinal alterations resulting from tissue manipulation with intraocular forceps and membrane scrapers [180]. Moreover, Binder et al [116] first demonstrated live 2D MIOCT imaging of human retinal surgery in between surgical steps and before/after surgery using a commercial Cirrus HD-OCT (Carl Zeiss Meditec; Oberkochen, Germany) adapted to the surgical microscope.…”

Intraoperative optical coherence tomography: past, present, and future

“…13,27 Both macroarchitectural and microarchitectural changes have been described in the retina following surgical manipulations. 46 In addition procedures where direct feedback has been documented includes subretinal perfluorocarbon liquid removal and subretinal injection of therapeutics. 35 In addition, more subtle changes occur in the outer retina with expansion of the EZ-RPE height following membrane peeling.…”