ABSTRACT
Video 1Rubber band-assisted closure of a mucosal defect after duodenal EMR.
ABSTRACT
PURPOSE: To delineate the feasibility and role of intraoperative optical coherence tomography (iOCT) in surgical decision-making during vitreoretinal surgical interventions for proliferative diabetic retinopathy (PDR). DESIGN: Prospective, single-site, multi-surgeon consecutive case series. PARTICIPANTS: Patients enrolled in the DISCOVER study who underwent vitreoretinal surgery for sequelae of PDR. METHODS: Subjects were identified from the first 2 years of the DISCOVER study that underwent vitreoretinal surgery for complications of PDR. Intraoperative imaging with a microscope-integrated iOCT system was performed at surgical milestones as determined by the surgeon. Data collected included clinical characteristics, image features, and survey-based surgeon feedback. MAIN OUTCOME MEASURES: Main outcomes were 1) the percentage of cases with successful acquisition of iOCT (feasibility) and 2) the percentage of cases in which iOCT altered surgical decision-making (utility). RESULTS: Eighty-one eyes with PDR underwent vitreoretinal surgery in the DISCOVER study. Successful iOCT imaging was obtained for 80 of 81 eyes (98.8%). Of these, 36 (44.4%) were female and 44 (54.3%) were male. The surgeon preferred real-time feedback in 47 cases (58.6%), static review in 29 cases (36.3%), and was indeterminate in 4 cases (5%). Surgeons reported that in 2 cases (2.5%) the iOCT interfered with the surgery (e.g., microscope malfunction). In 41 of the 81 cases (50.6%), surgeons reported that iOCT provided valuable information (e.g., identification of dissection planes, identification of retinal hole). In addition, the iOCT data provided information that specifically altered the surgeon's decision making (e.g., determination of peel completion, choice of tamponade) in 21 of 81 cases (26%). No adverse events were attributed to the iOCT system. CONCLUSIONS: The results suggest that iOCT is feasible during complex vitreoretinal surgeries in patients with PDR using a microscope-integrated OCT platform. Utilizing intraoperative OCT, appears to frequently offer key information that may impact surgical decision-making and potentially patient outcomes.
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PURPOSE: To investigate intraocular pressure (IOP) elevation and medication augmentation after Descemet stripping automated endothelial keratoplasty (DSAEK) in those with and without glaucoma. METHODS: The records of 379 patients who underwent DSAEK at the Cleveland Clinic Foundation between January 2009 and 2014 were retrospectively reviewed. Postoperative IOP elevations were considered significant if IOP was ≥22 mm Hg on at least 1 follow-up visit or if it increased by ≥10 mm Hg from baseline. RESULTS: The incidence rate of IOP elevation was 4% per person-month (confidence interval [CI], 3%-6%) in patients with preexisting glaucoma and 3% (CI, 2%-4%) in those without. Rates of medication augmentation were 4% per person-month (CI, 3%-5%) in patients with glaucoma and 1.8% (CI, 1.4%-2.4%) in those without. Incidence rates for both outcomes peaked at 1 month. Whites had nearly a 47% lower incidence of IOP elevation compared with nonwhites (P = 0.004); patients with pseudophakic bullous keratopathy had a 54% higher incidence of IOP elevation (P = 0.024); and those with Fuchs endothelial corneal dystrophy had a 36% lower incidence (P = 0.024). Patients with glaucoma had over a 2-fold higher incidence of medication augmentation compared with those without (hazard rate ratio = 2.08, P < 0.001). CONCLUSIONS: The incidence of post-DSAEK IOP elevation did not significantly differ by glaucoma status, although patients with glaucoma were more likely to have escalation of topical antihypertensive therapy. The incidence of IOP elevation was significantly associated with pseudophakic bullous keratopathy and nonwhite race. These patients should be followed closely in the early postoperative period, as elevated IOP can be a serious consequence of DSAEK.
