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To quantify ellipsoid zone (EZ) changes in integrity after epiretinal membrane (ERM) surgery, correlate findings to visual acuity, and determine predictors for prognosis.A post hoc analysis of eyes undergoing ERM surgery pooled from the prospective DISCOVER intraoperative optical coherence tomography study and eyes undergoing conventional ERM surgery without intraoperative optical coherence tomography. Quantitative EZ features were extracted using a multilayer machine learning enabled automated segmentation platform after image analyst review/correction for segmentation accuracy. Visual acuity and EZ integrity were quantitatively assessed and correlated before and after ERM surgery. Multiple linear regression was performed to assess preoperative visual acuity and EZ features as predictors for improvement in visual acuity or EZ integrity.There were 177 eyes from 177 subjects that underwent ERM surgery from the DISCOVER and conventional arms. Improvement in visual acuity and multiple EZ integrity features was noted after ERM surgery, including EZ partial attenuation and EZ-retinal pigment epithelium (RPE) volume (P0.05). A reduction in EZ partial attenuation and increase in EZ-RPE central subfield thickness (EZ-RPE CST) was significantly correlated with improved visual acuity after ERM surgery (P0.05). More robust EZ-RPE CST at baseline predicted visual acuity improvement after ERM peel in regression modeling (β = 0.005, P0.05).Longitudinal assessment of EZ features demonstrates significant postoperative improvement in multiple EZ integrity metrics after ERM surgery. Improving EZ integrity was correlated to improving the visual acuity. Ellipsoid zone integrity and visual acuity were significant predictors in regression modeling and may have value in clinical prognostication.

PURPOSE To evaluate association of the baseline macular hole (MH) geometric features and longitudinal ellipsoid zone integrity with the visual acuity outcome after surgical repair. METHODS This was a post-hoc analysis of eyes in the DISCOVER study undergoing vitrectomy repair for MH. Anatomical and functional data were collected through one year postoperatively. An automated retinal layer segmentation platform was used for the assessment of outer retinal metrics and volumetric reconstruction of MH. Association of longitudinal ellipsoid zone features and baseline MH height, width, and volume with VA outcomes were investigated. RESULTS Eighty-four eyes with MH were included. The mean baseline VA was 20 of 114 and increased to 20 of 45 (P < 0.001) at postoperative Month 12 (N = 45). Successful MH closure was achieved in 98.8% of cases. Ellipsoid zone integrity metrics significantly improved from baseline (P = 0.002) and postoperative Month 1 (P < 0.001) to post-operative Month 12. Ellipsoid zone metrics independently correlated with VA at all follow-up visits (P < 0.05). Increased baseline MH width and volume negatively correlated with the VA at postoperative Month 12 (P < 0.001). Preoperative VA and EZ integrity on optical coherence tomography were predictors for postoperative VA. CONCLUSION Baseline MH volumetric parameters and EZ parameters were associated with VA outcomes after repair.

Purpose To compare optical coherence tomography angiography (OCTA) review strategies for optimizing choroidal neovascularization (CNV) detection. Methods Eyes with CNV in the differential diagnosis were imaged with the Avanti RTVue XR HD (Optovue, Fremont, CA). Three modalities of review for CNV presence were used in each case: a single report generated using automated segmentation within Avanti software; a continuous slab descent video OCTA export; and a manual segmentation approach using cross-sectional OCT with decorrelation signal overlay. Scans were reviewed by two masked expert reviewers; a third reviewer was used for discrepancies. Results The study included 421 eyes, and 350 eyes had reports deemed sufficient quality for interpretation. Choroidal neovascularization was in the differential diagnosis in 107 of 350 patients. Overall CNV was identified in 55% (59/107) eyes. In those eyes with CNV, the automated segmentation identified CNV in 56% (33/59) of cases, continuous slab descent method identified CNV in 53% (31/59) of cases, and the manual segmentation group identified CNV in 92% (54/59) of cases. Conclusion Review strategies for detection of CNV on OCTA were highest using the manual segmentation method as compared to both the automated report and continuous slab descent methods. Although the manual segmentation method had a higher rate of detection, the practical aspects of the time required for segmentation make this method challenging in routine clinical practice.

To assess the relationship of dissociated optic nerve fiber layer (DONFL) and intraoperative membrane-peeling dynamics as visualized using intraoperative optical coherence tomography (OCT), and to evaluate the functional implications of DONFL.This was a post hoc analysis of eyes undergoing membrane peeling for vitreomacular interface disorders in the prospective PIONEER intraoperative OCT study. Retinal layer measurements in preincision and postpeel intraoperative OCT images were obtained. The primary outcome was development of DONFL appearance on spectral domain OCT at 6-month follow-up. Secondary outcomes included correlation of DONFL with surgical technique, surgical indication, intraoperative OCT findings, and retinal sensitivity.Ninety-five eyes were included. The prevalence of DONFL at 6 months was 36%. Increased inner retinal layer thickness on intraoperative OCT immediately after membrane peeling was associated with development of DONFL (P0.01). Macular hole repair was significantly associated with DONFL appearance. Peel technique (forceps vs. diamond-dusted membrane scraper) was not associated with DONFL. There was no difference in retinal sensitivity or visual acuity between eyes with or without DONFL.Acute postpeel increase in inner retinal thickness and macular hole repair were associated with development of DONFL appearance. However, it is unclear whether the surgical indication (e.g., macular hole) or the surgical manipulations performed (e.g., internal limiting membrane peeling) is the major factor that has an impact on DONFL appearance. Overall, these findings suggest that one mechanism in the development of DONFL appearance may be intraoperative trauma to the inner retina, potentially during internal limiting membrane peeling (e.g., macular hole repair).

TOPIC To assess the role and utility of intraoperative optical coherence tomography (iOCT) guidance during pars plana vitrectomy with chorioretinal biopsy for patients with suspicious chorioretinal lesions. CLINICAL RELEVANCE Chorioretinal lesions suspicious for malignancy sometimes require surgical biopsy for diagnosis and treatment guidance. Biopsy site selection is currently guided by presurgical imaging, and clinical assessment. We sought to determine whether iOCT provides useful information for biopsy site selection to ensure a diagnostic specimen and assessment of wound repair after biopsy. MATERIALS AND METHODS DISCOVER is a prospective study examining microscope-integrated iOCT systems in ophthalmic surgery. In this report, we examine all eyes in the DISCOVER study that underwent chorioretinal biopsy. Clinical characteristics, surgical technique, and imaging findings were reviewed. In addition, surgeon feedback data on iOCT utility and value to the procedure was also evaluated. RESULTS Six eyes were identified within the DISCOVER study that underwent chorioretinal biopsy. iOCT was used to assess retinal and choroidal lesions prior to chorioretinal incision. Following biopsy, iOCT was utilized to assess retinal attachment and wound margin integrity. Additionally, iOCT was performed in real-time during biopsy to ensure proper biopsy depth and position. In 2 cases, preoperative OCT evaluation of retinal lesions was not possible. Utilizing iOCT, comprehensive evaluation of anatomic features was successfully performed prior to biopsy. This facilitated identification of biopsy sites most likely to provide a diagnostic sample based on lesion morphology on iOCT. After completion of chorioretinal biopsy, iOCT verified completeness of biopsy site and the retinal-RPE relationship (e.g., complete apposition, partial detachment). CONCLUSION Microscope-integrated iOCT provides real-time guidance of biopsy site selection and verification of biopsy site stability following specimen collection.

Purpose: To evaluate the feasibility and utility of intraoperative optical coherence tomography (OCT) during pars plana vitrectomy surgery for dense vitreous hemorrhage. Methods: The Prospective Assessment of Intraoperative and Perioperative OCT for Ophthalmic Surgery study examined the utility of intraoperative OCT in ophthalmic surgery. Intraoperative scanning was performed with a microscope-mounted spectral domain OCT system. This report is a case series of those eyes undergoing pars plana vitrectomy for dense central vitreous hemorrhage that precluded preoperative OCT assessment. Intraoperative OCT images were qualitatively evaluated for retinal abnormalities that might impact intraoperative or perioperative management. Clinical variables were collected and assessed. Surgeon assessment of intraoperative OCT utility was also evaluated. Results: Twenty-three eyes were identified and included. The etiology for the vitreous hemorrhage was proliferative diabetic retinopathy (19 eyes, 82.6%), horseshoe retinal tear (1 eye, 4.3%), retinal vein occlusion with neovascularization (1 eye, 4.3%), presumed polypoid choroidal vasculopathy (1 eye, 4.3%), and presumed retinal arterial macroaneurysm (1 eye, 4.3%). Intraoperative OCT revealed epiretinal membrane (14 eyes, 60.9%), macular edema (14 eyes, 60.9%), posterior hyaloid traction (1 eye, 4.3%), and retinal detachment (1 eye, 4.3%). Surgeon feedback suggested that intraoperative OCT impacted surgical decision making in eyes where membrane peeling was performed. Conclusion: Intraoperative OCT during pars plana vitrectomy for vitreous hemorrhage may provide physicians with clinically relevant information that may impact surgical management, perioperative management, and patient outcomes.

To assess the microarchitectural changes occurring during surgery for vitreomacular traction using intraoperative optical coherence tomography (iOCT).A retrospective, consecutive case series of eyes undergoing pars plana vitrectomy for vitreomacular traction with performance of concurrent iOCT. A custom, microscope-mounted portable spectral domain optical coherence tomography system was used. Clinical characteristics and iOCT images were analyzed.Twelve eyes of 12 patients were included with a mean preoperative visual acuity of 20/78 improving to 20/51 (P = 0.02), postoperatively. Intraoperative optical coherence tomography was successfully performed in 100% of cases. Microarchitectural changes were noted on iOCT after surgical release of the vitreomacular traction particularly in the outer retina with increased subretinal hyporeflectivity (e.g., expansion of the distance between the retinal pigment epithelium and photoreceptor layers). In 5 of 12 eyes (42%), iOCT findings altered the surgical procedure (e.g., internal limiting membrane peeling, gas tamponade) to address the subclinical findings (e.g., full-thickness macular hole formation, residual membrane).Intrasurgical imaging using iOCT during vitreomacular traction surgery may identify subclinical changes (e.g., occult full-thickness macular hole formation) that may impact surgical decision making. Architectural changes may occur after surgical maneuvers that are particularly noted in the outer retina. The functional significance of these changes requires further investigation.

To evaluate the intrasurgical retinal architectural and macular hole (MH) geometric alterations that occur during surgical MH repair using intraoperative optical coherence tomography.A retrospective, multisurgeon, single-center, consecutive case series of 21 eyes undergoing surgical repair for MH with concurrent intraoperative optical coherence tomography using a custom microscope-mounted optical coherence tomography system was performed. All patients underwent surgical repair with pars plana vitrectomy, membrane peel, and gas tamponade. A novel three-dimensional segmentation algorithm was used for volumetric analysis of intrasurgical changes of MH geometry after surgical repair. Intraoperative optical coherence tomographic characteristics analyzed included MH volume, minimum diameter, base area, and hole height. Outer retinal architecture changes were analyzed both quantitatively and qualitatively.All 21 eyes were successfully imaged with intraoperative optical coherence tomography. Nineteen of 21 eyes had images of sufficient signal strength to allow for quantitative analysis. Significant changes were noted in MH geometry after internal limiting membrane peeling including increased MH volume, increased base area, and decreased top area (all P0.03). Additionally, increased subretinal hyporeflectance was noted by expansion of the height between the inner segment/outer segment and retinal pigment epithelium bands (P = 0.008). Peeling methods and surgeon experience did not correlate with the magnitude of architectural alterations. Macular hole algorithm measurements and alterations were associated with visual outcome and MH closure.Significant alterations occur in MH geometry and outer retinal structure after internal limiting membrane peeling. These changes are subclinical and unable to be appreciated with en face surgical microscope viewing and require intraoperative optical coherence tomography for visualization. Preliminary analysis of these measurements identified an association with visual outcome and successful MH closure. The functional significance of these changes deserves further study.