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Runkle, Anne P., MD*,†; Srivastava, Sunil K., MD*,†; Yuan, Alex, MD, PhD*,†; Kaiser, Peter K., MD*,†; Singh, Rishi P., MD*,†; Reese, Jamie L., BSN*,†; Ehlers, Justis P., MD*,†

doi: 10.1097/IAE.0000000000002017
Original Study

Purpose: 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.

Methods: 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.

Results: 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 (P < 0.01). 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.

Conclusion: 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).

This study uses intraoperative optical coherence tomography images to investigate the relationship between intraoperative membrane dynamics and postoperative development of dissociated optic nerve fiber layer appearance. Appearance of dissociated optic nerve fiber layer was correlated with acute postpeel increase in inner retinal thickness and macular hole repair, and there was no correlation between choice of surgical technique and development of dissociated optic nerve fiber layer appearance.

*Ophthalmic Imaging Center, Cleveland Clinic, Cleveland, Ohio; and

Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio.

Reprint requests: Justis P. Ehlers, MD, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue/i32, Cleveland, OH 44195; e-mail:

NIH/NEI K23-EY022947-01A1 (J.P.E.); NIH/NEI T32EY024236-01A1 (A.P.R.); Ohio Department of Development TECH-13-059 (J.P.E., S.K.S.).

S. K. Srivastava: Zeiss (C), Bioptigen/Leica (P), Bausch and Lomb (C, P), Allergan (R), Santen (C). P. K. Kaiser: Alcon (C), Bausch and Lomb (C), Bayer (C), Carl Zeiss Meditec (C), Genentech (C), Novartis (C), Neurotech (C), Ohr (C), Ophthotech (C), Oraya (C), Regeneron (C), Topcon (C). R. P. Singh: Zeiss (C), Genentech (C), Regeneron (C), Thrombogenics (C), Alcon (C). J. P. Ehlers: Bioptigen/Leica (P, C), Synergetics/Bausch and Lomb (P), Zeiss (C), Thrombogenics (C, R), Regeneron (R), Genentech (R), Santen (C), Alcon (C). The remaining authors have no conflicting interests to disclose.

© 2018 by Ophthalmic Communications Society, Inc.