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THE INTEGRATIVE SURGICAL THEATER: Combining Intraoperative Optical Coherence Tomography and 3D Digital Visualization for Vitreoretinal Surgery in the DISCOVER Study

Ehlers, Justis P., MD*,†; Uchida, Atsuro, MD, PhD*,†; Srivastava, Sunil K., MD*,†

doi: 10.1097/IAE.0000000000001999
Original Study

Purpose: To evaluate the feasibility of integrating intraoperative optical coherence tomography (OCT) with a digital visualization platform for vitreoretinal surgery.

Methods: The DISCOVER study is a prospective study examining microscope-integrated intraoperative OCT across multiple prototypes and platforms. For this assessment, a microscope-integrated OCT platform was combined with a three-dimensional (3D) surgical visualization system to allow for digital display of the OCT data stream on the large immersive display. Intraoperative OCT scans were obtained at various surgical milestones that were directly overlaid to the surgical view in a 55-inch passive 3D 4K high-definition display. Surgeon feedback was obtained related to system performance and integration into the surgical procedures through a prespecified surgeon questionnaire.

Results: Seven eyes of seven subjects were identified. Clinical diagnosis included epiretinal membrane (n = 3), macular hole (2), symptomatic vitreous opacity (1), and proliferative vitreoretinopathy (1). Optical coherence tomography images were successfully obtained and displayed on the 4K screen in all cases. Intraoperative OCT images facilitated identification of subtle retinal alterations. Surgeons reported that the 4K screen seemed to provide improved visualization of the OCT data stream compared with the semitransparent ocular view. Surgeons were able to examine the OCT data on the 4K screen without reverting to the external display system of the microscope. The system provided a uniform surgical visualization experience for both the surgeon and the assistant. In addition, the digital platform allowed all surgical personnel to simultaneously view both the OCT and the surgical field. All eyes underwent uneventful vitrectomy without reverting to the conventional microscope. No intraoperative adverse events occurred.

Conclusion: Integration of OCT into the digital visualization system may enable unique opportunities for surgeon feedback of intraoperative diagnostics. The overlay of the OCT data onto the 4K monitor seemed to provide excellent visualization of OCT details. Further research is needed to compare the conventional microscope–based approach to the digital 3D screen approach in regards to intraoperative OCT.

Significant advances over the last few years have enabled the use of optical coherence tomography during surgery and enhanced the potential of digital vitreoretinal surgery. In this report, those technologies are combined into a seamless integrative surgical theater, enabling the surgeons to view both the optical coherence tomography and the surgical field simultaneously on a large-screen immersive display. The merging of these technologies may allow for unique opportunities in the future for surgeon feedback and display features.

*Ophthalmic Imaging Center, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio; and

Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio.

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

NIH/NEI K23-EY022947-01A1 (J.P.E.); Ohio Department of Development TECH-13-059 (J.P.E.); Research to Prevent Blindness (Cole Eye Institutional Grant); Unrestricted travel grant from Alcon Novartis Hida Memorial Award 2015 funded by Alcon Japan Ltd (A.U.).

J. P. Ehlers: Bioptigen/Leica (P, C), Synergetics (P), Zeiss (C), Thrombogenics (C, R); Regeneron (R), Genentech (R), Santen (C), Alcon (C). S. K. Srivastava: Allergan (R), Bausch and Lomb (C), Bioptigen (P), Zeiss (C), Leica (C), Santen (C), Synergetics (P). The remaining author has no conflicting interests to disclose.

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J. P. Ehlers had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

© 2018 by Ophthalmic Communications Society, Inc.