Role of microscope-integrated optical coherence tomography (MiOCT) in surgical retina

How has intraoperative optical coherence tomography (iOCT) enhanced surgical decision-making in macular surgeries such as epiretinal membrane peeling, macular holes, and vitreomacular tractions? Dr. Rohan Chawla - Intraoperative OCT does sound very attractive too. However, the current generation intraoperative OCT has not lived up to the expectations. The resolution is not very great. The artifacts of overlying instruments obscure anatomy, and it does not have a quantitative tool. Thus, I do not use it routinely. However, yes, when sometimes on the table, there is a confusion between a full-thickness hole and a lamellar hole, I do switch it on Dr. Mohit Dogra - iOCT is helpful in selected surgical situations - surgery for lamellar macular hole and myopic foveoschisis with vitreoschisis. It is an objective visual endpoint for confirming complete removal of vitreous lamellae, epiretinal proliferation, and/or internal limiting membrane. How do you use iOCT for proliferative diabetic retinopathy (PDR) surgeries? DR RC Again, if I have a doubt regarding any iatrogenic break around the posterior pole, I like to check whether it is full-thickness or lamellar Can sometimes be of use to assess macular edema, which was not possible preoperatively. DR MD - iOCT is useful in surgery for taut posterior hyaloid membrane (TPHM) as it ensures that no vitreous remnant is present on the retinal surface. 3. What is your protocol for using iOCT in your practice? Do you use it for all macular surgeries or in selected ones? DR RC - Selected cases. I do not keep it on routinely. Only for specific situations as mentioned above DR MD - Extremely selected cases, namely, myopic foveoschisis, diabetic TPHM, and degenerative lamellar macular holes. 4. Are there measurable improvements in surgical outcomes or complication rates when intraoperative imaging is routinely used? DR RC - I do not think so. It also increases surgical time DR MD - Not for the most part, except in the aforementioned surgical scenarios. 5. Can intraoperative imaging reduce the incidence of postvitrectomy retinal detachments, and if yes, in which eyes? DR RC - Not in most cases. Only for PDR, like mentioned above. If OCT confirms a full-thickness break, then I would laser it and use a longer-lasting tamponade than just air itself DR MD - No. 6. How do you balance the increased operative time associated with iOCT with the potential benefits in precision and safety? DR RC - Use it for selected indications only DR MD - One of the major reasons for me not using iOCT in every case is the increased surgical time; hence, I use it exclusively for the aforementioned cases. 7. What is the major deterrent for using iOCT in all surgeries? DR RC - I have already mentioned the drawbacks earlier DR MD - Limited resolution, lack of real-time OCT feedback, back shadowing of instruments hampering visualization, and increased total surgical time. 8. Can you highlight a clinical or surgical situation where iOCT made a huge impact on surgical decision? DR RC - PDR cases where OCT did not show iatrogenic full-thickness hole formation gave me confidence to close the case under air alone DR MD - iOCT is extremely helpful in cases of subfoveal perflurocarbon liquid (PFCL) removal (using either the 41G subretinal cannula) by confirming the displacement of the PFCL bubble and/or demonstrating closure of the iatrogenic macular hole. 9. Which option seems surgeon-friendly and impactful- integrated OCT imaging in the microscope’s eyepiece versus picture in picture (PIP) option in 3d heads-up surgery? DR RC - Both are similar. Heads-up display gives a magnified view, easier to see. But again, resolution suffers DR MD - PIP option in 3D heads-up surgery. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.