Continuous intraoperative optical coherence tomography-guided shield ulcer debridement with tuck in multilayered amniotic membrane transplantation

Expanding Application of Optical Coherence Tomography Beyond the Clinic: A Narrative Review

Since its introduction, optical coherence tomography (OCT) has significantly progressed in addressing its limitations. By integrating artificial intelligence and multimodal imaging, OCT enhances both speed and image quality while reducing its size. OCT continues to advance, offering new possibilities beyond the in-office setting, including intraoperative applications. This review will explore the different types of home OCT and intraoperative OCT, as well as the uses of each device and their future potential in ophthalmology.

Surgical Treatment of Corneal Shield Ulcer in Vernal Keratoconjunctivitis: A Systematic Review

BACKGROUND

Vernal keratoconjunctivitis (VKC) severely affects the quality of life of affected patients. The development of a shield ulcer is considered one of the most severe late-stage complications, which when untreated leads to irreversible vision loss. In this systematic review, we outlined the results of surgical treatments of corneal shield ulcers in VKC.

METHODS

We searched 12 literature databases on 3 April 2023 for studies of patients with VKC in which shield ulcers were treated by any surgical treatment. Treatment results were reviewed qualitatively. Assessments of the risk of bias of individual studies were made using the Clinical Appraisal Skills Programme.

RESULTS

Ten studies with 398 patients with VKC were eligible for the qualitative review. Two categories of surgical approaches were described: supratarsal corticosteroid injection and debridement with or without amniotic membrane transplantation. Almost all patients experienced resolution or improvement of their shield ulcers, regardless of treatment modality. Time to healing was faster with surgical debridement. A small proportion experienced recurrence and side effects.

CONCLUSIONS

Surgical treatment for shield ulcers in VKC seems highly effective, but careful post-operative treatment and follow-ups are necessary due to the risk of recurrence and potential side effects.

Systemic diseases and the cornea

There is a number of systemic diseases affecting the cornea. These include endocrine disorders (diabetes, Graves' disease, Addison's disease, hyperparathyroidism), infections with viruses (SARS-CoV-2, herpes simplex, varicella zoster, HTLV-1, Epstein-Barr virus) and bacteria (tuberculosis, syphilis and Pseudomonas aeruginosa), autoimmune and inflammatory diseases (rheumatoid arthritis, Sjögren's syndrome, lupus erythematosus, gout, atopic and vernal keratoconjunctivitis, multiple sclerosis, granulomatosis with polyangiitis, sarcoidosis, Cogan's syndrome, immunobullous diseases), corneal deposit disorders (Wilson's disease, cystinosis, Fabry disease, Meretoja's syndrome, mucopolysaccharidosis, hyperlipoproteinemia), and genetic disorders (aniridia, Ehlers-Danlos syndromes, Marfan syndrome). Corneal manifestations often provide an insight to underlying systemic diseases and can act as the first indicator of an undiagnosed systemic condition. Routine eye exams can bring attention to potentially life-threatening illnesses. In this review, we provide a fairly detailed overview of the pathologic changes in the cornea described in various systemic diseases and also discuss underlying molecular mechanisms, as well as current and emerging treatments.

Intraoperative Optical Coherence Tomography Guided Ocular Surgeries: Critical Analysis of Clinical Role and Future Perspectives

Intraoperative imaging of ocular tissues for diagnostic and therapeutic applications has gained immense admiration in recent years. The real time cross-sectional imaging, as well as three and four dimensional reconstruction abilities of intraoperative optical coherence tomography (iOCT), has enhanced our knowledge on many fronts in surgical maneuvers. In this review, we discuss the iOCT discovered constructive knowledge in the cornea, cataract, refractive, glaucoma, pediatric ocular, and various retinal conditions. The practical utility with decision modifying aspects along the specified ocular tissues and with respect to specific ocular entities have been narrated. Moreover, limitations and future directions have also been emphasized to make ophthalmic care more comprehensive in the future.

Intraoperative optical coherence tomography in anterior segment surgery

Intraoperative optical coherence tomography (iOCT) enables real-time visualization of ocular structures during surgery and enhances our understanding of intraoperative dynamics. iOCT aids in decision-making during various anterior segment surgeries, and its efficacy and feasibility in anterior lamellar keratoplasty and endothelial keratoplasty is well established. The landmark DISCOVER study observed that iOCT altered the surgeon decision in 38% of cases undergoing lamellar keratoplasty and provided guidance regarding the need for secondary surgical intervention. iOCT also finds an application in phacoemulsification wherein it helps to assess corneal incisions, intralenticular pressure, and posterior capsule integrity during nuclear emulsification. iOCT aids in the visualization of angle structures during placement of tubes and shunts in glaucoma surgeries and allows precise creation of partial thickness scleral flaps. In addition, iOCT helps in establishing a diagnosis, as well as provide intraoperative guidance, in pediatric patients who are not cooperative for examination. The role of iOCT in refractive surgeries and ocular surface disorders is increasingly being evaluated. The limitations of present-day iOCT systems are related to instrument compatibility, automated tracking of the surgical field, and on-table volumetric analysis of the real-time images. Technological advances may facilitate complete integration of OCT in the surgical microscopes for all surgical procedures.

Surgical debridement of corneal shield ulcers in pediatric patients: two case reports and a review of the literature

Background

Ocular allergy is a common disease, especially in the pediatric population, with unpleasant and long-term consequences, including corneal complications and decreased visual acuity. This study reports two cases of corneal shield ulcer due to vernal keratoconjunctivitis, with good results of surgical debridement performed after failure of long-term clinical treatment. Furthermore, this study highlights that this therapeutic approach, although less common, is efficient in treating refractory cases that cause suffering in pediatric patients.

Case presentation

The first patient was a 7-year-old Caucasian boy with chronic ocular allergy, especially photophobia, who had been treated with eye drops, antihistamine, and corticosteroids for 60 days without success. Biomicroscopy of the right eye showed the presence of gelatinous limbus, giant papillae in the tarsal conjunctiva, and a shield ulcer measuring 6.0 mm vertically and 2.7 mm horizontally. Surgical debridement was performed, and the ulcer did not recur. The second patient was a 4-year-old Caucasian boy with chronic ocular allergy, especially itching and photophobia, who had been treated with eye drops for 1 year without success. Biomicroscopy of the left eye showed a shield ulcer, with a dense central corneal plaque, measuring 8 mm vertically and 3.5 mm horizontally. Surgical debridement of the ulcer was performed immediately because of the chronicity of the case and severity of the lesion, and the treatment was effective.

Conclusions

The treatment of shield ulcers caused by vernal keratoconjunctivitis in the two reported cases was curative and definitive by surgical debridement in the 7-month follow-up period. Therefore, the early debridement of shield ulcers refractory to drug treatment can considerably reduce the time of disease evolution and the probability of ocular complications caused by clinical treatment or disease chronicity. However, this approach is rarely described in the literature and needs to be included in the ophthalmologist’s therapeutic arsenal.

What Is the Impact of Intraoperative Microscope-Integrated OCT in Ophthalmic Surgery? Relevant Applications and Outcomes. A Systematic Review

Background: Optical coherence tomography (OCT) has recently been introduced in the operating theatre. The aim of this review is to present the actual role of microscope-integrated optical coherence tomography (MI-OCT) in ophthalmology. Method: A total of 314 studies were identified, following a literature search adhering to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. After full-text evaluation, 81 studies discussing MI-OCT applications in ophthalmology were included. Results: At present, three microscope-integrated optical coherence tomography systems are commercially available. MI-OCT can help anterior and posterior segment surgeons in the decision-making process, providing direct visualization of anatomic planes before and after surgical manoeuvres, assisting in complex cases, and detecting or confirming intraoperative complications. Applications range from corneal transplant to macular surgery, including cataract surgery, glaucoma surgery, paediatric examination, proliferative diabetic retinopathy surgery, and retinal detachment surgery. Conclusion: The use of MI-OCT in ophthalmic surgery is becoming increasingly prevalent and has been applied in almost all procedures. However, there are still limitations to be overcome and the technology involved remains difficult to access and use.