Intraoperative Interface Fluid Dynamics and Clinical Outcomes for Intraoperative Optical Coherence Tomography–Assisted Descemet Stripping Automated Endothelial Keratoplasty From the PIONEER Study

To correlate intraoperative interface fluid dynamics during Descemet stripping automated endothelial keratoplasty (DSAEK) using intraoperative optical coherence tomography (iOCT) in the Prospective Intraoperative and Perioperative Ophthalmic Imaging with Optical Coherence Tomography (PIONEER) study with postoperative outcomes. Prospective consecutive, interventional, comparative case series. One hundred seventy-eight eyes of 173 patients undergoing DSAEK from the Cole Eye Institute, Cleveland, Ohio. Eyes that underwent DSAEK between October 2011 and March 2014 from the PIONEER intraoperative and perioperative OCT study were included. An automated interface fluid segmentation algorithm evaluated intraoperative dynamics of interface fluid before and after surgical manipulations. iOCT images were also captured at multiple intraoperative time points for 2 different DSAEK techniques, 1 that used an active air infusion system and 1 that did not. Interface fluid metrics, graft nonadherence. iOCT measurements of interface fluid after final surgical manipulations and immediately before leaving the operating room identified that total fluid volume (P = .002), largest fluid volume pocket (P = .002), max fluid area (P = .006), mean fluid thickness (P = .03), and max fluid thickness (P = .01) significantly correlated with graft nonadherence rates within the first postoperative week. After placement and optimization of intraoperative lenticle adherence, iOCT revealed a significant difference between the area, volume, and thickness of maximum fluid pockets between the 2 surgical techniques, but both techniques resulted in significant reduction of interface fluid during the procedure. Larger residual interface fluid volume, area, and thickness at the end of surgery detected with iOCT are associated with early graft nonadherence and can be quantified with an automated algorithm. iOCT imaging can successfully capture technique-dependent differences in fluid dynamics during DSAEK.