© 2018 Petrovic et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php
and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you
hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission
for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).
Therapeutics and Clinical Risk Management 2018:14 1387–1390
erapeutics and Clinical Risk Management Dovepress
submit your manuscript | www.dovepress.com
Dovepress 1387
CASE REPORT
open access to scientific and medical research
Open Access Full Text Article
http://dx.doi.org/10.2147/TCRM.S167025
Intraoperative anterior optical coherence
tomography-guided synechiolysis in a post-
penetrating keratoplasty patient with peripheral
corneal opacication
Aleksandra Petrovic1,2
Christina Gianniou1,2
Kattayoon Hashemi1,2
Georgios Kymionis1,2
1Department of Ophthalmology,
University of Lausanne, Jules-Gonin
Eye Hospital, Lausanne, Switzerland;
2Cornea and Refractive Surgery
Department, Lausanne, Switzerland
Purpose: The aim of this study was to describe intraoperative optical coherence tomography
(OCT) as an adjunctive device for peripheral synechiolysis in a post-penetrating keratoplasty
patient.
Case report: A 75-year-old female patient presented for follow-up 9 months after a penetrating
keratoplasty in the left eye. She presented with anterior peripheral synechiae involving the
graft for three clock hours. Peripheral native cornea appeared totally opaque. Synechiolysis
was planned, and intraoperative OCT allowed us to detect nonclinically visible synechiae and
to confirm complete synechiolysis immediately after surgery. No postoperative complication
was recorded. Two months after surgery, the graft was clear and anterior segment OCT did not
reveal any residual synechiae or recurrence.
Conclusion: Intraoperative OCT is useful to overcome the difficulties in visualization through
clinically opaque corneas, as it gives real-time feedback upon the anatomy, the extension of the
remaining lesions, and the success of the surgery.
Keywords: penetrating keratoplasty, peripheral anterior synechiae, intraoperative optical
coherence tomography
Introduction
Optical coherence tomography (OCT) is a high-resolution imaging modality used to
image the anterior segment, first described in 1994.1 High-speed OCT provides in
vivo cross-sectional images of the anterior eye, similar to histological sections, and
could be a potential tool for noninvasive evaluation of the anterior chamber angle,2
especially in cases of corneal opacity.
Intraoperative real-time microscope-integrated OCT (iOCT) is an emerging
modality with the potential to revolutionize the surgical techniques by providing a
real-time dynamic feedback of the tissue alterations during surgery.3,4 In 2014, the
PIONEER study described the feasibility, utility, and safety of iOCT in ophthalmic
surgery and showed that the tool impacted surgical decision in .40% of the cases.3
iOCT has already been described in DMEK and DSAEK surgeries with advanced
bullous keratopathy.5–7
Anterior synechiae after penetrating keratoplasty (PK) is a major risk factor for
developing glaucoma and endothelial failure by rejection.8,9 Glaucoma, in turn, is a
Correspondence: Georgios Kymionis
Department of Ophthalmology,
University of Lausanne, Jules-Gonin
Eye Hospital, 15 Avenue de France,
1004 Lausanne, Switzerland
Tel +41 21 626 8585
Email gkymionis@gmail.com
Journal name: Therapeutics and Clinical Risk Management
Article Designation: Case report
Year: 2018
Volume: 14
Running head verso: Petrovic et al
Running head recto: iOCT-guided synechiolysis in post-PK patient
DOI: 167025
Therapeutics and Clinical Risk Management downloaded from https://www.dovepress.com/ by 139.81.74.75 on 08-Aug-2018
For personal use only.
Powered by TCPDF (www.tcpdf.org) 1 / 1
This article was published in the following Dove Press journal:
Therapeutics and Clinical Risk Management
Therapeutics and Clinical Risk Management 2018:14
submit your manuscript | www.dovepress.com
Dovepress
Dovepress
1388
Petrovic et al
major risk factor for graft failure, and furthermore, glaucoma
surgery is associated with shorter time to graft rejection.9
Although management of peripheral anterior synechiae
(PAS) after PK is not clearly defined in the literature, clini-
cians often tend to surgically treat this condition, in order to
avoid complications such as glaucoma and graft rejection.
We describe here the first case of iOCT-guided syn-
echiolysis in a patient with peripheral corneal opacity after
a PK.
Case report
A 75-year-old female patient presented for follow-up
9 months after a PK in the left eye.
She had undergone a deep sclerectomy for open-angle
glaucoma 12 years prior to the keratoplasty followed by cata-
ract surgery 3 years later and a Baerveldt tube implantation,
due to medically uncontrolled intraocular pressure, 5 years
later. Implantation of the Baerveldt tube was performed in the
sulcus to avoid any corneal touch. She had also been treated
for recurrent anterior uveitis. Uveitic workup was negative
for sarcoidosis, syphilis, lyme, and tuberculosis. As herpetic
origin could not be excluded, patient was treated with pro-
phylactic systemic valaciclovir to avoid recurrence.
One year after the last surgery, patient presented with
endothelial decompensation and stromal edema. A DMEK
was performed under local anesthesia, without any intra-
operative complication. Postoperative treatment consisted
of dexamethasone and ofloxacin drops four times a day.
Valaciclovir was continued. One month after surgery, the
patient presented with total corneal opacification, stromal
edema, and graft failure. After 2 months, she developed
anterior stromal fibrosis. A PK was planned. A 7.75 mm graft
was sutured after a 7.5 mm trephination. The postoperative
treatment included dexamethasone and tobramycine drops
(Tobradex®; Alcon, Fort Worth, TX, USA) six times a day.
Valaciclovir was continued. No postoperative complication
was recorded for the first 9 months.
Nine months after the surgery, the patient presented
with anterior peripheral synechiae involving the graft for
three clock hours. Peripheral native cornea appeared totally
opaque (Figure 1). Graft was clear with no sign of rejection.
Anterior chamber was calm, with no sign of recurrent uveitis.
Intraocular pressure was 15 mmHg.
Because of the history of uveitis, synechiolysis was
planned. Surgery was performed under local anesthesia
and was assisted by Leica enfocus Ultra deep OCT (Leica
Microsystems, Wetzlar, Germany), which delivers high defini-
tion real-time images of the anterior segment. Due to peripheral
corneal opacification, anterior synechiae could not be properly
seen with slit lamp microscopy or operative microscope.
Intraoperative OCT allowed us to detect nonclinically visible
synechiae and to confirm complete synechiolysis immediately
after surgery (Figure 2). Synechiolysis was performed using
a viscoelastic cannula (Viscoat®, Alcon, Fort Worth, USA)
and an ophthalmic dispersive device (Viscoat).
No postoperative complication was recorded. Postop-
erative treatment included tobramycine and dexamethasone
drops six times a day for 3 months with progressive tapering.
Valaciclovir was continued 1 g three times a day for 1 month
and then tapered weekly until 500 mg per day. Two months
after the surgery, vision was 0.2 limited by advanced glau-
comatous neuropathy. The graft was clear and anterior seg-
ment OCT (Spectralis, Heidelberg, Germany) did not reveal
any residual synechiae or recurrence.
Ethics
Written informed consent has been provided by the patient
for the publication of her case details and images.
Discussion
We describe a case of synechiolysis intraoperatively guided
by OCT. The device allowed good quality images of the
anterior segment, even in the presence of corneal opacifica-
tion, as infrared illumination used by the device scatters
less than light used by microscopes.7 iOCT helped localize
the synechiae, facilitated the synechiolysis, and confirmed
Figure 1 Color photography showing penetrating keratoplasty with peripheral
opacication.
Note: There is a clinically visible anterior synechiae from 3 to 6 o’clock.
Therapeutics and Clinical Risk Management downloaded from https://www.dovepress.com/ by 139.81.74.75 on 08-Aug-2018
For personal use only.
Powered by TCPDF (www.tcpdf.org) 1 / 1
Therapeutics and Clinical Risk Management 2018:14 submit your manuscript | www.dovepress.com
Dovepress
Dovepress
1389
iOCT-guided synechiolysis in post-PK patient
complete synechiolysis at the end of the procedure. Without
the device, operative strategy would be planned differently.
Anterior segment OCT would be performed preoperatively,
and synechiae position would be marked.
iOCT has already been described in anterior segment
surgery, especially for lamellar keratoplasty such as DMEK
and DSAEK.3,5–7 In DMEK, iOCT has been reported to help
in graft rotation without touching the graft as well as graft
orientation.5,6 In DSAEK surgery, iOCT has been reported
to help in graft–host interactions and to verify the presence
or absence of fluid interface.7 For both surgeries, iOCT may
expand their indications and diminish the need for PK, which
is a more invasive surgery with a higher comorbidity rate.
The actual impact on overall surgical time has been studied
and appears to be generally minimal.3
However, this device has still some limitations: distortion
of the images during eye movements and restriction of the
scanning zone necessitate frequent adjustment of the view-
ing field during surgery. Automated tracking would be a
welcome addition to facilitate rapid imaging of the region of
interest and to minimize surgeon burden of manual adjust-
ment.10 Moreover, metallic instruments create difficulties for
intraoperative OCT systems due to the light scattering and
shadowing characteristics of metal, which render underlying
tissue invisible.10
Conclusion
Despite these limitations, it seems that iOCT is a valuable
device in order to overcome the difficulties in visualization
through clinically opaque corneas.
To the best of our knowledge, this is the first report of
intraoperative OCT-guided anterior synechiolysis.
Disclosure
The authors report no conflicts of interest in this work.
References
1. Izatt JA, Hee MR, Swanson EA, et al. Micrometer-scale resolution
imaging of the anterior eye in vivo with optical coherence tomography.
Arch Ophthalmol. 1994;112(12):1584–1589.
2. Radhakrishnan S, Rollins AM, Roth JE, et al. Real-time optical coher-
ence tomography of the anterior segment at 1310 nm. Arch Ophthalmol.
2001;119(8):1179–1185.
3. Ehlers JP, Dupps WJ, Kaiser PK, et al. The prospective intraopera-
tive and perioperative ophthalmic ImagiNg with optical CoherEncE
TomogRaphy (PIONEER) study: 2-year results. Am J Ophthalmol. 2014;
158(5):999–1007.
4. Titiyal JS, Kaur M, Falera R. Intraoperative optical coherence tomog-
raphy in anterior segment surgeries. Indian J Ophthalmol. 2017;65(2):
116–121.
5. Cost B, Goshe JM, Srivastava S, Ehlers JP. Intraoperative optical
coherence tomography-assisted descemet membrane endothelial ker-
atoplasty in the DISCOVER study. Am J Ophthalmol. 2015;160(3):
430–437.
6. Saad A, Guilbert E, Grise-Dulac A, Sabatier P, Gatinel D. Intraopera-
tive OCT-assisted DMEK: 14 consecutive cases. Cornea. 2015;34(7):
802–807.
7. Pasricha ND, Shieh C, Carrasco-Zevallos OM, et al. Real-time
microscope-integrated OCT to improve visualization in DSAEK for
advanced bullous keratopathy. Cornea. 2015;34(12):1606–1610.
8. Price MO, Thompson RW Jr, Price FW Jr. Risk factors for various
causes of failure in initial corneal grafts. Arch Ophthalmol. 2003;121(8):
1087–1092.
9. Baltaziak M, Chew HF, Podbielski DW, Ahmed IIK. Glaucoma after
corneal replacement. Surv Ophthalmol. 2018;63(2):135–148.
10. Ehlers JP. Intraoperative optical coherence tomography: past, present,
and future. Eye. 2016;30(2):193–201.
Figure 2 Intraoperative OCT showing (A) peripheral anterior synechiae posterior to the opacication and (B) after surgery, deepening of the anterior chamber and lysis
of adhesion.
Abbreviation: OCT, optical coherence tomography.
Therapeutics and Clinical Risk Management downloaded from https://www.dovepress.com/ by 139.81.74.75 on 08-Aug-2018
For personal use only.
Powered by TCPDF (www.tcpdf.org) 1 / 1
erapeutics and Clinical Risk Management
Publish your work in this journal
Submit your manuscript here: http://www.dovepress.com/therapeutics-and-clinical-risk-management-journal
Therapeutics and Clinical Risk Management is an international, peer-
reviewed journal of clinical therapeutics and risk management, focusing
on concise rapid reporting of clinical studies in all therapeutic areas,
outcomes, safety, and programs for the effective, safe, and sustained
use of medicines. This journal is indexed on PubMed Central, CAS,
EMBase, Scopus and the Elsevier Bibliographic databases. The
manuscript management system is completely online and includes a
very quick and fair peer-review system, which is all easy to use. Visit
http://www.dovepress.com/testimonials.php to read real quotes from
published authors.
Therapeutics and Clinical Risk Management 2018:14
submit your manuscript | www.dovepress.com
Dovepress
Dovepress
Dovepress
1390
Petrovic et al
Therapeutics and Clinical Risk Management downloaded from https://www.dovepress.com/ by 139.81.74.75 on 08-Aug-2018
For personal use only.
Powered by TCPDF (www.tcpdf.org) 1 / 1
