Justis P. Ehlers, MD: A New “Level” of Control with Microscope Integrated Intraoperative OCT

Justis P. Ehlers, MD, started working on Intraoperative Optical Coherence Tomography, IOCT, with Cynthia Toth, MD, at Duke Eye Center, Durham, North Carolina. In 2010, Dr. Ehlers joined the Cleveland Clinic and co-established the Intraoperative OCT research program at the Cole Eye Institute with Dr. Sunil Srivastava. Intraoperative OCT has now gained commercial availability and FDA-clearance. Dr. Ehlers, who is the Norman C. and Donna L. Harbert Endowed Chair of Ophthalmic Research at the Cole Eye Institute of the Cleveland Clinic, provided his impressions of one of the current FDA-cleared microscope integrated systems, the ZEISS RESCAN® 700, during our recent discussion.

RetinaLink (RL): How has RESCAN changed your surgical workflow?
Justis P. Ehlers, MD (JPE): The biggest thing for me is how the intraoperative OCT facilitates the surgical thought process and further enables surgical judgment. It is additive to the information given by the standard microscope view and provides unique information on the microanatomy of the retina.

Intraoperative OCT provides objective imaging information that can be of tremendous value. One of the major advances seen with the microscope-integrated intraoperative OCT systems is the significant improvement in image acquisition efficiency and targeting to the region of interest. Prior to microscope integration, surgeons had to stop operating, take the image, and interpret the results. The integration into the microscope allows surgeons to be more active and efficient in capturing the images of interest. Our “level of control” has increased significantly.

RL: Have you changed your surgical plan after viewing scans intraoperatively?
JPE: I believe the intraoperative OCT provides me “one” more level of flexibility and I’m more “nimble”. Studies are being conducted now to see the correlation between OCT information and the surgeon’s modification of the surgical procedure based on that information. Based on multiple studies, it appears that intraoperative OCT provides information that alters the surgeons course of action in about 15-20% of cases, such as peeling additional membranes or reducing ICG utilization. The frequency of adding valuable information, such as reassurance of surgical impression is even higher. However, it’s too soon to know what the overall impact is for patient outcomes.

ZEISS RESCAN 700 Intraoperative OCT Imaging

RL: How does RESCAN affect your Fellows or younger surgeons and their learning curve?
JPE: Fellows love having extra information. For a young surgeon, I believe intraoperative OCT is a huge asset that may enhance surgical judgment. One study that was performed at Duke suggested that utilizing intraoperative OCT information enhances suturing technique in young surgeons when compared to the microscope alone.

RL: Does taking a scan at the end of your surgical case change your post-op protocol?
JPE: This is a great question. Yes, there are times I change my post-op protocol based on the intraoperative OCT information that I receive. Certain surgical procedures where you simply can’t definitely determine the anatomy, such as subclinical macular holes following VMT surgery, most often impact surgical decision-making at the end of the case.

RL: What cases is the RESCAN most useful for?
JPE: With our current technology, macular surgery is probably among the highest areas of return when utilizing intraoperative OCT, particularly epiretinal membranes. Beyond those cases, I have found intraoperative OCT to also be quite valuable in complex anatomy cases, such as proliferative diabetic retinopathy.

RL: What future applications do you foresee will benefit with IOCT?
JPE: The future of retina and retinal surgery is tremendously exciting. One of the key areas of need in intraoperative OCT is enhancements in the surgical feedback platform, such as novel approaches to software and image processing. Developments in these areas will foster continued growth of the technology and likely improve the system efficiency for surgical feedback.

One other exciting potential opportunity may be in image guided therapeutic delivery. The subretinal space may be a critical access area for new therapeutics, such as gene therapy and regenerative cell therapy. Utilizing intraoperative OCT, volumetric assessment will be possible and will allow for precision delivery of the optimal therapeutic amount. Finally, new technology, such as vibration-dampening instruments coupled with intraoperative OCT, may allow for new approaches to ultra-precise procedures, like vascular cannulation.

Dr. Ehlers will be Moderating an evening symposium from 5:30 – 8:30 pm, sponsored by ZEISS, with his colleagues, Drs. Sunil Srivastava, Jay Stewart, Glenn C. Yiu and Ruwan Silva on Friday, August 12, 2016, in San Francisco at the American Society of Retina Specialists. This symposium will be held at the Marriott Marquis Hotel, 780 Mission Street, Foothill G meeting room. To register click on Register here. The focus of this symposium will include Dr. Ehlers and faculty’s surgical experiences with the ZEISS RESCAN and utilizing this technology to enhance their intraoperative experience.

Dr. Justis Ehlers can be reached via e-mail – EHLERSJ@ccf.org


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