Better Decisions for Anterior Segment Surgery

Presentation from Dr. Ozana Moraru


Anterior segment surgery ranges from routine cataract surgery to more complex procedures such as Descemet Stripping Automated Endothelial Keratoplasty (DSAEK), Deep Anterior Lamellar Keratoplasty (DALK), Descemet Membrane Endothelial Keratoplasty (DMEK) and Penetrating Keratoplasty (PK), also referred to as corneal transplant.

During these surgeries, the use of an ophthalmic microscope together with intraoperative Optical Coherence Tomography (OCT) can guide decision making and support quality control with real-time, cross-sectional imaging of subsurface details.

Key Learnings

Dr. Ozana Moraru is an Ophthalmologist and Eye Surgeon at the Oculus Eye Clinic in Bucharest, Romania, as well as the Medical Director of the clinic. She performs ophthalmic surgery procedures using the Leica M844 ophthalmology microscope and Leica EnFocus intraoperative OCT.

With EnFocus, the surgeon has immediate confirmation of tissue reaction to surgical maneuvers. He can operate with greater confidence and assess successful completion.

At the European Society of Cataract & Refractive Surgeons (ESCRS) 2019 Congress, Dr. Moraru presented several keratoplasty cases and one cataract case in which the EnFocus intraoperative OCT provided vital information to manage surgical steps and intraoperative complications. This resulted in less patient readmissions and better outcomes.

Discover the video of her presentation below, as well as a full transcript. For more information about the Leica EnFocus intraoperative OCT or how to choose an ophthalmic microscope, contact a Leica representative. Our team will be happy to answer all of your questions and share its expert advice.

Transcription of the Presentation

EnFocus, intra-operative live tomography

[00:00 - 01:18]

“We will start with a very short presentation of this machine. It has two parts. One is attached to the microscope. You can see here the blue arrows. And the other one is the monitor on which you can see the image. It offers an image resolution less than 9µm. It is very important because it allows to visualize the Descemet membrane which is 5-10µm. And its image depth is 11mm so it enables the full anterior chamber visualization without fold over artefacts.

And the same time you can see, and we have in our OR two monitors on the wall: one is with the image from the operating microscope and the other one with the image from the OCT. So, anyone, residents, nurses, or colleagues who want to learn and assist to the surgery, are now able to see at the same time both images.

Case Series: introduction

[01:19 - 02:41]

I took a series of 18 cases in which the EnFocus intra-operative OCT really helped me in some surgery steps, very important surgery steps, and really helped me in making a decision on how to continue my surgery when I found myself, let’s say “in trouble”.

All surgeries have been performed at the Oculus Eye Clinic, by the same surgeon, between January 2017 and January 2019. Except for the PKs and the cataract eye of course, all the other cases, especially for the lamellar procedures, were during the surgeon’s learning curve. This is really where the OCT really helped me.

So, I took into consideration 17 corneal transplant eyes:

  • 9 were with Ultra-Thin-Descemet Stripping Automated Keratoplasties (UT-DSAEK) with the donor lamella prepared by the surgeon using an artificial anterior chamber device
  • 4 eyes were complex eyes with Pseudophakia and previous failed Penetrating Keratoplasties (PKs) that necessitated a new PK
  • 3 eyes had Deep Anterior Lamellar Keratoplasty (DALK) for Keratoconus
  • 1 eye was a case with pre-loaded DMEK graft for Fuchs Dystrophy

And you will see, in one phacoemulsification eye, I also found the OCT very helpful.

Intraoperative OCT role in Posterior Lamellar Transplant DSAEK

[02:42 - 09:18]

So, let’s start with DSAEK cases. In these cases, we can observe with the OCT complete Descemet detachment, the presence or not of Descemet remnants. We can have a better visualization of a poor positioned graft or folds or whatever, or spaces between the lamella and the stroma. We can see the correct position of the air bubble under the lamella or between the lamella and the stroma. We also have a better visualization of the angle, the iris-cornea angle, correct detachment of the iris and the synechia from the angle.

Let’s start with one of the cases. In five of my DSAEK eyes, OCT really helped me in seeing, in following the Descemet remnants – did I clean everything? And as you see here, with the red arrow you will see a remnant in the video with a yellow arrow. After I saw that of course, I went inside again and continued to detach the remnants of the Descemet. Thus, it helped prevent patient from possible incomplete lamella attachment in the remnant areas. And of course, that means a decreased surgery readmission rate.


In another case, as you will see, we have the similar way where the red arrow, you just saw it, there’s a bump remnant of a bit of stroma and of Descemet which really needed to be taken out. Otherwise, there was a risk not to fully and correctly stick the cornea to the lamella to the stroma and again it helped me in cleaning everything as you see now at the bottom of the video, the lower video, with the yellow arrow, it’s completely clean.


In another DSAEK eye, as you see, I was in my learning curve, the lamella didn’t go exactly where I wanted it to be positioned towards the stroma. It went directly to the iris. Half of it was on the iris and half of it in the anterior chamber. Without this OCT, you don’t know exactly where to put the air bubble. And with the OCT, as you see in the upper part, you see how it’s folded and with my syringe, with air bubble, I was able very well to push it towards the stroma. And moreover, where you just saw the red arrow, you saw that the lamella was in contact with the iris. So, I really needed to center it better and move it from the iris to set free the angle. Again, it helps visualize contact between the graft margin and iris as you see with the red arrow. And at the end everything is fine, everything looks fine and well centered and the iris, and the angle, is free.


This is another case in which the lamella went directly in the anterior chamber, folded. When I saw it like this, I didn’t know, I really didn’t know how it was folded. Like this or upside down with the fold towards the stroma? And this is really where intraoperative OCT makes a difference.

I knew exactly that it was folded towards the anterior chamber, towards the iris. So, I knew exactly where to put my air syringe with the air bubble. So, I unfolded very well, thus helping me avoid so many unnecessary and dangerous maneuvers in the anterior chamber and close to the graft. As you see now on OCT, and look how nicely it unfolds towards the stroma.


Another case which is the same as you see now, you’re looking here in the video, the graft is folded towards the stroma, so not like the previous case towards the iris, but towards the stroma. So, it is very dangerous, you don’t know exactly where to put the air bubble. In this case, I needed to put the air bubble on the opposite side, so between the lamella and the stroma, push it a little bit towards the iris and after I had it aligned completely, unfolded, I put another air bubble underneath the lamella and pushed it towards the stroma. Without intraoperative OCT, I wouldn’t have known how exactly or where exactly to go with my air bubble. It was really helpful.


You don’t want to have cases like this. Look here, I have a good position, I just want to center the lamella. I thought I was gentle enough but it seems I wasn’t. As you see, during my massage maneuvers, it folded again. In which direction is it folded because here you cannot see if it’s folded in this direction like in the previous case. It was very easy for me to know exactly where to go with a syringe with the air bubble and unfold it completely.


And the last of my DSAEK cases, there are two different cases but they are similar. You can look at any of them. Look here how we have the synechia, the iris. If you look here, you don’t see exactly the periphery in the microscope. You don’t see the periphery, you are not sure that the iris at the angle is free, but OCT helped me in visualizing the iris root stuck to the iris, to the cornea and even in contact with the graft lamella. So of course, I did what I was supposed to do: air injecting and BSS injection until I took out completely the iris from the angle. This was it at the end and OCT helped me in visualizing all this.  


And the DMEK cases in which as you will see, this is the graft. Usually the DMEK graft opens like this with an open part towards the stroma. In this case you see like a tube, you see a blue cylinder, you don’t know exactly how it’s open, like this or like this? And in this particular case, OCT helped me in visualizing how it is folded. So, it was completely unnatural, not normal folding. First of all, you need to [put] upside down this folded cylinder and only after that push it towards the stroma.

Intraoperative OCT role in Anterior Lamellar Transplant DALK & EnFocus benefits

[09:18 - 11:44]

Let’s go now to some DALK cases. It’s more or less classical for the beginning. One of the most difficult steps in this surgery is to obtain the big bubble, the bigger bubble, you are not sure if it is there or not. For example, in this case, I had an emphysema. Was it a big bubble or not? In order to be sure, I just went to the OCT and checked, looked at the emphysema in the cornea. Look how nicely you can see the lower part of the air bubble. It is there, so it helped me, it encourages me to go further with my lamellar technique, not to change, so I went with the classical way of continuing the DALK surgery.


On the contrary, this is a second case in which, although I tried three times, I didn’t get a bigger bubble and the OCT confirmed this, so I didn’t get an air bubble but it was helpful in making a decision to go in the same direction for the DALK, not to convert unnecessarily to PK, but to keep the DALK technique, not with a bigger bubble, but step by step and layer by layer surgery. And I continued with DALK surgery.


Another case of DALK in which the second day we had a double anterior chamber, you will see here on the OCT done in the cabinet, the space between the Descemet and the stroma. Of course, you need to go back to the OR and reattach the Descemet, which is what I did, you will see here. And OCT also helped me in visualizing if it is attached or not because you don’t know exactly how much air to inject. You don’t want to inject too much because you want to avoid higher IOP the next day, but you don’t want to inject too little because you are not sure that it is attached.

And look how intraoperative OCT helped me. First, I had several smaller air bubbles, it was not enough. Then, three bigger air bubbles, it was not enough. And there, afterwards, two bigger air bubbles, it was not enough. But at the end, I had an air bubble, completely uniform, only one, and everything was fine. And the second day the patient and the eye looked perfect.

Intraoperative OCT role in Penetrating Keratoplasties (PKs) & EnFocus benefits

[11:45 - 12:57]

Let’s go now to the PKs. I have a few cases like this in which you see the periphery and the cornea hole is completely white, and the pre-op OCT, we saw synechia and so on.

This is the case at the end of surgery, through the microscope. You don’t see anything in the periphery. It’s white, you don’t see, you need to check. Of course, you can check with the spatula but this means an extra maneuver, dangerous maybe for the endothelium. And this is how it looks the next day. And here you can see the video of the case. You will see here how the iris was attached to the cornea, to the host cornea, and sometimes even in the sutures.

So, it can help you in correcting your surgery or mistakes if you caught the iris in the sutures, or if it is caught in the angle, helping us avoid readmission the next day if it was the case. And these are similar cases and how they looked at the end of surgery. You don’t see anything in the periphery. OCT helped me again to check the angle and the sutures.

Intraoperative OCT role in Cataract Surgery & EnFocus benefits

[12:58 - 14:41]

Last case: believe it or not, I found it useful in at least one case of cataract surgery. Of course, I don’t have the OCT attached and open for cataract surgeries usually. But in a case like this I say, just open my OCT, connect my OCT, and let me check. Because you see here, it’s just a tiny second or less than that, maybe at the end of the surgery, I just want to make the IOP normal and look, just a tiny line, is it there or not, you cannot be sure, you can miss it for sure.

But I thought, is it a Descemet detachment, I placed my OCT and it did confirm my diagnosis. It was a Descemet detachment, as you see an accidental Descemet, a stupid accident. For an experienced surgeon, it is really stupid but things can happen. And with this OCT, I confirmed my diagnosis and I knew exactly what to do. If I wouldn’t have seen that, or if I hadn’t confirmed that, the next day the patient would have had white cornea, corneal edema, I wouldn’t have known exactly what it was, I would have brought him to the OCT in the cabinet and there I would have noticed oh, it’s a detachment of the Descemet, I need to go back to the OR and so on.

But now, with the help of intraoperative OCT, I could do all this in the same session. And again, I’ll check first with the smaller air bubbles, it was not enough, but in the end, I put some more air bubbles and I had a complete attached Descemet. So, again, I avoided readmission in the OR.


[14:42 - 16:05]

Let’s have some conclusions just to see what you have been missing if you haven’t tried it so far. Intraoperative OCT is known for its help in DMEK surgeries, but the benefits and help in decision-making steps of DSAEK, DALK and PK procedures and even in cataract surgery are less highlighted.

I now have two years’ experience in working with it and I can say that the EnFocus intraoperative OCT in corneal transplant allows better visualization when advanced corneal opacities preclude good anterior chamber visualization, that is for sure.

It brought me more confidence during the procedure, so surgical steps and intraoperative complications have been better managed during the surgery, offering us a higher safety profile for the surgery. And I think it is a must-have tool during the learning curve in lamellar corneal transplants.

The intraoperative OCT EnFocus is also valuable in cataract surgery as you just saw when some complications such as Descemet detachment occur. It brings a reduction of surgery readmission rate and a reduction of surgery complications.

Thank you very much.”

About EnFocus

EnFocus is an intraoperative OCT for surgical microscopes. It allows to visualize subsurface details with high definition real-time images of the posterior and anterior segments. In addition to its benefits in keratoplasty and cataract surgery, intraoperative OCT can aid decision-making in cornea, glaucoma and retina procedures. It is also an essential tool in the application  of gene therapies. EnFocus can be combined with the Leica Proveo 8 or M844 ophthalmology microscope for comprehensive visualization. 

For more information about the Leica EnFocus intraoperative OCT or how to choose an ophthalmic microscope, contact a Leica representative.

The statements of the healthcare professional included in this article reflect only her opinion and personal experience. They do not necessarily reflect the opinion of any institution with whom she is affiliated.

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