Intraoperative Optical Coherence Tomography For Identifying And Avoiding Prior Corneal Incisions During Descemet Stripping Automated Endothelial Keratoplasty

Healed clear corneal incisions (CCIs) exhibit reduced biomechanical integrity and may be prone to dehiscence during repeat anterior segment surgery. Intraoperative optical coherence tomography (iOCT) enables real-time, high-resolution corneal imaging. Although iOCT is widely used to assess graft orientation and interface fluid in lamellar keratoplasty, its role in identifying prior corneal wound tracts has not been described. This study evaluated the feasibility and clinical value of microscope-integrated iOCT for mapping previous CCIs and guiding incision placement during Descemet stripping automated endothelial keratoplasty (DSAEK) in previously operated eyes.

Retrospective consecutive case series conducted at a single tertiary center in 2025 by two experienced corneal surgeons using a microscope-integrated iOCT system (ZEISS ARTEVO 850, Carl Zeiss Meditec, Jena, Germany). All eyes had a history of prior phacoemulsification, and most had undergone additional ocular surgery, including trabeculectomy, goniotomy, Ahmed glaucoma valve implantation, pars plana vitrectomy, or previous keratoplasty.

Ten eyes of 10 patients undergoing DSAEK with known prior CCIs were included. Before creating paracenteses, 360-degree iOCT scanning was performed to map prior wound tracts. Hyperreflective linear signals with localized discontinuities of corneal architecture were interpreted as previous incisions. New incision sites were planned in structurally intact corneal areas, avoiding overlap with prior wounds. The primary outcome was successful identification and avoidance of prior CCIs. Secondary outcomes included intraoperative complications, wound leakage, graft detachment, and need for rebubbling.

Prior corneal wound tracts were successfully visualized using iOCT in all eyes (100%). Based on iOCT mapping, new paracenteses were successfully relocated to uninvolved corneal areas in all cases. No intraoperative complications, wound intersections, or leakage occurred. All grafts were attached and well-centered on postoperative day 1, with 100% attachment maintained at 30 days. No rebubbling procedures or postoperative infections were observed.

Microscope-integrated iOCT reliably identifies prior corneal incision tracts during DSAEK and facilitates safe, individualized incision planning. This technique allows visualization of prior CCIs that may not be clinically visible, particularly in edematous, opaque, or previously operated corneas. By mapping previous surgical sites before creating new incisions, surgeons can avoid areas of scarring and reduced biomechanical integrity, thus potentially minimizing the risk of wound dehiscence and improving wound apposition and airtight closure. This technique was easily incorporated into the routine surgical workflow.