To investigate the utility of intraoperative optical coherence tomography (OCT) for Descemet membrane endothelial keratoplasty (DMEK) surgery.

Prospective consecutive interventional case series.

DISCOVER (NCT02423213) is a prospective consecutive interventional case series examining the feasibility and utility of microscope-integrated intraoperative OCT in ophthalmic surgery. This report focuses on those eyes in the DISCOVER study undergoing DMEK surgery. The 8 cases were the first DMEK cases performed by the primary surgeon (J.M.G.) with microscope-integrated intraoperative OCT feedback. Qualitative OCT analysis was performed at multiple surgeon-defined time points, including host and donor tissue preparation, graft orientation, graft apposition, and tissue interface fluid dynamics.

Correct graft orientation was confirmed by intraoperative OCT prior to unscrolling in 100% of cases. Seven of 8 grafts were fully attached at the conclusion of surgery and on postoperative day 1. One graft had a linear paracentral fixed area of interface separation corresponding to posterior stromal irregularities that was visible during surgery and unchanged on postoperative day 1. Two eyes developed significant peripheral graft dehiscence visible by the first postoperative week. Both grafts were successfully reattached with repeat gas injection. All eyes demonstrated improvement in best-corrected visual acuity and there was a 100% graft survival rate at last follow-up (minimum 4 months). Surgeon feedback indicated that intraoperative OCT provided valuable information in all 8 cases.

Real-time intraoperative OCT can provide useful information that may directly impact surgical decision making during DMEK surgery. Intraoperative OCT may facilitate the transition for novice DMEK surgeons by increasing surgeon confidence and reducing the risk of iatrogenic graft failure.