Live volumetric (4D) visualization and guidance of in vivo human ophthalmic surgery with intraoperative optical coherence tomography.
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2016-08-19
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Abstract
Minimally-invasive microsurgery has resulted in improved outcomes for patients. However, operating through a microscope limits depth perception and fixes the visual perspective, which result in a steep learning curve to achieve microsurgical proficiency. We introduce a surgical imaging system employing four-dimensional (live volumetric imaging through time) microscope-integrated optical coherence tomography (4D MIOCT) capable of imaging at up to 10 volumes per second to visualize human microsurgery. A custom stereoscopic heads-up display provides real-time interactive volumetric feedback to the surgeon. We report that 4D MIOCT enhanced suturing accuracy and control of instrument positioning in mock surgical trials involving 17 ophthalmic surgeons. Additionally, 4D MIOCT imaging was performed in 48 human eye surgeries and was demonstrated to successfully visualize the pathology of interest in concordance with preoperative diagnosis in 93% of retinal surgeries and the surgical site of interest in 100% of anterior segment surgeries. In vivo 4D MIOCT imaging revealed sub-surface pathologic structures and instrument-induced lesions that were invisible through the operating microscope during standard surgical maneuvers. In select cases, 4D MIOCT guidance was necessary to resolve such lesions and prevent post-operative complications. Our novel surgical visualization platform achieves surgeon-interactive 4D visualization of live surgery which could expand the surgeon's capabilities.
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Carrasco-Zevallos, OM, B Keller, C Viehland, L Shen, G Waterman, B Todorich, C Shieh, P Hahn, et al. (2016). Live volumetric (4D) visualization and guidance of in vivo human ophthalmic surgery with intraoperative optical coherence tomography. Sci Rep, 6. p. 31689. 10.1038/srep31689 Retrieved from https://hdl.handle.net/10161/12788.
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Scholars@Duke
Liangbo Shen
Dr. Liangbo (Linus) Shen is a vitreoretinal surgery fellow at Duke University School of Medicine. He graduated summa cum laude in Biomedical Engineering from Duke, where he co-invented a patented stereoscopic heads-up display system for ophthalmic surgery and advanced intraoperative optical coherence tomography. He went on to earn his medical degree cum laude from Yale School of Medicine, where he co-developed the “entry time realignment” statistical method that enabled long-term natural history studies of geographic atrophy, choroideremia, Stargardt disease, Huntington’s disease, and USH2A-retinopathy. He also identified novel imaging biomarkers and developed a pixel-based analysis method that can reduce clinical trial sample sizes for geographic atrophy by more than tenfold compared with conventional methods.
Dr. Shen completed rigorous clinical and surgical training during his ophthalmology residency at the University of California, San Francisco. At UCSF, he also pursued research in imaging biomarkers of age-related macular degeneration and inherited retinal degenerations. His work included leading analyses for the METforMIN randomized trial on metformin and geographic atrophy progression, investigating cone structure changes in choroideremia, and inventing a syringe attachment for one-handed anterior chamber paracentesis.
Now at Duke, Dr. Shen continues to refine pixel-based imaging analysis to improve trial efficiency and to evaluate treatment response in geographic atrophy and inherited retinal degenerations. He has authored or co-authored more than 50 peer-reviewed publications in high-impact journals including Ophthalmology, JAMA Ophthalmology, and the American Journal of Ophthalmology.
Dr. Shen has been recognized with numerous national awards, including the Heed Fellowship, AUPO/RPB Resident and Fellow Research Forum Award, and best research awards at conferences. He has delivered talks on his research at major national and international conferences, including ARVO, AAO, ASRS, and AUPO.
Deeply committed to advancing the understanding of retinal diseases, Dr. Shen integrates engineering, imaging, and clinical research to develop diagnostics and treatments that improve patient care.
Sina Farsiu
I am the director of the Vision and Image Processing (VIP) Laboratory. Along with my colleagues, we investigate how to improve early diagnostic methods and find new imaging biomarkers of ocular and neurological diseases in adults (e.g. age-related macular degeneration, diabetic retinopathy, Glaucoma, Alzheimer) and children (e.g. retinopathy or prematurity). We also develop automatic artificial intelligence machine learning and deep learning algorithms to detect/segment/quantify anatomical/pathological structures seen on medical images.
On another front, we study efficient signal processing based methods to overcome the theoretical and practical limitations that constrain the achievable resolution of any imaging device. Our approach, which is based on adaptive extraction and robust fusion of relevant information from the expensive and sophisticated as well as simple and cheap sensors, has found wide applications in improving the quality of imaging systems such as ophthalmic SD-OCT, digital X-ray mammography, electronic and optical microscopes, and commercial digital camcorders. We are also interested in pursuing statistical signal processing based projects, including super-resolution, demosaicing, deblurring, denoising, motion estimation, compressive sensing/adaptive sampling, and sensor fusion.
Anthony Nanlin Kuo
Anthony Kuo, M.D. is Professor of Ophthalmology, Professor of Biomedical Engineering and Vice Chair for Technology and Director of Research Data at Duke University. He is a clinician-scientist with an active clinical practice in cornea and refractive surgery and an active laboratory program developing and translating high resolution optical coherence tomography (OCT) technologies for ophthalmic use.
In collaboration with colleagues at Duke, he is also involved in the development and translation of intra-surgical OCT technologies. His research has been sponsored by the National Institutes of Health, the U.S. Department of Defense, and the Coulter Foundation among others.
Cynthia Ann Toth
RESEARCH INTERESTS
Dr. Toth specializes in the evaluation and surgical treatment of vitreoretinal diseases in infants, children and adults, and in novel research resulting in the clinical application of optical coherence tomography (OCT) imaging in surgery and at the bedside. Her clinical interests and skills include the surgical treatment of macular diseases (such as, macular hole, epiretinal membrane and vitreomacular traction), retinal detachment, proliferative diabetic retinopathy, proliferative vitreoretinopathy (PVR), and retinopathy of prematurity (ROP).
Dr. Toth is a world expert in retinal imaging with optical coherence tomography (OCT) and pioneered both the first use of a research hand-held spectral domain OCT system for infant examination and the first intraoperative OCT-guided ophthalmic surgical system. For infants and children, Dr. Toth's multidisciplinary team has demonstrated novel eye findings that are visible only with OCT imaging and that are often associated with brain disease or challenges of brain development. In surgery, Dr. Toth performed the world's first intraoperative OCT imaging and the first swept-source OCT imaging with heads-up display during retinal surgery. With colleagues in the Duke Eye Center and in Biomedical Engineering, she perfecting such techniques. She has been repeatedly honored among the Best Doctors in America.
Dr. Toth is also professor in the Department of Biomedical Engineering in the Pratt School of Engineering. Her primary research interests are in translational research and early-application clinical trials with a focus on novel retinal imaging with spectral domain and swept source optical coherence tomography (SD and SSOCT). Dr. Toth's Laboratory, the Duke Advanced Research in Spectral Domain/Swept Source OCT Imaging (DARSI) Laboratory centers on improving early diagnostic methods, imaging biomarkers and therapies for both age-related macular degeneration (AMD) and for retinal diseases in children. Sina Farsiu, PhD, has collaborated to provide advanced image processing for OCT with in the DARSI Laboratory. In collaboration with Joseph Izatt, PhD in Biomedical Engineering, the DARSI team is currently applying OCT to the diagnosis and care of retinal diseases and especially in microsurgery in adults and in children in several studies including NIH funded investigations.
Dr. Toth was also co-founder and has been the Director of Grading for OCT for the Duke Reading Center and has designed and directed OCT analysis for numerous multicenter clinical trials including the Comparisons of AMD Treatment Trials (CATT). The Duke Reading Center provides support in training, data acquisition, and grading for multicenter clinical trials utilizing optical coherence tomography as an outcome measure.
Dr. Toth chaired the multicenter Age Related Eye Disease Study 2 Ancillary SDOCT (A2ASDOCT) Study and has participated as site PI in the AREDS2. She also led studies of macular translocation surgery (MT360) for patients with severe AMD, along with co-investigator Dr. Sharon Freedman. Macular translocation surgery was a salvage treatment for AMD patients who lost vision due to neovascular AMD, prior to the current era of anti-Vascular Endothelial Growth Factor treatments. The surgery resulted in an auto-transplant of the retina, isolating the retina from the underlying choroidal and retinal pigment epithelial pathology. Imaging and retinal function data from those studies have contributed to teasing out events in the macula related to vision loss.
Learn More about the Toth-DARSI Lab
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