[Real-time OCT-guided strategies for optimization of precision and safety in vitreoretinal surgery]

Intraoperative real-time optical coherence tomography (iOCT) enables a dynamic visualization of retinal structures at the micrometer level during vitreoretinal surgery and provides additional information that can directly influence the course of surgery. The aim of this study is the presentation of the clinical utility, limitations and current evidence base for the use of iOCT in vitreoretinal surgery.

A narrative review was conducted based on published studies, case series, subanalyses of prospective cohorts and systematic reviews addressing the use of iOCT in vitreoretinal procedures. The literature search was primarily performed using PubMed/MEDLINE.

During epiretinal membrane (ERM) and internal limiting membrane (ILM) peeling, iOCT can assist in identifying an appropriate initiation site for membrane peeling. It also enables real-time assessment of the tissue response and facilitates verification of complete membrane removal by detecting residual fragments. In macular hole surgery, iOCT enables intraoperative visualization of hole morphology and reliable assessment of ILM flap positioning, including after fluid-air exchange. In retinal detachment and proliferative vitreoretinopathy (PVR) surgery, iOCT not only facilitates the detection of residual subretinal fluid but also supports the evaluation of dissection planes and tractional membranes.

Although many studies report a substantial added value of intraoperative OCT, a significant functional benefit, such as improvements in visual acuity outcomes, recurrence rates or complication rates has not yet been conclusively demonstrated. Nevertheless, the ability to dynamically assess retinal structures at micrometer resolution makes it possible to guide intraoperative decision-making, minimize iatrogenic tissue damage and enhance visualization, thereby providing a clear practical advantage, especially in complex cases or when microscopic visualization is limited. To date, limited evidence, high costs and heterogeneous technical implementations with variable clinical applicability have hindered widespread adoption of iOCT; however, in light of considerable technological advancements in recent years, increasing acceptance of this intraoperative imaging modality can be observed.