Elsevier

Survey of Ophthalmology

Volume 56, Issue 2, March–April 2011, Pages 162-172
Survey of Ophthalmology

Diagnostic and Surgical Techniques
Advantages and Limitations of Small Gauge Vitrectomy

https://doi.org/10.1016/j.survophthal.2010.08.003Get rights and content

Abstract

Small gauge vitrectomy utilizing 23- and 25-gauge instrumentation has definite advantages, but also limitations, due to the physics of smaller instruments and sutureless surgery. Higher infusion and aspiration pressures are needed to remove the vitreous using 23- and 25-gauge probes. The advantages include decreased surgical times, less tissue manipulation, reduced inflammation and pain postoperatively with more rapid visual recovery. A disadvantage is greater instrument flexion than 20-gauge probes, making small gauge vitrectomy more appropriate for indications such as vitreous opacities, epiretinal membranes, macular holes, and simple retinal detachments. There are also some increased complications related to small gauge vitrectomy, including dislocation of cannulas intraoperatively, early postoperative hypotony, choroidal detachment, and possibly an increased risk of infectious endophthalmitis.

Section snippets

20-Gauge Vitrectomy

Conjunctival incisions are typically made to expose the sclera, followed by perpendicular incisions with the microvitreoretinal blade (MVR) through the sclera into the vitreous. The infusion cannula is sutured to the sclera, which provides added protection against accidental dislocation of the cannula. The 20-gauge sclerotomies are sutured closed at the end of the surgery, followed by the conjunctiva, to achieve a two-layer closure. Some sutureless trocar-based systems have been developed for

Intraoperative

The trocars used for 25- and 23-gauge vitrectomy cannula insertion are not as sharp as MVR blades used to make 20-gauge sclerotomies, so the force required to insert the trocar/cannula is substantially greater than the 20-gauge MVR blade. The trocars are designed so the cannula fits tightly through the scleral incision to minimize dislocation. Pressures as high as 63.7 mm Hg have been measure during trocar/cannula placement for 25-gauge vitrectomy.23 Similar problems are encountered with

Advantages of Small Gauge Vitrectomy

The primary advantage of 23- and 25-gauge vitrectomy is shorter operative times9, 16, 42, 65, 92, 117, 119, 120, 165 although one study with 25-gauge surgery65 and one with 23-gauge surgery162 found no net gain because of longer times required to remove vitreous with smaller diameter instruments. Factors favoring shorter operative times include selection of only “easier” cases for 23- and 25-gauge surgery, less thorough vitreous removal, and the absence of sutured sclerotomies. If more thorough

Advantages of Standard Gauge Vitrectomy

20-gauge vitrectomy still facilitates surgery in some eyes. In general, 20-gauge vitrectomy is helpful in eyes with more complicated pathology, where extensive dissection must be performed in the posterior pole or periphery. The array of picks, scissors, and forceps available for 20-gauge systems is currently much greater, allowing flexibility in managing a wide variety of vitreoretinal pathologies. The fluidics of 20-gauge instruments also allows surgery to be performed at lower infusion

Future Role of Small Gauge Instruments for Vitrectomy

Small gauge vitrectomy has an important role in vitreoretinal surgery, but should not replace 20-gauge instruments entirely. Currently, small gauge vitrectomy has some increased surgical complications (postoperative hypotony and possibly infectious endophthalmitis) that need to be corrected with refinements in surgical technique to make the risks comparable to 20-gauge vitrectomy. There are early reports of 27-gauge vitrectomy instruments, so even smaller instrumentation may become available in

Method of Literature Search

A PubMed search was performed on 11 June 2009 and repeated on 28 March 2010 (to find any newer publications) using the following search terms small gauge vitrectomy OR 23-gauge vitrectomy OR 25-gauge vitrectomy. There were no restrictions on date of publication but virtually all articles about small gauge vitrectomy have been published in the past 10 years. Articles in foreign languages were potentially included if they had an abstract with an English translation. Non-English articles were not

Disclosure

The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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