Minimally invasive vitrectomy surgery with 27-gauge equipment is improving with the development of new technology that is increasing efficiency and expanding functionality.
Take-home message: Minimally invasive vitrectomy surgery with 27-gauge equipment is improving with the development of new technology that is increasing efficiency and expanding functionality.
Reviewed by Yusuke Oshima, MD, PhD
Taktsuki, Japan-Continued advances in vitrectomy machines and instrumentation have led to progressive improvements in the efficiency of 27-gauge vitrectomy and made the ultrasmall-gauge surgery suitable for the full spectrum of vitreoretinal pathologies, said Yusuke Oshima, MD, PhD.
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Use of a 3-dimensional heads-up surgery platform (TrueVision 3D Surgical, TrueVision) that minimizes phototoxicity risk provides yet another novel benefit and represents the next step toward achieving ultra-minimally invasive vitrectomy surgery, added Dr. Oshima, founder and director, Oshima Eye Clinic, Taktsuki, Japan.
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“In 2010, we were excited to report our initial experience with 27-gauge vitrectomy that showed very favorable results in a set of selected cases comprised mainly of eyes with macular disease and simple vitreous hemorrhage. Five years later, the introduction of an ultra-high speed cutter (Dutch Ophthalmic Research Center International BV) that exerts less tractional force allowed expansion of 27-gauge vitrectomy to a broader range of eyes, including those with challenging tractional detachments,” he said.
Watch 27-gauge diabetic vitrectomy for fibrovascular membrane dissection. (Video courtesy of Yusuke Oshima, MD, PhD)
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“Most recently a 27-gauge twin-duty cycle cutter with a double-port (TDC cutter, Dutch Ophthalmic Research Center International BV) has been developed to provide a very high duty cycle regardless of the cutting rate and provides even better cutting efficiency than a conventional 25-gauge cutter. Now we are using the 3-D heads up surgery system that provides a sufficiently bright and clear fundus view on the display monitor with only 10% to 20% of the illumination power that is used for viewing through the surgical microscope.”
Risks of 23- and 25-gauge
The standardized 27-gauge vitrectomy procedures are performed with chandelier endoillumination and wide-angle viewing systems. Dr. Oshima noted that the small port of the 27-gauge vitreous cutter with its position near to the top of the tip enables direct dissection of fibrotic neovascular membranes because it is easy to insert into the small space between the membrane and retina. In addition, it allows for pinpoint aspiration of preretinal hemorrhage with reduced turbulence.
Using a bimanual technique for membrane dissection in which the membrane is lifted with a forceps in one hand, the 27-gauge cutter is used to sever the anchoring point before cutting the membrane en bloc.
“This approach with use of a 23-gauge or 25-gauge cutter carries a greater risk of bleeding from the anchor point. The ease of insertion of the 27-gauge cutter under the membrane makes it easier to cut the anchor point first without causing bleeding,” Dr. Oshima explained.
“Therefore, I no longer give an anti-VEGF injection as a preoperative adjuvant when performing 27-gauge vitrectomy for diabetic traction retinal detachment.”
He added that he likes to peel the internal limiting membrane (ILM) in eyes with diabetic tractional detachment because that step eliminates any scaffold for postoperative membrane proliferation.
“The grasping force of the 27-gauge cutter is sufficient for peeling the ILM,” Dr. Oshima said.
After laser photocoagulation, the 27-gauge procedure is easily concluded by simply removing the trocar cannula and the optical fiber.
“Subconjunctival bleeding is remarkably minimal with this approach and really quite similar to what we see with routine cataract surgery,” Dr. Oshima said.
Yusuke Oshima, MD, PhD
This article is based on a presentation given by Dr. Oshima at the 2015 Retina Subspecialty Day meeting. Dr. Oshima receives lecture fees from Alcon and is a consultant to Synergetics.