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Healthy Living: Shift in Retina Surgeon Practice 

By: Michael Johnson, MD – Eastern Maine Medical Center

Retina specialists have progressively shifted away from 20-gauge vitrectomy toward the use of either 23 or 25 gauge vitrectomy in the majority of total vitrectomy surgeries. The introduction of microincision sutureless vitrectomy systems and associated small-gauge instrumentation has revolutionized retinal surgery and led to better practice results across a range of vitreoretinal and macular disorders.
Advanced vitreoretinal instrumentation allows for the effective treatment of a variety of vitreous and retinal pathologies, with high-speed vitrectomy probes, forceps, scissors, endolaser probes, and new light sources facilitating safer surgeries. The higher cut rates that are now achievable also help to minimize vitreous turbulence and to reduce traction on the retinal surface.
Microincision technology and small-gauge transconjunctival vitreous surgery provide greater patient convenience and the prospect of faster recovery and visual rehabilitation.
Using these smaller-incision transconjunctival approaches, the average duration of surgery is shorter and less traumatic than 20-gauge surgery, leading to statistically significantly better and faster postoperative recovery, as well as increased patient comfort and satisfaction.
IOP and Flow Rates
Intraocular pressure and aspiration flow rates are important considerations in vitreoretinal surgery, and intraoperative hypotony is associated with choroidal detachment and suprachoroidal hemorrhage.
Addressing Limitations
In theory, smaller-gauge surgical instrumentation and high cutting rates should be safer because the combination increases fluidic stability and potentially minimizes vitreous turbulence by allowing only small pieces of vitreous to enter the port. Reduced traction should lower the chance of iatrogenic damage to the retinal surface and intraoperative retinal tears.
As incision size decreases, the issues of greater instrument flexion and diminished endoillumination arise. Although many of these issues have now been addressed, both the 25- and 27-gauge systems would still nonetheless benefit from stiffer instruments, better fluidics, and further enhanced illumination to broaden their potential applications.
Looking Forward
After careful case selection and navigating the learning curve of 27-gauge surgery, the benefits include enhanced wound sealing, cutting efficiency, reduced surgical trauma, and faster postoperative recovery, to achieve an overall improvement in surgical efficacy and efficiency even in challenging vitreoretinal disorders.
In addition, narrower-gauge instrumentation with higher achievable flow rates offers better options to surgeons looking for optimal fluidic stability during surgery. Many cases in tertiary retinal practices still require the instrumentation and benefits of the 23-gauge platform.
There is a role for all gauges, and all gauge options should be made available to patients. Some indications and pathologies are more applicable to 27-gauge surgery. However, we expect that 27-gauge surgery will, over time, provide similar performance features to 25-gauge instrumentation, with further innovations and advances in material design, handling properties, and lighting likely leading to increased migration toward and better outcomes with smaller-gauge vitrectomy.>