#7: Vitrectomy Procedures

In the early 1970s, Dr. Robert Machemer of Bascom Palmer Eye Institute developed closed, pars plana vitrectomy (PPV) to eliminate the need for keratoplasty and operate within a closed system that allowed for control of intraocular pressure. This procedure utilized a 17-gauge (1.5 mm) instrument that combined a vitreous cutter, infusion, and aspiration, and utilized 2.3 mm scleral incision. An alternate, 20-gauge (0.9 mm), 3-port vitrectomy system that separated vitreous cutting, infusion, and illumination components was developed soon after. This system remained the gold standard in vitreoretinal surgery for nearly three decades.

Comparison of 20-, 23-, and 25-gauge vitrectomy cutters

In the 1980s and 90s, a number of attempts to develop smaller-gauge, self-sealing vitrectomy procedures were initiated, but it took until 2002 for the movement to gain momentum when Dr. Gildo Fujii of the University of Southern California initially described his use of a sutureless, transconjunctival, 25-gauge (0.5 mm) PPV system in a variety of surgical cases. Within the next few years, 23- and 27-gauge systems (0.7 mm and 0.4 mm, respectively) were introduced.

Small-gauge vitrectromy quickly gained momentum among retinal surgeons. In a 2004 survey of the American Society of Retina Specialists (ASRS), only 52% of respondents had tried small-gauge vitrectomy. By 2007, 80% had used it for certain surgical cases. More recent data from a 2014 ASRS survey showed that 25-gauge instrumentation is most popular in the United States, whereas 23-gauge instrumentation is used most frequently internationally.

Initially, the use of small gauge vitrectomy was limited to less challenging cases such as epiretinal membrane removal and macular hole repair, but with surgical experience, improved endoillumination, and the development of a broader array of instruments, small gauge vitrectomy may now be used in nearly all vitreoretinal surgical cases.

Prior to the use of small gauge instruments, PPV required conjunctival and scleral incisions, both of which needed suturing at the conclusion of the procedure. The use of small gauge vitrectomy instruments allows surgeons to create a single, transconjunctival, scleral incision to access the vitreous.

The general advantages of small gauge vitrectomy are increased patient comfort, decreased corneal astigmatism, and decreased operative times. There is also typically less conjunctival scarring, which may be particularly beneficial in patients who have had multiple previous surgeries. Potential drawbacks include an increased risk of developing post-operative hypotony and endophthalmitis.