Tools for 25-gauge vitrectomy open door for other procedures

Memphis, TN-The ongoing development and enhancement of tools for 25-gauge vitrectomy are enabling surgeons to perform an ever-wider range of procedures safely and effectively with this technology, according to Steve Charles, MD.

When Eugene de Juan Jr., MD, and colleagues, working with Bausch & Lomb, introduced 25-gauge transconjunctival sutureless vitrectomy a few years ago, early reports suggested that it was ideal for procedures such as epimacular membranes, macular hole surgery, and vitreomacular traction syndrome, said Dr. Charles, who is founder of the Charles Retina Institute and a clinical professor of ophthalmology at the University of Tennessee, Memphis.

Other recommended applications included radial optic neurotomy and decompression of branch retinal vein occlusions, although use of 25-gauge technology for the two procedures has fallen into disrepute.

"I use 25-gauge technique for all cases, except that I will enlarge one wound to take out lens nucleus when it gets dislocated after a problem cataract surgery, and I enlarge one wound to inject silicone either at the beginning of the case if there is already silicone in the eye or at the end of the case if it is a new instillation, or if there is a foreign body to take out," he explained, describing what he refers to as "20-25 surgery."

Advances in instrumentation have fueled the expanded scope of 25-gauge surgical possibilities. For example, Dr. Charles uses a 25-gauge, lightweight pneumatic cutter (Alcon Laboratories).

"It is one-fourteenth the weight of the electric cutters, which results in improved dexterity and less fatigue," he said. "That is an enabling factor."

With increased experience using 25-gauge instruments, Dr. Charles has also concluded that the smaller tubes restricting flow are actually beneficial.

Because of the restricted fluidics of 25-gauge systems, it initially seemed that it would be impossible to remove dense scar tissue from the retina and that "difficult cases" such as those with dislocated lens material, diabetic traction detachments, and dense vitreous hemorrhages would have to be performed with the standard 20-gauge instruments.

"However, that is not true," Dr. Charles said. "Not only can these procedures be done with 25-gauge technology, they are actually better when done with 25-gauge instrumentation."

He explained that with 25-gauge technology, the restriction in flow, or port-based flow-limiting, accomplishes the same objective as fast cutting, namely improving stability and preventing the retina from flopping or jiggling around. The restricted flow also prevents surges in which the retina could flow through the tube.

"The startling realization is that the restricted nature of the fluidics is actually a huge advantage and is part and parcel of our move into expanded applications, such as proliferative vitreoretinopathy, giant retinal breaks, diabetic traction detachments, and dense vitreous hemorrhages." Dr. Charles added.

Disposable instruments Dr. Charles' other choices for 25-gauge instruments have included curved 25-gauge scissors from Dutch Ophthalmic Research Center (DORC). However, he planned to make a transition to 25-gauge disposable scissors (Alcon Laboratories) when the product was launched in late spring.

"It is very hard to maintain functionality in 25-gauge reusable instruments," Dr. Charles said. "They wear out quickly. While cleaning, sterilizing, and packaging them and opening the package, they can be damaged. The disposable instruments solve that problem. They are always sterile and always available. If you drop one, you can just get another one."

The 25-gauge scissors are effective for epiretinal membranes and diabetic traction detachments, he noted.

Dr. Charles now uses disposable 25-gauge DSP forceps (Alcon) to peel membranes and an 25-gauge MVR pick (Alcon) to initiate peeling. He prefers the DSP forceps because of the handle design, which is lighter, larger in diameter, and fits better in the hand.

For diabetic epiretinal membranes, he uses a disposable cutter (Alcon), citing advantages such as flow limiting and a tinier port.