DIAGNOSTIC AND SURGICAL

TECHNIQUES
MARCO ZARBIN AND DAVID CHU, EDITORS
Advantages and Limitations of Small Gauge
Vitrectomy
John T. Thompson, MD
Retina Specialists, Baltimore, Maryland, USA
Abstract. Small gauge vitrectomy utilizing 23- and 25-gauge instrumentation has denite 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 inammation and pain
postoperatively with more rapid visual recovery. A disadvantage is greater instrument exion 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. (Surv Ophthalmol 56:162--172, 2011. 2011 Elsevier Inc. All rights
reserved.)
Key words. 20-gauge vitrectomy 23-gauge vitrectomy 25-gauge vitrectomy small gauge
vitrectomy vitreous surgery
Small gauge vitrectomy (25-gauge and 23-gauge) is
becoming increasingly popular and is replacing
standard 20-gauge vitrectomy for many surgical
indications. The use of small gauge vitrectomy varies
substantially among vitreoretinal surgeons, with
some using it for almost all of their cases whereas
others rarely use it. Pars plana vitrectomy was
developed by Robert Machemer, and his rst
prototype used a 14-gauge instrument (2.1-mm
diameter). The VISC (vitreous infusion suction
cutter) was further rened to a 19-gauge instrument
in his later commercial instruments. Adoption of
20-gauge vitrectomy instruments was common by
the early 1980s and continued to predominate until
small gauge vitrectomy instruments became widely
available in 2004. The rst description of small
gauge instruments preceded their adoption by many
years. Peyman developed a 23-gauge vitrectomy
probe in 1990, primarily for vitreous and retinal
biopsy.
109,110
and Hilton also described an ofce-
based sutureless vitrectomy system.
46
Fuji and
colleagues deserve credit for popularizing 25-gauge
vitrectomy for a wide variety of surgical indica-
tions.
32--34
Eckardt developed 23-gauge vitrectomy
instrumentation as an alternative to 25-gauge in-
struments.
27
Soon small gauge vitrectomy systems
162
2011 by Elsevier Inc.
All rights reserved.
0039-6257/$ - see front matter
doi:10.1016/j.survophthal.2010.08.003
SURVEY OF OPHTHALMOLOGY VOLUME 56

NUMBER 2

MARCHAPRIL 2011
were available from multiple manufacturers, and
many vitreoretinal surgeons began to transition to
small gauge vitrectomy. The choice of instrument
gauge is denitely evolving, as surgeons decide
which cases are preferable for small gauge vitrec-
tomy versus the ones performed more easily with
20-gauge instrumentation.
161
Comparison of Surgical Techniques for
Standard vs. Small Gauge Vitrectomy
PREPARATION FOR VITRECTOMY
20-Gauge Vitrectomy
Conjunctival incisions are typically made to
expose the sclera, followed by perpendicular in-
cisions 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 20-gauge systems, but most surgeons still use
suture closure for cases where they choose 20-gauge
instrumentation.
23-Gauge Vitrectomy
The conjunctiva is displaced using a cotton tip
applicator or forceps, taking care not to tear it. The
trocars/cannulas are then placed obliquely through
the displaced conjunctiva and sclera. The angle of
entry into the sclera has a large inuence on
whether the sclerotomy seals well after the in-
struments are removed. In general the more oblique
(longer) the path through the sclera, the better the
edges re-appose when the cannulas are removed.
Angled incisions are associated with less leakage,
both for 23- and 25-gauge sclerotomies.
141
Oblique
23-gauge sutureless sclerotomies had closed in-
cisions visualized by optical computerized tomo-
graphy in all eyes by 24 hours following surgery,
although some exhibited mild wound gape.
82,146
Another study conrmed this by showing substantial
leakage with perpendicular incisions and minimal
leakage with oblique 23- and 25-gauge incisions in
a rabbit model.
147
Endoscopic evaluations of the
sclerotomies show vitreous plugging the wounds in
both 23- and 25-gauge cases.
96
Some surgeons favor
a biplane scleral incision, with a more oblique
initial, and more perpendicular nal, entry into the
vitreous to create a two-step incision in cross section,
although this is difcult to achieve consistently.
138
Ultrasound biomicroscopy of single plane and
23-gauge biplane incisions does not show any
statistically signicant difference in wound size.
153
Placement of the trocars increases intraocular
pressure since a moderate amount of force has to
be exerted to penetrate obliquely through the
sclera. The pressure elevation can cause problems
in eyes with recent corneal or scleral wounds, such
as with cataract surgery and penetrating kerato-
plasty. The infusion cannula is typically attached to
the inferotemporal cannula, but is not typically
sutured. Friction between the infusion cannula and
trocar cannula sleeve normally holds the infusion
cannula in place.
25-Gauge Vitrectomy
The conjunctiva is displaced before entry of the
trocars/cannula, similar to 23-gauge cases. Some
surgeons prefer to displace the conjunctiva toward
the cornea, while other surgeons displace the
conjunctiva superiorly.
131
Intraocular pressure rises
during insertion of the trocars, as with 23-gauge
vitrectomy. In the original 25-gauge vitrectomy,
trocars were placed perpendicular through the
sclera (similar to 20-gauge technique), but many
surgeons now advocate oblique incisions to promote
watertight wound closure.
55,80,81,116
Ultrasound bio-
microscopy has shown that perpendicular 25-gauge
wounds re-appose within 10 days to 2 weeks.
66,67,159
The increased exibility of the smaller 25-gauge
instruments limits the ability to use long, oblique
incisions due to deformation of the shaft when the
oblique entry is brought into the perpendicular
position that is most convenient when performing
the vitrectomy.
INTRAOPERATIVE CONSIDERATIONS ARISING
FROM THE PHYSICS AND BIOMECHANICS OF
SMALL GAUGE VITRECTOMY
Most 20-gauge vitrectomy is performed at in-
traocular pressures between 30 and 40 mm Hg.
Vitrectomy with 23-gauge instrumentation can be
performed at these infusion pressures, but 25-gauge
vitrectomy is more efcient at higher infusion
pressures, in the range of 40--50 mm Hg, because
of the smaller diameter of the instrument. Flow is
related to the fourth power of the internal diameter
of the vitrectomy probe based on Poiseuilles
equation and is inversely related to the length of
the 25-gauge vitrector and associated tubing. This
explains the marked decrease in ow with 25-gauge
(and moderate decrease with 23-gauge) probes
compared to 20-gauge (Fig. 1).
30,52,85,86
Increasing
the infusion pressure improves ow to make the
vitreous removal somewhat faster, but still not as
rapid as with a 20-gauge system. The higher infusion
SMALL GAUGE VITRECTOMY: ADVANTAGES AND LIMITATIONS 163
pressure means that some eyes with poor perfusion
have decreased blood ow through the central
retinal artery and choriocapillaris during small
gauge vitrectomy surgery. Visibly decreased ow in
the retinal vessels is rarely observed during 20-gauge
and 23-gauge vitrectomy, but is seen occasionally
with the higher infusion pressures utilized during
25-gauge vitrectomy.
The second and third factors that inuence how
long it takes to remove vitreous are the aspiration
pressure and the duty cycle of the vitrector. The
aspiration pressure maximum is set on the vitrec-
tomy machine console and controlled by the foot
pedal. Small gauge vitrectomy instruments require
higher aspiration pressures to achieve a reasonable
rate of vitreous removal. The maximum suction
setting is typically about 150 mm Hg for 20-gauge
vitrectomy, 400 mm Hg for 23-gauge, and 600 mm
Hg for 25-gauge. The duty cycle is the length of time
the vitrector port is open compared to the time it is
closed. Duty cycles with a longer time where the port
is open result in higher ow rates, and this can
partially compensate for the decreased ow in-
herent in smaller diameter 23- and 25-gauge in-
struments.
53
The commercially available small gauge
vitrectomy machines differ in their abilities to
control duty cycles.
One advantage of instruments with smaller port
sizes is the ability to nibble vitreous with very little
traction or to remove epiretinal proliferation
without incarcerating retina in the vitrector port.
In contrast, creation of a posterior vitreous de-
tachment with suction alone to lift the vitreous off of
the optic nerve is more difcult with small gauge
vitrectomy probes. The smaller port opening de-
creases the ability to engage and hold the vitreous.
Probe geometry is a fourth factor that effects the
rate of removal of vitreous, but this is controlled by
the probe manufacturer, not by the surgeon.
24
The smaller gauge vitrectomy probes ex more
when the light pipe and vitrector are used to rotate
the eye to allow removal of the peripheral vitreous.
The amount of instrument exion is minimal for
20-gauge probes. Twenty-three (23)-gauge probes
have some exion, causing a mild reduction in the
amount of peripheral vitreous that can be removed.
The use of oblique incisions to achieve water-tight
closure exacerbates this problem, as torsion on the
probe is required to hold the instruments perpen-
dicular to the sclera when removing the central
vitreous or dissecting epiretinal membranes in the
posterior pole. Instrument exion is even greater
with the 25-gauge probes and further limits the
amount of peripheral vitreous that can be removed.
Fig. 1. The differences in ow through 20-gauge, 23-gauge, and 25-gauge vitrectomy probes are calculated using
Poiseuilles law. To obtain equivalent ow at an infusion (intraocular) pressure of 30 mm Hg (horizontal arrow) using
a 20-gauge probe requires higher infusion pressures for a 23-gauge probe and an even higher infusion pressure for a 25-
gauge probe. This is partially compensated by increasing the aspiration pressure for 23- and 25-gauge probes to attempt
to achieve higher ow. The pressure differential between infusion and aspiration pressures are greater with small gauge
vitrectomy than 20-gauge vitrectomy.
164 Surv Ophthalmol 56 (2) March--April 2011 THOMPSON
Scleral indentation during vitrectomy brings the
peripheral vitreous centrally to allow removal by the
23- or 25-gauge probes. Instrument exion is also
why 23- and 25-gauge vitrectomies are not as well
suited for dissection of mid-peripheral epiretinal
membranes in eyes with diabetic retinopathy or
proliferative vitreoretinopathy and are generally
reserved for cases where epiretinal membrane
dissection is performed near the posterior pole.
Some vitrectomy instrument manufacturers are
redesigning their 25-gauge instruments to improve
instrument stiffness with harder metal shafts and to
improve ow rates by making the internal diameter
larger.
The smaller diameter of the 23- and 25-gauge
beroptic light pipes also decreases illumination
from conventional vitrectomy light sources. High
intensity xenon and metal halide light sources
capable of delivering brighter illumination have
been developed for small gauge vitrectomy. There
are also fewer accessory instruments (picks, forceps
and scissors) available for 23- and 25-gauge systems.
The cannula sleeve necessitates redesign of picks
and scissors with shorter or obliquely angulated tips,
which are less satisfactory for dissecting epiretinal
membranes. Similarly, scissors must have shortened
blades that result in less efcient cutting of tissue.
Multi-function instruments such as aspirating lasers
probes and scissors/forceps combined with endoil-
luminators) are not currently available in 23- and
25-gauge sizes.
COMPLETION OF VITRECTOMY
20-Gauge Vitrectomy
The instruments are removed, and the scleroto-
mies are sutured. The conjunctiva is then closed
over the sclerotomies. This two-layer closure is
watertight and airtight unless the sclera is damaged
or the conjunctiva has extensive scarring to the
sclera. Leakage of vitreous uid or gas through
a sutured 20-gauge sclerotomy in the rst few days
following surgery is rare.
23-Gauge Vitrectomy
The cannulas are removed, and the conjunctiva is
displaced over the sclerotomies with either a cotton
tip applicator or forceps. If the conjunctiva has been
sufcient displaced when the cannulas were placed,
the conjunctiva slides back over the sclerotomy,
helping to close it. If a conjunctival bleb forms or if
the eye becomes hypotonous after removing the
cannulas, this usually indicates that one or more of
the sclerotomies are leaking, and this sclerotomy
should be sutured closed. Often, the suture can be
placed through the sclerotomy via a transconjunc-
tival approach if the leaking sclerotomy is visible
through the conjunctiva, but this may create
a conduit for bacteria to enter the vitreous if
a full-thickness conjunctival/scleral suture is in-
advertently placed. If the leaking sclerotomy is not
visible beneath the conjunctiva, then a small radial
conjunctival incision can be made to expose the
sclerotomy, which is then is sutured. The radial
incision often closes well without the need for
a second layer of conjunctival closure. If the eye is
lled with gas at the end of the procedure, gas
bubbles leaking into the subconjunctival space will
more easily identify a leaking sclerotomy. Bubbling
sclerotomies must be sutured. If there is any
question about leakage, the sclerotomy should be
sutured closed. I have found that a gure-of-eight
8-0 polyglactin 910 suture works well for small gauge
vitrectomy incisions. If the eye is hypotonous, then
additional gas or balanced salt solution should be
injected through the pars plana with a 30-gauge
needle so that the intraocular pressure is normal-
ized before the patient leaves the operating room.
A useful technique to help minimize leakage from
the sclerotomies is to place an air bubble of about
15% in the eye even if gas is not otherwise needed
and ask the patient to remain supine for 24 hours.
This places the air bubble in apposition to the
sclerotomies and helps keep them closed in the rst
postoperative day until the sclerotomy edges natu-
rally close and the conjunctiva remains in apposition
to the sclerotomy. This technique has been shown
in to decrease postoperative hypotony.
97,144
An
alternative for 23- or 25-gauge vitrectomy is to use
tissue glue to close any leaking sclerotomies after
the cannulas are removed.
10
25-Gauge Vitrectomy
The cannulas are removed, and the conjunctiva is
displaced over the sclerotomies, similar to 23-gauge
cases. Since the infusion pressure is typically higher
for 25-gauge cases, it is important to lower the
infusion bottle or decrease the infusion pressure to
about 20 mm Hg before removing the cannulas to
minimize vitreous prolapse though the scleroto-
mies. The likelihood of leakage from 25-guage
sclerotomies appears to be reduced compared to
23-gauge sclerotomies as a result of the smaller
wound diameter. One recent study of 943 consecu-
tive 23-gauge vitrectomy by Parolini and colleag-
ues showed results and complications similar to
25-gauge vitrectomy.
105
Leakage through a scleroto-
my is more likely in eyes with prior vitrectomy or
where the conjunctiva is scarred to the sclera from
previous surgery. Eyes with thin sclera and those of
young children are also more likely to leak.
SMALL GAUGE VITRECTOMY: ADVANTAGES AND LIMITATIONS 165
Intraocular pressure should be normalized after
removal of the cannulas to avoid hypotony in the
early postoperative period.
Complications Associated with Small
Gauge Vitrectomy
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 MVRblade. The trocars are
designed so the cannula ts 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 insertion of
23-gauge cannulas, but redesign of the 23-gauge
cannula with a sharper trocar has helped.
56
The
relatively high force required to insert the trocar/
cannulas also causes deformation of the eye as well as
increased intraocular pressure that can lead to
rupture of prior corneal or limbal wounds or a staph-
yloma. Special care must be taken when performing
23- or 25-gauge vitrectomy in eyes with recent
sutureless cataract surgery since the corneal wound
may open, causing sudden decompression of the eye
and the development of hemorrhagic choroidal
detachments.
163
It is advisable to suture closed any
recent corneal or scleral wounds before the trocar/
cannulas are inserted. Sometimes the cannula sleeve
will be pulled out of the sclera when instruments are
withdrawn from the eye as the result of friction
betweenthe instrument andinner wall of the cannula
sleeve. The cannula sleeve can usually be reinserted
through the same scleral incision by placing the
trocar blade back through the sleeve, reinserting it
into the same scleral tunnel. If this sclerotomy cannot
be found, then a new sclerotomy can be made, but
care must be takento ensure that the original incision
does not leak. The cannula attached to the infusion
line may also spontaneous dislocate during scleral
depression, causing severe hypotony and potentially
choroidal detachments. The best response is to
immediately place the dislocated infusion cannula
in one of the other two ports to re-pressurize the eye.
I had the infusion cannula spontaneously dislocate
during scleral depression twice during surgery with
a 23-gauge infusion cannula, which has never
happened in thousands of 20-gauge cases when the
infusion cannula was sutured to the sclera. Another
rare but serious complication is dislocation of
a portion of the cannula sleeve into the vitreous
cavity causing a suprachoroidal hemorrhage.
18
Suprachoroidal detachment
102
and hemorrhage
61
have been reported with 25-gauge vitrectomy. Jam-
ming of the vitrectomy cutter
135
and breakage of the
vitrectomy cutter may occur with 25-gauge probes.
57
Retinal breaks have been reported following small
gauge surgery,
99
and some have observed retinal
breaks following removal of the cannula as the result
of vitreous prolapse into the wound. Tan and
colleagues found retinal breaks related to scleroto-
mies in 6.2% of eyes undergoing 25-gauge vitrectomy
for macular indications.
151
They also found a rela-
tively high incidence of intraoperative retinal breaks
with 25-gauge vitrectomy (15.8%), many were related
to creation of a posterior vitreous detachment.
123
In
another series there was a trend toward fewer
sclerotomy-related retinal breaks after 25-gauge
vitrectomy (3.1%) compared to 20-gauge cases
(6.4%).
124
Sometimes it is necessary to mix small
and large gauge vitrectomy instrumentation as some
instruments are only available in 20-gauge sizes. If the
20-gauge instrument is used for aspiration, the
23-gauge infusion cannula may not allow ingress of
sufcient uid to match the egress of vitreous,
leading to transient hypotony.
122
This occurs most
frequently when phacofragmentation of the lens is
required. A too slow infusion rate compared to the
suction produced by the larger 20-gauge phacofrag-
menter leads to hypotony.
122
Some 25-gauge
vitrectomy cutters are also shorter than the 20-gauge
cutter, preventing the instrument from reaching the
retinal surface in eyes with a long axial length.
140
Retinal toxicity has been reported in an eye with
23- and 25-gauge vitrectomy given subconjunctival
gentamicin at the conclusion of the case,
14,71
so
aminoglycosides or any other retinotoxic agents such
as 5-uorouracil should not be given subconjuncti-
vally if there are any sutureless sclerotomies.
POSTOPERATIVE
There are numerous reports of hypotony follow-
ing sutureless small gauge vitrectomy.
2,5,12,13,21,
36,40,42,51,112,125,126,133,164
The hypotony is usually
transient, lasts up to a few days following surgery,
and improves spontaneously once the sclerotomies
heal adequately. Localized choroidal detachments
were found in 69% of eyes using anterior segment
OCT in one study.
41
In some eyes the hypotony can
be more severe, causing large choroidals
102
or
escape of gas with inadequate tamponade in eyes
with retinal breaks or detachments. Improved
trocar/cannula placement using beveled rather
than perpendicular incisions and treatment of any
leaking sclerotomies at the end of the case have
decreased, but not eliminated this complication.
147
In contrast, early postoperative hypotony in eyes
166 Surv Ophthalmol 56 (2) March--April 2011 THOMPSON
where a sutured 20-gauge sclerotomy was used is
extraordinarily rare, and this concern and possible
increased risk of endophthalmitis has led some
surgeons to suture all of their sclerotomies for
23- and 25-gauge vitrectomy. Elevated intraocular
pressures occur in some eyes following small gauge
vitrectomy, and this appears more likely in eyes with
a prior history of glaucoma or ocular hypertension
and eyes where a large gas bubble was used.
137
Postoperative Endophthalmitis
Eyes undergoing 23- and 25-gauge vitrectomy may
have an increased risk of infectious endophthalmitis
compared to 20-gauge vitrectomy. Early series sug-
gested there was an increased risk of endophthalmi-
tis, whereas more recent series have had mixed
results, with some nding no increased risk of
infection. Early series that reported endophthalmitis
following 25-gauge vitrectomy include those of Taylor
and Aylward,
152
Taban and colleagues,
148
Acar and
colleagues,
3
and Matsuyama and colleagues.
88
Stud-
ies that have identied an increased risk of endoph-
thalmitis following 25-gauge vitrectomy include those
of Kunimoto and Kaiser,
70
Scott and colleagues,
127
and a nonsignicant increased trend reported by
Chen and colleagues.
20
Those that have found no
increased risk of infectious endophthalmitis follow-
ing 25-gauge vitrectomy include Mason and col-
leagues,
87
Shimada and colleagues,
130
and Hu and
colleagues.
50
Parolini and colleagues found no
increased risk of infectious endophthalmitis follow-
ing 23-gauge vitrectomy.
104
One explanation for the
possible increased incidence of endophthalmitis
following sutureless vitrectomy is that bacteria on
the ocular surface enter the eye through defects in
the conjunctiva and sclera. Singh and colleagues
showed passage of India ink into the eye in over two-
thirds of eyes with unsutured sclerotomies, while no
eyes hadentry of India ink if the 20-gauge or 25-gauge
sclerotomies were sutured.
141
Gupta showed similar
results with substantial leakage of India ink from the
external eye into the wound for both 23- and
25-gauge incisions.
38
Bacteria from the conjunctiva
was found to contaminate the vitreous through
transconjunctival 25-gauge incisions.
155
Ultrasound
biomicroscopy demonstrates that 25-gauge wounds
re-appose within 2 weeks.
139
Some surgeons have
advocated aggressive removal of the vitreous around
the cannulas to prevent vitreous prolapse into the
wounds. Inone study by Shimada and colleagues, this
decreased the rate of vitreous prolapse from 20% to
zero.
132
Nuclear sclerotic cataract formation following
small gauge vitrectomy is similar to standard gauge
vitrectomy.
154
Advantages of Small Gauge Vitrectomy
The primary advantage of 23- and 25-gauge
vitrectomy is shorter operative times
9,16,42,65,92,117,
119,120,165
although one study with 25-gauge sur-
gery
65
and one with 23-gauge surgery
162
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 vitreous
removal is desired or if the sclerotomies leak after
removing the trocars and need to be exposed/
sutured, operative times may not be reduced.
Many of the studies with small gauge vitrectomy
also found decreased inammation and pain post-
operatively
16,60,65,117,119
and improved patient
comfort.
90,160,162
Sutured sclerotomies induce astig-
matism in many eyes following 20-gauge vitrectomy,
but this is transient.
59
Astigmatism following 23- and
25-gauge vitrectomy is uncommon
8,35,98,167
and is less
than in 20-gauge cases.
106
Reduced astigmatism
helps with more rapid visual recovery.
42,60,106,165
The reduced astigmatism appears to be a conse-
quence of the absence of sclerotomy sutures.
68
Intraocular inammation is also reduced in small
gauge vitrectomy surgery.
58
Small gauge vitrectomy
has been used successfully for a wide variety of
vitreoretinal surgical indications.
6,7,15,17,19,22,24--
26,29,31,32,36,37,39,43,45,47,49,54,62,63,67,69,72,73,75--79,82--84,
89,93,94,101,108,111,115,118,121,128,134,136,143,145,149,150,157,
166,168
A number of surgeons describe the use of
small gauge vitrectomy instrumentation in eyes with
routine retinal detachments
1,11,44,48,62,64,74,91,95,142,156,158
and complex retinal detachments.
4,28,100,107,113,114,129
Advantages of Standard Gauge
Vitrectomy
20-gauge vitrectomy still facilitates surgery in some
eyes. Ingeneral, 20-gauge vitrectomy is helpful ineyes
with more complicated pathology, where extensive
dissectionmust be performedinthe posterior pole or
periphery. The array of picks, scissors, and forceps
available for 20-gauge systems is currently much
greater, allowing exibility inmanaging a wide variety
of vitreoretinal pathologies. The uidics of 20-gauge
instruments also allows surgery to be performed at
lower infusion pressures. Creating a posterior vitre-
ous detachment in a child with adherent posterior
hyaloids remains substantially easier with 20-gauge
instruments because of larger port sizes and greater
ow rates. Access to the mid-peripheral and periph-
eral retina is also superior with 20-gauge instruments
as the stiffness of the beroptic light pipe and
SMALL GAUGE VITRECTOMY: ADVANTAGES AND LIMITATIONS 167
vitrector allow the eye to be rotated more easily.
Currently cases that require pars plana 20-gauge
phacofragmentation require at least one 20-gauge
port, although manufacturers are working on pro-
totypes for 23-gauge phacofragmenters. The greater
cost of 23- and 25-gauge surgical packs also favors use
of 20-gauge vitrectomy, but the decreased surgical
times with 23- and 25-gauge surgery help to compen-
sate for the increased surgical pack costs.
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 vitrec-
tomy has some increased surgical complications
(postoperative hypotony and possibly infectious
endophthalmitis) that need to be corrected with
renements 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 the
future.
27,103
Cases that are ideal for small gauge
vitrectomy include easier cases such as vitrectomy
for epiretinal membrane, macular holes, anterior
segment adhesions or retained cortex after cataract
surgery, and vitreous hemorrhage. More complicated
cases, such as diabetic traction retinal detachments,
eyes with extensive brovascular proliferation, com-
plex retinal detachments requiring scleral buckles for
proliferative vitreoretinopathy, and giant retinal tears
can be performed using small gauge instruments, but
are often more easily performed using 20-gauge
instrumentation. The time saved in these more
complicated cases is minimal, since the opening
and closing are a smaller percentage of the surgical
time, and decreased postoperative inammation is
less an issue where extensive surgery is required to
treat more complex retinal pathology. Cases re-
quiring lensectomy should be done with 20-gauge
instruments since infusion/aspiration mismatch
with a 23- or 25-gauge infusion cannula and
a 20-gauge phacofragmenter can cause hypotony
during lens removal. Appropriate case selection is
important because converting a small gauge vitrec-
tomy to a standard gauge vitrectomy is wasteful,
requiring use of two vitrectomy packs. Improvements
in instrumentation and techniques to avoid compli-
cations unique to small gauge vitrectomy may allow
broader use of small gauge vitrectomy in the future.
Method of Literature Search
A PubMed search was performed on 11 June 2009
and repeated on 28 March 2010 (to nd 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 poten-
tially included if they had an abstract with an
English translation. Non-English articles were not
translated.
Disclosure
The authors reported no proprietary or commer-
cial interest in any product mentioned or concept
discussed in this article.
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Reprint address: John T. Thompson, MD, 6569 North Charles
St., Suite 605, Baltimore, MD 21204. e-mail: JThompson@
retinaspec.com
172 Surv Ophthalmol 56 (2) March--April 2011 THOMPSON