Enhancing retinal surgery with 27-gauge instrumentation

Reviewed by Maria H. Berrocal,  MD

Compared with larger instrumentation, 27-gauge instrumentation has several advantages, particularly in complex cases, said Maria H. Berrocal, MD.

Some common problems during retinal detachment surgery include iatrogenic breaks, perioperative hemorrhage, hypotony, and the need for re-operations, said Dr. Berrocal, director of Berrocal and Associates, San Juan, Puerto Rico.

Dr. Berrocal cited findings that iatrogenic breaks occur 13% to 35% of the time with 20- and 25-gauge instrumentation in complex pathologies.

Advantages of 27-gauge include new surgical techniques, blunt dissection, access to tight tissue planes, the ability to shave membranes, peel tissue, reduce traction on the retina, and aspirate with a vitrector. Photos courtesy of Maria H. Berrocal, MDIn contrast, “we’ve seen published cases of reduced intraoperative and sclerotomy-associated breaks with smaller gauges,” Dr. Berrocal said.

In one published series, no iatrogenic breaks or sclerotomy-associated tears were seen with 27-gauge usage.

Hypotony can occur in zero to 32% of patients at day 1 with use of 23-gauge instrumentation, Dr. Berrocal said. Up to 70% of eyes can have subclinical choroidal detachment.¹

With postoperative hemorrhage, a main problem of vitrectomy, the incidence is 5% to 80%, with one-third of eyes requiring an intervention or re-operation.

However, a new study found an incidence of only zero to 5% with 27-gauge usage, she said.²

The use of 27-gauge technology has several other advantages, including the ability to perform blunt dissection, access tight tissue planes, shave membranes, peel tissues, reduce traction on the retina, and aspirate with the vitrectomy probe.

“New approaches like blunt dissection and membrane shaving are possible, and the benefits are really appreciated when cases are more difficult,” Dr. Berrocal said. “There are reduced iatrogenic breaks, more delicate maneuvers, reduced trauma to the retina, reduced ancillary instrumentation, and improved efficiency.”

She has seen particular benefits with smaller instrumentation used in patients with diabetes complications.

“In some cases that may seem inoperable like this severe diabetic detachment, it’s possible to successfully tackle these pathologies in a safer manner,” she said.

Other advantages Dr. Berrocal has found with 27-gauge instrumentation include:

• > the ability to peel tissue in a controlled fashion,

• > aspiration that is not so forceful that it yanks tissue,

• > the ability to shave membranes from vessels, and

• > use of the vitrectomy probe to delicately aspirate, shave and excise tissue. 

References

1. Guthoff R, Riederle H, Meinhardt B, Goebel W. Subclinical choroidal detachment at sclerotomy sites after 23-gauge vitrectomy: Analysis by anterior segment optical coherence tomography. Ophthalmologica. 2010;224:301-307.

2. Khan MA, Shahlaee A, Toussaint B, et al. Outcomes of 27-gauge microincision vitrectomy surgery for posterior segment disease. Am J Ophthalmol. 2016;161:36-43.

Maria H. Berrocal, MD

E: mariahberrocal@.hotmail.com

This article was adapted from Dr. Berrocal’s presentation at Retina Subspecialty Day during the 2016 meeting of the American Academy of Ophthalmology. She did not indicate any financial interest in the subject matter.