Expanded line of 27-gauge instruments advantageous

Reviewed by Kevin J. Blinder, MD

The portfolio of retinal instruments continues to expand with a growing line of tools offering surgeons improved work efficiency while promoting better surgical outcomes with 27-gauge instruments. 

“Clinicians generally believe that smaller is better when it comes to retina instruments and, to a certain extent, they are right,” said Kevin J. Blinder, MD.

“When you use 27-gauge instruments--which I have been doing a fair bit recently--the surgical wounds are 100% self-sealing,” said Dr. Blinder, The Retina Institute, St. Louis, and professor of clinical ophthalmology and visual sciences, Washington University School of Medicine, St. Louis. “I have not seen any leaks in my patients to this point. Using smaller instrumentation is making sutures almost obsolete.”

Patients also tend to feel and look better after surgery using the smaller instruments, he said.

They tend to be more comfortable on the first postoperative day. Swelling and other visual signs of surgical trauma can be so minor that some patients look as though they have not undergone anything more invasive than an eye exam.

Improving from 20-gauge

Surgical instrument makers have long been working to reduce instrument size, but materials, technology, and manufacturing techniques have not always been able to meet surgeons’ needs. The standard for most retina instruments was 20-gauge (0.03575 inch nominal exterior diameter) for many years, Dr. Blinder said.

Surgeons were initially excited by the first 25-gauge instruments (0.02025 inch diameter), but disappointed at the lack of rigidity and control. The new generation of smaller instruments felt flimsy and difficult to control, resulting in too many less-than-ideal surgical outcomes.

The industry then retreated to 23-gauge (0.02825 inch diameter), in which the larger diameter instruments provided more rigidity and greater control. The manufacturing and material lessons learned in the development of 23-gauge instruments were applied to a new generation of 25-gauge tools. The newer iteration of 25-gauge provided a degree of rigidity and ease of control similar to 23-gauge devices, while causing less trauma during surgery. The current generation of 27-gauge instruments feels very similar to 25-gauge.

“I don’t see a lot of difference intraoperatively between 25- and 27-gauge, which is a desirable thing,” Dr. Blinder said. “Where I do see the difference is postoperatively, especially during the first day.”

The use of 27-gauge instrumentation makes for a less-invasive procedure than with larger gauge instruments, but the availability of 27-gauge products has been somewhat limited, he noted.

“These new products offer the control and usability typically provided by 23- and 25-gauge instruments with the added benefits of small size, which may help surgeons work more safely, efficiently, and effectively,” he said.

Newly available instruments

Newly available instruments

A new 27-gauge laser probe (27-gauge Directional Laser Probe, Bausch + Lomb) passes in and out of the cannula in a straight position, reducing the risk of bumping the natural lens when entering the eye. It also provides the ability to work around the posterior pole when applying laser treatment.

A technologic innovation uses a moving tube that allows the probe to adjust from straight to a curve of 85° without actuating the fiber toward the retina. Unlike standard straight and curved laser probes, the device gives the surgeon easy access to the extreme anterior periphery, allowing the surgeon greater flexibility and easier access to more of the eye.

More small-gauge instruments are becoming readily accessible to surgeons, including 27-gauge forceps, curved and straight laser probes, light pipes, chandeliers, infusion devices, and cannulas.

In addition, a smaller-gauge, diamond-dusted membrane scraper (27-gauge Diamond Dusted Membrane Scraper, Bausch + Lomb) also provides ophthalmologists with more device alternatives. The tool’s diamond-dusted silicone tip is designed to atraumatically facilitate the peeling of internal limiting membranes or epiretinal membranes during macular hole or macular pucker surgery. The new instruments have a nominal external diameter of 0.01625 inches.

Many surgeons use the instrument to begin the peel and then switch to forceps, although some surgeons, like Dr. Blinder, may seldom use the membrane scraper.

“Whether you use any specific instrument is not important,” he said. “What matters is that you have the full armamentarium at your disposal if you are going to switch over to 27-gauge. No matter how you approach any particular case, you need a complete line of instrumentation available.”

The use of 27-gauge instrumentation enables a less-invasive procedure than with larger-gauge instruments, but the availability of 27-gauge products has been slightly limited. He added that these new products offer the control and usability typically provided by 23- and 25-gauge instruments with the added safer benefits of small size. 

Kevin J. Blinder, MD

P: 314/367-1181     E: kjblinder@gmail.com

Dr. Blinder is a consultant for Bausch + Lomb.