Imaging, 27-gauge systems capture retina surgeons’ focus

Reviewed by Mary Elizabeth Hartnett, MD, and Carl Regillo, MD

Retina surgeons considered 2015 to be an exciting time in the subspecialty in all areas and pointed to the availability and increased use of 27-gauge instrumentation as one of the real highlights of surgical retina. Imaging is also capturing surgeons’ attention.

Cutting speeds and 27-gauge systems

“We have lived a very exciting decade in retina on the medical and surgical fronts and that remains the case up to the current time,” Carl Regillo, MD, said.

On the surgical front, both he and Mary Elizabeth Hartnett, MD, noted that increased cutting speeds with conventional 23- and 25-gauge instruments are important in that they result in increased safety during vitrectomy.

“Higher cut rates translate into less traction on the retina,” said Dr. Regillo, director of the Retina Service, Wills Eye Hospital, and professor of ophthalmology, Thomas Jefferson University, Philadelphia.

However, the 27-gauge systems are especially noteworthy because of the added level of control afforded to surgeons.

“The introduction of 27-gauge systems plays a role in how we approach certain vitreoretinal disorders that are treated surgically,” he said. “These systems are especially beneficial in the setting of tractional retinal detachments in patients with diabetic retinopathy.”

Another advantage enjoyed by surgeons in addition to better control is the improved ability to dissect membranes using the smaller 27-gauge probe.

However, these smaller instruments are not used across the board. They are thinner and, therefore, not as strong as the larger-gauge instruments.

“There is some instrument flexibility and we are likely to see the 27-gauge instruments being used selectively and not for all cases,” Dr. Regillo explained.

Dr. Hartnett, professor of ophthalmology, John A. Moran Eye Center, Salt Lake City, specializes in treating both pediatric and adult retinal cases, also sees 27-gauge instrumentation as promising-especially for tractional diabetic retinal detachments and uveitis-associated retinal detachments

“These instruments allow surgeons to get closer to the retina to remove membranes without exerting traction and injuring the retina or causing hemorrhage,” she said. “Rather than using a two-handed technique, surgeons can remove membranes from the retinal surface safely.”

However, despite the fact that the 27-gauge instrument systems seem as though they should be beneficial in pediatric retinal cases, Dr. Hartnett prefers the larger-gauge instruments because the vitreous is more formed in babies.

“Perhaps it is because the severity of the pathology is greater, but I find myself performing more two-handed techniques,” she said. “I often use even 23-gauge instruments to cut and aspirate vitreous gel.

“Twenty-seven gauge instruments are best in cases when surgeons want to perform very gentle dissections, such as in patients with diabetic retinal detachments with thin retinas and thick membranes,” she added. “The small gauge instruments facilitate removal of the membranes without damaging the underlying retinal tissue.”

Intraoperative imaging

Regarding optical coherence tomography (OCT), Dr. Regillo pointed out that intraoperative OCT is not just for research any longer. The technology is becoming increasingly important during the course of surgery.

OCT technology has been incorporated into the operating room microscope. Bioptigen Inc. has a unit that is commercially available.

“Use of OCT in the operating room is not yet widespread and surgeons are still getting a feel for where the technology is useful,” he said. “Nevertheless, this is exciting technology that has revolutionized our field in the clinic setting and it will be beneficial in the operating room as well.”

Dr. Hartnett also pointed to the increasing use of OCT during surgery. She uses the Bioptigen hand-held device to examine pediatric patients under anesthesia preoperatively.

She also has used the Resight 500/700 Fundus Viewing (Carl Zeiss Meditec) intraoperatively in patients with ROP to obtain a snapshot of retinal membranes, which provides a clear picture of what treatment the patient needs or the anatomy after membrane peeling but before ending the procedure. This can be useful for determining whether additional surgical tasks are necessary. In complex cases such as ocular trauma, OCT can be used to examine the anterior segment and angle structures.

“We have used it in combined cases with glaucoma or anterior segment,” she said. “In theory, it may be helpful to identify a bleeding structure in the posterior iris or ciliary body, but I have not tried that yet.”

Combination therapy

Dr. Hartnett noted that much research suggests that patients with diabetic macular edema can be treated with anti-VEGF drugs more than laser.

“The evidence is not as strong for laser with anti-VEGF drugs, although I do still use it in certain situations, such as in patients with microaneurysms with circinate rings, patients with proliferative diabetic retinopathy or neovascularization elsewhere and hemorrhages in branch vein occlusions who may not return regularly for repeat injections,” she said. “I do still perform panretinal photocoagulation.”

Mary Elizabeth Hartnett, MD

e: me.hartnett@hsc.utah.edu  

Carl Regillo, MD

e: cregillo@aol.com

Drs. Hartnett and Regillo have no financial interest in any aspect of this report.