27-Gauge Vitrectomy Surgery: Is Smaller Better?

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Studies will have to confirm whether the smallest of small-gauge vitrectomy instrumentation is better than earlier generations of fine-gauge instruments. For now, a study shows that the 27-gauge pars plana vitrectomy (PPV) system for posterior segment disease is at least as safe and effective as larger-gauge equivalents.¹

The retrospective interventional case series involved 360 patients (390 eyes) undergoing 27-gauge PPV (Constel­lation Vitrectomy 27+ Total Plus Pak, Alcon). “Surgical outcomes were com­parable to the initial experience with 23- and 25-gauge instruments, and no new safety concerns were identified at follow-up of at least 1 year,” said M. Ali Khan, MD, at the Doheny and Stein Eye Institutes in Los Angeles.

Dr. Khan stressed the importance of a study like this for yielding “real-world outcomes.” Surgeons decided which of some 5,000 vitrec­tomy cases presenting during the study period would undergo 27-gauge PPV. The most common indication was epiretinal membrane (n = 121), followed by vitreous floaters (n = 69) and diabetic tractional retinal detach­ment (n = 49).

IN ACTION. The 27-gauge device in use during repair of a tractional retinal detachment.

The findings. Across all indications, mean visual acu­ity improved from 20/105 to 20/50. Postoperative com­plication rates were low, the most common being tran­sient ocular hypertension (n = 44). Other complications included vitreous hemorrhage, transient hypotony, and cystoid macular edema. Overall, 21% of eyes underwent at least 1 additional intraocular surgery during follow-up, most commonly for cataract extraction.

Questions remain. It’s still unknown whether a significant difference exists among outcomes using the various small-gauge instruments, but some cas­es might lend themselves to particular instrumentation, Dr. Khan said. “The 27-gauge system may be preferred in cases with extensive membrane dissec­tion, such as diabetic tractional retinal detachment, during secondary intra­ocular lens placement, or in situations when biopsy is needed.” He added, “In cases when silicone oil is needed or the vitreous/media to be removed is dense, as in a chronic vitreous hemorrhage, a larger-gauge system may be preferred for the increase in flow rate.”

An Alcon-sponsored study compar­ing outcomes in cases randomized to 23-gauge or 27-gauge instrumentation, now in the data analysis phase, may provide more definitive answers.

In the meantime, said Dr. Khan, “I think each of the 27-, 25-, and 23-gauge systems can be used effectively for the surgical management of retinal disease.”

—Miriam Karmel

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1 Khan MA et al. Ophthalmology. Published online Nov. 13, 2017.

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Relevant financial disclosures—Dr. Khan: Allergan: C.

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