advantages and limitations of small gauge vitrectomy

SURVEY OF OPHTHALMOLOGY VOLUME 56 � NUMBER 2 � MARCH–APRIL 2011

DIAGNOSTIC AND SURGICALTECHNIQUESMARCO ZARBIN AND DAVID CHU, EDITORS

Advantages and Limitations of Small GaugeVitrectomyJohn T. Thompson, MD

Retina Specialists, Baltimore, Maryland, USA

� 2011 byAll rights

Abstract. Small gauge vitrectomy utilizing 23- and 25-gauge instrumentation has definite advantages,but also limitations, due to the physics of smaller instruments and sutureless surgery. Higher infusionand aspiration pressures are needed to remove the vitreous using 23- and 25-gauge probes. Theadvantages include decreased surgical times, less tissue manipulation, reduced inflammation and painpostoperatively with more rapid visual recovery. A disadvantage is greater instrument flexion than20-gauge probes, making small gauge vitrectomy more appropriate for indications such as vitreousopacities, epiretinal membranes, macular holes, and simple retinal detachments. There are also someincreased complications related to small gauge vitrectomy, including dislocation of cannulasintraoperatively, early postoperative hypotony, choroidal detachment, and possibly an increased riskof infectious endophthalmitis. (Surv Ophthalmol 56:162--172, 2011. � 2011 Elsevier Inc. All rightsreserved.)

Key words. 20-gauge vitrectomy � 23-gauge vitrectomy � 25-gauge vitrectomy � small gaugevitrectomy � vitreous surgery

Small gauge vitrectomy (25-gauge and 23-gauge) isbecoming increasingly popular and is replacingstandard 20-gauge vitrectomy for many surgicalindications. The use of small gauge vitrectomy variessubstantially among vitreoretinal surgeons, withsome using it for almost all of their cases whereasothers rarely use it. Pars plana vitrectomy wasdeveloped by Robert Machemer, and his firstprototype used a 14-gauge instrument (2.1-mmdiameter). The VISC (vitreous infusion suctioncutter) was further refined to a 19-gauge instrumentin his later commercial instruments. Adoption of20-gauge vitrectomy instruments was common by

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the early 1980s and continued to predominate untilsmall gauge vitrectomy instruments became widelyavailable in 2004. The first description of smallgauge instruments preceded their adoption by manyyears. Peyman developed a 23-gauge vitrectomyprobe in 1990, primarily for vitreous and retinalbiopsy.109,110 and Hilton also described an office-based sutureless vitrectomy system.46 Fuji andcolleagues deserve credit for popularizing 25-gaugevitrectomy for a wide variety of surgical indica-tions.32--34 Eckardt developed 23-gauge vitrectomyinstrumentation as an alternative to 25-gauge in-struments.27 Soon small gauge vitrectomy systems

0039-6257/$ - see front matterdoi:10.1016/j.survophthal.2010.08.003

http://dx.doi.org/10.1016/j.survophthal.2010.08.003






SMALL GAUGE VITRECTOMY: ADVANTAGES AND LIMITATIONS 163

were available from multiple manufacturers, andmany vitreoretinal surgeons began to transition tosmall gauge vitrectomy. The choice of instrumentgauge is definitely evolving, as surgeons decidewhich cases are preferable for small gauge vitrec-tomy versus the ones performed more easily with20-gauge instrumentation.161

Comparison of Surgical Techniques forStandard vs. Small Gauge Vitrectomy

PREPARATION FOR VITRECTOMY

20-Gauge Vitrectomy

Conjunctival incisions are typically made toexpose the sclera, followed by perpendicular in-cisions with the microvitreoretinal blade (MVR)through the sclera into the vitreous. The infusioncannula is sutured to the sclera, which providesadded protection against accidental dislocation ofthe cannula. The 20-gauge sclerotomies are suturedclosed at the end of the surgery, followed by theconjunctiva, to achieve a two-layer closure. Somesutureless trocar-based systems have been developedfor 20-gauge systems, but most surgeons still usesuture closure for cases where they choose 20-gaugeinstrumentation.

23-Gauge Vitrectomy

The conjunctiva is displaced using a cotton tipapplicator or forceps, taking care not to tear it. Thetrocars/cannulas are then placed obliquely throughthe displaced conjunctiva and sclera. The angle ofentry into the sclera has a large influence onwhether the sclerotomy seals well after the in-struments are removed. In general the more oblique(longer) the path through the sclera, the better theedges re-appose when the cannulas are removed.Angled incisions are associated with less leakage,both for 23- and 25-gauge sclerotomies.141 Oblique23-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 confirmed this by showing substantialleakage with perpendicular incisions and minimalleakage with oblique 23- and 25-gauge incisions ina rabbit model.147 Endoscopic evaluations of thesclerotomies show vitreous plugging the wounds inboth 23- and 25-gauge cases.96 Some surgeons favora biplane scleral incision, with a more obliqueinitial, and more perpendicular final, entry into thevitreous to create a two-step incision in cross section,although this is difficult to achieve consistently.138

Ultrasound biomicroscopy of single plane and

23-gauge biplane incisions does not show anystatistically significant difference in wound size.153

Placement of the trocars increases intraocularpressure since a moderate amount of force has tobe exerted to penetrate obliquely through thesclera. The pressure elevation can cause problemsin eyes with recent corneal or scleral wounds, suchas with cataract surgery and penetrating kerato-plasty. The infusion cannula is typically attached tothe inferotemporal cannula, but is not typicallysutured. Friction between the infusion cannula andtrocar cannula sleeve normally holds the infusioncannula in place.

25-Gauge Vitrectomy

The conjunctiva is displaced before entry of thetrocars/cannula, similar to 23-gauge cases. Somesurgeons prefer to displace the conjunctiva towardthe cornea, while other surgeons displace theconjunctiva superiorly.131 Intraocular pressure risesduring insertion of the trocars, as with 23-gaugevitrectomy. In the original 25-gauge vitrectomy,trocars were placed perpendicular through thesclera (similar to 20-gauge technique), but manysurgeons now advocate oblique incisions to promotewatertight wound closure.55,80,81,116 Ultrasound bio-microscopy has shown that perpendicular 25-gaugewounds re-appose within 10 days to 2 weeks.66,67,159

The increased flexibility of the smaller 25-gaugeinstruments limits the ability to use long, obliqueincisions due to deformation of the shaft when theoblique entry is brought into the perpendicularposition that is most convenient when performingthe 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 beperformed at these infusion pressures, but 25-gaugevitrectomy is more efficient at higher infusionpressures, in the range of 40--50 mm Hg, becauseof the smaller diameter of the instrument. Flow isrelated to the fourth power of the internal diameterof the vitrectomy probe based on Poiseuille’sequation and is inversely related to the length ofthe 25-gauge vitrector and associated tubing. Thisexplains the marked decrease in flow with 25-gauge(and moderate decrease with 23-gauge) probescompared to 20-gauge (Fig. 1).30,52,85,86 Increasingthe infusion pressure improves flow to make thevitreous removal somewhat faster, but still not asrapid as with a 20-gauge system. The higher infusion

Fig. 1. The differences in flow through 20-gauge, 23-gauge, and 25-gauge vitrectomy probes are calculated usingPoiseuille’s law. To obtain equivalent flow at an infusion (intraocular) pressure of 30 mm Hg (horizontal arrow) usinga 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 attemptto achieve higher flow. The pressure differential between infusion and aspiration pressures are greater with small gaugevitrectomy than 20-gauge vitrectomy.

164 Surv Ophthalmol 56 (2) March--April 2011 THOMPSON

pressure means that some eyes with poor perfusionhave decreased blood flow through the centralretinal artery and choriocapillaris during smallgauge vitrectomy surgery. Visibly decreased flow inthe retinal vessels is rarely observed during 20-gaugeand 23-gauge vitrectomy, but is seen occasionallywith the higher infusion pressures utilized during25-gauge vitrectomy.

The second and third factors that influence howlong it takes to remove vitreous are the aspirationpressure and the duty cycle of the vitrector. Theaspiration pressure maximum is set on the vitrec-tomy machine console and controlled by the footpedal. Small gauge vitrectomy instruments requirehigher aspiration pressures to achieve a reasonablerate of vitreous removal. The maximum suctionsetting is typically about 150 mm Hg for 20-gaugevitrectomy, 400 mm Hg for 23-gauge, and 600 mmHg for 25-gauge. The duty cycle is the length of timethe vitrector port is open compared to the time it isclosed. Duty cycles with a longer time where the portis open result in higher flow rates, and this canpartially compensate for the decreased flow in-herent in smaller diameter 23- and 25-gauge in-struments.53 The commercially available small gaugevitrectomy machines differ in their abilities tocontrol duty cycles.

One advantage of instruments with smaller portsizes is the ability to ‘‘nibble’’ vitreous with very littletraction or to remove epiretinal proliferationwithout incarcerating retina in the vitrector port.In contrast, creation of a posterior vitreous de-tachment with suction alone to lift the vitreous off ofthe optic nerve is more difficult with small gaugevitrectomy probes. The smaller port opening de-creases the ability to engage and hold the vitreous.Probe geometry is a fourth factor that effects therate of removal of vitreous, but this is controlled bythe probe manufacturer, not by the surgeon.24

The smaller gauge vitrectomy probes flex morewhen the light pipe and vitrector are used to rotatethe eye to allow removal of the peripheral vitreous.The amount of instrument flexion is minimal for20-gauge probes. Twenty-three (23)-gauge probeshave some flexion, causing a mild reduction in theamount of peripheral vitreous that can be removed.The use of oblique incisions to achieve water-tightclosure exacerbates this problem, as torsion on theprobe is required to hold the instruments perpen-dicular to the sclera when removing the centralvitreous or dissecting epiretinal membranes in theposterior pole. Instrument flexion is even greaterwith the 25-gauge probes and further limits theamount of peripheral vitreous that can be removed.


Scleral indentation during vitrectomy brings theperipheral vitreous centrally to allow removal by the23- or 25-gauge probes. Instrument flexion is alsowhy 23- and 25-gauge vitrectomies are not as wellsuited for dissection of mid-peripheral epiretinalmembranes in eyes with diabetic retinopathy orproliferative vitreoretinopathy and are generallyreserved for cases where epiretinal membranedissection is performed near the posterior pole.Some vitrectomy instrument manufacturers areredesigning their 25-gauge instruments to improveinstrument stiffness with harder metal shafts and toimprove flow rates by making the internal diameterlarger.

The smaller diameter of the 23- and 25-gaugefiberoptic light pipes also decreases illuminationfrom conventional vitrectomy light sources. Highintensity xenon and metal halide light sourcescapable of delivering brighter illumination havebeen developed for small gauge vitrectomy. Thereare also fewer accessory instruments (picks, forcepsand scissors) available for 23- and 25-gauge systems.The cannula sleeve necessitates redesign of picksand scissors with shorter or obliquely angulated tips,which are less satisfactory for dissecting epiretinalmembranes. Similarly, scissors must have shortenedblades that result in less efficient cutting of tissue.Multi-function instruments such as aspirating lasersprobes and scissors/forceps combined with endoil-luminators) are not currently available in 23- and25-gauge sizes.

COMPLETION OF VITRECTOMY

20-Gauge Vitrectomy

The instruments are removed, and the scleroto-mies are sutured. The conjunctiva is then closedover the sclerotomies. This two-layer closure iswatertight and airtight unless the sclera is damagedor the conjunctiva has extensive scarring to thesclera. Leakage of vitreous fluid or gas througha sutured 20-gauge sclerotomy in the first few daysfollowing surgery is rare.

23-Gauge Vitrectomy

The cannulas are removed, and the conjunctiva isdisplaced over the sclerotomies with either a cottontip applicator or forceps. If the conjunctiva has beensufficient displaced when the cannulas were placed,the conjunctiva slides back over the sclerotomy,helping to close it. If a conjunctival bleb forms or ifthe eye becomes hypotonous after removing thecannulas, this usually indicates that one or more ofthe sclerotomies are leaking, and this sclerotomyshould be sutured closed. Often, the suture can beplaced through the sclerotomy via a transconjunc-

tival approach if the leaking sclerotomy is visiblethrough the conjunctiva, but this may createa conduit for bacteria to enter the vitreous ifa full-thickness conjunctival/scleral suture is in-advertently placed. If the leaking sclerotomy is notvisible beneath the conjunctiva, then a small radialconjunctival incision can be made to expose thesclerotomy, which is then is sutured. The radialincision often closes well without the need fora second layer of conjunctival closure. If the eye isfilled with gas at the end of the procedure, gasbubbles leaking into the subconjunctival space willmore easily identify a leaking sclerotomy. Bubblingsclerotomies must be sutured. If there is anyquestion about leakage, the sclerotomy should besutured closed. I have found that a figure-of-eight8-0 polyglactin 910 suture works well for small gaugevitrectomy incisions. If the eye is hypotonous, thenadditional gas or balanced salt solution should beinjected through the pars plana with a 30-gaugeneedle so that the intraocular pressure is normal-ized before the patient leaves the operating room.A useful technique to help minimize leakage fromthe sclerotomies is to place an air bubble of about15% in the eye even if gas is not otherwise neededand ask the patient to remain supine for 24 hours.This places the air bubble in apposition to thesclerotomies and helps keep them closed in the firstpostoperative day until the sclerotomy edges natu-rally close and the conjunctiva remains in appositionto the sclerotomy. This technique has been shownin to decrease postoperative hypotony.97,144 Analternative for 23- or 25-gauge vitrectomy is to usetissue glue to close any leaking sclerotomies afterthe cannulas are removed.10

25-Gauge Vitrectomy

The cannulas are removed, and the conjunctiva isdisplaced over the sclerotomies, similar to 23-gaugecases. Since the infusion pressure is typically higherfor 25-gauge cases, it is important to lower theinfusion bottle or decrease the infusion pressure toabout 20 mm Hg before removing the cannulas tominimize vitreous prolapse though the scleroto-mies. The likelihood of leakage from 25-guagesclerotomies appears to be reduced compared to23-gauge sclerotomies as a result of the smallerwound diameter. One recent study of 943 consecu-tive 23-gauge vitrectomy by Parolini and colleag-ues showed results and complications similar to25-gauge vitrectomy.105 Leakage through a scleroto-my is more likely in eyes with prior vitrectomy orwhere the conjunctiva is scarred to the sclera fromprevious surgery. Eyes with thin sclera and those ofyoung children are also more likely to leak.


Intraocular pressure should be normalized afterremoval of the cannulas to avoid hypotony in theearly postoperative period.

Complications Associated with SmallGauge Vitrectomy

INTRAOPERATIVE

The trocars used for 25- and 23-gauge vitrectomycannula insertion are not as sharp as MVR bladesused to make 20-gauge sclerotomies, so the forcerequired to insert the trocar/cannula is substantiallygreater than the 20-gaugeMVRblade. The trocars aredesigned so the cannula fits tightly through thescleral incision to minimize dislocation. Pressures ashigh as 63.7 mm Hg have been measure duringtrocar/cannula placement for 25-gauge vitrectomy.23

Similar problems are encountered with insertion of23-gauge cannulas, but redesign of the 23-gaugecannula with a sharper trocar has helped.56 Therelatively high force required to insert the trocar/cannulas also causes deformation of the eye as well asincreased intraocular pressure that can lead torupture of prior corneal or limbal wounds or a staph-yloma. Special care must be taken when performing23- or 25-gauge vitrectomy in eyes with recentsutureless cataract surgery since the corneal woundmay open, causing sudden decompression of the eyeand the development of hemorrhagic choroidaldetachments.163 It is advisable to suture closed anyrecent corneal or scleral wounds before the trocar/cannulas are inserted. Sometimes the cannula sleevewill be pulled out of the sclera when instruments arewithdrawn from the eye as the result of frictionbetween the instrument and inner wall of the cannulasleeve. The cannula sleeve can usually be reinsertedthrough the same scleral incision by placing thetrocar blade back through the sleeve, reinserting itinto the same scleral tunnel. If this sclerotomy cannotbe found, then a new sclerotomy can be made, butcaremust be taken to ensure that the original incisiondoes not leak. The cannula attached to the infusionline may also spontaneous dislocate during scleraldepression, causing severe hypotony and potentiallychoroidal detachments. The best response is toimmediately place the dislocated infusion cannulain one of the other two ports to re-pressurize the eye.I had the infusion cannula spontaneously dislocateduring scleral depression twice during surgery witha 23-gauge infusion cannula, which has neverhappened in thousands of 20-gauge cases when theinfusion cannula was sutured to the sclera. Anotherrare but serious complication is dislocation ofa portion of the cannula sleeve into the vitreouscavity causing a suprachoroidal hemorrhage.18

Suprachoroidal detachment102 and hemorrhage61

have been reported with 25-gauge vitrectomy. Jam-ming of the vitrectomy cutter135 and breakage of thevitrectomy cutter may occur with 25-gauge probes.57

Retinal breaks have been reported following smallgauge surgery,99 and some have observed retinalbreaks following removal of the cannula as the resultof vitreous prolapse into the wound. Tan andcolleagues found retinal breaks related to scleroto-mies in 6.2% of eyes undergoing 25-gauge vitrectomyfor macular indications.151 They also found a rela-tively high incidence of intraoperative retinal breakswith 25-gauge vitrectomy (15.8%), many were relatedto creation of a posterior vitreous detachment.123 Inanother series there was a trend toward fewersclerotomy-related retinal breaks after 25-gaugevitrectomy (3.1%) compared to 20-gauge cases(6.4%).124 Sometimes it is necessary to mix smalland large gauge vitrectomy instrumentation as someinstruments are only available in 20-gauge sizes. If the20-gauge instrument is used for aspiration, the23-gauge infusion cannula may not allow ingress ofsufficient fluid to match the egress of vitreous,leading to transient hypotony.122 This occurs mostfrequently when phacofragmentation of the lens isrequired. A too slow infusion rate compared to thesuction produced by the larger 20-gauge phacofrag-menter leads to hypotony.122 Some 25-gaugevitrectomy cutters are also shorter than the 20-gaugecutter, preventing the instrument from reaching theretinal surface in eyes with a long axial length.140

Retinal toxicity has been reported in an eye with23- and 25-gauge vitrectomy given subconjunctivalgentamicin at the conclusion of the case,14,71 soaminoglycosides or any other retinotoxic agents suchas 5-fluorouracil 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 usuallytransient, lasts up to a few days following surgery,and improves spontaneously once the sclerotomiesheal adequately. Localized choroidal detachmentswere found in 69% of eyes using anterior segmentOCT in one study.41 In some eyes the hypotony canbe more severe, causing large choroidals102 orescape of gas with inadequate tamponade in eyeswith retinal breaks or detachments. Improvedtrocar/cannula placement using beveled ratherthan perpendicular incisions and treatment of anyleaking sclerotomies at the end of the case havedecreased, but not eliminated this complication.147

In contrast, early postoperative hypotony in eyes


where a sutured 20-gauge sclerotomy was used isextraordinarily rare, and this concern and possibleincreased risk of endophthalmitis has led somesurgeons to suture all of their sclerotomies for23- and 25-gauge vitrectomy. Elevated intraocularpressures occur in some eyes following small gaugevitrectomy, and this appears more likely in eyes witha prior history of glaucoma or ocular hypertensionand eyes where a large gas bubble was used.137

Postoperative Endophthalmitis

Eyes undergoing 23- and 25-gauge vitrectomy mayhave an increased risk of infectious endophthalmitiscompared to 20-gauge vitrectomy. Early series sug-gested there was an increased risk of endophthalmi-tis, whereas more recent series have had mixedresults, with some finding no increased risk ofinfection. Early series that reported endophthalmitisfollowing 25-gauge vitrectomy include those of Taylorand Aylward,152 Taban and colleagues,148 Acar andcolleagues,3 and Matsuyama and colleagues.88 Stud-ies that have identified an increased risk of endoph-thalmitis following 25-gauge vitrectomy include thoseof Kunimoto and Kaiser,70 Scott and colleagues,127

and a nonsignificant increased trend reported byChen and colleagues.20 Those that have found noincreased risk of infectious endophthalmitis follow-ing 25-gauge vitrectomy include Mason and col-leagues,87 Shimada and colleagues,130 and Hu andcolleagues.50 Parolini and colleagues found noincreased risk of infectious endophthalmitis follow-ing 23-gauge vitrectomy.104 One explanation for thepossible increased incidence of endophthalmitisfollowing sutureless vitrectomy is that bacteria onthe ocular surface enter the eye through defects inthe conjunctiva and sclera. Singh and colleaguesshowed passage of India ink into the eye in over two-thirds of eyes with unsutured sclerotomies, while noeyes had entry of India ink if the 20-gauge or 25-gaugesclerotomies were sutured.141 Gupta showed similarresults with substantial leakage of India ink from theexternal eye into the wound for both 23- and25-gauge incisions.38 Bacteria from the conjunctivawas found to contaminate the vitreous throughtransconjunctival 25-gauge incisions.155 Ultrasoundbiomicroscopy demonstrates that 25-gauge woundsre-appose within 2 weeks.139 Some surgeons haveadvocated aggressive removal of the vitreous aroundthe cannulas to prevent vitreous prolapse into thewounds. In one study by Shimada and colleagues, thisdecreased the rate of vitreous prolapse from 20% tozero.132

Nuclear sclerotic cataract formation followingsmall gauge vitrectomy is similar to standard gaugevitrectomy.154

Advantages of Small Gauge Vitrectomy

The primary advantage of 23- and 25-gaugevitrectomy is shorter operative times9,16,42,65,92,117,119,120,165 although one study with 25-gauge sur-gery65 and one with 23-gauge surgery162 found nonet gain because of longer times required to removevitreous with smaller diameter instruments. Factorsfavoring shorter operative times include selection ofonly ‘‘easier’’ cases for 23- and 25-gauge surgery, lessthorough vitreous removal, and the absence ofsutured sclerotomies. If more thorough vitreousremoval is desired or if the sclerotomies leak afterremoving the trocars and need to be exposed/sutured, operative times may not be reduced.Many of the studies with small gauge vitrectomyalso found decreased inflammation and pain post-operatively16,60,65,117,119 and improved patientcomfort.90,160,162 Sutured sclerotomies induce astig-matism in many eyes following 20-gauge vitrectomy,but this is transient.59 Astigmatism following 23- and25-gauge vitrectomy is uncommon8,35,98,167 and is lessthan in 20-gauge cases.106 Reduced astigmatismhelps 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 inflammation is also reduced in smallgauge vitrectomy surgery.58 Small gauge vitrectomyhas been used successfully for a wide variety ofvitreoretinal 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 ofsmall gauge vitrectomy instrumentation in eyes withroutine retinal detachments1,11,44,48,62,64,74,91,95,142,156,158

and complex retinal detachments.4,28,100,107,113,114,129

Advantages of Standard GaugeVitrectomy

20-gauge vitrectomy still facilitates surgery in someeyes. In general, 20-gauge vitrectomy is helpful in eyeswith more complicated pathology, where extensivedissectionmust be performed in the posterior pole orperiphery. The array of picks, scissors, and forcepsavailable for 20-gauge systems is currently muchgreater, allowing flexibility inmanaging a wide varietyof vitreoretinal pathologies. The fluidics of 20-gaugeinstruments also allows surgery to be performed atlower infusion pressures. Creating a posterior vitre-ous detachment in a child with adherent posteriorhyaloids remains substantially easier with 20-gaugeinstruments because of larger port sizes and greaterflow rates. Access to the mid-peripheral and periph-eral retina is also superior with 20-gauge instrumentsas the stiffness of the fiberoptic light pipe and


vitrector allow the eye to be rotated more easily.Currently cases that require pars plana 20-gaugephacofragmentation require at least one 20-gaugeport, although manufacturers are working on pro-totypes for 23-gauge phacofragmenters. The greatercost of 23- and 25-gauge surgical packs also favors useof 20-gauge vitrectomy, but the decreased surgicaltimes with 23- and 25-gauge surgery help to compen-sate for the increased surgical pack costs.

Future Role of Small Gauge Instrumentsfor Vitrectomy

Small gauge vitrectomy has an important role invitreoretinal surgery, but should not replace 20-gaugeinstruments entirely. Currently, small gauge vitrec-tomy has some increased surgical complications(postoperative hypotony and possibly infectiousendophthalmitis) that need to be corrected withrefinements in surgical technique to make the riskscomparable to 20-gauge vitrectomy. There are earlyreports of 27-gauge vitrectomy instruments, so evensmaller instrumentationmay become available in thefuture.27,103 Cases that are ideal for small gaugevitrectomy include ‘‘easier’’ cases such as vitrectomyfor epiretinal membrane, macular holes, anteriorsegment adhesions or retained cortex after cataractsurgery, and vitreous hemorrhage.More complicatedcases, such as diabetic traction retinal detachments,eyes with extensive fibrovascular proliferation, com-plex retinal detachments requiring scleral buckles forproliferative vitreoretinopathy, and giant retinal tearscan be performed using small gauge instruments, butare often more easily performed using 20-gaugeinstrumentation. The time saved in these morecomplicated cases is minimal, since the ‘‘opening’’and ‘‘closing’’ are a smaller percentage of the surgicaltime, and decreased postoperative inflammation isless an issue where extensive surgery is required totreat more complex retinal pathology. Cases re-quiring lensectomy should be done with 20-gaugeinstruments since infusion/aspiration mismatchwith a 23- or 25-gauge infusion cannula anda 20-gauge phacofragmenter can cause hypotonyduring lens removal. Appropriate case selection isimportant because converting a small gauge vitrec-tomy to a standard gauge vitrectomy is wasteful,requiring use of two vitrectomy packs. Improvementsin instrumentation and techniques to avoid compli-cations unique to small gauge vitrectomy may allowbroader use of small gauge vitrectomy in the future.

Method of Literature Search

A PubMed search was performed on 11 June 2009and repeated on 28 March 2010 (to find any newer

publications) using the following search terms smallgauge vitrectomy OR 23-gauge vitrectomy OR 25-gaugevitrectomy. There were no restrictions on date ofpublication but virtually all articles about smallgauge vitrectomy have been published in the past10 years. Articles in foreign languages were poten-tially included if they had an abstract with anEnglish translation. Non-English articles were nottranslated.

Disclosure

The authors reported no proprietary or commer-cial interest in any product mentioned or conceptdiscussed in this article.

References

1. Acar N, Kapran Z, Altan T, et al. Primary 25-gaugesutureless vitrectomy with oblique sclerotomies in pseudo-phakic retinal detachment. Retina. 2008;28(8):1068--74

2. Acar N, Kapran Z, Unver YB, et al. Early postoperativehypotony after 25-gauge sutureless vitrectomy with straightincisions. Retina. 2008;28(4):545--52

3. Acar N, Unver YB, Altan T, et al. Acute endophthalmitisafter 25-gauge sutureless vitrectomy. Int Ophthalmol. 2007;27(6):361--3

4. Altan T, Acar N, Kapran Z, et al. Transconjunctival25-gauge sutureless vitrectomy and silicone oil injectionin diabetic tractional retinal detachment. Retina. 2008;28(9):1201--6

5. Amato JE, Akduman L. Incidence of complications in25-gauge transconjunctival sutureless vitrectomy based onthe surgical indications. Ophthalmic Surg Lasers Imaging.2007;38(2):100--2

6. Androudi S, Stangos A, Brazitikos PD. Lamellar macularholes: tomographic features and surgical outcome. Am JOphthalmol. 2009

7. Altan T, Kapran Z, Eser I, et al. Comparative outcomes ofpars plana vitrectomy in acute postoperative endophthal-mitis with 25-gauge and 20-gauge techniques. Jpn JOphthalmol. 2009;53(5):506--11

8. Avitabile T, Castiglione F, Bonfiglio V, et al. Transconjunc-tival sutureless 25-gauge versus 20-gauge standard vitrec-tomy: correlation between corneal topography andultrasound biomicroscopy measurements of sclerotomysites. Cornea. 2010;20(1):19--25

9. Bahar I, Axer-Siegel R, Weinberger D. Pars plana vitrec-tomy: comparison of three techniques for the treatment ofdiabetic vitreous hemorrhage. Ophthalmic Surg LasersImaging. 2006;37(5):364--9

10. Batman C, Ozdamar Y, Aslan O, et al. Tissue glue insutureless vitreoretinal surgery for the treatment ofwound leakage. Ophthalmic Surg Lasers Imaging. 2008;39(2):100--6

11. Bourla DH, Bor E, Axer-Siegel R, et al. Outcomes andcomplications of rhegmatogenous retinal detachmentrepair with selective sutureless 25-gauge pars planavitrectomy. Am J Ophthalmol. 2010;149(4):630--4

12. Byeon SH, Lew YJ, Kim M, et al. Wound leakage andhypotony after 25-gauge sutureless vitrectomy: factorsaffecting postoperative intraocular pressure. OphthalmicSurg Lasers Imaging. 2008;39(2):94--9

13. Byeon SH, Chu YK, Lee SC, et al. Problems associated withthe 25-gauge transconjunctival sutureless vitrectomy systemduring and after surgery. Ophthalmologica. 2006;220(4):259--65


14. Cardascia N, Boscia F, Furino C, et al. Gentamicin-inducedmacular infarction in transconjunctival sutureless 25-gaugevitrectomy. Int Ophthalmol. 2008;28(5):383--5

15. Carvounis PE, Kopel AC, Kuhl DP, et al. 25-gaugeVitrectomy using sulfur hexafluoride and no pronepositioning for repair of macular hole. Retina. 2008;28(9):1188--92

16. Chang CJ, Chang YH, Chiang SY, et al. Comparison ofclear corneal phacoemulsification combined with 25-gaugetransconjunctival sutureless vitrectomy and standard20-gauge vitrectomy for patients with cataract and vitreor-etinal diseases. J Cataract Refract Surg. 2005;31(6):1198--207

17. Chee KY, Lam GC. Management of congenital cataract inchildren younger than 1 year using a 25-gauge vitrectomysystem. J Cataract Refract Surg. 2009;35(4):720--4

18. Chen CJ, Satofuka S, Inoue M, et al. Suprachoroidalhemorrhage caused by breakage of a 25-gauge cannula.Ophthalmic Surg Lasers Imaging. 2008;39(4):323--4

19. Chen E. 25-gauge transconjunctival sutureless vitrectomy.Curr Opin Ophthalmol. 2007;18(3):188--93

20. Chen JK, Khurana RN, Nguyen QD, et al. The incidenceof endophthalmitis following transconjunctival sutureless25- vs 20-gauge vitrectomy. Eye. 2009;23(4):780--4

21. Chieh JJ, Rogers AH, Wiegand TW, et al. Short-term safetyof 23-gauge single step transconjunctival vitrectomy sur-gery. Retina. 2009;29(10):1486--90

22. Cho YJ, Lee JM, Kim SS. Vitreoretinal surgery usingtransconjunctival sutureless vitrectomy. Yonsei Med J.2004;45(4):615--20

23. Dalma-Weiszhausz J, Gordon-Angelozzi M, Ustariz-Gonzalez O, et al. Intraocular pressure rise during 25-gauge vitrectomy trocar placement. Graefes Arch Clin ExpOphthalmol. 2008;246(2):187--9

24. DeBoer C, Fang S, Lima LH, et al. Port geometry and itsinfluence on vitrectomy. Retina. 2008;28(8):1061--7

25. de Preobrajenski N, Mrejen S, Adam R, et al. 23-gaugetransconjunctival sutureless vitrectomy: a retrospective studyof 164 consecutive cases. J Fr Ophtalmol. 2010;33(2):99--104

26. Eckardt C. Transconjunctival sutureless 23-gauge vitrec-tomy. Retina. 2005;25(2):208--11

27. Eckardt C, Eckardt T, Eckardt U. 27-gauge Twinlightchandelier illumination system for bimanual transconjunc-tival vitrectomy. Retina. 2008;28(3):518--9

28. Erakgun T, Egrilmez S. Surgical outcomes of transconjunc-tival sutureless 23-gauge vitrectomy with silicone oil in-jection. Indian J Ophthalmol. 2009;57(2):105--9

29. Faia LJ, McCannel CA, Pulido JS, et al. Outcomes following25-gauge vitrectomies. Eye. 2008;22(8):1024--8

30. Fang SY, DeBoer CM, Humayun MS. Performance analysisof new-generation vitreous cutters. Graefes Arch Clin ExpOphthalmol. 2008;246(1):61--7

31. Fine HF, Iranmanesh R, Iturralde D, et al. Outcomes of 77consecutive cases of 23-gauge transconjunctival vitrectomysurgery for posterior segment disease. Ophthalmology.2007;114(6):1197--200

32. Fujii GY, De Juan E Jr, Humayun MS. Improvements aftersheathotomy for branch retinal vein occlusion documentedby optical coherence tomography and scanning laserophthalmoscope. Ophthalmic Surg Lasers Imaging. 2003;34(1):49--52

33. Fujii GY, De Juan E Jr, Humayun MS, et al. Initialexperience using the transconjunctival sutureless vitrec-tomy system for vitreoretinal surgery. Ophthalmology.2002;109(10):1814--20

34. Fuji GY, De Juan E Jr, Humayun MS, et al. A new 25-gaugeinstrument system for transconjunctival sutureless vitrec-tomy surgery. Ophthalmology. 2002;109(10):1807--12

35. Galway G, Drury B, Cronin BG, et al. A comparison ofinduced astigmatism in 20-- vs 25-gauge vitrectomy pro-cedures. Eye. 2009;24(2):315--7

36. Gonzales CR, Singh S, Schwartz SD. 25-gauge vitrectomyfor paediatric vitreoretinal conditions. Br J Ophthalmol.2009;93(6):787--90

37. Gonzales CR, Boshra J, Schwartz SD. 25-gauge pars plicatavitrectomy for stage 4 and 5 retinopathy of prematurity.Retina. 2006;26(7 Suppl):S42--6

38. Gupta OP, Maguire JI, Eagle RC Jr, et al. The competencyof pars plana vitrectomy incisions: a comparative histologicand spectrophotometric analysis. Am J Ophthalmol. 2009;147(2):243--50

39. Gupta OP, Ho AC, Kaiser PK, et al. Short-term outcomes of23-gauge pars plana vitrectomy. Am J Ophthalmol. 2008;146(5):789--90

40. Gupta OP, Weichel ED, Regillo CD, et al. Postopera-tive complications associated with 25-gauge pars planavitrectomy. Ophthalmic Surg Lasers Imaging. 2007;38(4):270--5

41. Guthoff R, Riederie H, Meinhardt B, et al. Subclinicalchoroidal detachment at sclerotomy sites after 23-gaugevitrectomy: analysis by anterior segment optical coherencetomography. Ophthalmologica. 2010;224(5):301--7

42. Haas A, Seidel G, Steinbrugger I, et al. Twenty-three-gaugeand 20-gauge vitrectomy in epiretinal membrane surgery.Retina. 2010;30(1):112--6

43. Heath G, Rahman R. Combined 23-gauge suturelesstransconjunctival vitrectomy with phacoemulsification with-out face down posturing for the repair of idiopathicmacular holes. Eye. 24(2):214--20

44. Heimann H. Primary 25- and 23-gauge vitrectomy in thetreatment of rhegmatogenous retinal detachment----advancement of surgical technique or erroneous trend?Klin Monatsbl Augenheilkd. 2008;225(11):947--56

45. Hikichi T, Matsumoto N, Ohtsuka H, et al. Comparison ofone-year outcomes between 23- and 20-gauge vitrectomyfor preretinal membrane. Am J Ophthalmol. 2009;147(4):639--43

46. Hilton GF, Josephberg RG, Halperin LS, et al. Office-basedsutureless transconjunctival pars plana vitrectomy. Retina.2002;22(6):725--32

47. Hong S, Seong GJ, Kim SS. Posterior capsulectomy usinga 25-gauge microincision vitrectomy system for preventingsecondary opacification after congenital cataract surgery:outcome up to 4 years. Can J Ophthalmol. 2009;44(4):441--3

48. Horozoglu F, Yanyali A, Celik E, et al. Primary 25-gaugetransconjunctival sutureless vitrectomy in pseudophakicretinal detachment. Indian JOphthalmol. 2007;55(5):337--40

49. Huang Y, Xie L. Short-term outcomes of dry pars planaposterior capsulotomy and anterior vitrectomy in paediat-ric cataract surgery using 25-gauge instruments. Br JOphthalmol. 2010;94(8):1024--7

50. Hu AY, Bourges JL, Shah SP, et al. Endophthalmitis afterpars plana vitrectomy: a 20- and 25-gauge comparison.Ophthalmology. 2009;116(7):1360--5

51. Hsu J, Chen E, Gupta O, et al. Hypotony after 25-gaugevitrectomy using oblique versus direct cannula insertions influid-filled eyes. Retina. 2008;28(7):937--40

52. Hubschman JP, Gupta A, Bourla DH, et al. 20-, 23-, and 25-gauge vitreous cutters: performance and characteristicsevaluation. Retina. 2008;28(2):249--57

53. Hubschman JP, Bourges JL, Tsui I, et al. Effect of cuttingphases on flow rate in 20-, 23- and 25-gauge vitreouscutters. Retina. 2009;29(9):1289--93

54. Ibarra MS, Hermel M, Prenner JL, et al. Longer-termoutcomes of transconjunctival sutureless 25-gauge vitrec-tomy. Am J Ophthalmol. 2005;139(5):831--6

55. Inoue M, Shinoda K, Shinoda H, et al. Two-step obliqueincision during 25-gauge vitrectomy reduces incidence ofpostoperative hypotony. Clin Experiment Ophthalmol.2007;35(8):693--6

56. Inoue M, Shinoda K, Hirakata A. Twenty-three gaugecannula system with microvitreoretinal blade trocar. Br JOphthalmol. 2010;94(4):498--502

57. Inoue M, Noda K, Ishida S, et al. Intraoperative breakage ofa 25-gauge vitreous cutter. Am J Ophthalmol. 2004;138(5):867--9


58. Inoue Y, Kadonosono K, Yamakawa T, et al. Surgically-induced inflammation with 20-, 23-, and 25-gauge vitrec-tomy systems: an experimental study. Retina. 2009;29(4):477--80

59. Jampel HD, Thompson JT, Nunez M, et al. Cornealastigmatic changes after pars plana vitrectomy. Retina.1987;7(4):223--6

60. Kadonosono K, Yamakawa T, Uchio E, et al. Comparison ofvisual function after epiretinal membrane removal by 20-gauge and 25-gauge vitrectomy. Am J Ophthalmol. 2006;142(3):513--5

61. Kapamajian M, Gonzales CR, Gupta A, et al. Suprachor-oidal hemorrhage as an intraoperative complication of 25-gauge pars plana vitrectomy. Semin Ophthalmol. 2007;22(3):197--9

62. Kapran Z, Acar N, Unver YB, et al. Passive removal ofsilicone oil with a 25-gauge sutureless system. Jpn JOphthalmol. 2008;52(1):63--6

63. Kapran Z, Acar N. Removal of silicone oil with 25-gaugetransconjunctival sutureless vitrectomy system. Retina.2007;27(8):1059--64

64. Kapran Z, Acad N, Altan T, et al. 25-gauge suturelssvitrectomy with oblique sclerotomies for the managementof retinal detachment in pseudophakic and phakic eyes.Eur J Ophthalmol. 2009;19(5):853--60

65. Kellner L, Wimpissinger B, Stolba U, et al. 25-gauge vs20-gauge system for pars plana vitrectomy: a prospectiverandomised clinical trial. Br J Ophthalmol. 2007;91(7):945--8

66. Keshavamurthy R, Venkatesh P, Garg S. Ultrasoundbiomicroscopy findings of 25 G transconjunctival sutureless(TSV) and conventional (20G) pars plana sclerotomy inthe same patient. BMC Ophthalmol. 2006;6:7

67. Kim MJ, Park KH, Hwang JM, et al. The safety and efficacyof transconjunctival sutureless 23-gauge vitrectomy. KoreanJ Ophthalmol. 2007;21(4):201--7

68. Kim YK, Hyon JY, Woo SJ, et al. Surgically inducedastigmatism after 23-gauge transconjunctival suturelessvitrectomy. Eye. 2010;24(5):799--804

69. Konstantinidis L, Berguiga M, Beknazar E, et al. Anatomicand functional outcome after 23-gauge vitrectomy, peeling,and intravitreal triamcinolone for idiopathic macularepiretinal membrane. Retina. 2009;29(8):1119--27

70. Kunimoto DY, Kaiser RS. Wills Eye Retina Service. In-cidence of endophthalmitis after 20- and 25-gauge vitrec-tomy. Ophthalmology. 2007;114(12):2133--7

71. Kuo HK, Lee JJ. Macular infarction after 23-gaugetranconjunctival sutureless vitrectomy and subconjunctivalgentamicin for macular pucker: a case report. Can JOphthalmol. 2009;44(6):720--1

72. Kusuhara S, Ooto S, Kimura D, et al. Outcomes of 23- and25-gauge transconjunctival sutureless vitrectomies foridiopathic macular holes. Br J Ophthalmol. 2008;92(9):1261--4

73. Kychenthal A, Dorta P. 25-gauge lens-sparing vitrectomy forstage 4A retinopathy of prematurity. Retina. 2008;28(3 Suppl):S65--8

74. Lai MM, Ruby AJ, Sarrafizadeh R, et al. Repair of primaryrhegmatogenous retinal detachment using 25-gauge trans-conjunctival sutureless vitrectomy. Retina. 2008;28(5):729--34

75. Lakhanpal RR, Humayan MS, De Juan E Jr, et al. Outcomesof 140 consecutive cases of 25-gauge transconjunctivalsurgery for posterior segment disease. Ophthalmology.2005;112(5):817--24

76. Lakhanpal RR, Javaheri M, Ruiz-Garcia H, et al. Trans-vitreal limited arteriovenous-crossing manipulation with-out vitrectomy for complicated branch retinal veinocclusion using 25-gauge instrumentation. Retina. 2005;25(3):272--80

77. Lam DS, Fan DS, Mohamed S, et al. 25-gauge trans-conjunctival suture-less vitrectomy system in the surgicalmanagement of children with posterior capsular opacifica-tion. Clin Experiment Ophthalmol. 2005;33(5):495--8

78. Lommatzsch A, Heimes B, Trieschmann M, et al. Long-term results after pars plana vitrectomy with 25 gaugetechnique. Ophthalmologe. 2008;105(5):445--51

79. Lopez-Guajardo L, Dapena I, Teus MA. Dislocated poste-rior chamber intraocular lens scleral fixation techniquethrough 23-gauge vitrectomy cannulas. Ophthalmic SurgLasers Imaging. 2008;39(5):429--33

80. Lopez-Guajardo L, Vleming-Pinilla E, Pareja-Esteban J,et al. Ultrasound biomicroscopy study of direct and oblique25-gauge vitrectomy sclerotomies. Am J Ophthalmol. 2007;143(5):881--3

81. Lopez-Guajardo L, Pareja-Esteban J, Teus-Guezala MA.Oblique sclerotomy technique for prevention of incompe-tent wound closure in transconjunctival 25-gauge vitrec-tomy. Am J Ophthalmol. 2006;141(6):1154--6

82. Lopez-Guajardo L, Benitez-Herreros J, Teus-Guezala M.Optical coherence tomography as a method for studyingsutureless microincisional vitrectomy sclerotomies. Am JOphthalmol. 2009;148(2):321--2

83. Lott MN, Manning MH, Singh J, et al. 23-gauge vitrectomyin 100 eyes: short term visual outcomes and complications.Retina. 2008;28(9):1193--200

84. Ma J, Yao K, Zhang Z, et al. 25-gauge vitrectomy andtriamcinolone acetonide-assisted internal limiting mem-brane peeling for chronic cystoid macular edema associ-ated with branch retinal vein occlusion. Retina. 2008;28(7):947--56

85. Magalhaes O Jr, Maia M, Maia A, et al. Fluid dynamics inthree 25-gauge vitrectomy systems: principles for use invitreoretinal surgery. Acta Ophthalmol. 2008;86(2):156--9

86. Magalhaes O Jr, Chong L, DeBoer C, et al. Vitreousdynamics: vitreous flow analysis in 20-, 23-, and 25-gaugecutters. Retina. 2008;28(2):236--41

87. Mason JO 3rd, Yunker JJ, Vail RS, et al. Incidence ofendophthalmitis following 20-gauge and 25-gauge vitrec-tomy. Retina. 2008;28(9):1352--4

88. Matsuyama K, Kunitomi K, Taomoto M, et al. Early-onsetendophthalmitis caused by methicillin-resistant staphylo-coccus epidermidis after 25-gauge transconjunctival suture-less vitrectomy. Jpn J Ophthalmol. 2008;52(6):508--10

89. Meier P, Sterker I, Tegetmeyer H, et al. 23-gauge-lentectomy for the treatment of congenital cataract.Ophthalmologe. 2010;107(3):241--5

90. Mentens R, Stalmans P. Comparison of postoperativecomfort in 20 gauge versus 23 gauge pars plana vitrectomy.Bull Soc Belge Ophtalmol. 2009;311:5--10

91. Miller DM, Riemann CD, Foster RE, et al. Primary repair ofretinal detachment with 25-gauge pars plana vitrectomy.Retina. 2008;28(7):931--6

92. Misra A, Ho-Yen G, Burton RL. 23-gauge suturelessvitrectomy and 20-gauge vitrectomy: a case series compar-ison. Eye. 2009;23(5):1187--91

93. Miyahara T, Ohta K, Yamamoto Y, et al. 25-gauge vitrectomyto treat ocular complications of familial amyloid polyneur-opathy. J Glaucoma. 2007;16(1):169--70

94. Moreno-Montanes J, Barrio-Barrio J, Garcia-Layana A.Combined cataract surgery and 25-gauge sutureless vitrec-tomy for posterior lentiglobus. J Cataract Refract Surg.2007;33(3):380--2

95. Mura M, Tan SH, De Smet MD. Use of 25-gauge vitrectomyin the management of primary rhegmatogenous retinaldetachment. Retina. 2009;29(9):1299--304

96. Nagpal M, Wartikar S, Nagpal K. Comparison of clinicaloutcomes and wound dynamics of sclerotomy ports of20, 25, and 23 gauge vitrectomy. Retina. 2009;29(2):225--31

97. Nam DH, Ku M, Sohn HJ, et al. Minimal fluid--air exchangein combined 23-gauge sutureless vitrectomy, phacoemulsi-fication, and intraocular lens implanatation. Retina. 2010;30(1):125--30

98. Okamoto F, Okamoto C, Sakata N, et al. Changes incorneal topography after 25-gauge transconjunctival su-tureless vitrectomy versus after 20-gauge standard vitrec-tomy. Ophthalmology. 2007;114(12):2138--41


99. Okuda T, Nishimura A, Kobayashi A, et al. Postoperativeretinal break after 25-gauge transconjunctival suturelessvitrectomy: report of four cases. Graefes Arch Clin ExpOphthalmol. 2007;245(1):155--7

100. Oliveira LB, Reis PA. Silicone oil tamponade in 23-gaugetransconjunctival sutureless vitrectomy. Retina. 2007;27(8):1054--8

101. Oshima Y, Ohji M, Tano Y. Surgical outcomes of 25-gaugetransconjunctival vitrectomy combined with cataract sur-gery for vitreoretinal diseases. Ann Acad Med Singapore.2006;35(3):1875--80

102. Ooto S, Kimura D, Itoi K, et al. Suprachoroidal fluid asa complication of 23-gauge vitreous surgery. Br J Oph-thalmol. 2008;92(10):1433--4

103. Oshimi Y, Wakabayashi T, Sato T, et al. A 27-gaugeinstrument system for transconjunctival suturelss micro-incision vitrectomy surgery. Ophthalmology. 2010;117(1):93--102

104. Parolini B, Romanelli F, Prigione G, et al. Incidence ofendophthalmitis in a large series of 23-gauge and 20-gaugetransconjunctival pars plana vitrectomy. Graefes Arch ClinExp Ophthalmol. 2009;247(7):895--8

105. Parolini B, Prigione G, Romanelli F, et al. Postoperativecomplications and intraocular pressure in 943 consecutivecases of 23-gauge transconjunctival pars plana vitrectomywithn 1-year follow-up. Retina. 2010;30(1):107--11

106. Park DH, Shin JP, Kim SY. Surgically induced astigmatismin combined phacoemulsification and vitrectomy; 23-gaugetransconjunctival sutureless vitrectomy versus 20-gaugestandard vitrectomy. Graefes Arch Clin Exp Ophthalmol.2009;247(10):1331--7

107. Park KH, Woo SJ, Hwang JM, et al. Short-term outcomes ofbimanual 23-gauge transconjunctival sutureless vitrectomyfor patients with complicated vitreoretinopathies. Ophthal-mic Surg Laser Imaging. 2010;41(2):207--14

108. Patelli F, Radice P, Zumbo G, et al. 25-gauge macularsurgery: results and complications. Retina. 2007;27(6):750--4

109. Peyman GA. A pneumovitrector for the diagnostic biopsy ofthe vitreous. Ophthalmic Surg Lasers. 1996;27(3):246--7

110. Peyman GA. A miniaturized vitrectomy system forvitreous and retinal biopsy. Can J Ophthalmol. 1990;25(6):285--6

111. Quiroz-Mercado H, Garcia-Aguirre G, Ustariz-Gonzalez O,et al. Perfluorocarbon-perfused vitrectomy using a trans-conjunctival 25-gauge system. Retina. 2007;27(7):926--31

112. Rezende FA, Regis LG, Kickinger M, et al. Decompressionretinopathy after 25-gauge transconjunctival suturelessvitrectomy: report of 2 cases. Arch Ophthalmol. 2007;125(5):699--700

113. Riemann CD, Miller DM, Foster RE, et al. Short-termoutcomes of 25-gauge vitrectomy with silicone oil for repairof complicated retinal detachment. Retina. 2008;28(10):1556

114. Riemann CD, Miller DM, Foster RE, et al. Outcomes oftransconjunctival sutureless 25-gauge vitrectomy with sili-cone oil infusion. Retina. 2007;27(3):296--303

115. Rizzo S, Belting C, Cresti F, et al. Sutureless 25-gaugevitrectomy for idiopathic macular hole repair. Graefes ArchClin Exp Ophthalmol. 2007;245(10):1437--40

116. Rizzo S, Genovesi-Ebert F, Vento A, et al. Modified incisionin 25-gauge vitrectomy in the creation of a tunneledairtight sclerotomy: an ultrabiomicroscopic study. GraefesArch Clin Exp Ophthalmol. 2007;245(9):1281--8

117. Rizzo S, Genovesi-Ebert F, Murri S, et al. 25-gauge,sutureless vitrectomy and standard 20-gauge pars planavitrectomy in idiopathic epiretinal membrane surgery:a comparative pilot study. Graefes Arch Clin Exp Oph-thalmol. 2006;244(4):472--9

118. Romano MR, Groenwald C, Das R, et al. Removal ofDensiron-68 with a 23-gauge transconjunctival vitrectomysystem. Eye. 2009;23(3):715--7

119. Romero P, Salvat M, Almena M, et al. Experience with 25-gauge transconjunctival vitrectomy compared to a 20-gauge

system. Analysis of 132 cases. J Fr Ophthalmol. 2006;29(9):1025--32

120. Romero-Aroca P, Almena-Garcia M, Baget-Bernaldiz M,et al. Differences between the comination of the 25-gaugevitrectomy with phacoemulsification versus 20-gauge vitrec-tomy and phacofragmentation. Clin Ophthalmol. 2009;3:671--9

121. Sakimoto S, Tsukamoto Y, Saito Y. Removal of silicone oildroplet adhering to a silicone intraocular lens using 25-gauge instrumentation. J Cataract Refract Surg. 2009;35(2):383--5

122. Sallam A, Zambarakji HJ. Infusion aspiration mismatchduring 25-gauge vitrectomy with conversion to 20-gaugevitrector. Ann Ophthalmol (Skokie). 2008;40(1):51--2

123. Sandinha T, de Souza C, Essex R, et al. Revisitingtransconjunctival sutureless 25-gauge vitrectomy: stillworthwhile? Clin Experiment Ophthalmol. 2009;37(7):649--53

124. Scartozzi R, Bessa AS, Gupta OP, et al. Intraoperativesclerotomy-related retinal breaks for macular surgery, 20- vs25-gauge vitrectomy systems. Am J Ophthalmol. 2007;143(1):155--6

125. Schadlu R, Shah GK. Early postoperative intraocularpressure after 23-gauge sutureless small-incision pars planavitrectomy. Retina. 2009;29(7):1043--4

126. Schweitzer C, Delyfer MN, Colin J, et al. 23-gaugetransconjunctival sutureless pars plana vitrectomy: resultsof a prospective study. Eye. 2009;23(12):2206--14

127. Scott IU, Flynn HW Jr, Dey S, et al. Endophthalmitis after25-gauge and 20-gauge pars plana vitrectomy: incidenceand outcomes. Retina. 2008;28(1):138--42

128. Sen J, Groenewald C, Hiscott PS, et al. Transretinalchoroidal tumor biopsy with a 25-gauge vitrector. Ophthal-mology. 2006;113(6):1028--31

129. Shah CP, Ho AC, Regillo CD, et al. Short-term outcomes of25-gauge vitrectomy with silicone oil for repair of compli-cated retinal detachment. Retina. 2008;28(5):723--8

130. Shimada H, Nakashizuka H, Hattori T, et al. Incidence ofendophthalmitis after 20-and 25-gauge vitrectomy causesand prevention. Ophthalmology. 2008;115(12):2215--20

131. Shimada H, Nakashizuka H, Hattori T, et al. Conjunctivaldisplacement to the corneal side for oblique--parallelinsertion in 25-gauge vitrectomy. Eur J Ophthalmol. 2008;18(5):848--51

132. ShimadaH,NakashizukaH,HattoriT, et al.Vitreousprolaspsethrough the scleral wound in 25-gauge transconjunctivalvitrectomy. Eur J Ophthalmol. 2008;18(4):659--62

133. Shimada H, Nakashizuka H, Mori R, et al. 25-gauge scleraltunnel transconjunctival vitrectomy. Am J Ophthalmol.2006;142(5):871--3

134. Shimada H, Nakashizuka H, Mori R, et al. Expandedindications for 25-gauge transconjunctival vitrectomy. Jpn JOphthalmol. 2005;49(5):397--401

135. Shinoda H, Nakajima T, Shinoda K, et al. Jamming of25-gauge instruments in the cannula during vitrectomyfor vitreous haemorrhage. Acta Ophthalmol. 2008;86(2):160--4

136. Shinoda H, Sninoda K, Satofuka S, et al. Visual recoveryafter vitrectomy for macular hole using 25-gauge instru-ments. Acta Ophthalmol. 2008;86(2):151--5

137. Singh CN, Iezzi R, Mahmoud TH. Intraocular pressureinstability after 23-gauge vitrectomy. Retina. 2010;30(4):629--34

138. Singh A, Stewart JM. 25-gauge sutureless vitrectomy:variations in incision architecture. Retina. 2009;29(4):451--5

139. Singh A, Chen JA, Stewart JM. Ocular surface fluidcontamination of sutureless 25-gauge vitrectomy incisions.Retina. 2008;28(4):553--7

140. Singh A, Fawzi AA, Stewart JM. Limitation of 25-gaugevitrectomy instrumentation in highly myopic eyes. Oph-thalmic Surg Lasers Imaging. 2007;38(5):437--8

141. Singh RP, Bando H, Brasil OF, et al. Evaluation of woundclosure using different incision techniques with 23-gauge


and 25-gauge microincision vitrectomy systems. Retina.2008;28(2):242--8

142. Siqueira RC, Gil AD, Jorge R. Retinal detachment surgerywith silicone oil injection in transconjunctival sutureless23-gauge vitrectomy. Arq Bras Oftalmol. 2007;70(6):905--9

143. Soheilian M, Mirdehghan SA, Peyman GA. Suturelesscombined 25-gauge vitrectomy, phacoemulsification, andposterior chamber intraocular lens implantation formanagementof uveitic cataract associated with posteriorsegment disease. Retina. 2008;28(7):941--6

144. Sood V, Rayhman R, Denniston AK. Phacoemulsificationand foldable intraocular lens implantation combined with23-gauge transconjunctival suturelsss vitrectomy. J CataractRefract Surg. 2009;35(8):1380--4

145. Spirn MJ. Comparison of 25-, 23-, and 20-gauge vitrectomy.Curr Opin Ophthalmol. 2009;20(3):195--9

146. Taban M, Sharma S, Ventura AA, et al. Evaluation of woundclosure in oblique 23-gauge sutureless sclerotomies withvisante optical coherence tomography. Am J Ophthalmol.2009;147(1):101--7

147. Taban M, Ventura AA, Sharma S, et al. Dynamic evaluationof sutureless vitrectomy wounds: an optical coherencetomography and histopathology study. Ophthalmology.2008;115(12):2221--8

148. Taban M, Ufret-Vincenty RL, Sears JE. Endophthalmitisafter 25-gauge transconjunctival sutureless vitrectomy.Retina. 2006;26(7):830--1

149. Talwar D, Kulkarni A, Azad RV, et al. A new technique forsampling fluid from the retro-silicone oil space in siliconeoil-filled eyes. Ophthalmic Surg Lasers Imaging. 2003;34(2):149--50

150. Tan CS, Wong HK, Yang FP, et al. Outcome of 23-gaugesutureless transconjunctival vitrectomy for endophthalmi-tis. Eye. 2008;22(1):150--1

151. Tan HS, Mura M, De Smet MD. Iatrogenic Retinal Breaksin 25-gauge macular surgery. Am J Ophthalmol. 2009;29(6):854--9

152. Taylor SR, Aylward GW. Endophthalmitis following25-gauge vitrectomy. Eye. 2005;19(11):1228--9

153. Texeira A, Allemann N, Yamada AC, et al. Ultrasoundbiomicroscopy in recently postoperative 23-gauge transcon-junctival vitrectomy sutureless self-sealing sclerotomy. Retina.2009;29(9):1305--9

154. Tewari A, Shah GK, Fang A. Visual outcomes with 23-gaugetransconjunctival sutureless vitrectomy. Retina. 2008;28(2):258--62

155. Tominaga A, Oshima Y, Wakabayashi T, et al. Bacterialcontimination of the vitreous cavity associated with trans-conjunctival 25-gauge microincision vitrectomy surgery.Ophthalmology. 2010;117(4):811--7

156. Tsang CW, Cheung BT, Lam RF, et al. Primary 23-gaugetransconjunctival sutureless vitrectomy for rhegmatoge-nous retinal detachment. Retina. 2008;28(8):1075--81

157. Valmaggia C. Pars plana vitrectomy with 25-gauge instru-ments in the treatment of idiopathic epiretinal membranes.Klin Monatsbl Augenheilkd. 1997;224(4):292--6

158. Von Fricken MA, Kunjukunju N, Weber C, et al. 25-gaugesutureless vitrectomy versus 20-gauge vitrectomy for therepair of primary rhegmatogenous retinal detachment.Retina. 2009;29(4):444--50

159. Wan T, Hu J, Luo Y, et al. Experimental study of the healingcondition of sclerotomy sites after 25-gauge transconjunc-tival sutureless sclerotomy and 20-gauge vitrectomy. Yan KeXue Bao. 2007;23(1):37--42

160. Wickham L, Bunce CS, Kwan AS, et al. A pilot randomizedcontrolled trial comparing the post-operative pain experiencefollowing vitrectomy with a 20-gauge system and the 25-gaugetransconjunctival system. Br J Ophthalmol. 2010;94(1):36--40

161. Williams GA. 25-, 23-, or 20-gauge instrumentation forvitreous surgery? Eye. 2008;22(10):1263--6

162. Wimpissingwer B, Kellner L, Brannath W, et al. 23-gaugeversus 20-gauge system for pars plana vitrectomy: a pro-spective randomised clinical trial. Br J Ophthalmol. 2008;92(11):1483--97

163. Wong RW, Kokame GT, Mahmoud TH, et al. Complicationsassociated with clear corneal cataract wounds duringvitrectomy. Retina. 2010;30(6):850--5

164. Woo SJ, Park KH, Hwang JM, et al. Risk factors associatedwith sclerotomy leakage and postoperative hypotony after23-gauge transconjunctival sutureless vitrectomy. Retina.2009;29(4):456--63

165. Yang SJ, Yoon SY, Kim JG, et al. Transconjunctival suturelsssvitrectomy for the treatment of vitreretinal complicationsin patients with diabetes mellitus. Ophthalmic Surg LasersImaging. 2009;40(5):461--6

166. Yanyali A, Celik E, Horozoglu F, et al. 25-gauge trans-conjunctival sutureless pars plana vitrectomy. Eur JOphthalmol. 2006;16(1):141--7

167. Yanyali A, Celik E, Horozoglu F, et al. Cornealtopographic changes after transconjunctival (25-gauge)sutureless vitrectomy. Am J Ophthalmol. 2005;140(5):939--41

168. Yoon YH, Kim DS, Kim JG, et al. Sutureless vitrectomysurgery using a new 25-gauge transconjunctival system.Ophthalmic Surg Lasers Imaging. 2006;37(1):12--9

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advantages and limitations of small gauge vitrectomy

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