MILESTONES IN RETINA

Expert perspectives on the evolution of retina practice, procedures, technologies and instrumentation.

MILESTONE

27-Gauge Vitrectomy

Taku Wakabayashi, MD, PhD, and Yusuke Oshima, MD, PhD

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Yusuke Oshima, MD, PhD (right) and Taku Wakabayashi, MD, PhD (left) in 2010. Photo courtesy of Taku Wakabayashi, MD, PhD.

The driving force behind our initial development of the 27-gauge vitrectomy system in the mid to late 2000s was not simply the pursuit of a smaller incision, but the desire to increase the safety, efficacy, and overall quality of the transconjunctival sutureless vitrectomy system.

In the early era of 25- and 23-gauge transconjunctival vitrectomy, some surgeons refrained from peripheral vitreous shaving under the hypothesis that the residual vitreous could help seal sclerotomies.[1] However, concerns were raised about the potential increase in endophthalmitis risk due to bacterial contamination from transconjunctival instrument insertion and vitreous wicks at the sclerotomy sites.[2,3]

Yasuo Tano, MD (1948-2009). Photo courtesy of Taku Wakabayashi, MD, PhD.

Extensive vitrectomy may theoretically reduce the risk of bacterial contamination and vitreous wicking,[3,4] but in turn may increase wound-sealing–related complications, such as hypotony, choroidal detachment, and endophthalmitis. Surgeons adopted 2-stage, angled incisions,5 but this did not necessarily prevent the complications. Sclerotomy suturing reduces wound-sealing–related complications but increases patient discomfort and conjunctival scarring.

These experiences prompted the development of the 27-gauge (0.4 mm) system as an ideal way to achieve  truly sutureless vitrectomy—following the “smaller is better” maxim for preventing wound-sealing–related complications even after extensive vitrectomy. Our experience with successful fluid-air exchange and intravitreal injections through a 27-gauge needle also convinced us of the advantage of a 27-gauge system.

We worked day and night on developing the technology. The contribution and mentorship of Yasuo Tano, MD, as chair of the department, was instrumental. Dr. Tano, a protégé of Robert Machemer, MD, fostered a culture of relentless innovation in vitreoretinal surgery. This environment and culture facilitated the development of the 27-gauge vitrectomy system, aiming to improve patient care through continuous innovation.

Increasing utilization of 27-gauge systems in Japan. Image courtesy of Alcon.

We developed a wide variety of 27-gauge instruments, presented the preliminary outcomes of the prototype at the ASRS Annual Scientific Meeting in 2009, and published the paper in 2010.[6]

Figure 1. The 27-gauge vitrectomy for diabetic traction retinal detachment. Photo courtesy of Taku Wakabayashi, MD, PhD.

Further development of high-speed cutters, high-performance vitrectomy machines, and stiffer instruments allowed us to utilize the 27-gauge system for a wide variety of vitreoretinal diseases, including macular diseases, retinal detachment, and diabetic traction retinal detachment (Figure 1).[7,8]

We believe that the gently performed surgery with slow inflow and outflow and minimal risk of wound-sealing–related complications with 27-gauge vitrectomy provides the least-invasive surgery.

The 27-gauge system continues to evolve, with its dual-blade technology now nearly matching the efficiency of the 25-gauge single-blade system. We hope its ongoing development will be widely embraced, achieving our original goal of improving surgical outcomes to benefit patients throughout the world.

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‍References

  1. Benitez-Herreros J, Lopez-Guajardo L, Camara-Gonzalez C, et al. Influence of incisional vitreous incarceration in sclerotomy closure competency after transconjunctival sutureless vitrectomy. Invest Opthalmol Vis Sci. 2013;54(6):4366-4371. doi:10.1167/iovs.13-12008
  2. Kunimoto DY, Kaiser RS; Wills Eye Retina Service. Incidence of endophthalmitis after 20- and 25-gauge vitrectomy. Ophthalmology. 2007;114(12):2133-2137. doi:10.1016/j.ophtha.2007.08.009
  3. Tominaga A, Oshima Y, Wakabayashi T, Sakaguchi H, Hori Y, Maeda N. Bacterial contamination of the vitreous cavity associated with transconjunctival 25-gauge microincision vitrectomy surgery. Ophthalmology. 2010;117(4):811-817. doi:10.1016/j.ophtha.2009.09.030
  4. Shimada H, Nakashizuka H, Hattori T, Mori R, Mizutani Y, Yuzawa M. Incidence of endophthalmitis after 20- and 25-gauge vitrectomy causes and prevention. Ophthalmology. 2008;115(12):2215-2220. doi:10.1016/j.ophtha.2008.07.015
  5. Eckardt C. Transconjunctival sutureless 23-gauge vitrectomy. Retina. 2005;25(2):208-211. doi:10.1097/00006982-200502000-00015
  6. Oshima Y, Wakabayashi T, Sato T, Ohji M, Tano Y. A 27–gauge instrument system for transconjunctival sutureless microincision vitrectomy surgery. Ophthalmology. 2010;117(1):93-102.e2. doi:10.1016/j.ophtha.2009.06.043
  7. Yoneda K, Morikawa K, Oshima Y, Kinoshita S, Sotozono C; Japan Microincision Vitrectomy Surgery Study Group. Surgical outcomes of 27-gauge vitrectomy for a consecutive series of 163 eyes with various vitreous diseases. Retina. 2017;37(11):2130-2137. doi:10.1097/IAE.0000000000001442
  8. Shinkai Y, Oshima Y, Yoneda K, et al; 27G Vitrectomy Study Group. Multicenter survey of sutureless 27-gauge vitrectomy for primary rhegmatogenous retinal detachment: a consecutive series of 410 cases. Graefes Arch Clin Exp Ophthalmol. 2019;257(12):2591-2600. doi:10.1007/s00417-019-04448-2

(Milestone essay published 2024)