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

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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]

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.

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] 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.[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)