Innovations in 27 - Gauge Vitrectomy for Sutureless Microincision

T he common thinking regarding surgical wounds is that “much smaller is much better.” Based on this concept, microincision vitrectomy surgery (MIVS) with 25or 23-gauge instruments has taken over from conventional 20-gauge vitrectomy in many cases, and the technology has evolved radically during the past several years. Along with the development of ergonomic instrumentation and new-generation vitrectomy machines, there has been a rapid adoption of smaller gauge instrumentation on a global scale over the past several years (Figure 1). The above-mentioned trends and future perspectives in modern MIVS led us to initiate a 27-gauge vitrectomy project in 2007. Development of a 27-gauge chandelier illumination fiber was the first step.1 After years of strenuous efforts, DORC was the first company to offer a complete 27-gauge vitrectomy system. The preliminary surgical results using the first-generation 27-gauge vitrectomy system to treat vitreoretinal diseases were reported in 2010.2 At that time, the system was used only in select cases— mainly macular disease and simple vitreous hemorrhage— similar to the situation in the early days of 25-gauge vitrectomy. Nevertheless, both the anatomical and visual results were very promising. The most remarkable findings were that there was no need to transition to a larger gauge, no suturing was required, and no hypotony was observed in any of the study cases. To explore the potential for more widespread use of this ultrasmall-gauge system, its functionalities must be upgraded to treat more challenging conditions, such as cases of advanced proliferative diabetic retinopathy and primary rhegmatogenous retinal detachment. The most critical aspect of 27-gauge vitrectomy that must be improved is the cutting efficiency of vitreous cutter. According to the Hagen-Poiseuille law (Figure 2), the flow volume of fluid through a pipe can be increased by increasing the pressure differences between the ends of the pipe and/or by decreasing the coefficient of viscosity. This suggests that the cutting efficiency (vitreous flow) of the 27-gauge vitreous cutter can be improved by (1) reducing the bite size at higher cut rates to decrease the flow viscosity (resistance) and/or (2) maintaining a longer opening time of the cutting port with a maximum aspiration pressure. In this article, we describe 2 recently introduced technologies that may help surgeons realize ultrahigh performance with 27-gauge vitrectomy probes. Innovations in 27-Gauge Vitrectomy for Sutureless Microincision Vitrectomy Surgery