Twenty-seven-gauge vitrectomy: a consecutive, single-centre case series with exclusive use over a 4-year period

BACKGROUND

To assess the safety and effectiveness of the exclusive use of 27-gauge instruments for all vitreoretinal diseases requiring vitrectomy.

METHODS

In this retrospective study, 1020 consecutive surgeries were performed on 958 eyes of 848 patients using 27-gauge instruments from March 2017 to June 2021. Patients with a minimum follow-up of 3 months were included. Surgical case-mix, best-corrected visual acuity (BCVA), intraocular pressure (IOP), intra- and post-operative complications, and surgery times were recorded.

RESULTS

The study patients were followed up for averagely 11 months. Of the 1020 vitrectomies, 958 were primary procedures. Of the 148 retinal detachment (RD) cases, 138 (93%) required a single vitrectomy. Primary macular hole closure was achieved in 143 of 145 (99%) cases. The average surgical times were 55 and 38 min for RD surgeries and for all other indications, respectively. BCVA improved significantly at the final visit (20/49) compared with the pre-operative visit (20/78) (p < 0.01). IOP was similar at the pre-operative (14.8mmHg) and final (14.3mmHg) visits. Complications recorded include transient hypotony in 39 eyes, iatrogenic retinal breaks in 2 eyes, and a vitreous bleed in 1 other eye.

CONCLUSION

This study revealed that 27-gauge vitrectomy instruments can be used for a wide range of indications, with exclusive use in certain settings. The outcomes were similar to other gauges, including for rhegmatogenous retinal detachment, with minimal complications.

27‑Gauge vitrectomy vs. 25‑gauge vitrectomy in the management of proliferative diabetic retinopathy with preoperative intravitreal injection of conbercept

Small-gauge vitrectomy has become popular due to its notable advantages, including less trauma, shortened convalescence and improved manoeuvrability. The aim of the present study was to compare the surgical outcomes of 27-gauge (27-G) vitrectomy with those of 25-gauge (25-G) vitrectomy in the management of proliferative diabetic retinopathy (PDR) with preoperative intravitreal injection of conbercept. The data of 48 consecutive patients with PDR (48 eyes) were retrospectively collected. The patients underwent conbercept intravitreal injection and pars plana vitrectomy with a 27-G group (23 eyes) or 25-G group (25 eyes) vitrectomy system. The operating time, suturing rate, endodiathermy rate, postoperative best-corrected visual acuity (BCVA), intraocular pressure (IOP) and complications were recorded. The mean postoperative BCVA at final follow-up was significantly improved compared with that at the baseline in both groups (P<0.001 for both). The differences in the mean BCVA changes between the two groups were not significant (P>0.99), and no differences were observed in the final central foveal thickness (P=0.51) between the two groups. The final IOP remained stable compared with that at the baseline in the 27-G group (P=0.36) and the 25-G group (P=0.05). The suturing rate was significantly decreased in the 27-G group compared with the 25-G group (P=0.04). There were no significant differences between the two groups in terms of the operating time (P=0.18), rate of endodiathermy use (P>0.99), iatrogenic retinal breaks (P=0.42) or postoperative recurrent vitreous haemorrhage (P>0.99). In addition, no case of ocular hypotony was observed in either group. In conclusion, 27-G vitrectomy was as efficient and safe as 25-G vitrectomy in the management of PDR in terms of operating time and complications. With reference to the literature, preoperative conbercept injection appears to assist in decreasing the incidence of intraoperative and postoperative complications.

Effects of Image Processing Using Honeycomb-Removal and Image-Sharpening Algorithms on Visibility of 27-Gauge Endoscopic Vitrectomy

Endoscopic vitrectomy with small gauge probes has clinical potentials, but intraocular visibility is inherently limited by low resolution and dim illumination due to the reduced number of optic fibers. We investigated whether honeycomb-removal and image-sharpening algorithms, which enable real-time processing of live images with a delay of 0.004 s, can improve the visibility of 27-gauge endoscopic vitrectomy. A total of 33 images during endoscopic vitrectomy were prepared, consisting of 11 original images, 11 images after the honeycomb-removal process, and 11 images after both honeycomb-removal and image-sharpening procedures. They were randomly presented to 18 vitreous surgeons, who rated each image on a 10-point scale. The honeycomb-removal algorithm almost completely suppressed honeycomb artifacts without degrading the background image quality. The implementation of image-sharpening algorithms further improved endoscopic visibility by optimizing contrast and augmenting image clarity. The visibility score was significantly improved from 4.27 ± 1.78 for the original images to 4.72 ± 2.00 for the images after the honeycomb-removal process (p < 0.001, linear mixed effects model), and to 5.40 ± 2.10 for the images after both the honeycomb-removal and image-sharpening procedures (p < 0.001). When the visibility scores were analyzed separately for 10 surgeons who were familiar with endoscopic vitrectomy and 8 surgeons who were not, similar results were obtained. Image processing with honeycomb-removal and image-sharpening algorithms significantly improved the visibility of 27-gauge endoscopic vitrectomy.

Outcomes of Primary 27-Gauge Vitrectomy for 73 Consecutive Cases With Uveitis-Associated Vitreoretinal Disorders

Background: Since the advent of 27-gauge microincision vitrectomy system a decade ago, evidence regarding the feasibility, safety, and effectiveness of 27-gauge pars plana vitrectomy (PPV) has increased. Aim: To assess the effectiveness and safety profile of 27-gauge PPV for various vitreoretinal conditions associated with uveitis. Methods: We retrospectively investigated 73 consecutive cases that underwent primary 27-gauge PPV for uveitis-related ocular disorders between October 2014 and April 2021. The primary outcome measures were mean change in logMAR best-corrected decimal visual acuity (BCVA) pre-operatively to 3 months post-operatively, the proportion of BCVA improvement category defined as the degree of logMAR BCVA difference ("improved" [≤-0.3], "unchanged" [-0.3 to 0.3], and "worsened" [≥0.3]) pre-operatively to 3 months post-operatively, the mean change in intraocular inflammation scores pre-operatively to 3 months post-operatively; and intraoperative and post-operative complications. Results: The mean logMAR BCVA significantly improved from 0.69 pre-operatively to 0.42 at 3 months post-operatively (P = 0.017). The percentages of eyes with "improved," "unchanged," and "worsened" BCVA at 3 months post-operatively were 37, 50, and 13%, respectively. The mean anterior chamber cell score was 0.6 pre-operatively and 0.2 at 3 months post-operatively (P = 0.001), the mean anterior chamber flare score was 0.4 pre-operatively and 0.1 at 3 months post-operatively (P = 0.004), and the mean vitreous haze score was 1.9 pre-operatively and 0.1 at 3 months post-operatively (P < 0.001). Surgery-related complications occurred in 35 (48%) eyes, 68% of which were related to intraocular pressure and transient. Conclusions: Given its risk-benefit profile, 27-gauge PPV is a promising option for the treatment of vitreoretinal disorders in uveitis.

27-gauge sutureless vitrectomy under topical anesthesia: A pilot study

BACKGROUND

The implementation of the 27-gauge (G) sutureless vitrectomy technique is associated with a marked shortening of surgery time, faster healing of scleral and conjunctival wounds, less severe conjunctival scarring, limited postoperative corneal astigmatism, and marked improvement in the postoperative comfort of patients. The traditional methods of anesthesia for vitrectomy surgery are quite varied and each has its own potential for complications.

OBJECTIVES

To assess the feasibility and safety of 27G pars plana vitrectomy (PPV) performed under local topical anesthesia for diabetic maculopathy, asteroid hyalosis and vitreomacular traction syndrome associated with high myopia.

MATERIAL AND METHODS

Three carefully selected patients with various vitreoretinal disorders underwent primary 27G PPV performed by a single surgeon under local topical anesthesia. Patients were analyzed in regard to best corrected visual acuity, intraocular pressure, intraoperative/postoperative complications, intraoperative/postoperative pain, and surgery time.

RESULTS

All patients showed postoperative improvement in visual acuity. No decrease in intraocular pressure below 10 mm Hg was documented on postoperative day 1. Furthermore, no postoperative complications were recorded during the six-month follow-up, and evident improvement in the anatomical status was confirmed using ophthalmic coherence tomography in all cases.

CONCLUSION

Our findings support that 27G PPV performed solely under local topical anesthesia is safe and effective for treating selected vitreoretinal disorders.

27-gauge micro-incision vitrectomy surgery for visually significant macular membranes and full-thickness macular holes: a retrospective study

BACKGROUND

To evaluate visual and safety outcomes for 25-gauge (25G) and 27-gauge (27G) micro-incision vitrectomy platforms (MIVS) for the treatment of epiretinal membrane and full-thickness macular holes.

METHODS

Retrospective analysis of all patients who underwent internal limiting membrane (ILM) peel surgery from January 2017 through December 2018. 207 cases met the eligibility criteria for inclusion. Primary endpoint was post-operative Best-Corrected Distance Visual Acuity (BCVA) at 6 months.

RESULTS

For all patients combined, mean logMAR BCVA improved from 0.57 (± 0.40) to 0.37 (± 0.36) post-operatively (p < 0.001). For 25G ERMs, logMAR BCVA improved from 0.51 (± 0.28) to 0.30 (± 0.25) post-operatively (p < 0.001). For 27G ERMs, logMAR BCVA improved from 0.33 (± 0.28) to 0.28 (± 0.27) post- operatively (p = 0.15). For 25G FTMHs, logMAR BCVA improved from 0.87 (± 0.48) to 0.51 (± 0.44) post-operatively (p < 0.001). For 27G FTMHs, logMAR BCVA changed from 0.89 (± 0.47) to 0.96 (± 0.60).

CONCLUSION

Final visual outcomes improved for both 25G and 27G ERM groups and the 25G FTMH group. Both 25G and 27G were safe and well tolerated MIVS platforms for the treatment of ERM and FTMH.

Hybrid 23/27 Gauge Vitrectomy - Combining the Charm of 27G with the Efficacy of 23G

Background

Minimally invasive transconjunctival sutureless vitrectomy (MIVS) has evolved into the standard of care, smaller incisions thought to result in lower ocular surface trauma and shorter times to recovery. The currently most relevant limitations in macular surgery may be light intensity and 27G instrument stability. Therefore, we thought to compare standard 23 and 27G vitrectomy with a hybrid technique using one 23G and two 27G ports regarding surgical times and short-term outcomes.

Methods

This retrospective comparison included 90 single-center consecutive cases of eyes undergoing elective micro-invasive vitrectomy for epiretinal membranes or idiopathic macular holes between October 2017 and June 2018. The main criteria for the comparison were total surgical time as primary outcome parameter and treatment-demanding intra- and postoperative complications along with recovery of best-corrected visual acuity (BCVA) and central retinal thickness (CRT) from prior to surgery to 1 month thereafter as secondary parameters as independent parameters for the recovery from the pre-existing pathology and the surgical trauma.

Results

Surgical times were shorter with 23G and 23/27G compared to 27G (23G: 38.4±13.1; 27G: 48.1±15.3; 23/27G: 34.9±9 mins; p=0.0005) with no differences in BCVA and CRT outcomes. Switching from 27G to a larger port size was not necessary in any instance. Cryotherapy was applied in 15%, 30%, and 22.5% to suspected retinal pathologies, beyond these, in 5%, 0%, and 7.5% for retinal tears. Four postoperative retinal detachments occurred (4.4%), one in the 23G and three in the 23/27G group requiring re-vitrectomy.

Conclusion

In this exploratory case series, 23/27G hybrid vitrectomy, combining the advantages of 23G and 27G techniques, resulted in shorter surgical times without evident disadvantages. The combination with cataract surgery was unproblematic.

Comparison of 27-gauge versus 25-gauge vitrectomy results in patients with epiretinal membrane: 6-month follow-up

PURPOSE

To compare the 27G versus 25G vitrectomy in patients with epiretinal membrane (ERM).

PATIENTS AND METHODS

Sixty pseudophakic eyes of 60 consecutive patients treated by pars plana vitrectomy (PPV) using 27G (30 eyes) or 25G (30 eyes) were prospectively evaluated including eye's inflammation, surgery time, ERM + ILM removal time and complications. Additionally, 1, 3, 7, 14, 30, 90 and 180 days after PPV, the following were estimated: intraocular pressure (IOP), sclerotomy wound closure time, distance best corrected visual acuity (DBCVA), foveal macular thickness (FMT) and surgically induced astigmatism (SIA).

RESULTS

The eye's inflammation resolved within 30 days after surgery in both groups. The surgery and ERM + ILM times were longer in the 27G group (p ≤ 0.02). The most common postoperative complication was hypotony in both groups, more common in 25G group (23.3% vs. 10% of eyes). In 27G group, the mean IOP prior to 180 days postoperatively was higher (p < 0.05) and the sclerotomy wound closure time was shorter (p < 0.001). Mean DBCVA values (7, 14, 30 days after surgery) were significantly better in 27G group (p < 0.001). The mean FMT values were similarly and significantly reduced in both groups 1 day postoperatively (p < 0.05) as compared to preoperative values and then stabilized during follow-up. Mean SIA was lower in 27G group 30, 90 and 180 days after surgery (p < 0.001).

CONCLUSION

The use of 27G PPV in patients with ERM significantly reduced sclerotomy wound closure time and surgically induced astigmatism, better stabilized intraocular pressure and allowed to achieve faster visual acuity improvement, as compared to 25G PPV.

Multiple subretinal fluid blebs after pars plana vitrectomy for rhegmatogenous retinal detachment repair

PURPOSE

To investigate the incidence of and clinical risk factors for multiple subretinal fluid (SRF) blebs after pars plana vitrectomy (PPV).

METHODS

This study examined patients who underwent PPV (25- or 27-gauge) to repair a primary rhegmatogenous retinal detachment (RRD). Clinical characteristics, including age, sex, axial length, symptom duration, and postoperative best-corrected visual acuity (BCVA), were compared between eyes with and without multiple SRF blebs. Intentional drainage retinotomy and cryotherapy use were also performed. Main outcome measures were the effect of these parameters on multiple SRF bleb incidence 1 month after surgery.

RESULTS

A total of 108 eyes of 106 patients (76 men and 32 women; mean age = 58.9 ± 9.0 years) were included. Multiple SRF blebs were observed in 8 eyes (7.4%). Logistic regression analysis showed that creation of intentional drainage retinotomy and 27-gauge PPV are risk factors for the development of multiple SRF blebs. The number and size of blebs spontaneously decreased over time, and SRF had completely resolved in 5 eyes (62.5%) 1 year after surgery.

CONCLUSION

Multiple SRF blebs developed even after small gauge vitrectomy. The SRF did not affect postoperative BCVA and gradually absorbed without treatment.

A comparison between topical and retrobulbar anesthesia in 27-gauge vitrectomy for vitreous floaters: a randomized controlled trial

Background

To compare the safety and efficacy of topical anesthesia versus retrobulbar anesthesia in 27-gauge pars plana vitrectomy (PPV) for vitreous floaters.

Methods

30 patients with vitreous floaters were randomized into Group T (topical anesthesia, proparacaine eye drop) and Group R (retrobulbar anesthesia), and underwent 27-gauge PPV. A 5-point visual analogue pain scale (VAPS) was used to assess patients’ pain experience of anesthesia and surgery procedure (during surgery, 2 h and 1 day after surgery).

Results

The VAPS of anesthesia procedure was 1.27 ± 0.59 for patients in Group R, while it was all 0 for patients in Group T (p < 0.001). There was no significant difference for VAPS during surgery (Group T: 1.13 ± 0.74, Group R: 0.67 ± 0.62, p = 0.67), 2 h (Group T: 0.80 ± 1.01, Group R: 0.67 ± 0.62, p = 0.67) and 1 day (Group T: 0.20 ± 0.41, Group R: 0.27 ± 0.46, p = 0.68) after surgery between these two groups. Only one patient (6.7%) in Group T required additional topical anesthesia during the surgery. Most of the patients reported the pain experience came from initial trocar insertion in both groups. None of the patients required post operative analgesia in both groups. No intraoperative or postoperative complications were noted in both groups.

Conclusion

This study suggested that topical anesthesia is a safe and effective anesthetic approach for patients with floaters who underwent 27-gauge PPV.

Trial registration

ClinicalTrials.govNCT03049163. Registered 8 February 2017.

Electronic supplementary material

The online version of this article (10.1186/s12886-018-0838-7) contains supplementary material, which is available to authorized users.

Outcomes of transconjunctival sutureless 27-gauge vitrectomy for vitreoretinal diseases

AIM

To evaluate the safety and efficacy profile of 27-gauge (27G) pars plana vitrectomy (PPV) for the treatment of various vitreoretinal diseases.

METHODS

The clinical outcomes of 61 eyes (58 patients) with various vitreoretinal diseases following 27G PPV were retrospectively reviewed.

RESULTS

Surgical indications included rhegmatogenous retinal detachment (n=24), full-thickness macular hole (n=12), diabetic retinopathy (n=11), vitreous hemorrhage (n=6), Eales disease (n=4), pathological myopia-related vitreous floater (n=2), and macular epiretinal membrane (n=2). The mean follow-up was 166.4±61.3d (range 98-339d). The mean logMAR best-corrected visual acuity (BCVA) improved from 1.7±1.1 [0.02 decimal visual acuity (VA) equivalent] preoperatively to 1.2±1.0 (0.06 decimal VA equivalent) at the last postoperative visit (P<0.001). The mean operative time was 49.9min. With the exception of complicated cataract in one eye, no intraoperative complications were encountered. No case required conversion to conventional 20-, 23- or 25G instrumentation in all surgical maneuvers except for silicone oil infusion, which required a 25G oil injection syringe. Postoperative complications included transient ocular hypertension, vitreous hemorrhage, persistent intraocular pressure elevation, subconjunctival oil leakage, and recurrent retinal detachment. No cases of hypotony, endophthalmitis, and sclerotomy-related tears were observed.

CONCLUSION

The current results suggest that 27G PPV system is a safe and effective treatment for various vitreoretinal diseases. When learning to perform 27G PPV, surgeons may encounter a learning curve and should gradually expand surgical indications from easy to pathologically complicated cases.

Outcomes of transconjuctival sutureless 27-gauge vitrectomy for stage 4 retinopathy of prematurity

AIM

To report our initial experience with lens-sparing vitrectomy for stage 4 retinopathy of prematurity using the 27-gauge (G) system.

METHODS

This retrospective case series involved nine eyes of five babies with active stage 4 ROP, who underwent 27-G lens-sparing vitrectomy. Surgery was done using 27-G valved cannulas and sclerotomies were made 1.5 mm from the limbus. Bilateral sequential vitrectomy was done in eight eyes.

RESULTS

At one-year follow-up, anatomical outcome was favourable in all nine (100%) eyes. High-speed cutting and smaller sclerotomies were helpful in reducing the intra and post-operative complications.

CONCLUSION

27-G vitrectomy is well suited for stage 4 ROP surgeries.