VITREORETINAL SURGERY
Insights

Small-gauge Vitrectomy Systems

Interview with Gregory M. Fox, MD, Retina Associates, PA, Shawnee, KS, USA

Q. How significant is vitreous cutter speed?

Ultrahigh cutter speed (up to 16,000 CPM) helps lower vitreous traction during vitrectomy, which is important in retinal detachment surgeries and vitreous base shaving. Higher speed vitrectors help to safely remove the vitreous so you can then efficiently address an epiretinal membrane (ERM) or peeling of the internal limiting membrane (ILM).

Q. Describe your current experience regarding 27-gauge vitrectomy surgery.

I have been successfully using a 27-gauge vitrectomy platform from DORC for the past few years. The small-gauge microforceps are highly effective in assisting ERM removal, ILM peeling and for macular hole surgery. Their new two-dimensional cutting (TDC) system offers higher flow rates in 27-gauge surgery, greater than those seen using a 25-gauge approach. This feature is really going to boost the popularity of 27-gauge vitrectomy amongst U.S. surgeons.

The first question many surgeons will ask is whether 27-gauge is slower than 25-gauge surgery, i.e., does it slow you down? Currently there is lower flow with a 27-gauge approach compared to 25-gauge surgery. But using the new DORC TDC vitreous cutter, which has a significantly longer open duty cycle, vitreous removal is a lot faster; also, a duty cycle of 92% creates constant aspiration flow independent from cutting speed, allowing increased precision for flow control vitrectomy. Currently I use the 27-gauge system for all macular hole and ERM cases, which together make up approximately half of all my vitreoretinal surgery cases.

Q. What are the advantages of using smaller gauges for vitrectomy surgery?

The advantages of using smaller gauges for vitrectomy surgery are faster healing, less inflammation, quicker recovery time and more comfortable patients. And I view a 27-gauge approach as the real sutureless vitrectomy. Even in patients who have undergone a previous vitrectomy, the incidence of hypotony and wound leakage using a 27-gauge system is rare. For me, I have pretty much switched away from 25-gauge to a 27-gauge transconjunctival system because of these advantages. Patients recover faster and the eyes are much less inflamed.

Q. Does 27-G instrumentation meet expectations?

The rigidity and consistency of 27-gauge instrumentation makes the transition from 25-gauge surgery to even smaller-gauge vitrectomy straightforward. The microforceps are comfortable and do a reliable job in holding the membrane without shredding, stepped laser probes provide good access to the peripheral retina and the instrument kit includes a 27-gauge endodiathermy.

Q. Limitations and expectations?

Most surgeons will make decisions regarding the selection of ophthalmic surgical devices based in part on the quality and consistency of likely support and maintenance, as well as technical performance features based on clinical evaluation and experience.

Surgical platforms include the Alcon Constellation Vision System, Bausch + Lomb Stellaris PC Vision Enhancement System and, recently introduced, the DORC EVA VacuFlow VTi aspiration system. The latter offers a unique fluid control system that brings together a series of precise computer controlled operating pistons and closure valves that work in very small flow chambers. There are some excellent surgical systems now available and it will be interesting to see whether the added flexibility of utilizing different flow and vacuum parameters with the EVA system will prove an advantage over conventional peristaltic- or venturi-based ophthalmic surgery machines.

It is worth recalling that flow and fluidic control are essential because we work over a very mobile retina and, for successful outcomes, surgeons need to remove the vitreous without disturbing the retina, especially so in retinal detachment repair. That is key to the safety of vitreoretinal surgery. Flow control plays a role in being able to have vitreous enter into the port reliably with very little retina movement and to help minimize surgical complications or surgeon error.

I am interested in getting the EVA platform in and seeing to what extent it gives the Constellation a run for its money, for routine and in tougher complex vitreoretinal cases. ■