Vitrectomy with 25-gauge instruments appropriate for majority of cases

The smaller instrumentation results in faster visual recovery, less pain and faster surgical times, surgeon says.

ByJared Schultz

ByMary E. Archer, ELS

Eugene de Juan Jr.

WAILEA, U.S.A. – Vitreoretinal surgery with 25-gauge instruments gives surgeons “numerous advantages,” according to one researcher and clinician.

Eugene de Juan Jr., MD, said that 25-gauge instrumentation should be used “in the majority of vitrectomy cases because of improved patient outcomes, greater safety and shorter operating times.”

At Retina 2006, held in conjunction with Hawaiian Eye 2006, Dr. de Juan said that since 25-gauge technology was introduced in 2000, “all major vitreous surgical instrument manufacturers have embraced this technology,” including Bausch & Lomb, Alcon, Synergetics and DORC International. He said most of these companies are also working to improve their systems.

Better vision recovery, less pain

Dr. de Juan said faster visual recovery is one of the primary advantages of this new technology, mainly because the 25-gauge procedure is sutureless.

In the past he would use absorbable Vicryl sutures to close the sclerotomy and would routinely tell patients to wait 6 weeks for their vision to return when dealing with macular puckers, Dr. de Juan said.

“We were inducing astigmatism with the sutures,” he said. “After 25-gauge, the vision is often good the next day and better at 1 week.”

He also said that there is no pain during surgery, which he called an “amazing” development.

“That was something we never had after surgery. It was kind of like, bite on this knife, you’re going to be okay,” he said.

Faster surgical times, less cost

The most expendable part of the financial structure of the medical care system is the operating room, Dr. de Juan said. He said every trip to the OR costs surgical time and money.

With the 25-gauge system, he said, his clinical studies have shown that even inexperienced surgeons are able to cut their opening and closing vitrectomy times in half.

“We are going to be doing vitrectomies in the office; I think that’s where this is going,” he said.

However, he said that some operating room practices have not caught up with the efficiency these new systems, such as the decreased amount of infusion required for vitrectomies.

“We hang a liter bottle or a 500 mL bottle of balanced salt solution when we do our case, and we use 50 mL.”

New postoperative concerns

Dr. de Juan said that the risk of endophthalmitis after surgery with 25-gauge instrumentation remains unclear.

He suggested that the decreased infusion in the surgery might mean there will be a higher risk of infection after 25-gauge vitrectomies.

“Because of reduced conjunctival washing and shortened surgical times, the surgery becomes similar to cataract in terms of infection risk,” he said. “Before, we were never concerned about conjunctival prophylaxis. Now I am very concerned.”

He also addressed the concerns that have arisen regarding postop hypotony, and said that while it is an issue, experience with the system will make it a non-issue.

“After a few cases this problem essentially never happens again,” he said. “The reason is you don’t let it happen again; you don’t leave the table with the eye leaking.”

For more information:

Eugene de Juan Jr., MD, can be reached at the Beckman Vision Center, 10 Koret Way, K321, San Francisco, CA 94143-0730 U.S.A.; +1-415-514-3178; fax: +1-323-442-6519; e-mail: forsight@gmail.com.

Mary E. Archer, ELS, is Executive Editor of OSN U.S. Edition. Jared Schultz is an OSN Staff Writer who covers all aspects of ophthalmology. He focuses geographically on Europe and the Asia-Pacific region.