25-gauge vitreoretinal surgery successful in pediatric patients

WAIKOLOA, Hawaii — Using smaller instruments during vitreoretinal surgery is advantageous for pediatric patients, according to a surgeon speaking here.

Steven D. Schwartz

Despite limited literature on 25-gauge instruments in the pediatric population, Steven D. Schwartz, MD, said that in addition to the advantages shown in adults, such as more rapid healing, improved patient comfort and less surgical trauma, the reduced instrument sizes seem to be conducive to the smaller eyes of children.

"So 25-gauge vitrectomy has distinct advantages, we feel, in the pediatric populations," he said. "We do not feel there is an increased risk of 25-gauge surgery in kids."

At Retina 2008, held in conjunction with Hawaiian Eye 2008, Dr. Schwartz presented a retrospective study performed at the University of California, Los Angeles, in which he and colleagues performed a 5-year chart review of consecutive patients younger than 18 years. All cases underwent 25-gauge pars plana vitrectomy for various indications.

The study included 56 eyes of 49 children who averaged 4.5 years of age, ranging from 2 months to 17 years. Follow-up ranged from 10 days to 4.2 years; 26 eyes had retinopathy of prematurity (ROP).

The anatomic goal was achieved in 75% of eyes. It was not achieved in 16% of eyes, and 9% did not have sufficient follow-up to determine whether success was achieved, Dr. Schwartz said.

He said the sutureless techniques commonly used with 25-gauge instruments could potentially be a problem for pediatric patients. In particular, premature infants could pose a risk due to the potential for hypotony, bleeding in vasoproliferative diseases and the likelihood of rubbing their eyes postoperatively.

"We were really worried about postop bleeds," he said. "In ROP, bleeding is really better to avoid. I know it sounds crazy to say it that simply, but it's bad. If you're doing any pediatric vitreoretinal surgery, it's a lot different than managing vitreous hemorrhage in adults."

Dr. Schwartz said he and his colleagues have modified the 25-gauge vitrectomy procedure to further ensure pediatric safety. They accomplished this by incorporating conjunctival dissection, a 22-gauge needle, 20-gauge sclerotomies without trocars, a 20-gauge shielded bullet, and closure of the sclerotomies and conjunctiva.

"The transconjunctival approach may not be appropriate for younger babies. Careful placement of sclerotomies is important. We like to cover them in certain circumstances," he said. "We do actually suture up these 25-gauge incisions."