27-Gauge Precision Vitrectomy (Part 2: How to Conquer Potential Limitations)

Yoshihiro Yonekawa MD
Mass Eye and Ear / Boston Children’s Hospital
Editor, RETINA Roundup

We are continuing our series on 27G vitrectomy. In Part 1, we discussed the potential benefits of using the smallest vitrectomy platform. In Part 2 today, I’m hoping to present commonly perceived limitations of 27G, and provide a few suggestions on how these potential issues can be tackled.

 “The instruments keep bending!”

For 27G surgery, I ask our fellows to operate in the eye without the eye knowing that we’re operating on it. Meaning, really focus on where the fulcrum of the cannulas are and slide in and out without putting pressure on the cannulas, so that the eye stays in primary position as much as possible. Placing the cannulas closer to midline by 3:00 and 9:00 if facial anatomy allows, will also facilitate the movement of the eye with both hands using equal force, which will decrease the force on each cannula. The 3:00 and 9:00 cannula placement will also facilitate easier access to superior pathology.

“It’s so slow!”

I agree that if you keep cutting BSS, the vitrectomy will be slow. Since the gel does not come to you and you have to go to where the gel is in 27G surgery, we have to be more cognizant of where the edge of the vitreous being cut is with optimal lighting. This forces you, I think, to be a more precise surgeon. The core vitrectomy does take a minute or two longer, but it shouldn’t be much longer. It definitely helps to maximize the aspiration setting.

“I want my pic, forceps and scissors!”

As mentioned in Part 1, the instrumentation selection for 27G is relatively limited for now, but the cutter alone acts as a multi-functional tool and your need for extra instruments will be less. This is similar to how 23/25G now allow most diabetic cases to be done without scissors, and this benefit is accentuated with 27G. That being said, more and more 27G instruments are being introduced into the market.

“What about silicone oil injection?”

You can place the 25G silicone oil injector onto the 27G cannula. It doesn’t insert all the way, but it sits snuggly at the proximal end, and it will inject as fast as 25G normally allows. It’s nowhere as fast as 23G injectors though, and I wouldn’t use 5000 cs, but 1000 cs is not an issue.

A few have suggested not suturing 27G sclerotomies with oil, but personally, I still suture all oil filled eyes because subconjunctival silicone oil can potentially be a terrible experience for patients.

Hope this was helpful!