Minimally invasive, sutureless, 25-gauge vitrectomy has been an option for only a few years but appears to be gaining converts, although with widespread acknowledgment that the system has limitations when compared with the well-established 20-gauge technology.
Generally, surgeons agree that some instruments they would like to have are not available in 25-gauge format, many of the first generation of miniaturized tools were too flexible and easily bent, and their size also caused problems with illumination. However, manufacturers have responded to these challenges and already made improvements, such as new light sources.
"Many surgeons have not tried the 25-gauge system because the complement of tools that we use is not complete, but it is growing," said Allen C. Ho, MD, professor of ophthalmology, Wills Eye Hospital, Thomas Jefferson University, Philadelphia.
"It is a relatively new technology that a lot of us have adopted to some degree. Most of us use 20-gauge instruments predominantly because they are still more versatile," said Carl D. Regillo, MD, professor of ophthalmology, Wills Eye Hospital and Thomas Jefferson University. "I was not doing many 25-gauge procedures 2 or 3 years ago but I am doing a lot more now. That is growing as these instruments are improving."
Adoption is a matter of both personal preference and the typical caseload of a practice, because some procedures are more easily performed with 25-gauge technology than others.
Surgeons who perform a lot of macular surgery involving puckers, holes, and diabetic macular disease might be more inclined to try 25-gauge surgery because these procedures require fewer instruments and the necessary tools are available in this size, Dr. Ho said. Alternatively, physicians who have a preponderance of retinal detachment cases or re-operations tend to stick with 20-gauge systems because all the tools are available.
Personal preference and attitudes toward new technology are also a factor in the shift toward 25-gauge vitrectomy.
"My group consists of six individuals and we have all adopted the technique at different rates for different reasons. That is just the way life is with new technology. Some people are early adopters, and some people are not," said Edgar L. Thomas, MD, of Retina-Vitreous Associates, Los Angeles.
"I do almost 100% of my cases with 25-gauge technology. I have found very few cases that I had to convert. There are some specific cases where I know I'll have to convert preoperatively, but I will start with 25 gauge and change one of the sites to 20 gauge because I need a particular instrument," Dr. Thomas added. "The technology is not perfected, so you have to give up a few little things along the way in order to do it."