COMPARATIVE STUDY BETWEEN A

STANDARD 25-GAUGE VITRECTOMY

SYSTEM AND A NEW ULTRAHIGH-SPEED
25-GAUGE SYSTEM WITH DUTY CYCLE
CONTROL IN THE TREATMENT OF
VARIOUS VITREORETINAL DISEASES
STANISLAO RIZZO, MD, FEDERICA GENOVESI-EBERT, MD, PHD, CLAUDIA BELTING, MD

Aim: To compare a standard 25-gauge vitrectomy system with a new ultrahigh-speed

(UHS) 25-gauge system with duty cycle control for pars plana vitrectomy.
Methods: In this prospective, controlled clinical trial, 120 patients (divided into 2 groups
of 60 patients) underwent a 3-port pars plana vitrectomy for the treatment of epiretinal
membranes, macular holes, retinal detachment, and complications of diabetic retinopathy.
Evaluations were performed preoperatively, intraoperatively, on the first 3 postoperative
days, and at 1 week, 1 month, and 3 months. Main outcome measures were vitrectomy
time, induction of posterior vitreous detachment, and intra- and postoperative
complications. Vitrectomy time included retinal manipulation, but did not include wound
opening and closure.
Results: The duration of surgery was significantly different between the groups. Patients
in the new UHS 25-gauge group had a significantly shorter duration of vitrectomy time (P ,
0.0001). Mean overall vitrectomy time was 1,583.7 6 875.4 seconds (26 minutes) in the
standard 25-gauge group and 1,106.3 6 575.9 seconds (18 minutes) in the UHS 25-gauge
group. Twenty-nine patients (48.3%) in the standard group and 27 patients (45.0%) in the
UHS group experienced induction of posterior vitreous detachment. Thirteen patients
(21.7%) in the standard 25-gauge group and 1 patient (1.7%) in the new UHS group had
intraoperative iatrogenic retinal breaks.
Conclusion: The new-generation UHS 25-gauge system may provide a new paradigm of
high-flow, smaller-diameter instrumentation, thus increasing the efficiency of the small-
gauge technique and the safety of the surgery.
RETINA 31:2007–2013, 2011

available by Fujii et al.3 First reports4 emphasized

T hree-port 20-gauge vitrectomy systems have been
the gold standard for vitreous surgery since 1974.1
During the past 30 years, instrumentation has
improved significantly. The standard (STD) system,
which requires conjunctival incisions and sclerotomies
of 0.89 mm diameter (20 gauge), was subsequently
made smaller and less traumatic. A 23-gauge system
was developed in the 1980s by Peyman,2 and 23-gauge
instruments have mainly been used for pediatric
ophthalmic surgery.
In 2002, a 25-gauge sutureless transconjunctival
system was developed and made commercially
several advantages of the sutureless 25-gauge pars
plana vitrectomy, such as the potential to reduce the
length of surgery by avoiding the extra efforts
necessary to open and close sclera and conjunctiva
separately. This option also minimizes postoperative
inflammation at the sclerotomy sites, thus decreasing
the patient’s postoperative discomfort and hastening
recovery.5–10 Moreover, the microcannulas of the
system permit interchangeability of instruments
between entry sites, protecting the vitreous base from
mechanical traction. All these proven or potential

2007
2008 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES
advantages over classic 20-gauge vitrectomy have
shifted the procedure of choice for macular surgery
and for other retinal pathologies toward sutureless 25-
gauge surgery.
However, one of the main drawbacks of small-
gauge systems is that suction and flow rates are
significantly lower than the comparable parameters in
20-gauge systems because of the smaller diameter of
the 25-gauge system, thus resulting in increased
vitrectomy time because of longer bulk vitreous
removal,4,11 which counterbalances the time saved
in wound opening and closure.12–15 Moreover, the
removal of tight vitreous strands, epiretinal mem-
branes, or denser hemorrhages or clots may also be
difficult.
Recently, a new vitrectomy system with an
ultrahigh-speed (UHS) cut rate (5,000 cuts per minute)
and duty cycle control has become available. Duty
cycle15 is a basic parameter that can greatly influence
the flow rate, as it is the percentage of time the cutter
port is open, relative to the complete cutting cycle.12
The theoretical advantage of this new system is that
a higher cut rate may minimize vitreous turbulence by
allowing only small bits of vitreous to enter the port,
potentially exerting less traction on the retinal
surface16,17; moreover, the chance to work with
a maximum port opening while also using higher
cutting rate may increase the efficiency of the
system.12,18 The aim of this study was to compare
the efficiency and safety of this new vitrectomy system
with the STD 25-gauge system.
Methods
An interventional, prospective, controlled trial was
designed to compare the new 25-gauge UHS Alcon
Constellation vitrectomy system (5,000 cps per
minute) with the currently used 25-gauge Alcon
Accurus system (1,500 cps per minute) in a group of
diseases requiring vitreous surgery (Alcon Laborato-
ries, Inc, Ft. Worth, TX).
Patients were fully informed of all aspects of the
procedure, and all provided written informed consent.
The case series was conducted in adherence to the
tenets of the Declaration of Helsinki.
Inclusion criteria were epiretinal membranes,
macular holes, retinal detachment (RD), and
From the Azienda Ospedaliera-Universitaria Pisana, Eye
Surgery Clinic, Pisa, Italy.
The authors have no conflicts of interest to disclose.
Reprint requests: Stanislao Rizzo, MD, Azienda Ospedaliera-
Universitaria Pisana, Eye Surgery Clinic, Pisa, Italy; e-mail:
stanos@tin.it
 2011  VOLUME 31  NUMBER 10
complications of diabetic retinopathy. Exclusion
criteria were previous vitrectomy or scleral buckling
surgery and cases requiring silicone oil tamponade.
As soon as the patients meet the inclusion criteria
and were consecutively enrolled, they were assigned
to the 2 groups using the following method: the first
patient recruited was assigned to the 25-gauge
Constellation cohort and the second to current-
generation 25-gauge Accurus group, and so on.
A complete ophthalmologic examination, including
inspection of peripheral retina by using indirect
ophthalmoscopy was performed preoperatively, on
the first 3 postoperative days, and at 1 week, 1 month,
and 3 months after surgery. Main outcome measures
were vitrectomy time, rate of induction of posterior
vitreous detachment (PVD), and intra- and post-
operative complications.
Vitrectomy time was evaluated by using a stopwatch
from the entering of the probe in the eye to the last
tool’s withdrawal, without considering duration of
wound opening and wound closure. All surgeries were
performed by one experienced surgeon (S. Rizzo).
Surgical technique was as follows: a complete pars
plana vitrectomy was always performed using Trie-
sence (Alcon) as vitreous highlighter. Brilliant Peel–
assisted (Fluoron) internal limiting membrane peeling
was performed where required.
Air–fluid exchange was always carried out at the
end of each surgery, and endolaser treatment and gas
endotamponade were performed when required. If gas
was not used, the eyes were left filled by air.
Intraoperative complications were recorded.
The 2 vitrectomy systems used (Alcon Accurus
25 gauge and Alcon Constellation 25 gauge) showed
differences in machine and probe features. The
current-generation Accurus 25-gauge vitrectomy
probe (1,500 cps per minute) is a single actuation
line spring-return pneumatic cutter with no duty cycle
control, while the new-generation Constellation
(Ultravit) has a dual-drive line system with 2 air lines
and no spring. The cutter uses pulse pressure to open
the port, and the inner cutter cannula is attached to
a diaphragm that, via the pressure actuators, moves
forward and back to open and close the port, which is
located closer to the tip in comparison with Accurus.
The flexibility in drive schemes allows duty cycle
control. With this device, duty cycle control is
independent of cut rate; on the contrary, with the
Accurus system, duty cycle and flow are dependent on
cut rate and change with the cutting speed only.
Duty cycle is defined as a parameter of time—it is
the percentage of time the cutter port is open. With
vitrectomy probes, we define ‘‘on’’ when the port
opened and ‘‘off’’ when the port closed. For example,
 EFFECTIVENESS OF ULTRAHIGH-SPEED 25-G  RIZZO ET AL
a device that is on one-tenth of the time is at a 10%
duty cycle; if it is on half of the time, it is at 50% duty
cycle.
The Constellation probe offers 3 modalities of
setting duty cycle: ‘‘core’’ modality with maximum
port opening to achieve higher flow rates and
efficiency; ‘‘shave’’ with minimum port opening to
allow lower flow rates; and ‘‘50/50’’ with 50% port
opening for those users who prefer that the cutter be
open and closed the same amount of time.
In the current study, a core modality (maximum port
opening) of duty cycle control and a proportional
vacuum setting (fixed cut rate, variable aspiration
value) have been chosen for all surgeries. We used the
highest cutting rate available (1,500 cuts per minute
dealing with STD system and 5,000 cuts per minute
when using new UHS vitrector), and in both groups
the technique was as follows: the port was moved
toward the vitreous, and constantly advanced while
cutting; we avoided withdrawing the probe and pulling
back; proportional vacuum was increased until
vitreous removal rate was sufficient.
Results
Out of 143 eligible patients, 128 patients affected by
various vitreoretinal diseases accepted to be in the
study and were enrolled. A total of 120 patients
(120 eyes) underwent pars plana vitrectomy between
October 2008 and April 2009 and were divided into 2
groups: 60 eyes were operated on with the 25-gauge
Constellation vitrectomy system and 60 with the
current-generation 25-gauge Accurus. Eight patients
postponed the surgery because of private matters and
were excluded.
No significant differences were found between the
groups at baseline regarding age or gender (Tables 1
and 2). Statistical analyses were performed on the
following three parameters: vitrectomy time, rate of
induction of PVD, and rate of retinal breaks. Mean
vitrectomy time for each pathology is shown in
Table 3, and times for UHS were significantly lower
than for STD (P , 0.0001). For vitrectomy time,
comparisons between the two study systems were
performed using an analysis of covariance, which used
Table 1. Summary of Age by Instrument
N Mean (SD) Median Minimum Maximum
UHS 60 63.2 (12.0) 65.0 20 82
STD 60 62.3 (12.2) 65.0 23 81
2009
Table 2. Gender Distribution
Female Male
n (%) n (%)
UHS 41 (68.3) 19 (31.7)
STD 32 (54.2) 27 (45.8)
study system as a fixed factor and procedure type as
a covariable.
Mean overall vitrectomy time was 1,583.7 6 875.4
seconds (26 minutes) in the STD 25-gauge group and
1,106.3 6 575.9 seconds (18 minutes) in the UHS
25-gauge group. The rates of induction of PVD
are shown in Table 4. For induction of PVD, the
comparisons between the two study systems were
performed using a Cochran–Mantel–Haenszel test
comparing the rates of induction of PVD between
systems, stratified by procedure type.
No statistically significant difference was found
between UHS and STD systems with respect to rates
of induction of PVD (P = 0.8695). Induction of PVD
occurred in 29 of 60 eyes (48.3%) in the STD
25-gauge group and in 27 of 60 eyes (45.0%) in the
UHS group.
Interestingly, the rates tended to vary among the
procedure types. For example, the rate of induction of
PVD in patients with macular holes was 83.3% in
the STD group and 81.8% in the UHS group, while the
rate of PVD in patients with RDs was 28.6% in the
STD group and 18.2% in the UHS group.
The rates of retinal breaks are shown in Table 5. For
retinal breaks, the comparisons between the two study
systems were performed using a Cochran–Mantel–
Haenszel Test comparing the rates of retinal breaks
between systems, stratified by procedure type. A
statistically significant difference was found between
UHS and STD with respect to rates of retinal breaks
(P = 0.0006). The rate of retinal breaks was
significantly lower for patients in the UHS group
compared with patients in the STD group. Iatrogenic
retinal breaks occurred in 13 of 60 eyes (21.7%) in
the STD 25-gauge group and in 1 of 60 eyes (1.7%) in
the new UHS group. All the iatrogenic tears occurred
during core and peripheral vitreous removal and were
treated with endolaser.
Of the overall 13 retinal breaks that occurred in the
STD group, 11 were located in the periphery, in
the preequatorial region, with no preference for the
quadrant and took place during the shaving of
the vitreous basis. The remaining two were posterior
and occurred in proliferative diabetic retinopathy in
the areas where the membranes had been dissected as
were caused by the cutting-edge of the vitrectomy
2010 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES  2011  VOLUME 31  NUMBER 10

Table 3. System
STD UHS
Procedure n Mean (SD) n Mean (SD)
Epiretinal membrane 30 1,162.1 (130.9) 27 725.7 (50.8)
Macular hole 12 1,562.6 (244.6) 11 985.1 (55.5)
Proliferative diabetic retinopathy 4 4,173.3 (380.9) 6 2,327.7 (123.9)
Retinal detachment 7 2,634.4 (253.7) 11 1,752.6 (130.4)
Vitreomacular traction 7 896.0 (83.3) 5 540.2 (16.8)
Overall 60 1,583.7 (875.4) 60 1,106.3 (575.9)

probe. None of the breaks was because of an
aggressive dissection with scissors. The only tear that
occurred in the UHS group was in the periphery far
from the sclerotomy.
Postoperative complications included 2 RDs that
occurred in the STD group within 3 months after
vitrectomy. The late retinal tears responsible for the
two RDs occurred in the STD group during the follow-
up, were also located in the periphery, not in
correspondence with the sclerotomy sites.
Discussion
In our study, the mean overall vitrectomy time was
significantly shorter in UHS 25-gauge group, thus
indicating an increased efficiency in the cutter
performance. The higher duty cycle in the new UHS
Constellation may explain the better efficiency
showed in our series.
It is currently well known that duty cycle is one of the
primary underlying mechanisms that affect flow rates
through vitreous cutters. Fang et al12 performed an
experimental study to evaluate the effect of duty cycle
on the flow performance of new-generation cutters
relative to currently used instrumentation. They
demonstrated that the rates of vitreous removal with
the new-generation 25-gauge pneumatic cutter are
significantly greater than those of the current-genera-
tion 25-gauge pneumatic cutter at all cut speeds.
Although a number of factors can influence flow
rates (such as aspiration medium, variable operational
parameters, and fixed physical characteristics of the
cutter), the authors concluded that the high vitreous
removal rates of the new cutters were most likely
because of their maintenance of high duty cycle as cut
speed increases.
On the contrary, when dealing with the STD probe,
the higher cut speeds cause a reduction of the duty
cycle with consequent decrease in the flow rate. The
data in our clinical study are, therefore, in accordance
with the data reported in the experimental study of
Fang et al, as the reduced vitrectomy time achieved
with UHS 25-gauge probes was allowed by the ability
to maintain high flow rates at 5,000 cps per minute. In
a previously performed experimental study, Alcon
demonstrated that the Constellation probe had a flow
rate of 6.0 cc per minute at 650 mmHg vacuum at
5,000 cps per minute, while the Accurus 25-gauge
probe had a flow rate of 3.5 cc per minute at 600
mmHg vacuum at 1,500 cps per minute. Indeed, the
location of the port closer to the tip on the
Constellation probe might also allow surgeons to
better approach the tissues directly with the vitrector.
Besides efficacy, safety is the most important
parameter for any new therapy, be it a device or
a drug. Although future large clinical series are
required to confirm these findings, in our series, we
achieved a lower complication rate with the UHS
vitrector. One complication of vitrectomy surgery is

Table 4. Induction of PVD

STD UHS
No Yes No Yes
Procedure n (%) n (%) n (%) n (%)
Epiretinal membrane 23 (76.7) 7 (23.3) 20 (74.1) 7 (25.9)
Macular hole 2 (16.7) 10 (83.3) 2 (18.2) 9 (81.8)
Proliferative diabetic retinopathy 1 (25.0) 3 (75.0) 2 (33.3) 4 (66.7)
RD 5 (71.4) 2 (28.6) 9 (81.8) 2 (18.2)
VMT — 7 (100.0) — 5 (100.0)
Overall 31 (51.7) 29 (48.3) 33 (55.0) 27 (45.0)
 EFFECTIVENESS OF ULTRAHIGH-SPEED 25-G  RIZZO ET AL
Table 5. Retinal Break
STD
No
Procedure n (%)
Epiretinal membrane 27 (90.0)
Macular hole 9 (75.0)
Proliferative diabetic retinopathy 2 (50.0)
RD 5 (71.4)
VMT 4 (57.1)
Overall 47 (78.3)
retinal breaks. These may result in RD, which would
severely limit postoperative visual recovery. Despite
the recent evolution of vitreoretinal surgical techni-
ques, the incidence of retinal breaks is still clinically
significant. There have been several reports regarding
the incidence of vitrectomy-related retinal breaks,
which reportedly range from 2% to 14% of cases.19–22
After mini-invasive 25-gauge vitrectomy for mac-
ular surgery, Tan et al23 recently reported an incidence
of retinal breaks of 15.8%, while previous studies
reported incidences of 0% to 3.1%.24–26 The incidence
in 20-gauge vitrectomy was found to be between 0%
and 7.2%.25–27 However, Guillaubey et al28 dealing
with 20 gauge found an incidence of 32.1% in patients
operated for epiretinal membranes with induction of
a PVD. In our series, we reported 1 intraoperative
iatrogenic retinal break out of 60 cases (1.7%) in new
UHS group, and 13 out of 60 cases (21.7%) with
2 (3.3%) secondary RDs in the Accurus group.
One explanation could be based on the possible
learning curve, but this was not our case, as the
surgeon was an experienced vitreoretinal surgeon and
before starting this study he was already skilled as he
had performed more than 2,500 small-gauge proce-
dures; moreover, the 2 groups were operated on
consecutively in the same period, 1 patient with
Accurus and the next with the Constellation vitrec-
tomy system, so there was no temporal interval
between the 2 groups.
In particular, the rate of retinal tears during
25-gauge vitrectomy was 10% for idiopathic macular
pucker and 25% for idiopathic macular hole with STD
vitrectomy and 0 with UHS. Therefore, for macular
surgery, our incidence rate can be comparable.
However, our more elevated incidence of intra-
operative retinal breaks concerned complicated RD
with mobile or ischemic retina: In these cases, an STD
speed cutter may cause greater traction on the engaged
vitreous fibers that reflect on the retinal surface, thus
causing a higher number of iatrogenic retinal breaks in
comparison with higher-speed vitrectors. The
2011
UHS
Yes No Yes
n (%) n (%) n (%)
3 (10.0) 27 (100.0) —
3 (25.0) 11 (100.0) —
2 (50.0) 6 (100.0) —
2 (28.6) 11 (100.0) —
3 (42.9) 4 (80.0) 1 (20.0)
13 (21.7) 59 (98.3) 1 (1.7)
difference in tears rate may therefore be attributable
to the performance of the new cutters. High-frequency
cutting (port-based flow limiting) may be critical in
avoiding iatrogenical retinal breaks.
Cutter frequency is measured in cuts per minute.
Flow rate and cutting frequency determine the average
vitreous fibers that travel between cuts (average
effluent fiber length) and therefore the amount of
vitreoretinal traction. The main advantage of faster
cutting is that it prevents uncut vitreous from going
through the port as cutting interrupts flow, thus
reducing the tractions on the retina. Moreover, it
achieves the so-called ‘‘port-based flow-limiting’’
vitrectomy because the decreased pulse flow (volume
per open–close cycle) allows for greater fluidic
stability with decreased motion of the detached retina
and less pulsatile tractions on the attached retina. Our
data showed that even if the technique was the same
for both groups of patients, higher cutting rate (5,000
cuts per minute) could best realize port-based flow
limitation thus allowing the maximum fluidic stability
with decreased motion of the detached retina and less
pulsatile tractions on the attached retina.
In fact, in our series the higher rate of intraoperative
retinal breaks concerned the more severe cases of
complicated RD with mobile or ischemic retina that
were tractioned and hurt by the STD cut rate frequency
(13 of 60 eyes). However, in the UHS group, only 1
case of 60 suffered from iatrogenic tear.
The main limitation of this study is that it is
interventional, prospective but not randomized: This
could include some potential bias in the patients’
selection. However, as the patients series were
comparable and the technique was the same (modality
proportional-vacuum, aspiration parameters), the only
variable that can explain the difference in the
incidence rate is the difference in the frequency of
cutting rate, leading us to conclude that UHS is safer.
Although retinal breaks that occur during the
vitrectomy may be attributable to diverse causes of
vitreous traction on the retina (including vitreous
2012 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES
incarceration into the sclerotomy site during opera-
tion, inadvertent vitreous traction during instrument
insertion and withdrawal, undue vitreous traction to
the focal area of vitreoretinal adhesion), induction of
PVD may play a critical role. Guillaubey et al28
reported that the rate of RD occurring after macular
hole surgery was higher than that after epiretinal
membrane surgical procedures and suggested that
these findings may be associated with the surgical
detachment of the posterior vitreous face, causing
a peripheral retinal break. Recently, Chung et al29 in
a similar study reported that postoperative RDs and the
incidence of iatrogenic retinal breaks were higher in
patients operated on for macular holes where the
prevalence of PVD was significantly higher, thus
addressing the correlation of induction of a PVD with
the incidence of retinal breaks.
In our series, however, we performed PVD in-
duction in almost the same number of patients in the
two groups, so we had the same potential risk of
tearing the retina. However, in the UHS group, we
noticed a lower incidence of iatrogenic retinal breaks,
and postoperative RD occurred only in the STD group,
with an incidence rate of 3.3%. In our study, all the
iatrogenic tears occurred during core and peripheral
vitreous removal. With the STD 25-gauge system, we
clearly observed that the tractions exerted by the cutter
reverberated on the peripheral retina.
We speculate that this difference in tear rate may be
attributable to the performance of the new cutters,
which can maintain their high flow rates with
increasing speed during all vitrectomy phases.
Surgeons have the ability to take smaller ‘‘bites’’ of
the vitreous while maintaining a high flow rate. It is
also possible to use a high cut rate and reduce the flow
when closer to the retina by reducing aspiration with
the use of the foot pedal control.
One other explanation may be that high-speed
cutting rates can limit flow, thus allowing fluidic
stability and improving safety during vitrectomy as we
have mentioned above. Port-based fluid limitation has
been described by Steve Charles, who showed that
high cutting rates increase the resistance to flow
through the port by blocking the port more
frequently.30 The increased resistance at the port
may be advantageous by limiting rapid flow surge
after sudden elastic deformation of the tissue through
the port because of low resistance, especially when
removing dense membranes. Faster cutters can,
therefore, prevent uncut vitreous collagen fibers from
moving through the cutters’ port. On the contrary,
slowing the cutting rate decreases resistance, which
increases the flow and the likelihood that vitreous
traction will produce retinal damage. Moreover,
 2011  VOLUME 31  NUMBER 10
higher cutting rates result in decreased flow per
opening cycle, less fluctuation in pressures, and
greater fluidic stability, which is particularly important
when working near the mobile peripheral retina.
Recently published studies support these assump-
tions. Quantifying traction force applied to the retina
by vitreous cutters during vitrectomy has always been
a challenge during pars plana vitrectomy, but Teixeira
et al carried out a porcine eyes ocular model to
measure the traction force applied to the retina by
conventional pneumatic and electrical vitreous cutters
during vitrectomy by quantifying the force in dynes;
they demonstrated that retinal traction increased with
increasing aspiration vacuum and proximity to the
retina; conversely, retinal traction decreased with
increasing cut rate. The traction forces decreased by
2.51 dynes for each 500 cuts per minute increase (P ,
0.05), so they showed that the traction was directly
proportional to the aspiration vacuum and inversely
proportional to the cut rate.31,32
So, in conclusion, the new-generation UHS 25-gauge
Constellation vitreous cutter may provide a new
paradigm for high-flow, smaller-diameter instrumenta-
tion, thus increasing the efficiency of the small-gauge
technique and the safety of the surgery.
Key words: ultrahigh-speed, duty cycle, 25-gauge
vitrectomy system, pars plana vitrectomy, vitreoretinal
diseases.
References
1. O’Malley C, Heintz RM Sr. Vitrectomy with an alternative
instrument system. Ann Ophthalmol 1975;7:585–588, 591–594.
2. Peyman GA. A miniaturized vitrectomy system for vitreous
and retinal biopsy. Can J Ophthalmol 1990;25:285–286.
3. Fujii GY, De Juan E Jr, Humayun MS, et al. Initial
experience using the transconjunctival sutureless vitrec-
tomy system for vitreoretinal surgery. Ophthalmology 2002;
109:1814–1820.
4. Fujii GY, De Juan E Jr, Humayun MS, et al.A new 25-gauge
instrument system for transconjunctival sutureless vitrec-
tomy surgery. Ophthalmology 2002;109:1807–1812, discus-
sion 1813.
5. Chen JC. Sutureless pars plana vitrectomy through self-sealing
sclerotomies. Arch Ophthalmol 1996;114:1273–1275.
6. Jackson T. Modified sutureless sclerotomies in pars plana
vitrectomy [letter]. Am J Ophthalmol 2000;129:116–117.
7. Kwok AK, Tham CC, Lam DS, et al. Modified sutureless
sclerotomies in pars plana vitrectomy. Am J Ophthalmol 1999;
127:731–733.
8. Lam DS, Chua JK, Leung AT, et al. Sutureless pars plana
anterior vitrectomy through self-sealing sclerotomies in
children. Arch Ophthalmol 2000;118:850–851.
9. Rahman R, Rosen PH, Riddell C, Towler H. Self-sealing
sclerotomies for sutureless pars plana vitrectomy. Ophthalmic
Surg Lasers 2000;31:462–466.
 EFFECTIVENESS OF ULTRAHIGH-SPEED 25-G  RIZZO ET AL
10. Rizzo S, Genovesi-Ebert F, Murri S, et al. 25-Gauge,
sutureless vitrectomy and standard 20-gauge pars plana
vitrectomy in idiopathic epiretinal membrane surgery:
a comparative pilot study. Graefes Arch Clin Exp Ophthalmol
2006;244:472–479.
11. Kellner L, Wimpissinger B, Stolba U, Brannath W, Binder S.
25-Gauge vs 20-gauge system for pars plana vitrectomy:
a prospective randomised clinical trial. Br J Ophthalmol 2007;
91:945–948.
12. Fang SY, DeBoer CMT, Humayun MS. Performance analysis
of new-generation vitreous cutters. Graefes Arch Clin Exp
Ophthalmol 2008;246:61–67.
13. Hubschman JP. Comparison of different vitrectomy systems.
J Fr Ophthalmol 2005;28:606–609.
14. Oshima Y, Ohji M, Tano Y. Surgical outcomes of 25-gauge
transconjunctival vitrectomy combined with cataract surgery
for vitreoretinal diseases. Ann Acad Med Singapore 2006;35:
175–180.
15. Charles S. An engineering approach to vitreoretinal surgery.
Retina 2004;24:435–444.
16. Hubschman JP, Gupta A, Bourla DH, Culjat M, Yu F, Schwartz S.
20-, 23-, and 25-Gauge vitreous cutter performance and
characteristics evaluation. Retina 2008;28:249–257.
17. Magalhaes O Jr, Chong L, Deboer C, et al. Vitreous dynamics:
vitreous flow analysis in 20-, 23-, and 25-gauge cutters. Retina
2008;28:236–241.
18. Sato T, Kusaka S, Oshima Y, Fujikado T. Analyses of cutting
and aspirating properties of vitreous cutters with high-speed
camera. Retina 2008;28:749–754.
19. Aaberg TM, Blair CJ, Gass JDM. Macular holes. Am
J Ophthalmol 1970;69:555–562.
20. McDonald HR, Verre WP, Aaberg TM. Surgical management
of idiopathic epiretinal membranes. Ophthalmology 1986;93:
978–983.
2013
21. Carter JB, Michels RG, Glaser BM, de Bustros S. Iatrogenic
retinal breaks complicating pars plana vitrectomy. Ophthal-
mology 1990;97:848–853, discussion 854.
22. Patelli F, Radice P, Zumbo G, Frisone G, Fasolino G. 25-Gauge
macular surgery: results and complications. Retina 2007;27:
750–754.
23. Tan SH, Mura M, De Smet MD. Iatrogenic retinal breaks in
25-gauge macular surgery. Am J Ophthalmol 2009;148:
427–430.
24. Faia LJ, McCannel CA, Pulido JS, Hatfield RM, Hatfield ME,
McNulty VE. Outcomes following 25-gauge vitrectomies. Eye
2008;22:1024–1028.
25. Scartozzi R, Bessa AS, Gupta OP, Regillo CD. Intraoperative
sclerotomy-related retinal breaks for macular surgery, 20- vs
25-gauge vitrectomy systems. Am J Ophthalmol 2007;143:
155–156.
26. Moore JK, Kitchens JW, Smiddy WE, Mavrofrides,
Gregorio G. Retinal breaks observed during pars plana
vitrectomy. Am J Ophthalmol 2007;144:32–36.
27. Williams GA. 25-, 23-, or 20-Gauge instrumentation for
vitreous surgery? Eye 2008;22:1263–1266.
28. Guillaubey A, Malvitte L, Lafontaine PO, et al. Incidence of
retinal detachment after macular surgery: a retrospective study
of 634 cases. Br J Ophthalmol 2007;91:1327–1330.
29. Chung SE, Kim KH, Kang SW. Retinal breaks associated
with the induction of posterior vitreous detachment. Am
J Ophthalmol 2009;147:1012–1016.
30. Charles S. American Academy of Ophthalmology, 2002,
Subspecialty Day (oral communication). Retina 2002;337–
340.
31. Teixeira A, Chong LP, Matsuoka N, et al. Vitreoretinal traction
created by conventional cutters during vitrectomy. Ophthal-
mology 2010;117:1387–1392.
32. Teixeira A, Chong L, Matsuoka N, et al. Novel method to
quantify traction in a vitrectomy procedure. Br J Ophthalmol
2010;94:1226–1229.