A 27–Gauge Instrument System for

Transconjunctival Sutureless Microincision

Vitrectomy Surgery
Yusuke Oshima, MD,1 Taku Wakabayashi, MD,1 Tatsuhiko Sato, MD,1 Masahito Ohji, MD,2
Yasuo Tano, MD1,†

Objectives: To evaluate the efficiency, preliminary safety, and feasibility of a 27-gauge instrument system for
transconjunctival microincision vitrectomy surgery (MIVS) in a variety of vitreoretinal diseases.
Design: Experimental, interventional case series.
Participants: Thirty-one eyes (31 patients) underwent a variety of vitreoretinal procedures using the 27-
gauge transconjunctival MIVS system to treat epiretinal membrane (n ⫽ 10), idiopathic macular holes (n ⫽ 7),
diabetic vitreous hemorrhage (n ⫽ 5), vitreous opacity with suspicion of intraocular lymphoma (n ⫽ 4), focal
diabetic traction retinal detachment (n ⫽ 3), macular traction syndrome (n ⫽ 1), and macular edema secondary
to central retinal vein occlusion (n ⫽ 1).
Methods: We developed a 27-gauge instrument system that includes an infusion line, a high-speed vitreous
cutter, an illumination system, and a variety of vitreoretinal instruments, such as membrane forceps and
sharp-tipped endophotocoagulation probes. The duty cycle of the 27- and 25-gauge cutters was measured for
several cut rates using a high-speed imaging camera. Infusion and aspiration rates were measured using
balanced saline solution (BSS) and porcine vitreous with different aspiration levels. Surgical outcomes, including
anatomic success, visual outcomes, operating times, and intraoperative and postoperative complications, were
evaluated.
Main Outcome Measures: Duty cycle of cutters, infusion and aspiration rates, and surgical results of
27-gauge vitrectomy.
Results: Although the infusion and aspiration rates of the 27-gauge system measured in BSS were reduced
to an average of 62% and 80%, respectively, compared with those of the 25-gauge system, the duty cycle of the
27-gauge cutter, 61% at 1000 cpm and 38% at 1500 cpm, was equal to or better than those of the 25-gauge
cutter (62% and 28%, respectively). Analysis of the fluid dynamics showed that vented gas-forced infusion can
be set to range from 20 to 30 mmHg to control intraocular pressure (IOP) during 27-gauge vitrectomy. Anatomic
success was achieved in all study eyes (100%); 20 eyes (65%) had visual improvement of 3 lines or more. No
eyes required conversion to larger gauge instrument. All sclerotomies self-sealed without hypotony (IOP ⱕ 7
mmHg) from 1 day postoperatively.
Conclusions: Although the fluid dynamics and cutting efficiency of 27-gauge instruments are lower com-
pared with 25-gauge MIVS, the 27-gauge system is feasible and may reduce concerns about wound sealing-
related complications in selected cases.
Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.
Ophthalmology 2010;117:93–102 © 2010 by the American Academy of Ophthalmology.

Recent establishment of transconjunctival microincision vit-
rectomy surgery (MIVS) with 25- or 23-gauge instrumen-
tation has provided potential advantages over traditional
20-gauge surgery, including faster wound healing, less con-
junctival scaring, decreased operating time, elimination of
astigmatism, improved patient comfort, and less postopera-
tive inflammation with early visual recovery.1– 8 These ad-
vantages are attributed to a self-sealing sclerotomy that
obviates the need for conjunctival peritomy and suturing.
However, wound sealing-related complications, such as hy-
potony, choroidal detachment, and an increasingly higher
incidence of bacterial contamination or postoperative en-
dophthalmitis, are critical concerns accompanying the use
of and expanding indications for MIVS.9 –16 Changing the
insertion technique from 1- to 2-step entry4 or from vertical
to angled insertion17–19 may facilitate the efficiency of self-
sealing, but it is not always beneficial in every case, espe-
cially in young or myopic eyes with thin sclera and liquefied
vitreous gel or in fluid-filled eyes after vitrectomy with
extensive removal of peripheral vitreous.10 –12
Before the introduction of 25- or 23-gauge MIVS, much
smaller-gauge instrumentation had been used for postoper-

© 2010 by the American Academy of Ophthalmology ISSN 0161-6420/10/$–see front matter 93

Published by Elsevier Inc. doi:10.1016/j.ophtha.2009.06.043
 Ophthalmology Volume 117, Number 1, January 2010

ative management. For example, we have performed

transconjunctival fluid–fluid exchange and fluid–air ex-
change through a 27-gauge needle for many years in vitrec-
tomized eyes. There have been no reports on complications
related to wound integrity with a 27-gauge needle. The
27-gauge (0.40 mm) needle is proposed to be the optimal
size for self-sealing of scleral wounds.
Recent development of bright illuminating light source
(i.e., xenon and mercury vapor illuminators) has made it
possible to introduce 27-gauge light probes.20 –22 The
brightness of the intraocular illumination is equal to or
brighter than the illumination achievable with 20-gauge
probes with conventional halogen or metal halide light
bulbs. In addition, the 27-gauge light probe facilitates reli-
able sutureless closure of the scleral wounds after removal.
Those developments encouraged us to further develop the
27-gauge instrument system to enhance the advantages of
MIVS and minimize the potential complications associated
with 25- and 23-gauge MIVS.
The current study evaluates the feasibility and safety of
the newly developed 27-gauge instrument system and report
the preliminary outcomes using this system to treat various
vitreoretinal disorders.
Figure 1. A, Twenty-seven-gauge 1-step entry infusion line. B, High-
magnification image of the beveled sharp tip and 4-mm–long metallic tube
Patients and Methods (bar ⫽ 1 mm).

Development of 27-Gauge Instrument System

specifications and performance compared with a standard commer-
The 27-gauge vitrectomy system for MIVS includes a 27-gauge cially available 25-gauge pneumatic vitreous cutter (Alcon Labo-
infusion line, a 27-gauge high-speed vitreous cutter, an illumina- ratories Inc.) in vitro. To strengthen the shaft rigidity of 27-gauge
tion system, and a variety of vitreoretinal instruments as listed in vitreous cutter, we designed a prototype 27-gauge vitreous cutter
Table 1. with a shaft length of 25 mm (Fig 2). The shaft rigidity of the
The 27-gauge infusion line (Synergetics Inc., St. Charles, MO), prototype 27-gauge pneumatic vitreous cutters was evaluated by
with a beveled sharp-tipped metallic tube 4 mm long, is designed measuring the tip displacement under a known force (0.5 N) 20
for 1-step perpendicular insertion through the pars plana (Fig 1). mm from the cutter base compared with that of a 25-gauge vitreous
To evaluate the flow rate of the 27-gauge infusion line compared
with that of a standard commercially available 25-gauge infusion
cannula (Alcon Laboratories Inc., Fort Worth, TX), we quantified
infusion volume of balanced saline solution (BSS) per minute at
pressures of 20, 30, 40, 50, and 60 mmHg generated by the vented
gas forced infusion (VGFI) system (Alcon Laboratories Inc.) and
then converted the volume measures at each pressure to milliliters
per second. Five individual measurements were taken for each
bottle height to ensure reliability and reproducibility. The infusion
rate was compared with the fluid aspiration rate of the 27-gauge
vitreous cutter to estimate the optimal infusion pressure setting for
VGFI control.
We developed a pneumatic, high-speed 27-gauge vitreous cut-
ter in collaboration with Dutch Ophthalmic Research Center In-
ternational BV (Zuidland, The Netherlands) and evaluated its

Table 1. List of 27-Gauge Vitrectomy Instruments

High-speed vitreous cutter

One-step infusion line
One-step short shaft light pipe
Microforceps (asymmetric, end-gripping, pick-forceps type)
Membrane spatula Figure 2. A, Twenty-seven-gauge vitreous cutter with a shaft length of 25
Endophotocoagulation probe (blunt tip, sharp tip) mm (bar ⫽ 10 mm). B, C, High-magnification image of the tip of the
Trocar-cannula system 27-gauge vitreous cutter. The numbers indicate the internal and external
Micro-vertical scissors
diameters in millimeters. The distance between the tip and the cutting
Sharp-point diathermy probe
port in (B) and (C) are expressed in millimeters.

94
 Oshima et al 䡠 27-Gauge Vitrectomy

rigidity.24 The light pipe can be used with a 1-handed single-step

entry without the need for pre-incision.
To expand the surgical indications of 27-gauge vitrectomy to a
variety of vitreoretinal disorders that require more complex in-
traocular procedures, that is, internal limiting membrane (ILM)
peeling and endophotocoagulation, we developed a 27-gauge mi-
croforceps (Fig 4A–C), a membrane spatula (Fig 5A–C), standard
blunt-tipped and sharp-tipped endolaser probes (Fig 6), and trocar-
cannula systems (Fig 7A, B)25; other microsurgical instruments
that comply with the 27-gauge standards also have been designed
(Table 1). Although the trocar-cannula system is unnecessary for
every 27-gauge vitrectomy, it is helpful to avoid missing the
27-gauge entry site for instrument insertion in complex cases
sometimes requiring frequent instrument exchanges during surgery.
Figure 3. The 27/29-gauge illumination light pipe with a shaft length of
13 mm (bar ⫽ 10 mm). A high-magnification image of the tip consisting
of a 27-gauge outer needle and a 29-gauge inner optic fiber is shown in the Surgical Indications and Techniques
upper left corner. To evaluate the feasibility, preliminary safety, and efficiency of a
27-gauge instrument system for MIVS, a clinical pilot study was
performed with the surgical indications for 27-gauge vitrectomy
cutter. Next, we performed fluid aspiration tests (milliliters/sec- limited to macular diseases, persistent simple vitreous hemorrhage,
ond) and duty cycle measurements of the 27-gauge vitreous cutter vitreous opacity, and focal traction retinal detachment associated
in BSS compared with those of a 25-gauge vitreous cutter. The
same vitrectomy machine was used for both cutters and all mea-
surements (Accurus, Alcon Laboratories Inc.). We used 100, 200,
300, 400, 500, and 600 mmHg vacuum pressures with cut rates of
0, 1000, and 1500 cuts per minute (cpm). Five individual mea-
surements were recorded for each aspiration and cut rate setting.
The duty cycle of the cutting port of the 27-gauge and 25-gauge
vitreous cutters were evaluated using a high-speed imaging camera
(FASTCAMMAX; Photron Ltd., Tokyo, Japan) at 3000 frames per
second at cutting speeds of 0, 1000, 1500, 2000, and 2500 cpm, as
we reported previously.23 The duty cycle of the cutting port was
defined as the total opened area per second at each cutting speed
divided by the total opened area per second at 0 cpm.
To evaluate the practical performance of the 27-gauge vitreous
cutter compared with that of a standard 25-gauge vitreous cutter, a
vitreous cutting and aspiration test using porcine vitreous in a
closed chamber was conducted with a minor modification of the
previous reported procedure.1 Briefly, we collected porcine vitre-
ous samples from dissected pig eyes and deposited the samples
into screw tubes, which then were covered with flexible sealing
film (parafilm-M, Alcan Inc., Neenah, WI) to make sealed cham-
bers. Two cannulas covered with closure valves (Dutch Ophthal-
mic Research Center) were passed through sealing film: one for a
vitreous cutter insertion and the other for connection to the VGFI
system. The infusion of air produces a constant chamber pressure,
which was estimated by the infusion rate and fluid aspiration rate
of each gauge system at the standard cut rate of 1000 cpm and
1500 cpm under 600 mmHg of vacuum. Each test tube was filled
with a known volume of porcine vitreous, and the tubes also were
weighted to provide a check of the volume measurements. The
actual change in volume was calculated on the basis of the known
vitreous density. The cutting and aspirating efficiency was evalu-
ated on the basis of the flow rate calculated according to the
volume removed over time (milliliter/second). Five trials per each
of the 4 testing conditions were performed to ensure reliability and Figure 4. A, The 27-gauge end-gripping microforceps with a shaft length
reproducibility. of 28 mm (bar ⫽ 10 mm). B, C, High-magnification image of the tip of the
In the current study, we newly developed a 27/29-gauge illu- microforceps with the grasping end open (B) and closed (C). The distance
mination light pipe for 27-gauge vitrectomy. This light pipe has a between the 2 tips of the grasping end is 900 ␮m when opened (B) and is
29-gauge optical fiber that passes through a 27-gauge thin-walled wide enough to grasp tough and thick proliferative epiretinal tissues. D,
needle with the fiber tip slightly protruding from the needle (Fig 3). Magnified posterior view under the 27/29-gauge chandelier endoillumina-
The maximum illumination is 20 lumens when used with a xenon tion in an eye with a macular hole. Because the tip of the grasping end is
illuminator (Photon, Synergetics Inc.) and 25 lumens when used fine and the shortened shaft is rigid, the forceps is also useful for peeling
with a mercury vapor illuminator (Photon II, Synergetics Inc.). The the ILM during macular hole surgery. The retinal boundary (arrowheads)
shaft length was shortened to 13 mm to strengthen the shaft after removal of the ILM.

95
 Ophthalmology Volume 117, Number 1, January 2010
Figure 5. A, A 27-gauge membrane spatula with the side bevel at a
20-degree angle. The length of the shaft is 28 mm (bar ⫽ 10 mm). B, C,
High-magnification image of the tip of the membrane spatula. D, The
magnified fundus view under 27/29-gauge light pipe endoillumination in
an eye with proliferative diabetic retinopathy. The membrane spatula is
used to separate and dissect the thin fibrotic membranes from the retinal
surface.
with proliferative diabetic retinopathy. Eyes were excluded if there
was a history of vitrectomy, other vitreoretinal pathologies, par-
ticularly peripheral abnormalities or extensive retinal detachment,
corneal opacities precluding adequate posterior visualization, or
postoperative follow-up period less than 3 months.
The use of a 27-gauge instrument system for MIVS and review
patient data for analysis was approved by the institutional review
board of Osaka University Medical School Hospital. All patients
provided written informed consent after they received a detailed
description of the surgical procedure and alternatives. This study
adhered to the tenets of the Declaration of Helsinki.
The setting for transconjunctival 27-gauge MIVS is similar to
that of a 23- or 25-gauge system and follows the standard 3-port
style, that is, 1 port for infusion and the other 2 ports for intraoc-
ular instrumentation. However, complex techniques to create a
self-sealing wound structure are not required with the 27-gauge
vitrectomy system. After retrobulbar anesthesia was induced with
2% lidocaine and conjunctival disinfection with povidone-iodine,
the 27-gauge vitrectomy is ready immediately after creation of
27-gauge sclerotomies at the pars plana by simple perpendicular
incision using a 27-gauge needle or direct 1-step insertion of the
sharp-point instruments through the pars plana. Conjunctival dis-
placement to misalign the conjunctival and scleral incisions during
creation of a sclerotomy transconjunctivally is recommended when
using the 27-gauge system. The trocar-cannula system, if neces-
sary, may be helpful to avoid missing the 27-gauge sclerotomy
96
during instrument insertion. All surgeries used the wide-angle
viewing system (ClariVit wide angle, Volk Optical Inc., Mentor,
OH) and a magnified contact lens for macular work as necessary.
The VGFI system with the experimentally estimated optimal pres-
sure was used for 27-gauge vitrectomy. Core vitrectomy using the
27-gauge vitreous cutter was performed with intravitreal injection
of triamcinolone acetonide to visualize the vitreous gel and iden-
tify the location of vitreoretinal adhesions. If a posterior hyaloid
detachment had not occurred, it was created using a membrane
spatula. In eyes with an epiretinal membrane, macular hole, and
macular edema, the ILM was removed using a 27-gauge micro-
forceps. In eyes with a focal traction retinal detachment caused by
proliferative diabetic retinopathy, the fibrovascular membranes
were cut and removed using the 27-gauge cutter. If the fibrovas-
cular membranes extensively adhered to the detached retina, mem-
brane separation and dissection from the retina were performed
using a membrane spatula (Fig 5D). Peripheral vitrectomy, vitre-
ous base shaving, and endolaser photocoagulation up to the ante-
rior retina using a 1-step 27-gauge sharp-point laser probe were
performed under a wide-angle viewing system without scleral
depression. Fluid– gas exchange was performed in eyes with a
macular hole or traction retinal detachment by flushing with 50 ml
of a premixed nonexpansile concentration of 20% sulfur hexafluo-
ride. Phacoemulsification and aspiration and an acrylic foldable
intraocular lens implantation were performed simultaneously
through a 2.2-mm clear corneal incision in patients with a preex-
isting cataract. At the end of surgery, endoillumination with gentle
scleral indentation helped to identify peripheral retinal pathologic
features. After simple removal of all inserted instruments, the
surgery was concluded without sutures. Topical antibiotic oint-
ment was applied, and the eye was patched and shielded. Patients
who had undergone fluid– gas exchange were instructed to remain
face down for 3 to 7 days.
Data Analysis
Patient medical records and surgical notes were reviewed. The data
collected included patient age; gender; diagnosis; preoperative and
Figure 6. A, Comparison of the standard 27-gauge blunt tip laser probe
(top) with the newly designed 27-gauge sharp point laser probe (bottom).
Both probes have a shaft length of 32 mm (bar ⫽ 10 mm). The sharp laser
probe is convenient for 1-step direct entry into the vitreous cavity without
using a cannula for instrument insertion. B, C, High-magnification image
of the blunt tip (B) and sharp tip (C) of the laser probes. The sharp-tipped
laser probe consists of a 27-gauge needle through which a 200-␮m laser
fiber passes. The sharp-tipped laser probe can be inserted and removed
several times during surgery because of the 1-step easy entry and small
gauge for easy wound self-sealing. It is convenient to change the direction
of insertion to complete endolaser photocoagulation during surgery.
 Oshima et al 䡠 27-Gauge Vitrectomy

Figure 8. Comparison of the opening and closing movements of the

cutting port of the 27-gauge vitreous cutter (solid line) and 25-gauge
vitreous cutter (dotted line) at different cutting speeds. In the 27-gauge
vitreous cutter, the total opening at each cut rate is represented by the
total of the gray areas, and the duty cycle is measured as the total gray areas
at each cut rate divided by the gray area at 0 cpm. The values of the duty
cycles are shown in Table 3. cpm ⫽ cuts per minute.

Results

Figure 7. Two types of 27-gauge trocar-cannula systems are prepared. A,

The 27-gauge trocar-cannula system consists of a microvitreoretinal blade
trocar and a polyimide cannula (upper left) for 1-step entry. B, Another
type of 27-gauge trocar-cannula system consists of an inserter and a steel
cannula with a closure valve (upper left) for 2-step entry.
postoperative best-corrected visual acuity (VA) at 1 month and
final follow-up visits; preoperative and postoperative intraocular
pressure (IOP) at the 1-day, 1-week, 1-month, and final follow-up
visits; operating time; anatomic success; wound self-sealing; and
intraoperative and postoperative complications. The VA was mea-
sured using the Landolt C acuity chart and analyzed on a logarithm
of minimal angle of resolution scale. Visual improvement was
defined as an increase of at least 0.3 logarithm of minimal angle of
resolution unit. Where appropriate, the Mann–Whitney rank-sum
test, Student t test, and Fisher exact test were used to compare the
differences between groups. Statistical analysis was performed
using SPSS software version 10.0J (SPSS, Inc., Chicago, IL).
P⬍0.05 was considered statistically significant.
The inner and outer diameters, port area, shaft length, and rigidity
of the 27-gauge vitreous cutter are summarized in Table 2. In
contrast with a standard commercially available 25-gauge vitreous
cutter with internal and external diameters of 0.347 and 0.515 mm,
respectively, the 27-gauge vitreous cutter had internal and external
diameters of 0.275 and 0.409 mm, respectively. The distance
between the tip and the cutting port of the 27-gauge vitreous cutter
(0.211 mm) is shorter than that of the 25-gauge vitreous cutter
(0.330 mm). The port area of the 27-gauge vitreous cutter (0.079
mm2) was slightly wider than that of the 25-gauge vitreous cutter
(0.066 mm2). The 27-gauge vitreous cutter with a shortened shaft
length of 25 mm showed its rigidity comparable to that of the
25-gauge cutter. The duty cycle of the 27-gauge vitreous cutter
compared with that of the 25-gauge cutter is shown in Figure 8.
The duty cycle of the 27-gauge vitreous cutter at 1000 cpm (61%)
and 1500 cpm (38%) was equal to or better than that of the
standard 25-gauge cutter (62% and 28%, respectively) (Table 3).
However, the duty cycle of the 27-gauge cutter decreased to 21%
or less when the cut rate exceeded 2000 cpm.
The 27-gauge vitreous cuter had a gradual reduction in aspira-
tion rate with increasing cut rates (Fig 9). Because the optimal cut

Table 2. Comparison of Specifications and Stiffness of the 25- and 27-Gauge Vitreous Cutters

Diameter (mm) Distance between Port Shaft Stiffness Displacement (mm)

Tip and Cutting Area Length under Known Force (0.5 N)
Vitreous Cutter Internal External Port (mm) (mm2) (mm) 20 mm from the Cutter Base
25-gauge* 0.347 0.515 0.330 0.066 32 3.3
27-gauge† 0.275 0.409 0.211 0.079 25 5.8

*The commercially available 25-gauge vitreous cutter is from Alcon Laboratories Inc.
†
The 27-gauge vitreous cutter is produced by Dutch Ophthalmic Research Center International BV.

97
 Ophthalmology Volume 117, Number 1, January 2010

Table 3. Duty Cycles of the 25- and 27-Gauge Vitreous Cutters

Size 0 cpm 1000 cpm 1500 cpm 2000 cpm 2500 cpm
25-gauge* 100% 62% 28% NA NA
27-gauge† 100% 61% 38% 21% 7%

cpm ⫽ cuts per minute; NA ⫽ not available.

*The commercially available 25-gauge vitreous cutter is from Alcon
Laboratories Inc.
†
The 27-gauge vitreous cutter is produced by Dutch Ophthalmic Research
Center International BV.

rates for the 27-gauge cutter explored ranged from 1000 to 1500
cpm on the basis of the duty cycle analysis, the BBS aspiration
rates ranging from 0.05 to 0.07 ml/sec at the aspiration vacuum
level of 600 mmHg were estimated to be the most efficient for
27-gauge vitrectomy. Under this condition, the safety range of the
pressure generated by VGFI, which generates the infusion flow
supply, is estimated to be adjusted between 20 and 30 mmHg (Fig
10). The 27-gauge vitreous cutter had aspiration rates of 80% in
BSS (Fig 11) and 40% in porcine vitreous (data not shown)
compared with that of a 25-gauge cutter when operated at maximal
vacuum level (600 mmHg) with a cutting speed of 1500 cpm, the
maximal cutting speed for the 25-gauge vitreous cutter.
During the study period from June 2007 to November 2008, 31
eyes of 31 patients (17 men and 14 women) were enrolled and
underwent transconjunctival 27-gauge MIVS for a variety of vit-
reoretinal diseases, including epiretinal membranes (10 eyes), id-
iopathic macular holes (7 eyes), diabetic vitreous hemorrhage (5
eyes), diagnostic vitrectomy for vitreous opacity with suspicion of
intraocular lymphoma (4 eyes), focal diabetic traction retinal de-
tachment (3 eyes), macular traction syndrome (1 eye), and macular
edema secondary to central retinal vein occlusion (1 eye). The
mean patient age ⫾ standard deviation was 62.9⫾8.3 years (range,
40 – 84 years). The mean axial length was 24.7⫾1.3 mm (range,
22.1–27.8 mm). The mean postoperative follow-up time was
6.9⫾3.5 months (range, 3–20 months). The clinical data from the
31 eyes are shown in Table 4 (available at http://aaojournal.org).
Among the 31 eyes, the mean operating time was 34.3⫾18.8
minutes (range, 10 – 88 minutes). All surgeries were completed
using 27-gauge instruments without conversion to 25- or 23-gauge
in any cases. Cataract surgery with intraocular lens implantation
was simultaneously performed in 19 eyes complicated with cata-
racts. Fluid–air exchange followed by instillation of 20% sulfur
hexafluoride gas or air tamponade alone was performed in 11 eyes
(35%). No intraoperative complications occurred except for a
peripheral retinal break in the 1 eye. At the end of surgery,
Figure 10. Infusion rates of BSS using the 27- and 25-gauge infusion lines
are measured at different pressures generated by the VGFI system. The
safety range of the pressure generated by VGFI is estimated to be set
between approximately 20 and 30 mmHg. The infusion rates of the
27-gauge system are 60% and 62% at a VGFI of 20 and 30 mmHg,
respectively, compared with that of the 25-gauge system. cpm ⫽ cuts per
minute.
27-gauge sclerotomies in all 31 eyes were self-sealed without
suture placement after simple removal of 27-gauge instruments.
The mean preoperative IOP was 14.6⫾3.0 mmHg (range, 10 –19
mmHg), and the mean postoperative IOPs at 1 day, 1 week, and the
final visit were 14.7⫾5.1 mmHg (range, 9 –31 mmHg), 14.5⫾3.1
mmHg (range, 9 –22 mmHg), and 13.8⫾2.4 mmHg (range, 9 –19
mmHg), respectively (Fig 12). There were no significant preoper-
ative and postoperative IOP differences at any follow-up visits
(P⫽0.203). Although the mean day 1 postoperative IOP in eyes
with long-acting gas or air tamponade (17.2⫾6.8 mmHg) was
higher than that in eyes without gas tamponade (13.4⫾3.4 mmHg),
the differences between groups did not reach significance through-
out the follow-up period (P⫽0.134). All study eyes achieved
anatomic success with successful removal of an epiretinal mem-
brane, ILM, or both, reattachment of the detached retina, closure of
the macular holes, or clearance of the clouded media.
The VA levels of the 31 study eyes at baseline and the last
visits are shown in Figure 13. The mean preoperative VA was 0.17

Figure 11. Comparison of the aspiration rates of BSS at a 600 mmHg

vacuum level between the 27- and the 25-gauge vitreous cutters at differ-
ent cut rates. The aspiration rates of the 27-gauge vitreous cutter are 46%,
Figure 9. Aspiration rates of BSS using different aspiration vacuum levels 70%, and 80% at 0, 1000, and 1500 cpm, respectively, compared with that
and cut rates using the 27-gauge vitreous cutter. cpm ⫽ cuts per minute. of a standard 25-gauge vitreous cutter.

98
 Oshima et al 䡠 27-Gauge Vitrectomy

macular holes 1 month after surgery as confirmed by slit-lamp

microscopic examination and optical coherence tomography. The
mean preoperative VA was 0.17 (range, 0.1– 0.5). At the last
follow-up visit, the mean VA was 0.55 (range, 0.3– 0.9), which
was a significant (P⬍0.001) improvement from baseline.
In the 4 eyes that underwent diagnostic vitrectomy for an
unexplained vitreous opacity, vitreous specimens were collected
for immunochemical and cytologic diagnosis. Of these, 3 eyes
were diagnosed with primary intraocular lymphoma and 1 eye was
diagnosed with late-onset bacterial endophthalmitis associated
with Propionibacterium acnes.
In the other 2 study eyes, 1 with macular traction syndrome and
1 with macular edema secondary to central retinal vein occlusion,
Figure 12. Changes in IOP (mean ⫾ standard deviation) in 27-gauge vitrectomy with posterior hyaloid separation and ILM peeling was
vitrectomy. Overall, there are no significant differences in IOP before and performed successfully using a 27-gauge vitrectomy system. Al-
after surgery at any postoperative visits (circles). Although the mean IOP though the preoperative VA improved slightly after surgery, opti-
in eyes with gas tamponade (squares) is higher than that in eyes without cal coherence tomography confirmed the reduction of the macular
gas tamponade (triangles) at postoperative day 1, there are no significant thickness with resolution of macular cyst formation.
differences in IOP between the groups at any postoperative visits. IOP ⫽
intraocular pressure.
Discussion
(range, hand motion to 0.8). At the last follow-up visit, the mean
VA significantly improved to 0.62 (range, 0.1–1.2; P⬍0.001). During the past 2 years, we have developed a 27-gauge
Overall, 20 eyes (65%) had visual recovery exceeding 0.3 loga- vitrectomy system including an array of 27-gauge instru-
rithm of minimal angle of resolution unit. Vitreous hemorrhages ments for MIVS (Table 1). A major concern of developing
recurred in 2 patients (6%), both with diabetes, and resolved a small-gauge system is reduced endoillumination. Thanks
spontaneously during follow-up without additional surgery. No to the advances in brighter light sources using a xenon or
other postoperative complications, such as transient or persistent mercury vapor bulb, we previously developed chandelier
hypotony, choroidal detachment, retinal detachment, or endoph-
thalmitis, developed throughout the follow-up period.
endoillumination devices using 27- or 29-gauge optical
In the 10 eyes that underwent vitrectomy for an idiopathic fibers for wide-angle viewing during vitrectomy.20,21 In the
epiretinal membrane, all membranes were peeled successfully current study, we developed a new 27-gauge light pipe with
using a 27-gauge microforceps (Videos 1 and 2, available at a short shaft (13 mm) and a sharp tip that has several
http://aaojournal.org).26 The remnants of the peeled membranes advantages over the previously developed self-retaining
and vitreous floaters then were removed intravitreally using the chandelier fibers for 27-gauge vitrectomy. The shortened
27-gauge vitreous cutter. In this subgroup, the retinal thickness at
the macula measured by optical coherence tomography decreased
remarkably in 9 of 10 eyes (90%) 1 month after surgery. The mean
VA significantly improved from 0.42 (range, 0.2– 0.8) preopera-
tively to 0.90 (range, 0.5–1.2) at the last postoperative visit (P ⫽
0.001) without any visual impairment after surgery.
In the 8 eyes with proliferative diabetic retinopathy, 5 had a
persistent fundus-obscuring vitreous hemorrhage and 3 had a trac-
tion retinal detachment with extensive fibrovascular proliferation.
During diabetic vitrectomy (Video 3, available at http://aaojournal.
org), the 27-gauge vitreous cutter was used to cut and remove the
dense vitreous hemorrhage; grasp, peel, and dissect the fibrovas-
cular membrane; and gently compress the bleeding point for he-
mostasis. Endolaser photocoagulation was applied uneventfully in
all 8 eyes. No iatrogenic retinal breaks developed during fibrovas-
cular membrane removal. Although a peripheral retinal break was
encountered in 1 eye during peripheral vitreous shaving, it was
treated successfully with endolaser photocoagulation and air tam-
ponade. Anatomic success, including complete retinal reattach-
ment, was achieved in all 8 eyes without additional surgery. In this
subgroup, the overall mean VA significantly improved from 0.04
(range, hand motion to 0.3) preoperatively to 0.61 (range, 0.1–1.2)
at the last postoperative visit (P ⫽ 0.006) despite 1 eye with Figure 13. The scatter-plot shows the changes in baseline and final
limited visual improvement because of preexisting and persistent best-corrected VA after 27-gauge vitrectomy. The VA is converted to
diabetic macular edema. logarithm of the minimum angle of resolution. Overall, the mean best-
In the 7 eyes that underwent 27-gauge vitrectomy for an idio- corrected VA improved significantly after surgery (P⬍0.001). BCVA ⫽
pathic macular hole, posterior hyaloids separation followed by best-corrected visual acuity; CRVO ⫽ central retinal vein occlusion;
ILM removal using a 27-gauge microforceps was performed suc- ERM ⫽ epiretinal membrane; MH ⫽ macular hole; MTS ⫽ macular
cessfully (Video 4, available at http://aaojournal.org). All 7 eyes traction syndrome; PDR ⫽ proliferative diabetic retinopathy; VO ⫽
were filled with 20% sulfur hexafluoride. All 7 eyes had closed vitreous opacity.

99
 Ophthalmology Volume 117, Number 1, January 2010
shaft increases the shaft rigidity.24 By fully inserting the
shaft into the vitreous cavity and using the root of the shaft
as a fulcrum point, the 27-gauge light pipe can be used to
control ocular movements during surgery. The sharp tip of
the light pipe, similar to a 27-gauge needle, facilitates 1-step
transconjunctival entry into the vitreous cavity. The 29-
gauge inner optical fiber with a cone-shape tip that gener-
ates 25 output lumens provides sufficient wide-angle endoi-
llumination for intraocular manipulation as functional as
chandelier illumination. Because of the short (13 mm) shaft
length, inadvertent contact with the retinal surface is un-
likely, as is theoretical retinal phototoxicity with a conven-
tional light pipe.
Development of a practical 27-gauge vitreous cutter was
the most critical step for establishing a 27-gauge vitrectomy
system. We developed a 27-gauge cutter with its port area
larger than that of a commercially available 25-gauge cutter.
The shorter shaft length (25 mm) is similar in rigidity to that
of a conventional 25-gauge cutter, thus eliminating instru-
ment fragility during clinical use. Because a trocar-cannula
system is no longer needed for every case in 27-gauge
vitrectomy, the shaft length used to pass through a cannula
is not needed. Therefore, in the current study the 25-mm
shaft length was sufficient to perform core and peripheral
vitrectomy in eyes with the axial length from 22 to 28 mm.
The actual performance (cutting and aspirating efficiency)
of a vitreous cutter is related to both the gauge size and the
duty cycle.23 Although the internal diameter (0.275 mm) of
the 27-gauge vitreous cutter is smaller than that of the
25-gauge vitreous cutter (0.347 mm), the duty cycle of the
27-gauge cutter is equal to or slightly better than that of a
conventional 25-gauge cutter with cut rates ranging from
1000 to 1500 cpm. The shortened shaft also may contribute
to reduced fluid resistance during aspiration. Therefore, the
actual aspiration rate of the 27-gauge cutter in BSS and
porcine vitreous reached 80% and 40% of that of 25-gauge
cutter with an aspiration level of 600 mmHg and a cut rate
of 1500 cpm. However, we also found that 27-gauge vit-
rectomy with a cut rate greater than 2000 cpm may not be
practical because of a poor duty cycle less than 21%.
Further advances to optimize the balance between the pneu-
matic pressure and the strength of the spring coil of the
pneumatic cutter are needed to improve the duty cycle of the
27-gauge cutter at a higher cut rate.
The balance between the aspiration rate of the vitreous
cutter and the infusion rate is important to maintain the IOP
in a safety range during vitrectomy. The aspiration rate of
the 27-gauge vitreous cutter in BSS ranged from 0.05 to
0.07 ml/sec with the cut rate ranging from 0 to 1500 cpm.
Therefore, the pressure of the VGFI to maintain the infusion
rate within this range can be set from approximately 20 to
30 mmHg (Fig 10). Because the vitreous humor is consid-
erably more viscous than BSS, the actual aspiration rates
during vitrectomy should be lower than the aforementioned
aspiration rate measured in BSS. This pressure range allows
for a greater margin of safety for the IOP to prevent hypot-
ony or inadvertent ocular hypertension during vitrectomy.
In the current study, we performed 27-gauge vitrectomy
in 31 eyes of 31 patients and demonstrated the feasibility
and preliminary safety of this new system to treat less-
100
complicated vitreoretinal pathologies. Although the perfor-
mance of the current 27-gauge vitreous cutter is not yet
adequate for treating complex proliferative vitreoretinal pa-
thologies, which sometimes require extensive peripheral
vitreous shaving and manipulations, multiple instrument
exchanges, or a bimanual technique, our results showed that
the 27-gauge vitrectomy system is feasible and adequate for
treating eyes with a macular hole, epiretinal membrane,
macular edema, macular traction syndrome, simple vitreous
hemorrhage, focal traction retinal detachment, or vitreous
biopsy for cytologic diagnosis. The pathologies treated in
this series are the most amenable to begin using the 27-
gauge vitrectomy system with the currently available instru-
ments, because no eyes in our series required conversion to
larger-gauge instrumentation during 27-gauge vitrectomy
and were more likely to have good postoperative anatomic
and visual recoveries.
The setting for 27-gauge vitrectomy is similar to that of
23- and 25-gauge instrumentation. However, special tech-
niques for creating a self-sealing wound, such as angled-
incision technique or a 2-step entry method, are no longer
required. The 27-gauge vitrectomy can begin immediately
after creating sclerotomies at pars plana by simple perpen-
dicular insertion using 27-gauge instruments, most of which
are designed for 1-step entry without a pre-incision. Be-
cause of its small gauge size with less risk of vitreous
incarceration to the scleral wounds, 27-gauge vitrectomy
can be performed without use of a trocar-cannula system in
patients undergoing treatment of simple vitreous hemor-
rhage or diagnostic vitrectomy, which has less chance for
instrument exchanges during surgery. After simply remov-
ing all instruments, surgery can be concluded at once with
all sclerotomies self-sealed without suture placement.
The anatomic outcomes of 27-gauge vitrectomy in this
pilot study were favorable and comparable to those reported
using 25- or 23-gauge vitrectomy systems.2,3,5,27 Macular
edema caused by epiretinal membranes, vitreoretinal trac-
tion, or retinal vein occlusion resolved in 11 of 12 eyes after
vitrectomy with epiretinal and ILM peeling using 27-gauge
instruments. Successful macular hole closure was achieved
in all 7 eyes after vitrectomy with ILM peeling and gas
tamponade. Performing diabetic vitrectomy with the 27-
gauge system allowed successful reattachment of the de-
tached retina in 3 eyes and removal of a dense vitreous
hemorrhage in all 5 eyes despite 2 eyes with a self-limited
recurrent hemorrhage. Vitrectomy to obtain cytologic spec-
imen using the 27-gauge cutter effectively resulted in the
diagnosis of primary intraocular lymphoma in 3 of 4 eyes
and late-onset bacterial endophthalmitis in 1 eye. There was
significant improvement in the mean preoperative to mean
postoperative VA in all study eyes (P⬍0.001) and in the
subgroups with epiretinal membranes (P ⫽ 0.001), idio-
pathic macular holes (P⬍0.001), and diabetic complications
(P ⫽ 0.006). Overall, the visual improvement exceeding 3
lines was achieved in 20 eyes (65%) at the final follow-up
visit. No eyes had significant visual impairment after sur-
gery or any limitations or untoward effects from the 27-
gauge instrumentation. Although we may have overesti-
mated the current visual results because cataract surgery
simultaneously performed in 61% of study eyes may have
 Oshima et al 䡠 27-Gauge Vitrectomy
contributed partially to the visual recovery, these results
were comparable to those in our previous series in which we
used the 25-gauge system.27
By using the 27-gauge system, opening and closing
procedures can be simplified further than for the current 23-
or 25-gauge systems, which may contribute to a decrease in
the total operating time for this system. Nevertheless, the
operating time using the 27-gauge system for treating chal-
lenging cases, such as traction retinal detachment, must be
longer than for macular diseases, and theoretically it may be
longer than when using 23-gauge or conventional 20-gauge
instrument because of the substantially lower infusion and
aspiration rates of the 27-gauge vitrectomy system. How-
ever, the overall mean operating time of 34.3 minutes
(range, 10 – 88 minutes) in the current series with 27-gauge
instruments did not differ greatly from that (mean, 37.4
minutes; range, 28 –74 minutes) with the 25-guage system,
as we previously reported.27 This range of operating time
seems to be within acceptable limits. Although a retinal tear
inadvertently occurred in 1 eye during peripheral vitreous
shaving despite use of the 27-gauge vitreous cutter, it was
treated with 27-gauge endolaser photocoagulation and not
related to any postoperative complications. Because of its
small gauge of nature, wide port design, and shorter dis-
tance from the cutting port to the tip, the 27-gauge cutter can
perform several functions concurrently during surgery (i.e.,
as a cutter, aspirator, peeling forceps, and membrane scis-
sors). This multifunctionality is especially helpful during
diabetic vitrectomy. The blunt tip of the 27-gauge cutter can
be inserted more easily into the spaces between the fibro-
vascular membrane and the retina, allowing successful mem-
brane segmentation, dissection, and removal using only the
vitreous cutter without instrument exchange (Video 3, avail-
able at http://aaojournal.org). Reducing the use of various
instruments for manipulation may eliminate sclerotomy-
related complications, save the time required for instrument
exchange, and contribute to less-invasive and time-efficient
surgery.
The overall mean IOP before and after surgery was stable
with no significant difference among the examination time
points. The most remarkable finding in 27-gauge vitrectomy
is that no eyes in our series developed wound sealing-
related complications such as subconjunctival air bubbles,
conjunctival swelling, or hypotony (ⱕ7 mmHg) from post-
operative day 1 throughout the follow-up period, suggesting
favorable self-sealing structures of the 27-gauge scleral
wounds. Recurrent vitreous hemorrhage was the only post-
operative complication that developed in 2 eyes treated for
diabetic vitreous hemorrhage and spontaneously resolved
without additional surgical intervention. Because recurrent
bleeding in diabetic retinopathy is a well-known postoper-
ative complication often reported in previous studies,28,29
this complication in the current series was more likely
attributable to the underlying retinal pathologies rather than
having resulted directly from the small gauge and sutureless
nature of the 27-gauge vitrectomy system. In contrast with
the recently reported increased risk of vitreous wick, hypot-
ony, bacterial contamination, and infection related to
transconjunctival sutureless vitrectomy using 23- or 25-
gauge instruments,9 –16,30,31 no other complications such as
retinal detachment or endophthalmitis developed in the cur-
rent series, suggesting that the wound sealing-related com-
plications occasionally encountered with an unsutured scle-
rotomy using the 23- or 25-gauge system can be minimized
by using the smaller 27-gauge system.
This series had potential weaknesses in that it was ret-
rospective, uncontrolled, and noncomparative, had a small
number of cases, and reflected the initial experience from 1
institution. Nevertheless, the feasibility and safety of 27-
gauge vitrectomy in selected cases have been confirmed for
the first time by the current study. Although the develop-
ment of 27-gauge vitrectomy is an ongoing project and has
not yet been established as a widely accepted system for all
cases at present, it has great potential usefulness and advan-
tages that can contribute to the quality and safety of MIVS.
Another advantage of MIVS is that it is a minimally inva-
sive surgery. Surgeons should pay attention more to reli-
ability and safety rather than to shorter surgical time. A
gently performed surgery with slow inflow and outflow,
elimination of the risk of wound integrity-related concerns,
and theoretically less postoperative inflammation with 27-
gauge vitrectomy may be the least invasive MIVS at
present.
In conclusion, the current results confirmed the prelimi-
nary safety and practicality of the 27-gauge instrument
system for transconjunctival sutureless MIVS in selected
cases. The favorable wound-sealing structures with few
postoperative complications and acceptable operating time
suggests the potential of the 27-gauge system for treating
macular diseases, simple vitreous opacity or hemorrhage,
and moderately severe diabetic retinopathy. Similar to the
recent evolution of other small-gauge systems, further de-
velopment and refinement of the 27-gauge instrument func-
tionality and rigidity are under way and critical to the
widespread use of this system for the full spectrum of
vitreoretinal diseases in the future.
References
1. Fujii GY, De Juan E Jr, Humayun MS, et al. A new 25-gauge
instrument system for transconjunctival sutureless vitrectomy
surgery. Ophthalmology 2002;109:1807–12.
2. Lakhanpal RR, Humayun MS, de Juan E Jr, et al. Outcomes of
140 consecutive cases of 25-gauge transconjunctival surgery
for posterior disease. Ophthalmology 2005;112:817–24.
3. Ibarra MS, Hermel M, Prenner JL, Hassan TS. Long term
outcomes of transconjunctival sutureless 25-gauge vitrectomy.
Am J Ophthalmol 2005;139:831– 6.
4. Eckardt C. Transconjunctival sutureless 23-gauge vitrectomy.
Retina 2005;25:208 –11.
5. Fine HF, Iranmanesh R, Iturralde D, Spaide RF. Outcomes of
77 consecutive cases of 23-gauge transconjunctival vitrectomy
surgery for posterior segment disease. Ophthalmology 2007;
114:1197–200.
6. Kadonosono K, Yamakawa T, Uchino E, et al. Comparison of
visual function after epiretinal membrane removal by 20-
gauge and 25-gauge vitrectomy. Am J Ophthalmol 2006;142:
513–5.
7. Rizzo S, Genovesi-Ebert F, Murri S, et al. 25-gauge, suture-
less vitrectomy and standard 20-gauge pars plana vitrectomy
101
 Ophthalmology Volume 117, Number 1, January 2010
in idiopathic epiretinal membrane surgery: a comparative pilot
study. Graefes Arch Clin Exp Ophthalmol 2006;244:472–9.
8. Shinoda H, Shinoda K, Satofuka S, et al. Visual recovery after
vitrectomy for macular hole using 25-gauge instruments. Acta
Ophthalmol 2008;86:151–5.
9. Acar N, Kapran Z, Unver YB, et al. Early postoperative
hypotony after 25-gauge sutureless vitrectomy with straight
incisions. Retina 2008;28:545–52.
10. Byeon SH, Lew YJ, Kim M, Kwon OW. Wound leakage and
hypotony after 25-gauge sutureless vitrectomy: factors affect-
ing postoperative intraocular pressure. Ophthalmic Surg La-
sers Imaging 2008;39:94 –9.
11. Hsu J, Chen E, Gupta O, et al. Hypotony after 25-gauge
vitrectomy using oblique versus direct cannula insertions in
fluid-filled eyes. Retina 2008;28:937– 40.
12. Woo SJ, Park KH, Hwang JM, et al. Risk factors associated
with sclerotomy leakage and postoperative hypotony after
23-gauge transconjunctival sutureless vitrectomy. Retina 2009;
29:456–63.
13. Singh A, Chen JA, Stewart JM. Ocular surface fluid contam-
ination of sutureless 25-gauge vitrectomy incisions. Retina
2008;28;553–7.
14. Gupta OP, Maguire JI, Eagle RC Jr, et al. The competency of
pars plana vitrectomy incisions: a comparative histologic and
spectrophotometric analysis. Am J Ophthalmol 2009;147:
243–50.
15. Kunimoto DY, Kaiser RS, Wills Eye Retina Service. Inci-
dence of endophthalmitis after 20- and 25-gauge vitrectomy.
Ophthalmology 2007;114:2133–7.
16. Scott IU, Flynn HW Jr, Dev S, et al. Endophthalmitis after
25-gauge and 20-gauge pars plana vitrectomy: incidence and
outcomes. Retina 2008;28:138 – 42.
17. López-Guajardo L, Pareja-Esteban J, Teus-Guezala MA.
Oblique sclerotomy technique for prevention of incompetent
wound closure in transconjunctival 25-gauge vitrectomy.
Am J Ophthalmol 2006;141:1154 – 6.
18. Shimada H, Nakashizuka H, Mori R, et al. 25-gauge scleral
tunnel transconjunctival vitrectomy. Am J Ophthalmol 2006;
142:871–3.
Footnotes and Financial Disclosures
Originally received: February 25, 2009.
Final revision: May 8, 2009.
Accepted: June 22, 2009.
Available online: October 31, 2009. Manuscript no. 2009-278.
1
Department of Ophthalmology, Osaka University Medical School, Suita,
Japan.
2 Deceased.
Department of Ophthalmology, Shiga University of Medical Science,
Otsu, Japan.
Presented in part at: the Retina Subspecialty Day of the Annual Meeting
of American Academy of Ophthalmology, November 7, 2008, Atlanta,
Georgia.
Financial Disclosure(s):
The author(s) have made the following disclosure(s):
102
19. Rizzo S, Genovesi-Ebert F, Vento A, et al. Modified incision
in 25-gauge vitrectomy in the creation of a tunneled airtight
sclerotomy: an ultrabiomicroscopic study. Graefes Arch Clin
Exp Ophthalmol 2007;245:1281– 8.
20. Oshima Y, Awh CC, Tano Y. Self-retaining 27-gauge transcon-
junctival chandelier endoillumination for panoramic viewing dur-
ing vitreous surgery. Am J Ophthalmol 2007;143:166 –7.
21. Oshima Y, Chow DR, Awh CC, et al. Novel mercury vapor
illuminator combined with a 27/29-gauge chandelier light
fiber for vitreous surgery. Retina 2008;28:171–3.
22. Eckardt C, Eckert T, Eckardt U. 27-gauge Twinlight chande-
lier illumination system for bimanual transconjunctival vitrec-
tomy. Retina 2008;28:518 –9.
23. 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 –54.
24. Ohji M, Tano Y. A stiffer and safer light pipe for 25-gauge
vitrectomy. Arch Ophthalmol 2007;125:1415– 6.
25. Inoue M, Shinoda K, Shinoda H, et al. 25-gauge cannula
system with microvitreoretinal blade trocar. Am J Ophthalmol
2007;144:302– 4.
26. Sakaguchi H, Oshima Y, Tano Y. 27-gauge transconjunctival
nonvitrectomizing vitreous surgery for epiretinal membrane
removal. Retina 2007;27:1131–2.
27. 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– 80.
28. Schachat AP, Oyakawa RT, Michels RG, Rice TA. Compli-
cations of vitreous surgery for diabetic retinopathy. II. Post-
operative complications. Ophthalmology 1983;90:522–30.
29. Tolentino FI, Cajita VN, Gancayco T, Skates S. Vitreous
hemorrhage after closed vitrectomy for proliferative diabetic
retinopathy. Ophthalmology 1989;96:1495–500.
30. Shimada H, Nakashizuka H, Hattori T, et al. Vitreous prolapse
through the scleral wound in 25-gauge transconjunctival vit-
rectomy. Eur J Ophthalmol 2008;18:659 – 62.
31. Shimada H, Nakashizuka H, Hattori T, et al. Incidence of
endophthalmitis after 20- and 25-gauge vitrectomy: causes
and prevention. Ophthalmology 2008;115:2215–20.
Dr. Ohji is a consultant for Sanwa Kagaku Institute, Tokyo, Japan, and has
received lecture fees from Alcon Japan Ltd., Tokyo, Japan; Novartis
Pharmaceutical Ltd., Tokyo, Japan; and Pfizer Japan Inc., Tokyo, Japan,
but has no proprietary or commercial interest in any materials and products
discussed in this article. No other authors have a proprietary interest or
conflict of interest in any materials and products mentioned in this article.
†
Supported in part by research grants from the Ministry of Education,
Science and Culture, Tokyo, Japan.
Correspondence:
Yusuke Oshima, MD, Department of Ophthalmology, Osaka University
Medical School, 2-2 Yamadaoka, E-7, Suita, Osaka 565-0871, Japan.
E-mail: oshima@ophthal.med.osaka-u.ac.jp.
 Oshima et al 䡠 27-Gauge Vitrectomy

Table 4. Data from 31 Cases Treated with 27-Gauge

Lens Surgical Surgical

Case Age (yrs) Gender Eye Diagnosis Status Treatment Gas Time
1 75 F L ERM Phakia PPV, PEA, IOL 15
2 57 M L ERM Phakia PPV 25
3 53 M R PDR/VH IOL PPV 22
4 63 F R MH IOL PPV SF6 25
5 60 M R PDR/VH IOL PPV Air 29
6 66 M R PDR/TRD Phakia PPV, PEA, IOL SF6 85
7 66 M L ERM Phakia PPV, PEA, IOL 28
8 66 M R PDR/VH Phakia PPV, PEA, IOL 38
9 40 M R PDR/TRD Phakia PPV, PEA, IOL SF6 88
10 72 M L VO Phakia PPV 28
11 68 F L VO IOL PPV 15
12 64 F L VO IOL PPV 25
13 56 M R PDR/TRD Phakia PPV, PEA, IOL Air 51
14 64 F L ERM Phakia PPV, PEA, IOL 28
15 84 F L VO IOL PPV 25
16 58 M R ERM Phakia PPV, PEA, IOL 25
17 67 F L ERM Phakia PPV, PEA, IOL 21
18 61 M R MH Phakia PPV, PEA, IOL SF6 56
19 56 F R MH Phakia PPV, PEA, IOL SF6 50
20 64 F R ERM Phakia PPV, PEA, IOL 23
21 66 M L ERM Phakia PPV 15
22 64 F R ERM Phakia PPV, PEA, IOL 18
23 59 F L MH Phakia PPV, PEA, IOL SF6 35
24 59 M R MTS Phakia PPV, PEA, IOL 40
25 51 M R ERM Phakia PPV 20
26 56 F L MH Phakia PPV, PEA, IOL SF6 35
27 63 F R PDR/VH Phakia PPV, PEA, IOL 45
28 76 M L CRVO/CME IOL PPV 10
29 59 M L PDR/VH Phakia PPV, PEA, IOL 59
30 65 F L MH Phakia PPV SF6 38
31 72 M L MH Phakia PPV, PEA, IOL SF6 45

CME ⫽ cystoid macular edema; CRVO ⫽ central retinal vein occlusion; ERM ⫽ epiretinal membrane; F/M ⫽ female/male; HM ⫽ hand motions;
PEA ⫽ phacoemulsification and aspiration; PPV ⫽ pars plana vitrectomy; R/L ⫽ right/left; TRD ⫽ traction retinal detachment; VA ⫽ visual acuity;

102.e1
 Ophthalmology Volume 117, Number 1, January 2010

Transconjunctival Microincision Vitrectomy Surgery

IOP before IOP 1 Day IOP 1 Week IOP at Last VA at
Surgery after Surgery after Surgery Visit Baseline VA at 1 Last Follow-up
(mmHg) (mm Hg) (mm Hg) (mm Hg) VA Month Visit (mos) Comment
11 10 12 11 0.5 1.0 1.0 20
12 22 16 15 0.8 0.9 1.0 13
19 14 22 15 HM 0.15 0.5 12 Recurrent VH, resolved without reoperation
10 26 16 17 0.1 0.4 0.6 10
11 12 11 11 0.6 1.0 1.0 9
17 12 12 11 0.07 1.0 1.2 9
19 18 13 15 0.4 1.0 0.9 8
18 11 12 11 0.01 0.5 0.6 8 Recurrent VH, resolved without reoperation
19 14 15 15 0.3 0.5 0.5 8
19 11 18 13 0.3 0.2 0.4 8
16 11 13 18 0.8 1.0 1.0 8
18 15 14 15 0.2 0.4 0.4 8
18 11 17 15 0.02 1.2 1.2 7 Trocar-cannula system used
13 16 14 16 0.5 0.6 1.0 7
13 14 12 14 0.7 0.6 0.5 7
18 15 16 13 0.3 0.8 0.9 6
14 11 15 15 0.2 0.5 1.0 6
12 31 21 13 0.15 0.6 0.7 6
14 10 18 17 0.1 0.4 0.4 5
16 10 12 12 0.6 0.4 0.6 5
13 11 12 12 0.3 0.9 1.0 5
12 10 15 14 0.7 0.8 1.2 5
14 14 14 12 0.5 0.8 0.9 5
18 18 14 19 0.2 0.2 0.4 4
14 15 15 14 0.3 0.3 0.7 4
15 18 20 16 0.1 0.2 0.4 4
11 9 9 9 0.04 0.8 0.9 4 Intraoperative Retinal tear formation
10 12 11 11 0.1 0.1 0.1 3
15 14 16 16 0.04 0.1 0.1 3 Persistent macular edema after surgery
12 18 15 14 0.3 0.5 0.8 3 Trocar-cannula system used
13 22 11 10 0.2 0.3 0.3 3 Trocar-cannula system used

IOL ⫽ intraocular lens; IOP ⫽ intraocular pressure; MH ⫽ macular hole; MTS ⫽ macular traction syndrome; PDR ⫽ proliferative diabetic retinopathy;
VH ⫽ vitreous hemorrhage; VO ⫽ vitreous opacity.

102.e2