25-GAUGE PARS PLANA VITRECTOMY

FOR RETAINED LENS FRAGMENTS

LAWRENCE Y. HO, MD, MARK K. WALSH, MD, PHD,
TAREK S. HASSAN, MD

Purpose: The purpose of this study was to report the outcomes and complications of
25-gauge pars plana vitrectomy for the management of retained lens fragments after
complicated cataract surgery.
Methods: This is a retrospective consecutive case series of 17 patients who presented
with retained lens fragments, ranging from mostly cortex to the entire lens, which were
managed using only 25-gauge instrumentation.
Results: Eight men and 9 women (mean age, 73.1 years) were followed for a mean
of 4.5 months after 25-gauge vitrectomy for removal of retained lens fragments. Mean
preoperative visual acuity was 20/427 and mean final postoperative visual acuity was
20/62. Mean surgical operating time was 48.5 minutes. Mean preoperative intraocular
pressure was 24.5 mmHg and mean 1-day postoperative intraocular pressure was
17.9 mmHg. No cases required the use of a phacofragmatome, no sutures were required
to close the sclerotomies, and there were no cases of postoperative hypotony. Cystoid
macular edema and glaucoma developed postoperatively in 29.4% and 5.9% of eyes,
respectively. There were no cases of postoperative retinal detachment or endophthalmitis.
Conclusion: A 25-gauge vitrectomy technique, without the use of a phacofragmatome,
may be a suitable alternative to 20-gauge vitreous surgery using a phacofragmatome in the
management of retained lens fragments after complicated cataract surgery. Clinical outcomes
and complication rates are comparable to those found in the literature for 20-gauge surgery.
RETINA 30:843–849, 2010

M odern vitrectomy techniques and instrumenta-

tion have undergone considerable advancement
since the introduction of the first 17-gauge vitreous
cutter for pars plana vitrectomy (PPV) in 1972.1 The
desire for smaller surgical incisions and instrumenta-
tion led to the introduction of the first 25-gauge
vitreous cutter in 1990,2 which paved the way for
the development of the current microcannula-based
25-gauge transconjunctival sutureless 3-port vitrec-
tomy technique in use today.3
Compared with PPV with 20-gauge techniques, 25-
gauge transconjunctival PPV eliminates the need for
From the Associated Retinal Consultants, William Beaumont
Hospital, Royal Oak, Michigan.
Supported by Ronald G. Michels Fellowship Foundation
(M.K.W.) and Heed Ophthalmic Foundation (M.K.W.) and by
Bausch and Lomb Consultant (T.S.H.).
The study was conducted under approval from the William
Beaumont Hospital Human Investigation Committee, patient data
were handled in compliance with Health Insurance Portability and
Accountability Act privacy rules, and the study adhered to the
Declaration of Helsinki.
Reprint requests: Tarek S. Hassan, MD, Associated Retinal
Consultants, William Beaumont Hospital, 3535 West Thirteen Mile
Road, Suite 344, Royal Oak, MI 48073; e-mail: tsahassan@yahoo.com
a conjunctival peritomy and has been shown to reduce
surgically induced sclerotomy trauma, corneal astig-
matism, postoperative patient discomfort, intraocular
inflammation, and mean operative times and thereby
allow for faster postoperative anatomical and visual
recovery.3–7 However, complications, including wound
leakage, hypotony, vitreous incarceration, choroidal
detachment, and endophthalmitis, have been associated
with the small, sutureless, self-sealing wounds.8–13
Indications for 25-gauge PPV have expanded rapidly
in the past several years. In the field of pediatric retinal
surgery, small-gauge instrumentation has been used in
the management of posterior capsular opacification,
congenital and infantile cataract, and retinopathy of
prematurity.14–16 In adult retinal surgery, 25-gauge
instrumentation has been described in combined PPV
with phacoemulsification and intraocular lens implan-
tation, repair of complicated rhegmatogenous or trac-
tional retinal detachments, intraocular foreign body
removal, removal of retained lens fragments, removal of
epiretinal membranes, and macular hole repair.17–24
This study evaluates the surgical success and fea-
sibility of using 25-gauge PPV in the management of

843
844 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES  2010  VOLUME 30  NUMBER 6
retained crystalline lens material after complicated
cataract surgery. To our knowledge, this is the only
consecutive case series of such eyes managed with
25-gauge instrumentation alone without the use of a
20-gauge phacofragmatome.
Methods
The medical records of all consecutive patients who
underwent PPV for retained lens material by a single
surgeon (T.S.H.) at Associated Retinal Consultants,
P.C., Royal Oak, MI, between November 1, 2005, and
November 1, 2008, were reviewed. All surgeries were
performed at William Beaumont Hospital, Royal Oak,
MI, and none of the patients encountered during this
interval underwent 20-gauge management with phaco-
fragmentation. The study protocol was approved
by the Human Investigation Committee of William
Beaumont Hospital and was done in compliance with
Health Insurance Portability and Accountability Act
regulations. All patients who underwent 25-gauge PPV
for crystalline lens material retained in the vitreous
cavity, ranging from simply cortex to the entire lens,
after complicated cataract surgery, with a minimum of
2-month postoperative follow-up, were included and
no patients were excluded.
Pre-, intra-, and postoperative medical record data
were retrospectively collected. Demographic infor-
mation, preexisting eye diseases, prior eye surgical
procedures, pre- and postoperative ocular medications,
details of the initial and final examinations including
visual acuity, intraocular pressure (IOP) by Tono-Pen
tonometry (Medtronic Solan, Jacksonville, FL), PPV
surgery details, and postoperative complications were
noted. Hypotony was defined as an IOP of #5 mmHg.
Snellen visual acuity was converted to logarithm of the
minimum angle of resolution acuities for statistical
analysis.
Patients were referred 1 day to 10 days after
complicated phacoemulsification cataract surgery for
visually significant senile cataracts by the anterior
segment surgeon and then underwent PPV at the
discretion of the retina specialist. Indications for
surgery included retained nuclear material and/or
a sizeable retained lens cortex with or without marked
intraocular inflammation, uncontrolled glaucoma, or
retinal detachment. Preoperative characteristics of all
included patients are summarized in Table 1. All
surgical procedures were performed using a 3-port
transconjunctival microcannula-based 25-gauge PPV
system (Millennium TSV25 System, Bausch & Lomb,
Rochester, NY). The procedures that were done before
January 1, 2007 (7 cases) were done using an electric
cutter with a maximum cut rate of 1,500 cuts/minute
and those performed afterward (7 cases) used the
supplemental Adaptable Vitrectomy Enhancer vitre-
ous cutter probe (MID Labs, San Leandro, CA), which
allowed for a maximum cut rate of 2,500 cuts/minutes
when used with the Millennium TSV25 System.
The preoperative eye preparation in all cases
consisted of eyelid and periorbital scrubbing with
10% povidone-iodine solution using standard sterile
techniques. The operative eye was draped, an eyelid
speculum was inserted, and the stability of the cataract
wound was examined. A single 10-0 nylon suture was
placed to close any leaking cataract incision. After
conjunctiva and Tenon’s fascia were displaced, the
first trocar and microcannula were inserted through the
sclera at the pars plana, 3.0 mm from the corneo-
scleral limbus, at an angle of ;30° by a beveled
incision. The trocar was removed from the cannula
and the 25-gauge infusion line was attached to the
inferotemporal microcannula and opened. Two more
microcannulas were placed in a similar manner, one
each in the superotemporal and superonasal quadrants.
A noncontact wide-angle viewing system (BIOM,
Oculus Inc., Wetzlar, Germany) was used to facilitate
visualization. Vitrectomy was performed with the
25-gauge vitreous cutter from anterior to posterior
starting with the removal of vitreous and lens material
immediately surrounding the intraocular lens. The
vitreous surrounding the retained lens fragments was
removed. All lens material was removed with only the
25-gauge vitreous cutter in every case. The phaco-
fragmatome was not used in any eye. For larger pieces
of lens nucleus, a bimanual technique was used in
which the light pipe guided and then pushed the lens
material into the vitreous cutter probe. The vitreous
cutting and aspiration parameters at the beginning of
each case were maximal cut rate (1,500 or 2,500 cuts/
minute) and aspiration of 550 mmHg. Cut speeds
were reduced in some eyes from their maximum to
600 cuts/minute to remove very dense nuclear
material. Epiretinal membrane peeling, with or
without internal limiting membrane peeling, was per-
formed in some eyes when macular traction was
identified. At the end of every case, the retinal peri-
phery was examined through the wide-angle viewing
system or indirect ophthalmoscope with scleral
depression in search of residual lens material in the
vitreous base, retinal tears, or retinal detachments.
At the conclusion of every case, each microcannula
was removed and a cotton swab was placed on the
tract of the oblique sclerotomies. The wounds were
examined for leaking fluid, air, or gas and none
required suture closure. Subconjunctival antibiotics
(50 mg/mL cefazolin or 40 mg/mL gentami-cin),
topical erythromycin ointment, and atropine sulfate
Table 1. Demographic Information and Findings in Patients Who Underwent 25-Gauge PPV for Retained Lens Fragments After Complicated Cataract Surgery

Lens Size of
Medications Inserted at Initial Time Retained
Before Time of Initial Log Initial to Lens Final Final
Age Preexisting Cataract Cataract Snellen MAR IOP Initial PPV Indication Nucleus Snellen LogMAR
(Years) Sex Eye Disease Surgery Surgery Acuity Acuity (mmHg) RD (Days) for PPV (%) Acuity Acuity
84 Female Glaucoma Latanaprost, PCIOL 20/150 + 0.84 24 None 7 Inflammation, 50% 20/25–2 0.14
timolol glaucoma,
nuclear
material
76 Female None None ACIOL CF at 2 14 None 3 Inflammation, 33% 20/60–2 0.52
2 feet nuclear
material
67 Female None None PCIOL 20/150+ 0.84 17 None 7 Inflammation, 50% 20/30+2 0.14
nuclear
material
77 Male None None PCIOL 20/400 1.3 16 None 4 Inflammation, 50% 20/60 0.48
nuclear
material
71 Male None None PCIOL 20/50–2 0.44 34 None 9 Inflammation, Cortex only 20/20 0
glaucoma,
cortical
material
64 Female None None PCIOL 20/100 0.7 26 None 6 Inflammation, Cortex only 20/20 0
glaucoma,
cortical
material
69 Male None None PCIOL 20/100 0.7 14 Yes 12 Inflammation, 33% 20/20 0
RD, nuclear
material
80 Female None None PCIOL HM at 2ft 3 11 None 2 Inflammation, 100% 20/80+ 0.58
nuclear (entire lens)
material
83 Female None None PCIOL 20/100–2 0.85 21 None 17 Inflammation, 25% 20/30 0.18
glaucoma,
nuclear
25-GAUGE PPV FOR RETAINED LENS FRAGMENTS  HO ET AL

material
80 Male Early dry None PCIOL HM at 2 ft 3 48 None 9 Glaucoma, 25% 20/30 0.18
AMD nuclear
material

(continued on next page)

845
 846

Table 1. (continued )
Lens Size of
Medications Inserted at Initial Time Retained
Before Time of Initial Log Initial to Lens Final Final
Age Preexisting Cataract Cataract Snellen MAR IOP Initial PPV Indication Nucleus Snellen LogMAR
(Years) Sex Eye Disease Surgery Surgery Acuity Acuity (mmHg) RD (Days) for PPV (%) Acuity Acuity
60 Female Macula-on None PCIOL 20/50+ 0.375 18 None 8 Inflammation, 100% 20/50+2 0.35
RD glaucoma, (entire lens)
repaired nuclear
with material
scleral
buckle
69 Female None None PCIOL 6/200 1.6 33 None 4 Inflammation 25% 20/40 0.3
glaucoma,
nuclear
material
58 Female Anterior Prednisolone PCIOL 20/30–2 0.24 17 None 9 Inflammation, ,25% 20/25–2 0.14
uveitis acetate, nuclear
timolol, material
dorzolamide
75 Male Glaucoma, Carteolol ACIOL CF at 2 feet 2 44 None 16 Inflammation, Cortex only 20/50–2 0.44
early dry glaucoma,
AMD cortical
material
77 Male PDR, None ACIOL CF at 2ft 2 25 None 2 Inflammation, Cortex only 20/100–1 0.78
history glaucoma,
of PPV cortical
for ME material
85 Male CRVO, Latanaprost PCIOL CF at 2 feet 2 30 None 2 Inflammation, ,25% HM at 3
CME, glaucoma, 2 feet
POAG cortical
material
67 Male PDR, None PCIOL 20/100–2 0.85 25 None 1 Inflammation, 100% 20/100–1 0.78
history glaucoma, (entire lens)
of PPV nuclear
for TRD material
RD, retinal detachment; LogMAR, logarithm of the minimum angle of resolution; AMD, age-related macular degeneration; PDR, proliferative diabetic retinopathy; ME, macular
edema; CRVO, central retinal vein occlusion; CME, cystoid macular edema; POAG, primary open-angle glaucoma; TRD, tractional retinal detachment; PCIOL, posterior chamber
intraocular lens; ACIOL, anterior chamber intraocular lens; CF, count fingers; HM, hand motions.
RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES  2010  VOLUME 30  NUMBER 6
 25-GAUGE PPV FOR RETAINED LENS FRAGMENTS  HO ET AL
1% drops were administered and an eye pad and shield
were placed over the operative eye.
All patients were examined on postoperative day
1 and at ;1 week, 4 weeks, and 8 weeks to 12 weeks
postoperatively. They were examined at increasingly
longer intervals and on an as-needed basis thereafter.
Patients were monitored for complications, including
sclerotomy site leakage or hemorrhage, vitreous
incarceration, retinal tears or detachments, hypotony,
glaucoma, choroidal detachment or hemorrhage,
endophthalmitis, and cystoid macular edema.
Results
There were 17 eyes of 17 consecutive patients who
met inclusion criteria and underwent 25-gauge PPV
for retained lens material between November 1, 2005,
and November 1, 2008. Anterior segment surgeons
had performed phacoemulsification in all eyes; an
anterior chamber intraocular lens was placed at the
time of cataract surgery in 3 patients (17.6%) and
a posterior chamber intraocular lens was placed in
14 patients (82.4%). The referred patients in this series
included 8 men and 9 women with a mean age of
73 years (range, 58–85 years) and a mean follow-up
after PPV of 134 days (range, 35–475 days). Three
patients (17.6%) had preexisting glaucoma, 2 patients
(11.8%) had dry macular degeneration, 2 patients
(11.8%) had a history of proliferative diabetic retino-
pathy, 1 patient (5.9%) had a central retinal vein
occlusion with macular edema, 1 patient (5.9%) had
a history of uveitis that was inactive at the time of PPV,
and 1 patient (5.9%) had a prior rhegmatogenous
retinal detachment that had been repaired with PPV.
The mean Snellen visual acuity on initial examina-
tion by the retina specialist was 20/427 (logarithm of
the minimum angle of resolution acuity 1.33) with
a range of 20/30–2 to hand motion at 2 feet. The mean
IOP at presentation was 24.5 mmHg (range, 11–48
mmHg). One patient (5.9%) had a retinal detachment
on initial retinal examination. The indications for PPV
are listed in Table 1. The mean interval between
cataract surgery and PPV was 6.9 days (range, 2–17
days) with 58.8% of the patients having PPV within 7
days. The retained lens material discovered at the time
of surgery ranged from cortex only to an entire
dislocated lens (Table 1). Surgical operative times
ranged from 18 minutes to 96 minutes with a mean
duration of 48.5 minutes. Twelve patients (70.6%) had
retained lens material that included at least 25% of the
nucleus, and all patients had retained cortical material
before PPV. No eye required the enlargement of
a sclerotomy site and use of a 20-gauge phacofrag-
matome to remove lens material. Perfluorocarbon
847
liquid was used in 1 patient (5.9%) to elevate the lens
from the retinal surface during its removal, and 3
patients (17.6%) had epiretinal membranes peeled at
the time of surgery. One patient (5.9%) had a retinal
tear seen intraoperatively that was treated with laser
retinopexy. The patient who presented with a macula-
off retinal detachment was repaired with vitrectomy,
scleral buckling, external drainage of fluid, laser
retinopexy, and fluid-gas exchange using 24% sulfur
hexafluoride. At the end of PPV, 4 mg triamcinolone
acetonide was injected into the vitreous cavity in 6
patients (35.3%). No patient required a suture for the
sclerotomy sites at the end of surgery.
On postoperative day 1, none of the eyes were hypo-
tonus and the mean IOP was 17.9 mmHg. The mean
IOP was reduced from 24.5 mmHg (standard devia-
tion, 10.5) preoperatively to 17.9 mmHg (standard
deviation, 4.5) on final examination (P = 0.018). At the
most recent postoperative examination, the mean
Snellen visual acuity had improved to 20/62 (loga-
rithm of the minimum angle of resolution acuity =
0.49) (P = 0.001).
Cystoid macular edema developed postoperatively
in 5 eyes (29.4%) after PPV. Two eyes were treated
with topical nonsteroidal antiinflammatory medication
and 3 were treated with a combination of topical
prednisolone acetate 1% and topical nonsteroidal anti-
inflammatory medication. Complete cystoid macular
edema resolution was seen in all eyes. One patient
(5.9%), who had no preexisting glaucoma and
received no intravitreal triamcinolone developed
persistent elevated IOP refractory to medical man-
agement postoperatively, and a Baerveldt glaucoma
implant (Advanced Medical Optics, Santa Ana, CA)
was subsequently placed. For the three patients with
the worst visual outcomes in our series, two had
proliferative diabetic retinopathy with macular ische-
mia and one had a prior central retinal vein occlusion
with macular edema. No patients developed a retinal
tear, retinal detachment, or endophthalmitis after PPV.
Discussion
In this study, we have shown that 3-port microcan-
nula-based transconjunctival sutureless 25-gauge PPV
can be used as an alternative to traditional 20-gauge
PPV with phacofragmentation for the removal of
retained crystalline lens fragments after complicated
cataract extraction, even in cases in which large pieces
of nucleus are present. The final visual acuity out-
comes in this series are comparable with those seen in
prior studies that evaluated the removal of retained
lens material with traditional 20-gauge techniques, in
which 44% to 71% of eyes achieved a final visual
848 RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES  2010  VOLUME 30  NUMBER 6
acuity of $20/40 and 10% to 21% ended with a final
visual acuity of #20/200.25–32 Our study found that
after removal of retained lens material with only a 25-
gauge vitreous cutter and without any phacofragmen-
tation, 52.9% of patients achieved a visual acuity of $
20/40 and 2 patients (11.8%) had a final acuity of
#20/200. It is noted that the published 20-gauge series
with comparable results included more patients and
had longer follow-up making direct comparison of
outcomes difficult.24–32
Reported postoperative complications after
20-gauge techniques include glaucoma (2-11%),
retinal detachment (8–22%), and cystoid macular
edema (28%).25–32 We found that with using 25-gauge
PPV techniques alone, our incidence of postoperative
complications compare favorably or similarly: glau-
coma (5.9%), retinal detachment (0%), and cystoid
macular edema (29.4%). We also report no cases of
postoperative endophthalmitis or hypotony.
This study is only the second reported series to
describe the use of 25-gauge PPV techniques for re-
moval of retained lens material. Our study is unique
because we did not require a 20-gauge phacofrag-
matome to remove dense nuclear material. In the only
other series that described 25-gauge PPV techniques
to remove retained lens material, Kiss and Vavvas
reported that 3 of their 6 patients (50%) required the
20-gauge phacofragmatome to remove dense nuclear
material. In the cases in which the vitreous cutter was
used without a phacofragmatome, the retained lens
material was described as being only lens cortex.23 We
demonstrated that it is possible to remove large and
dense nuclear material using only the 25-gauge vitre-
ous cutter. The disparity between these two series is
likely attributable to differences between the vitreous
cutters that were used or, less likely, differences in the
densities of retained lens material between the series.
We used a cutter that has been shown to have the
highest flow rate, longest duty cycle, and largest cutter
port size of any currently commercially available 25-
gauge probe and to exhibit higher water and vitreous
flow rates than those seen even with current 20-gauge
vitreous cutters at high cut speeds (e.g., 2,500 cuts/
minute). Probes with these characteristics would be
expected to more efficiently and effectively remove
dense intraocular material such as fibrovascular mem-
branes, as shown by Fang et al,33 and presumably lens
nuclear material, as seen in this series. Future vitreous
cutters that further increase duty cycles and flow rates
(by a variety of mechanisms) would be expected to
allow for similar or improved abilities for smaller
gauge vitreous cutters to remove the lens nucleus.
Limitations of this study include its retrospective
nature, absence of controls, short follow-up, and small
sample size. Surgery was performed using only 1
25-gauge PPV system, and our results may not be
applied broadly to all commercially available 25-
gauge vitrectomy probes. Finally, this was not a trial
that compared 20- and 25-gauge techniques, so eyes
were not randomized to receive 1 surgical method or
the other at the time of presentation. However, as one
of several strengths of the study, it was a consecutive
case series of all eyes that presented to one surgeon
with dislocated crystalline lens material after compli-
cated cataract surgery during a set period of time.
There was no selection bias because 20-gauge techni-
ques were not planned for any eye before PPV and no
patients were excluded from this study. All cases were
done with the consistent technique of a single surgeon
at a single institution and there was adequate follow-
up for the evaluation of postoperative complications.
This series not only demonstrated that 25-gauge
PPV for retained lens material, including nuclear
remnants of significant size and density, is feasible, but
also that it can be considered as a viable alternative to
traditional 20-gauge phacofragmentation techniques
given its similar visual and anatomical outcomes and
low complication rates. The benefits of smaller gauge
vitreous surgery such as reduced operative trauma,
postoperative pain, intraocular inflammation, and cor-
neal astigmatism as well as faster postoperative anato-
mical and visual recovery compared with vitreous
surgery done with 20-gauge instrumentation are poten-
tially available in eyes having dislocated crystalline
lens material after complicated cataract surgery.
Further prospective controlled studies that compare
25-gauge versus 20-gauge phacofragmatome instru-
mentation for the removal of retained lens material
may add to our understanding of this expanded indica-
tion of 25-gauge transconjunctival sutureless PPV.
Key words: 25-gauge vitrectomy, complicated
cataract surgery, retained lens material, retained lens
fragments, small gauge vitrectomy, transconjunctival
sutureless vitrectomy.
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