Abstract
Purpose. To summarise the surgical advances and evolution of small gauge vitrectomy and discuss its principles and application in modern vitreoretinal surgery. The advent of microincisional vitrectomy systems (MIVS) has created a paradigm shift away from twenty-gauge vitrectomy systems, which have been the gold standard in the surgical management of vitreoretinal diseases for over thirty years. Advances in biomedical engineering and surgical techniques have overcome the technical hurdles of shifting to smaller gauge instrumentation and sutureless surgery, improving surgical capabilities and expanding the indications for MIVS.
Highlights
Introduction and History of Microincisional VitrectomySurgery (MIVS)Robert Machemer introduced pars plana vitrectomy (PPV) in 1971
Improvements in electric and pneumatic cutters led to 20G three-port vitrectomy becoming the standard technique for vitreoretinal surgery for over thirty years, until the advent of microincisional vitrectomy surgery (MIVS)
Newer valved cannula designs remove the need for plugs and consist of a cap-like silicone membrane mounted onto the cannulas (DORC, Dutch Ophthalmic Research Corporation, Zuidland, the Netherlands), or built into the cannula head (Alcon, Fort Worth, Texas, US)
Summary
With its smaller instrumentation intended to be transconjunctival, self-sealing, and sutureless, has theoretical advantages including decreased ocular trauma and inflammation, decreased corneal astigmatism, reduced operating times, faster postoperative recovery, increased patient comfort, reduced conjunctival scarring, and conjunctival preservation, especially in patients with prior or pending glaucoma surgery [14,15,16]. Smaller gauge vitrectomy using transconjunctival trocar/cannula systems, have reduced the scleral incision diameter to 0.64 mm for 23G, 0.51 mm for 25G, and 0.4 mm for 27G. The once only placement of the cannulas maintains the alignment between the conjunctiva and sclera and is less traumatic to wound borders than the repeated insertion and withdrawal of instruments through a 20G sclerotomy. It increases the chances of self-sealing sclerotomy closure and minimizes the risk of suture-related inflammatory reaction, or subsequent atrophy and thinning over the sclerotomy site. Placing the sclerotomies closer to the horizontal meridian reduces the need to rotate instruments significantly for peripheral and superior access and avoids displacement of the infusion as the eye is rotated inferiorly [19]
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