Small Gauge Suture-less Vitrectomy

• by Patrick Monahan, M.D.
• Year 2014

The advent of small instruments for vitrectomy surgery has significantly changed the surgery. With reduced complications and much easier surgery and recovery, many conditions such as vitreous floaters can now be treated that would have been difficult or risky in the past. Small instrument surgery has mostly replaced regular vitrectomy surgery for most applications.

During regular vitrectomy surgery, small holes (sclerotomies) are made in the scleral wall of the eye for instruments to enter. These #20-gauge instruments can catch on the eye tissue as they repeatedly enter and exit the eye. With the smaller, #25-gauge instruments, and now #27-gauge instruments, scleral ports are placed in the scleral wall. The small instruments enter and exit through these ports which protect the eye tissues from the instruments and, hence, reduce the risk of tearing by the retinal tissue. The instruments and ports are so small (the size of a very small needle) that at the end of the case, they can be removed, and the eye wall tissue closes, being self-sealing. While regular vitrectomy surgery requires suturing, small instrument surgery does not. This makes recovery much easier and much more comfortable.

Prior to Surgery

A history and physical exam has to be done on any patient prior to going to surgery. Surgery is done as an outpatient. No food or drink should be taken 8 hours prior to surgery (except a medication with a small sip of water as directed by your doctor). When the patient comes to the hospital on the day of surgery, they will go to a preop area. There they will have the eye dilated and be prepared for surgery. An IV will be placed in the arm.

In the Operating Room

The anesthesiologist will give some medicine through the IV which will make the patient very sleepy for a minute. During that time, a shot is given into the upper cheek below the eye to numb the eye. The patient does not feel or remember this. The patient is then awake during the surgery but kept very relaxed. Vitrectomy surgery for most cases takes from 20 to 60 minutes, depending on the complication of the case. The patient then goes to Recovery for 30 to 45 minutes and then is allowed to go home after surgery.

Following surgery

The patient will have a patch and shield on the eye. Depending on the particular problem, your doctor may have you keep the patch and shield on for 3 to 7 days. There are a few drops to be placed in the eye after surgery usually starting that evening or the next morning. These will usually go in 3 times a day in the first couple of weeks and then taper off for a couple of weeks. Most patients do not have any pain but can have a slight irritation for 1 to 2 days after surgery. Only a couple of Tylenol the night of surgery are required for the majority of patients.

Floaters

For vitrectomy surgery to remove floaters, there is a noticeable and immediate improvement following surgery. The patients notice a significant clearing of the vitreous floaters. It is not uncommon to have slightly blurred vision in the first postop day, but this usually clears quickly. No postoperative positioning is necessary, and within 3 to 5 days, patients can usually resume normal activities including driving. Extensive exercising should be restricted for 2 weeks.

Epiretinal Membranes

Patients with epiretinal membranes (macular pucker), the vision after surgery takes longer to improve depending on the length of time the abnormality in the eye was present as well as the difficulty of the surgery. Most patients are returned back to baseline vision within 2 to 4 weeks, but further improvement can take several months. Some conditions such as macular holes or retinal detachments require a gas bubble be placed in the eye. The vision can be quite poor until the bubble dissipates since you cannot focus through a gas bubble. The bubble does go away on its own and is naturally replaced with a liquid produced by the eye. (See Face-Down Positioning)