In the December issue of Retina Today, Rohit Ross Lakhanpal, MD, discussed surgical techniques to help limit complications in small-gauge vitreoretinal surgery. These potential complications include the failure to achieve complete wound closure and subsequent early postoperative hypotony, thus allowing an intraocular influx of extraocular fluid and microorganisms. The chief advantages of small-gauge surgery relative to the standard 20-gauge approach are decreased operating times, expedited patient recovery, reduced fluid loss during surgery and improved fluidic stability. Many potential pitfalls of small-gauge surgery, such as hypotony, endophthalmitis, choroidal hemorrhage, or retinal detachment, may be avoided or limited by closure of sclerotomies. In this article, we suggest sutured small-gauge surgery as a prudent compromise between traditional 20-gauge vitrectomy and small gauge surgery in select cases.

–Thomas Albini, MD; and Rohit Ross Lakhanpal, MD

DESCRIPTION OF TECHNIQUE
Using blunt Westcott scissors, three radial conjunctival periotomies (superotemporal, superonasal, and inferotemporal) are performed for 2 mm to 3 mm to bare sclera. The anterior aspect of each periotomy is initiated approximately 1 mm posterior to the surgical limbus to create an uninterrupted and smooth perilimbal region postoperatively.

The first 23-gauge trocar-cannula system is then passed perpendicularly through the bare sclera at an area that is approximately 3.5 mm posterior to the surgical limbus in each desired area. No beveling or angling of the trocar-cannula system is required because postoperative scleral sutures will be passed at the end of the case. Once all three 23-gauge cannulas are in place, the surgical case is carried out to completion.

At the conclusion of the case, each of the cannulas is removed sequentially and closed with a single 7-0 Vicryl suture in an interrupted fashion. The leftover 7-0 Vicryl suture is then used to close the overlying small conjunctival periotomies in a single, interrupted, and buriedknot fashion. The time it takes to create these periotomies is trivial, generally less than 1 minute. A well-trained fellow or practicing vitreoretinal surgeon can typically close the periotomies and overlying conjunctiva in fewer than 6 minutes. Therefore the total added time to open and close a 23-gauge surgery with planned suture closure is approximately 7 minutes.

Keep in mind that time is saved when passing the trocar- cannula complexes through the sclera in a perpendicular fashion, instead of the angled/posterior approach required with planned transconjunctival sutureless vitrectomy. Moreover, additional time is saved and frustration averted because an unanticipated scleral wound closure with planned transconjunctival sutureless vitrectomy is avoided. In that scenario, it is often difficult to find the wound to pass a combined transconjunctival/transcleral suture in one fell swoop through hemorrhagic and/or chemotic conjunctiva at the end of the case and requires trying, and potentially failing, to first adequately close the scleral wound. Alternatively, wound closure may be delayed by asking for Westcott scissors (Acme United Corporation, Fairfield, CT) and obtaining the suture by the circulating nurse.

DISCUSSION
Other than sutureless closure, small-gauge surgery affords many benefits over 20-gauge surgery such as smaller incisions, trocars to improve fluidic stability, less manipulation of scleral wound edges, and superior vitreous cutters for stripping membranes. In selected cases, it is important to minimize the increased surgical risk of hypotony associated with these technological advances. In our anecdotal experience, pediatric patients, uveitis patients, patients with thin or weak sclera, and patients who rub their eyes due to allergies, irritation, or force of habit, may be exceptionally susceptible to postoperative complications following sutureless surgery. Future research in large case series should help better define clinical characteristics associated with postoperative hypotony following smallgauge surgery.

The added step of suturing sclerotomies may often replace a full or partial air-fluid exchange, now routinely employed by many surgeons at the end of a case to decrease the rate of postoperative hypotony in sutureless surgery. This may result in improved patient satisfaction because avoiding a postoperative air bubble will result in better vision in the immediate postoperative period (Figures 1 and 2). Although the recovery may not be as quick and comfortable as sutureless surgery, it is appears to be more comfortable than wound closure in traditional 20-gauge surgery, perhaps because the sutures are not placed at the limbus. Most patients would probably prefer the added mild discomfort in exchange for avoiding significant complications. Surgeons should consider sutured small-gauge surgery, particularly in patients thought to be at risk for postoperative hypotony.

Andrew A. Moshfeghi, MD, MBA, is the Medical Director of Bascom Palmer Eye Institute at Palm Beach Gardens and the Bascom Palmer Surgery Center and is an Assistant Professor of Ophthalmology, Vitreoretinal Diseases and Surgery at the Bascom Palmer Eye Institute of the University of Miami's Miller School of Medicine. He states that he receives research funding from Thrombogenics, Inc., and Genentech, is a consultant for Genentech, Inc., Allergan, Inc., and Bausch + Lomb, and is a speaker for Genentech, Inc., and Allergan, Inc. Dr. Moshfeghi can be reached via e-mail at amoshfeghi@med.miami.edu.

Rohit Ross Lakhanpal, MD, is a Partner at Eye Consultants of Maryland, PA, and Principal of Timonium Surgery Center LLC. He is also a Clinical Assistant Professor of Ophthalmology at The University of Maryland School of Medicine. He reports no financial or proprietary interest in any of the products or techniques mentioned in this article. He has been a consultant in the past for Bausch + Lomb and Alcon Surgical. He is currently the Vice President of the Vit-Buckle Society (VBS). Dr. Lakhanpal is Section Co-Editor of the VBS page in Retina Today and on EYETUBE.NET. He can be reached at +1 410 581 2020 or via e-mail at retinaross@yahoo.com.

Thomas Albini, MD, is an Assistant Professor of Clinical Ophthalmology at the Bascom Palmer Eye Institute in Miami, FL. He specializes in vitreoretinal diseases and surgery and uveitis. He has served as a speaker for Bausch + Lomb and Alcon Surgical and as a consultant for Alcon Surgical. He is currently the Membership Chair of the Vit- Buckle Society (VBS). Dr. Albini is Section Co-Editor of the VBS page in Retina Today and on EYETUBE.NET. He can be reached at +1 305 482 5006 or via e-mail at talbini@med.miami.edu.