Small-gauge Surgery in Vitreoretinal Disorders – There is More than Meets the Eye

Abstract

The impact of ageing-associated diseases has increased exponentially due to the known factors of longer life expectancy (the 'silver tsunami'), greater demands by the elderly for a good quality of life and the progress and increased availability of diagnostic and treatment options.In this era of consumerism, patients are overwhelmed by information from all sides -whether it be doctors' recommendations, dissenting experts, confusing statistics or testimonials on the Internet -and are therefore more involved in the decision-making process with potentially expanding medical-legal controversies. The classic model of medical decision-making based on economic theory developed by the mathematician Daniel Bernoulli became unsatisfactory and problematic in medicine where outcome and utility are not measurable in money.We should ask healthy people how much they think a given medical condition would affect their quality of life. Some people are maximalist and want everything done; others are minimalists who desire the least treatment necessary. Another group take a naturalist approach, looking for natural solutions and, finally, there are the believers who are certain that they will find a good solution for their condition. Both patients and physicians are deeply influenced by dramatic stories. Vitreoretinal surgery may carry an elevated risk of complications because we work on tissue with a thickness of microns. However, when we pioneered 23-gauge surgery, we experienced an increased rate of retinal detachment following macular surgery.7 Furthermore, we registered an increased rate of endophthalmitis 7 in comparison to 20-gauge surgery, mainly centred on wound stability and imperfect architecture of sclerotomies.Nonetheless, we thought that we were right. We were sure that a new technological revolution was coming in the ophthalmology world and that a transition towards the 'small calibre is better' paradigm would be the future.The recent introduction of high-speed 25-gauge vitrectomy systems with duty cycle has not only allowed less trauma for the patient with speedier recovery and a decreased rate of surgical complications, but also the opportunity to complete surgical manoeuvres in a safer way with less risk of retinal tractions. The idea that 'one size fits almost all' is becoming true and may be translated to the everyday surgical practice.