Abstract
Objective:
To investigate the mechanical properties of 23-, 25- and 27-gauge vitrectomy vitrectors across three different vitrectomy systems to inform surgical techniques.
Design:
An experimental study that did not involve any human subjects
Methods:
Nine vitrectors (3 each of 23-, 25-, and 27 gauge) from Alcon, Dutch Ophthalmic Research Center (DORC) and Bausch and Lomb (B/L) were measured. Measurements were performed using electroforce displacement at the tip and 15mm from the tip. Five measurements were performed at each location and fully elastic deformation was ensured.
Main Outcome Measures:
The main parameter being measured was the force in grams (gramforce) necessary to deflect the vitrectors vertically downward by 1mm, either at the tip of the vitrector or 15mm from the tip.
Results:
A total of 90 measurements were made. Across brands, B/L demonstrated the least stiffness at both the tip and at 15mm for 23-gauge (8.0(0.3)gf, 67.3(1.0))gf, 25-gauge (6.8(0.3)gf, 60.5(0.4)gf) and 27-gauge (3.3(0.1)gf, 33.9(0.5)gf) vitrectors. While there was only a small decrease in stiffness in the 25- gauge vitrector compared to the 23-gauge vitrector at 15mm, this difference was statistically significant for Alcon (P<0.001), DORC(P<0.001) as well as B/L (P<0.001).
Conclusion:
Based on this study, 25-gauge vitrectors, although larger than 27-gauge vitrectors and less stiff than 23-gauge vitrectors, may offer favorable compromise between stiffness and gauge size. However, surgeon experience, preference, and the type of surgery being performed should be paramount when making the final vitrector selection. Knowledge of these mechanical properties may aid surgeons in choosing between gauge size and vitrectomy system to optimize their comfort and efficiency.
Vitreoretinal surgeons have access to a wide array of vitrectomy vitrectors that vary in gauge sizes, vitrector geometries, duty cycles and cut rates. The most common gauge sizes in use today are the 23-, 25- and 27-gauge vitrectors.1,2 Any of these vitrector sizes can be used for a range of case types including tractional retinal detachment, dense vitreous hemorrhage, macular hole and pucker, rhegmatogenous retinal detachment, proliferative vitreoretinopathy and tractional retinal detachment. 3–6 In general, smaller gauge systems may be favored for more delicate dissections while larger gauges may offer greater efficiency and speed.
Differences between vitrectomy sizes may impact their flow rate, efficiency, instrument stability or perceived tremor.7–9 Gauge size may also affect other mechanical properties.1 Most concerning are instances where intraoperative bending and breakage of the vitrector tip have been noted. 10,11 While instrument bending may in part occur secondary to poor surgical technique and inability to rotate optimally within trocars, it can still occur in experienced surgeons’ hands. The stiffness of the vitrector is particularly important when surgeons are working in the anterior vitreous as a bent instrument may lead to unintended contact with the lens, contributing to the development or progression of a visually significant cataract. 10–12 A bent vitrector may also malfunction mechanically.
A systematic comparison of vitrectors across brands and gauge sizes is yet to be reported. Therefore, the purpose of this study is to perform an analysis of the mechanical properties and differences that exist between 23-, 25- and 27-gauge vitrectors across three major brands.
Methods
Nine vitreous vitrectors and their respective trocars from Alcon, Dutch Ophthalmic Research Center (DORC), and Bausch and Lomb (B/L) were included in the study. The specific models used in the experiments are included in Supplemental Table 1. The total length of each probe and the outer diameter was measured with a digital caliper (model 62379–531, Van Waters and Rogers) from the distal tip to its insertion in millimeters.
A material testing device, Electroforce 5500 (Thermal Analysis instruments, USA), was used to determine the bending stiffness of each vitrector at the tip and at 15mm from the tip (Figures 1 and 2). The tip was defined as half a millimeter from the most distal point of the vitrector. These two points were chosen as they define the general limits of vitrector depth when inserted into the eye.6 Additionally, the 15mm point was chosen due to its clinical relevance. It is an estimate of where the surgeon is applying force during surgery when maneuvering the vitrector within the posterior chamber.
Figure 1. Electroforce Setup Model.
Model of cantilever with point force setup for vitrectomy vitrector deflection measurements
Figure 2. Electroforce Displacement Setup.
Electroforce displacement setup
To measure stiffness, an increasing downwards point vertical load was applied at a rate of 0.1mm/second at either location until the total displacement of the vitrector reached 1.0mm. The final gram force (gf) required to achieve a 1.0mm displacement was recorded. A maximum displacement of 1mm was set to avoid permanent elastic deformation of the vitrector. A force of 0.1 gf was applied to each vitrector before starting each experiment to ensure contact between the machine and vitrector. After each trial, the machine was reset to its initial start point, and a reading of 0.1 gf was assessed to ensure that the deformation was elastic. Five trials were performed at both the tip and 15mm distal from the tip for a total of 10 trials on each vitrector. All measurements were performed in a laboratory setting at room temperature.
One way ANOVA and post hoc Tukey analysis was performed to compare the stiffness of each gauge size among the different brands.
Results
The lengths of 23-gauge vitrectors for Alcon, DORC and B/L were 32.4mm, 32.2mm and 32.5mm respectively. The lengths of 25-gauge vitrectors for Alcon, DORC and B/L were 32.3mm, 32.3mm and 32.6mm respectively. The lengths of 27-gauge vitrectors for Alcon, DORC and B/L were 32.6mm, 28.8mm and 32.5mm respectively.
The outer diameters of 23-gauge vitrectors for Alcon, DORC and B/L were 0.61mm, 0.64mm and 0.64mm respectively. The outer diameters of 25-gauge vitrectors for Alcon, DORC and B/L were 0.50mm, 0.49mm and 0.50mm respectively. The outer diameters of the 27-gauge vitrectors for Alcon, DORC and B/L were 0.41, 0.40mm and 0.40mm respectively.
The mean forces required to displace the tip of Alcon 23-gauge, 25-gauge, and 27-gauge vitrectors by 1.0mm were 10.9 (0.1) gf, 6.7 (0.3) gf, and 3.5 (0.1) gf, respectively. The average forces required to displace the 15mm point of Alcon vitrectors by 1.0mm for 23-, 25- and 27-gauge vitrectors were 82.2 (0.5) gf, 74.0 (1.2) gf, and 45.2 (0.7) gf, respectively. The average forces required to displace the tip of 23-, 25- and 27-gauge DORC vitrectors were 9.6 (0.3) gf, 8.4 (0.2) gf, and 4.3 (0.1) gf, respectively. The average forces required to displace the 15mm point of 23-, 25- and 27-gauge DORC vitrectors were 81.9 (0.6) gf, 77.0 (1.6) gf, and 42.0 (0.6) gf, respectively. The average forces required to displace the tip of 23-, 25- and 27-gauge B/L vitrectors were 8.0 (0.3) gf, 6.8 (0.3) gf, and 3.3 (0.1) gf, respectively. The average forces required to displace the 15mm point of 23-, 25- and 27-gauge DORC vitrectors were 67.3 (1.0) gf, 60.5 (0.4) gf, and 33.9 (0.5) gf, respectively. Within each brand, the 23 gauge vitrector was stiffer than the 25 gauge vitrector and the 25 gauge vitrector was stiffer than the 27 gauge vitrectors at both the tip and the 15mm point. All of these differences were statistically significant (P<0.001) and represented in Figures 3 and 4.
Figure 3. Force and Displacement of Vitrectors at Tip Within Brands.
Comparison of gauge sizes within brands at the tip. * indicates significance at P<0.001. n.s. indicates no significant difference.
Figure 4. Force and Displacement of Vitrectors at 15mm Within Brands.
Comparison of gauge sizes within brands at 15mm. * indicates significance at P<0.001 and n.s. indicates no significant difference between groups.
Brand Comparison of Stiffness at Tip
Among the tips of 23-, 25-, and 27-gauge vitrectors, there were significant associations among the brands of vitrectors and the mean forces to displace the tip of the vitrectors (P<.001 for all). Post hoc analysis for 23-gauge vitrectors indicated that Alcon vitrectors were significantly more resistant to displacement than both DORC (P<.001) and B/L vitrectors (P<.001), and DORC vitrectors were more resistant than B/L vitrectors (P<.001). Post hoc analysis for 25-gauge vitrectors indicated that DORC vitrectors were significantly more resistant to displacement than both Alcon (P<.001) vitrectors and B/L vitrectors (P<.001), however no significant difference resulted between 25-gauge Alcon and B/L vitrectors (P=.31). Post hoc analysis for 27-gauge vitrectors indicated that DORC vitrectors were significantly more resistant to displacement than both Alcon (P<.001) and B/L vitrectors (P<.001), and Alcon vitrectors were more resistant than B/L vitrectors (P<.001). These results are shown in Figure 5.
Figure 5. Comparison of Force and Displacement of Vitrectors Between Brands at Tip.
Comparison of vitrector brands at each gauge size at tip. *indicates P<0.001 and n.s. indicates no significant difference.
Brand Comparison of Stiffness at 15mm
Among the 15-mm points of 23-, 25-, and 27-gauge vitrectors, there were significant associations between the brands of vitrectors and the mean forces to displace the tip of the vitrectors (P<.001 for all). Post hoc analysis for 23-gauge vitrectors indicated that Alcon and DORC vitrectors were each significantly more resistant to displacement than B/L vitrectors (P<.001), however no significant difference resulted between Alcon and DORC vitrectors (P<.59). Post hoc analysis for 25-gauge vitrectors indicated that DORC vitrectors were significantly more resistant to displacement than both Alcon (P<.001) vitrectors and B/L vitrectors (P<.001), and Alcon vitrectors were more resistant than B/L vitrectors (P<.001). Post hoc analysis for 27-gauge vitrectors indicated that Alcon vitrectors were significantly more resistant to displacement than both DORC (P<.001) and B/L vitrectors (P<.001), and DORC vitrectors were more resistant than B/L vitrectors (P<.001). These results are summarized in Figure 6.
Figure 6. Comparison of Force and Displacement of Vitrectors Between Brands at 15mm.
Comparison of vitrector brands at each gauge size at 15mm. *indicates P<0.001 and n.s. indicates no significant difference.
Discussion
Vitrectomy is commonly used in treatment of diabetic retinopathy, proliferative vitreoretinopathy, retinal detachment, endophthalmitis and vitreous hemorrhage.13 There are several brands of vitrectors and multiple gauge sizes. Each brand and vitrector size possesses differences in port geometry, vitrector cut rate, stiffness, and other factors. The current study examines the mechanical properties of 23-, 25- and 27- gauge vitrectors among 3 commonly used brands.
Our analysis disclosed that at the tip of the vitrectors at each gauge size, B/L vitrectors required less force to bend compared to both Alcon and DORC vitrectors. Furthermore, similar associations were demonstrated at 15mm proximal from the tip of the vitrectors at each gauge size, with even more pronounced flexibility of B/L vitrectors compared to Alcon and DORC. This difference in stiffness for B/L can be explained through variation between brands in the thickness of the vitrector walls, the inner and outer diameter of the vitrectors and the material used to create the vitrector.14 Use of material with a smaller Young’s constant or thinner walls increases susceptibility to deflection and thus reduces stiffness according to the equation for the application of a point load on a cantilever. 15 Increases in flexibility of the vitrector may present challenges during surgery. One study notes that increased flexibility leads to greater paradoxical movements during surgery. When stress was applied at the proximal end, more flexible instruments demonstrated a greater magnitude of reverse movement at the distal end. This required the surgeon to sub-optimally stabilize the proximal end with their finger while performing surgery. 16
Although Alcon and DORC vitrectors were consistently stiffer than B/L vitrectors, our analysis revealed that between Alcon or DORC, neither demonstrated superior mechanical stiffness across all gauge sizes. This can be explained through variability in gauge length, outer diameter and the material used. 14 However, there is evidence suggesting that despite superior mechanical properties, the vitrectors from Alcon and DORC may not always translate to better surgical outcomes. In one case report, there is documentation of intraoperative DORC vitrector breakage during epiretinal membrane surgery. 11 In two other case reports, there is documentation of intraoperative Alcon vitrector breakage during limbal laceration and tractional retinal detachment surgery. 10,17
The current study also demonstrates that between the 23-, 25- and 27-gauge vitrectors, the 23-gauge vitrectors are the stiffest at both tip and 15mm, followed by 25- and then 27-gauge vitrectors. This can be explained by the outer diameter measurements performed on the vitrectors. The 23-gauge vitrector had the largest outer diameter, followed by the 25-gauge vitrector and then the 27-gauge vitrector. A greater outer diameter increases the moment of inertia for the vitrector and subsequently increases the stiffness. 15,18 This correlates with a previous study that suggests diameter differences may contribute to greater 23- gauge vitrector stiffness when compared to smaller gauge sizes. 14 The advantages of increased stiffness and a larger outer diameter in 23-gauge vitrectomy are that the surgeon has greater control over the distal end of the vitrector and there is a significant reduction in surgical time. 15,18 One study found that on average, 23-gauge vitrectomy required 6 fewer minutes per operation when compared to 25-gauge vitrectomy.3,19 It is important to note that these results are for comparison of single blade and not bi-blade cutters. A disadvantage of the larger outer diameter for 23-gauge vitrectomy is the larger wound size which may require more frequent suturing of sclerotomies. One study showed that 23-gauge vitrectomy, when indicated for floaters or macular surgery, produced significantly greater redness and post operative inflammation than 27-gauge vitrectors. 20
The 25-gauge vitrector was the next stiffest vitrector. Our analysis showed that the difference in stiffness between 23- and 25-gauge vitrectors was smaller than the difference between the 25 gauge and 27 gauge groups. However, there is evidence that this difference is clinically relevant. In three separate case reports, intraoperative breakage of 25-gauge vitrectors is described. 10,11,17 That said, this complication is rare and there is inconclusive evidence on the clinical relevance of 25-gauge vitrectomy compared to 23- gauge vitrectomy. One retrospective study found that the rate of post-surgical complications following 23-gauge vitrectomy was double that of 25-gauge vitrectomy when indicated for retinal detachment.21 Another retrospective study demonstrated that the rate of vitreous rebleeding following 25-gauge vitrectomy was half that of vitreous rebleeding following 23-gauge vitrectomy. 21,22 However, the same study showed that while 25 gauge vitrectomy had a lower risk of complication when compared to 23 gauge vitrectomy, the difference was not statistically significant. 22
Compared to the 23-gauge and 25-gauge vitrectors, the 27-gauge vitrector was significantly less stiff. The decreased stiffness presents a risk particularly in surgery within the anterior vitreous base as any unintended contact with the lens base may contribute to the development or progression of a visually significant cataract in the patient. 10–12 One method currently being used to combat this problem of 27-gauge fragility is reduction of vitrector length. 23,24 While effective at improving stiffness, this method limits the usefulness of the 27-gauge vitrector as it cannot be used in patients with longer axial lengths. 16 The main advantage of the 27-gauge vitrector is the reduced wound size from a smaller outer diameter. Subsequently, 27-gauge vitrectomy tends to be more self-sealing. One study found that when comparing 27- and 25-gauge vitrectors in treating proliferative diabetic retinopathy, the 27-gauge vitrectors required significantly fewer sutures when compared to the 25-gauge vitrectors. 25
The current study has several limitations. First, it is a mechanical investigation of vitrectors. Other variables including cut speed and duty cycle may affect the performance of these vitrectors in patients. Other limitations such as human error and surgeon technique cannot be assessed. Investigators were not able to be blinded to the brands because they appear distinct and in-vivo and intraoperative physics may be different than an experimental set up. Furthermore, the axis of rotation and stress during surgery varies during the case and this study only examined two commonly encountered points on that axis. Additionally, another limitation is that not all vitrectors tested were single blade vitrectors. All B/L cutters in addition to the 25 gauge ALCON vitrector were bi-blade cutters.
In conclusion, the stiffness of vitrectors is crucial when it comes to selecting the right vitrectomy system and gauge for each surgeon. However, other factors such as user interface, cut rate, aspiration rate and the type of surgery being performed are also important considerations when selecting the optimal setup. Based on this study, 25-gauge vitrectors, although larger than 27-gauge vitrectors and less stiff than 23- gauge vitrectors may offer an optimal tradeoff between stiffness and gauge size. This is because the difference between the stiffness of the 23- and 25-gauge vitrectors is far smaller than the difference between the 25 and 27 gauge vitrectors. That said, surgeon experience, preference, and the type of surgery being performed take precedence. Importantly, for vitrectomies performed with the primary goal of clearing the visual axis – such as in the case of vitreous floaters or vitreous hemorrhage – the discrepancy in mechanical properties of the vitrectors may not be relevant. However, if the vitrector is being used to dissect or peel membranes in procedures where the vitrector is being subject to greater force, then the increased flexibility of the smaller gauge vitrectors described in this paper may present more problems. To further characterize the mechanical properties of vitrectors, future studies may focus on identifying the point of elastic deformation or breakage. Knowledge of these mechanical properties will hopefully better aid surgeons in choosing between vitrectors for their patients to improve safety, efficiency, and outcomes.
Supplementary Material
Supplementary Table 1 Brand and Lot Numbers of Vitrectors Used
A systematic comparison of the mechanical stiffness properties for 23, 25 and 27 gauge vitrectomy vitrectors across three brands revealed that 25 gauge vitrectors may offer the optimum tradeoff between stiffness and gauge size.
Financial Support:
This work was supported by the Macula Foundation. Bascom Palmer Eye Institute received funding from the NIH Core Grant P30EY014801, Department of Defense Grant #W81XWH-13– 1-0048, and a Research to Prevent Blindness Unrestricted Grant. The sponsors or funding organizations had no role in the design or conduct of this research.
Footnotes
Conflict of Interest:
Dr. Patel is a consultant for Alimera, Allergan Alcon, Eye Point, Genentech, Novartis. Dr. Yannuzzi is a consultant for Alimera Science, Genentech, Alcon, and Novartis. Dr. Sridhar is a consultant for Alcon, Dorc, Oxurion, Genentech, and Regeneron.
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Associated Data
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Supplementary Materials
Supplementary Table 1 Brand and Lot Numbers of Vitrectors Used