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[Eye Reports 2011; 1:e3] [page 5]

Outcomes of 23-gauge pars
plana vitrectomy in combined
scleral buckling and vitrectomy
for complex rhegmatogenous
retinal detachments
Scott D. Schoenberger,1
Daniel M. Miller,1,2
Christopher D. Riemann,1,2
Robert E. Foster,2 Michael R. Petersen2
1Department of Ophthalmology,
University of Cincinnati; 2Cincinnati Eye
Institute, Cincinnati, Ohio, USA

Abstract 

Rhegmatogenous retinal detachments asso-
ciated with proliferative vitreoretinopathy,
giant retinal tears, ocular trauma, proliferative
diabetic retinopathy, or necrotizing retinitis
are considered more complex than those with-
out these factors. The aim of the current
review is to address the surgical outcomes and
complications of 23-gauge pars plana vitrecto-
my with scleral buckling (23GPPV/SB) for
repair of these complex retinal detachments.
This retrospective study involved 54 eyes of 53
patients who underwent 23GPPV/SB between
July 2007 and September 2009. Preoperative
diagnosis, surgical technique, preoperative
and postoperative visual acuities, intraopera-
tive and postoperative complications, and
anatomic reattachment rates were examined.
Fifty-four eyes of 53 patients were reviewed in
this study and indications for surgery varied.
Mean logarithm of the minimal angle of reso-
lution�(logMAR) pre- and post-operative visu-
al�acuities were 1.166 (20/293) and 0.780
(20/120), respectively, which led to a statisti-
cally significant improvement in logMAR
(P=0.0165). Single operation and final reat-
tachment rates were 87% (47 of 54 eyes) and
100%, respectively. Postoperative complica-
tions included choroidal effusion/hemorrhage
(14.8%, 8 of 54 eyes) and vitreous hemorrhage
(11.1%, 6 of 54 eyes). Other more infrequent
complications included hyphema (9.3%, 5 of 54
eyes), hypotony (5.6%, 3 of 54 eyes) and ocular
hypertension > 35 mmHg (3.7%, 2 of 54 eyes).
A total of 31.5% (17 of 54 eyes) of patients had
a complication in the postoperative time peri-
od, but 58.8% of these resolved spontaneously
without requiring an intervention. 23GPPV/SB
may be considered for complex retinal detach-
ment repair with good anatomic reattachment
rates, but with relatively high complication
rates.

Introduction

Advancements in surgical instrumentation
have led to changes in the surgical repair of
rhegmatogenous retinal detachments (RRDs).
Key components of RRD repair include pars
plana vitrectomy (PPV), scleral buckling proce-
dure (SBP), intraocular gas and silicone oil
(SO) infusion, endolaser photocoagulation,
perfluorocarbon liquids, and wide-angle view-
ing systems.1-4 The evolution of smaller gauge
vitrectomy instruments has been a significant
technological advance in vitreoretinal surgery.
There has been a trend towards the use of
smaller gauge vitrectomy instruments to treat
increasing complex posterior segment patholo-
gy.5-7 Twenty three- and 25-gauge instruments
have been used in primary pseudophakic reti-
nal detachment repair.8 There have also been
reports of their use in more complex retinal
detachments requiring silicone oil.9,10

There is a spectrum of pathology in the
treatment of RRDs. Generally, RRDs associated
with proliferative vitreoretinopathy (PVR),
giant retinal tears (GRT), ocular trauma, pro-
liferative diabetic retinopathy (PDR), or necro-
tizing retinitis are considered more complex
than RRDs without these factors.11 Many vitre-
oretinal surgeons would manage these more
complex cases utilizing 20-gauge pars plana
vitrectomy, and in many instances, with com-
bined scleral buckling.12-18 However, the man-
agement of complex RRDs varies by surgeon
preference and experience.
The aim of this retrospective study was to

examine the anatomic success, visual out-
comes, and complications of patients with
complex RRDs treated with 23-gauge pars
plana vitrectomy with scleral buckling
(23GPPV/SB). Indications for surgery in this
review included RRDs associated with PVR
(any grade), GRT, ocular trauma, high myopia
and multiple tears.

Materials and Methods

Patients who underwent 23-gauge PPV with
SBP between July 2007 and September of 2009
by one of four surgeons at the Cincinnati Eye
Institute were retrospectively identified. All
patients provided preoperative informed con-
sent for surgery. After the final follow up visit
for each patient, data were retrospectively
reviewed and were collected in accordance
with compliance guidelines set forth by the
Health Insurance Portability and Accounta -
bility Act of 1996. Institutional review board
(IRB) approval was obtained from the
University of Cincinnati IRB prior to data col-
lection. All patients undergoing 23GPPV/SB
between the time frames mentioned above

with at least one month of follow-up were
included in the study. 
All patients underwent either local anesthe-

sia with monitored anesthesia care and
retrobulbar anesthesia or general anesthesia.
The periocular skin was prepared with 5%
povidone-iodine followed by a drop of povi-
done-iodine in the inferior fornix. The eye
was prepared and draped in standard fashion
and a lid speculum was placed. A 360-degree
encircling scleral buckle was placed using
standard techniques. The site of all breaks
was identified with indirect ophthalmoscopy
and scleral depression. The buckle was posi-
tioned to support the identified breaks and/or
vitreous base. A #42 band or #41 band
(Labtician, Oakville, Ontario, Canada) was
sutured into position utilizing 5-0 nylon hori-
zontal mattress sutures and the buckle was
opposed with a Watzke sleeve (Labtician). The
buckle was raised to a moderate height prior
to proceeding with vitrectomy. Simultaneous
clear corneal cataract surgery was performed
by the vitreoretinal surgeon using standard
phacoemulsification techniques in three of
the cases. A 10-0 nylon suture was placed in
the corneal incision at the conclusion of the
cataract surgery. 
All PPV and cataract surgery was performed

utilizing the Accurus® Vitreoretinal Surgical
System (Alcon Laboratories Fort Worth, TX,
USA) and either Xenon (Alcon) or Photon
(Synergetics, O’Fallon, MO, USA) light
sources. The trocar/cannula system (Alcon)
was used to place 23-gauge cannulas in the
superonasal, superotemporal and inferotem-
poral quadrants. The trocar/cannula incisions
were made in a beveled fashion through bare

Eye Reports 2011; volume 1:e3

Correspondence: Daniel M. Miller, 1945 CEI
Drive, Cincinnati, OH 45242, USA. 
Tel. +1.513.984.5133 - Fax: +1.513.984.2390.
Email: dmiller@cincinnatieye.com

Key words: pars plana vitrectomy, scleral buck-
ling, complex rhegmatogenous retinal detach-
ment.

Conflict of interest: the authors report no con-
flicts of interest. 

Contributions: all the authors contributed equally.

Received for publication: 17 April 2011.
Accepted for publication: 24 June 2011.

This work is licensed under a Creative Commons
Attribution NonCommercial 3.0 License (CC BY-
NC 3.0).

©Copyright S.D. Schoenberger et al., 2011
Licensee PAGEPress, Italy
Eye Reports 2011; 1:e3
doi:10.4081/eye.2011.e3

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[page 6] [Eye Reports 2011; 1:e3]

sclera. The conjunctiva had been previously
recessed during the peritomy for scleral buck-
ling. Cannulas were placed inferotemporally,
superotemporally, and superonasally 3 mm
posterior to the limbus for pseudophakic eyes
and 4 mm for phakic eyes. The infusion line
was connected to the inferotemporal cannula.
Wide-angle fundus visualization was achieved
using either the BIOM noncontact wide field
imaging system (Oculus, Munich, Germany)
or the AVI contact panoramic viewing system
(Advanced Visual Systems Inc., NY, NY, USA). 
The surgical procedures varied slightly

depending upon the location and extent of the
retinal detachment and the individual prefer-
ences of the four surgeons. Generally, a core
vitrectomy was performed followed by meticu-
lous peripheral vitreous dissection with par-
ticular attention to relieving all traction at the
sites of retinal breaks and along detached reti-
na. Scleral depression was performed when
necessary. In many cases, Perfluoron (Alcon)
was utilized to stabilize detached retina and
facilitate egress of subretinal fluid through
peripheral retinal breaks. Membrane peeling
was performed using end-grasping forceps.
Retinectomy was performed in some cases
utilizing either the vitreous cutter or intraoc-
ular scissors. A fluid-air exchange with a soft
tip extrusion needle with active suction or the
vitreous cutter itself was used to drain sub-
retinal and posterior pole fluid. A directional
endolaser (Synergetics) and/or laser indirect
ophthalmoscope was utilized to demarcate
retinal breaks and in some cases to perform
360 degree laser or demarcate a retinectomy
border. Nonexpansile mixtures of either per-
fluoropropane (C3F8) or sulfur hexafluoride
(SF6) were used, and in many cases, 5000
centistoke silicone oil (Bausch and Lomb, San
Dimas, CA, USA) was utilized for tamponade. 
At the conclusion of each procedure, the

sclerotomies were closed with 7-0 vicryl
sutures for many of the patients. The overly-
ing conjunctiva was closed with 6-0 plain gut
suture. Subconjunctival antibiotic and dexam-
ethasone was administered. Ciloxan oph-
thalmic ointment was placed on the surface of
the eye followed by a patch and shield.
Patients were instructed to position either
face down or one side down for on average 7
days.
Patient medical records were reviewed.

Age, gender, eye, ophthalmic history, pre- and
post-operative Snellen visual acuities, surgery
data, intra- and post-operative complications,
final attachment rates and need for subse-
quent retinal detachment repair were
obtained. Length of follow up was also record-
ed. A total of 54 eyes in 53 patients were iden-
tified. One male patient underwent surgery on
both eyes during the course of the study; one
eye had a RRD with high myopia and the other
eye had a GRT. With the exception of patient

gender, all statistical analysis and percentages
were in reference to the number of eyes.
Snellen visual acuities were converted to

logMAR values for statistical analysis using
the following equation: logMAR = - log (visual
fraction). LogMAR acuities were converted
back to Snellen visual acuities for reporting
mean preoperative and postoperative visual
acuities. For visual acuities worse than
20/400, visual function was recorded as count
fingers (CF), hand motion (HM) or light per-
ception (LP). No patients had no light percep-
tion vision pre or postoperatively. LogMAR val-
ues were assigned as 2.0 (CF vision), 2.3 (HM
vision) or 2.6 (LP vision), as has been used in
other studies.19-20 A student’s t-test with a 5%
level of significance was used to determine if
there was a statistical difference in the pre
and postoperative logMAR visual acuities, and
to compare postoperative complication rates
among those with silicone filled eyes versus
gas filled eyes. 

Results

Patient demographics are summarized in
Table 1. There were 54 eyes of 53 patients who
underwent 23GPPV/SB. Mean age of the 54
eyes was 53.96 years (range of 18-88 years,
standard deviation of 15.33). Right eyes were
affected in 48.1% (26 of 54 eyes), while left
eyes were affected in 51.9% (28 of 54 eyes). 41
of 53 patients (77.4%) were males, while the
remaining 12 patients (22.6%) were females.
One male patient underwent surgery on both
eyes during the study. The mean follow up
time for each eye was 8.96 months (standard
deviation 5.61, range 1 to 23 months).
The indications for surgery included the fol-

lowing: RRD with any grade of PVR (15 of 54
eyes, 27.8%), multiple breaks associated with
RRD (13 of 54 eyes, 24.1%), GRT (9 of 54 eyes
16.7%), high myopia (8 of 54 eyes, 14.8%),
trauma (4 of 54 eyes, 7.4%), and other (5 of 54
eyes, 4.8%). Lens status was as follows: 37.0%
of eyes were phakic (20 of 54 eyes), 59.3%
were pseudophakic (32 of 54 eyes), one was
aphakic (1.9%) and one had an anterior cham-
ber intraocular lens (1.9%). Fifteen of 54 eyes
(27.8%) had undergone a prior pars plana vit-
rectomy.
Table 2 summarizes surgical techniques

and intraoperative variables. A 360-degree
encircling scleral buckle was placed in all
eyes. The number of eyes with simultaneous
cataract extraction was three of 54 (5.6%) and
one eye underwent a retinectomy at the time
of surgery. The most commonly used tam-
ponading agent was SF6 (61.1%, 33 of 54
eyes), with silicone oil (24.1%, 13 of 54 eyes)
and C3F8 (14.8%, 8 of 54 eyes) used less fre-
quently. The vast majority of eyes had a 42

band placed (88.9%, 48 of 54 eyes) as opposed
to a 41 band (11.1%, 6 of 54 eyes). Perfluoro-
n-octane (PFO) was used in 66.7% of eyes (36
of 54  eyes). All sclerotomies were left open in
three eyes and a portion was left open in four
eyes. All 23-gauge sclerotomy incisions were
closed with a single interrupted 7-0 vicryl
suture in the majority of cases (47 eyes).  
Visual outcomes, anatomic success and

Article

Table 1. Patient demographics.

Gender Number of patients (%)
Male 41 (77.4)*
Female 12 (22.6)

Age of 54 eyes
Mean 53.96 years
Standard deviation 15.33

Follow up time of 54 eyes
Mean 8.96 months
Standard deviation 5.61

Number of eyes (%)

Eye involved 
Right 26 (48.1)
Left 28 (51.9)

Diagnosis 
RRD with PVR 15 (27.8)
Multiple tears 13 (24.1)
GRT 9 (16.7)
Myopia 8 (14.8)
Traumatic 4 (7.4)
Other 5 (4.8)

Prior PPV 
Yes 15 (27.8)
No 39 (72.2)

Lens Status 
Phakic 20 (37.0)
Pseudophakic 32 (59.3)
ACIOL 1 (1.9)
Aphakic 1 (1.9)

*One male patient had surgery on both eyes. RRD, rhegmatogenous
retinal detachment; PVR, proliferative vitreoretinopathy; GRT, giant
retinal tear; ACIOL, anterior chamber intraocular lens.

Table 2. Intraoperative features.

Number of eyes
(% of eyes)

Additional step
Retinectomy 1 (1.9%)
Cataract extraction 3 (5.6%)
PFO 36 (66.7%)

Intraocular tamponade
SF6 33 (61.1%)
C3F8 8 (14.8%)
Silicone Oil 13 (24.1%)

Band Placed
41 6 (11.1%)
42 48 (88.9%)

PPV, pars plana vitrectomy; PFO, perfluoro-n-octane.

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[Eye Reports 2011; 1:e3] [page 7]

complications are summarized in Table 3.
Mean logMAR preoperative visual acuity was
1.166 (20/293) with a standard deviation of
0.941. Mean logMAR postoperative visual acu-
ity was 0.780 (20/120) with a standard devia-
tion of 0.685. Visual acuity significantly
improved by 0.386 logMAR units (P=0.0165).
The anatomic reattachment rate was 87.0%
after one operation (47 of 54 eyes), with all
eyes ultimately remaining attached.  Seven
eyes developed recurrent retinal detachment
(rhegmatogenous and/or tractional) and
required additional surgery. Six were due to
PVR and one was related to a choroidal hemor-
rhage. Two eyes required a third retinal
detachment repair.
Additional postoperative complications

other than recurrent retinal detachment were
common in this series reflecting the complex-
ity of the underlying pathology. As listed in
table 3, complications were separated based on
when they presented clinically: intraoperative/
immediate (postoperative day one) or delayed
(postoperative day two or beyond). Choroidal
effusion or hemorrhage occurred in 8 of 54
eyes (14.8%). Five eyes had an intraoperative
or immediate choroidal effusion or hemor-
rhage. Only one of the eight eyes with a
choroidal effusion or hemorrhage had co-
existing hypotony. Vitreous hemorrhage
occurred in 6 eyes (11.1%), of which two were
immediate and resolved spontaneously. Three
of four eyes with a delayed vitreous hemor-
rhage occurred in eyes that re-detached and
required additional surgery. A hyphema
occurred in five eyes (9.3%). Delayed hyphe-
mas (three of five eyes) resolved spontaneous-
ly, but the two eyes with immediate hyphemas
also developed vitreous and suprachoroidal
hemorrhages. Hypotony occurred in three of 54
eyes (5.6%). It resolved spontaneously in two
eyes, but one eye also developed a choroidal
hemorrhage, hyphema, vitreous hemorrhage,
and ultimately required a second retinal
detachment repair. Ocular hypertension with
an intraocular pressure greater than 35 mmHg
occurred on POD1 in 2 of 54 eyes (3.7% of
eyes), but resolved by the next postoperative
visit. A total of 17 eyes (31.5%) had one of
these complications at some point during the
intraoperative or postoperative course, but
over half of these (59.9%) resolved without any
intervention. Two patients had at least four
complications, including hyphema, vitreous
hemorrhage, choroidal hemorrhage and a reti-
nal detachment. They attained final Snellen
visual acuities of 20/200 and 20/400. There was
a nonsignificant trend towards decreased com-
plications in silicone filled eyes (15.4% versus
36.6% in gas filled eyes, P=0.157). 

Discussion

Prior studies have described complex rheg-
matogenous retinal detachments as those that
have included PVR, GRT, ocular trauma,
high/pathologic myopia, PDR, and necrotizing
retinitis.11 Surgeon preference influences the
surgical approach to more complex pathology.
Many surgeons would consider combined scle-
ral buckling and 20-gauge PPV for these
cases.15-18,21-24

A recent trend in vitreoretinal surgery has
been the application of smaller gauge vitrecto-
my instruments for increasing complex retinal
pathologies. Twenty three-gauge PPV has been
shown to be associated with more rapid visual
recovery than traditional 20-gauge PPV in
epiretinal membrane surgery.25 Others have
used 23-gauge PPV for a multitude of posterior
segment pathology with few complications and
improved visual acuity.26-28 Given the recent lit-
erature supporting the use of smaller vitrecto-
my instruments with a good visual outcome
and safety profile, the goal of the current
review was to describe results using 23-gauge
pars plana vitrectomy in combination with
scleral buckling in these complex retinal
detachment repairs.
The main outcome measures included pre-

operative and postoperative visual acuities,
postoperative complications, and anatomic
success. Visual acuities were significantly bet-
ter postoperatively. Preoperative Snellen
acuities averaged about 20/300 and postopera-
tively were about 20/120. The role of induced
corneal astigmatism by surgery was not
addressed in this study, but prior studies have
shown this to be less of an issue in those
undergoing 23-gauge PPV as compared to 20-
gauge PPV.25 Surgically induced corneal astig-
matism is unlikely to be a critical factor in
patients with complex RRDs and generally
poor postoperative visual acuity results.
However, a large proportion of patients with
complex rhegmatogenous RRD do achieve
good visual acuities and PPV-induced astigma-
tism may be a factor in their visual rehabilita-
tion. Immediate and delayed complications
were not uncommon, as nearly one third of
patients had a hyphema, ocular hypertension
or hypotony, choroidal effusion or hemorrhage,
vitreous hemorrhage or retinal detachment at
some point in the postoperative period. The
most common complications were choroidal
effusions/hemorrhages and vitreous hemor-
rhages. One hypothesis is that there may be
transient hypotony postoperatively in these
cases. This may occur even when 23-gauge
sclerotomy sites are closed with 7-0 vicryl
sutures. The trocar system used in this series
produces an irregular t-shaped sclerotomy site
even when made in a beveled fashion and thus
may not close completely as with a linear 20-

gauge incision. Several patients also had other
risk factors for transient hypotony, including
high myopia and prior pars plana vitrectomy.
Overall, postoperative complications (with the
exception of recurrent retinal detachment)
were generally self-limited and did not affect
final anatomic result or visual acuity results. 
The complication rates reported in this

study are higher than those previously pub-
lished by others for 20 gauge PPV with scleral
buckling. Wickham et al.22 and Gartry et al.14

reported vitreous hemorrhage in approximate-
ly 5-7% and choroidal hemorrhage in 4% of
patients undergoing combined 20-gauge PPV
with scleral buckling. However, the inclusion
and exclusion criteria were different from the
current review. In the former,22 patients were
excluded if they had prior PPV, had grade C or
greater PVR or GRTs. The latter article14

reviewed cases of relatively uncomplicated
RRD, excluding GRTs and more advanced PVR.
Albrieux et al. compared 23-gauge PPV to 20
gauge PPV for RRD repair.29 They found a sim-
ilar rate of postoperative complications and
anatomic reattachment among the two groups.
While the rate of complications was lower than
the current review (one choroidal detachment
in the 23 gauge group, no hypotony, no report-
ed vitreous hemorrhage or hyphema), SBP was
not performed, and patients were excluded if

Article

Table 3. Visual outcomes and complica-
tions.

Mean preoperative visual acuity
Snellen 20/293
LogMAR 1.166

Mean postoperative visual acuity
Snellen 20/120
LogMar 0.780

LogMAR improvement 0.386
Number of eyes

(% of eyes)

Anatomic Success
After one surgery 47 (87.0)
After two surgeries 52 (96.3%)
Final 54 (100%)

Immediate or intraoperative 
complications
Ocular hypertension 2 (3.7%)
Hypotony 1 (1.9%)
Hyphema 2 (3.7%)
Vitreous hemorrhage 2 (3.7%)
Choroidal effusion/hemorrhage 5 (9.3%)

Delayed complications 
(Prestenting POD2 and beyond)
Ocular hypertension 0 (0.0%)
Hypotony 2 (3.8%)
Hyphema 3 (5.6%)
Vitreous hemorrhage 4 (7.4%)
Choroidal effusion/hemorrhage 3 (5.6%)

Number of eyes 17 (31.5%)
with any complication

VA, visual acuity; logMAR, logarithm of the minimal angle of resolu-
tion; POD2, postoperative day 2.

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they had prior PPV, traumatic RD, PVR grade C,
GRTs, among other exclusion criteria. 
In the current review, patients had an

anatomic reattachment rate of 87% after one
surgery, but reached final reattachment in all
cases. The reattachment rates in this study
were similar to those reported by others for
more complex retinal detachments.10,12,14,15,22

Single operation reattachment rates were
lower than those reported by Stangos et al.
(92.3%) and Weichel et al. (94%), but these
patients underwent 20 gauge PPV with SBP for
pseudophakic RRDs without associated PVR or
GRT.13,28 The anatomic reattachment reported
by Albrieux et al. for PPV without SBP was
74.3% (20 gauge group) and 80% (23 gauge
group).29 The anatomic reattachment rate in
the current review was similar to another
study comparing 20 (89.3%), 23 (88.9%) and
25 gauge PPV (93.3%) without SBP for
pseudophakic RRDs in patients without prior
PPV.30

There are significant limitations to this ret-
rospective study. First, the sample size is fairly
small and indications for surgery were vari-
able. Also, there are a large number of con-
founding variables that were present, includ-
ing a history of prior PPV, gas or silicone used
for intraocular tamponade, use of PFO, closure
of sclerotomies and simultaneous cataract
extraction or retinectomy. Certainly, some of
these variables might play a role in the single
operation reattachment rates and the develop-
ment of postoperative complications. 
The potential advantages of 23GPPV/SB sur-

gery versus 20-gauge includes smaller sclero-
tomy size, cannula based infusion line place-
ment (versus suture fixation), and possibly
reduced astigmatism. In the past, smaller
gauge surgeries for more complex detach-
ments have been limited due to reduced
instrument rigidity and a reduced armamen-
tarium of instruments (e.g. scissors).
However, a wider array of ancillary instru-
ments is available and 23-gauge PPV instru-
ments have significant rigidity allowing com-
plete eye rotation/control and dissection of
dense fibrovascular tissue. Recent studies
have shown similar flow rates between 23- and
20-gauge instruments thus enabling high vac-
uum based maneuvers.31,32 Eventually, when a
23-gauge fragmotome for lensectomy is pro-
duced, the 23-gauge platform may replace 20-
gauge PPV in most cases. 
In summary, we conclude that 23-gauge pars

plana vitrectomy with scleral buckling is a
viable alternative to the traditional 20-gauge
pars plana vitrectomy with scleral buckling.
Our retrospective study shows a significant
improvement in visual acuity after surgery,
with a high single operation reattachment rate
and a final reattachment rate of 100%.
However, our study did show that postoperative
complications (especially vitreous hemorrhage

and choroidal effusion/hemorrhage) are high-
er than those reported in some prior stud-
ies14,22 and that these complications need to be
further studied. It is unknown whether the
higher complication rate is related to the 23
gauge platform or a difference in patient popu-
lation, with more complex PVR, ocular trauma,
and GRTs included in the current review.
Ideally, a study to compare traditional 20-gauge
PPV with scleral buckling and 23-gauge PPV
with scleral buckling would help elucidate
whether or not these complications are related
to smaller gauge vitrectomy instruments and
incisions, or related to the highly complex
nature of retinal detachment repair in these
patients. 

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