Microincision vitrectomy surgery (MIVS) is changing the way that vitreoretinal specialists operate. As with any new technology, MIVS has a number of significant advantages, as well as a few new challenges.

From the patient's perspective, MIVS not only has a better postoperative appearance, but it is more comfortable. The use of a trocar and cannula system causes less disruption of the conjunctiva and sclera, and the incisions themselves are quite a bit smaller (0.51 mm for 25 G and 0.64 mm for 23 G) versus 0.9 mm with 20 G vitrectomy. Another reason is the MIVS scleral incisions are beveled. These ideally are self-sealing and often do not require suturing (more on that later).

Overall, patients come in on postoperative day 1 usually with minimal to no discomfort and they are not usually troubled by slowly dissolving Vicryl sutures rubbing under their eyelids for two weeks. Because the incisions into the conjunctiva are smaller, there is less bleeding, which results in a better cosmetic appearance (still not as good as after cataract surgery, but for a retina surgeon, it is pretty good).

Visual recovery also seems to be faster with MIVS; the wounds are smaller and require fewer sutures so these eyes have less postoperative astigmatism. Even if sutures are required, because of the small size these wounds can normally be closed with a single simple interrupted 8-0 Vicryl suture. Recently, a colleague from Maine suggested using 6-0 plain gut sutures. Although I've just started using them, they seem to work well, and these patients seem to have even less scratchiness. (If you try this, please make sure to rinse the suture and keep it short.)

From the surgeon's perspective, there are a number of advantages to MIVS. For most cases, MIVS is faster than standard 20 G vitrectomy. With the previous-generation MIVS systems, especially 25 G, vitrectomy removal took longer, but the time saved in opening and closing the eye made the overall surgical time for 'straight-forward' cases about the same or somewhat less than 20 G vitrectomy.

The new-generation MIVS systems offer 5,000 cuts-per-minute. The surgeon is able to remove the vitreous remarkably efficiently, and the vitrectomy time is better than with standard 20 G vitrectomy. For those accustomed to 20 G systems, a 20 G 5,000 cuts-per-minute probe is available, but given how efficient the MIVS systems are at this rate, 20 G vitrectomy does not distinguish itself.