Purpose To evaluate the incidence and characteristics of iatrogenic retinal breaks in 20-gauge macular surgery with an intensified search strategy.

Design Retrospective, non-comparative interventional case series.

Participants 218 consecutive operations in 209 patients who underwent 20-gauge vitrectomy vitrectomy for idiopathic macular pucker or idiopathic macular hole.

Methods Retrospective review of patient records undergoing 20-gauge vitrectomy with intensified peripheral search for retinal defects.

Main outcome measures Incidence of breaks related to the sclerotomies, the incidence of breaks occurring elsewhere, the incidence of lesions suspicious for traction, the location of identified breaks and intraoperative induction of posterior vitreous detachment.

Results Retinal breaks occurred in 24.3% of operations. In 17.4% breaks were related to the sclerotomies and in 9.6% of breaks were found elsewhere. In 6.4% of eyes, only lesions suspicious for traction were detected. Retinal detachment occurred in 1.8% of cases. The occurrence of breaks was significantly related to induction of PVD.

Conclusions With intensified intraoperative search, a much higher incidence of retinal breaks was found than previously reported in the literature. Despite the high incidence of breaks, the incidence of postoperative rhegmatogenous retinal detachment was low. These findings support the rationale that intensive intraoperative search for iatrogenic breaks is crucial for the prevention of postoperative retinal detachments in macular surgery.