Eyeworld

36 | EYEWORLD | WINTER 2025 ATARACT C by Ellen Stodola Editorial Co-Director About the physicians Brandon Baartman, MD Vance Thompson Vision Omaha, Nebraska Kamran Riaz, MD Clinical Professor Thelma Gaylord Endowed Chair in Ophthalmology Vice Chair for Clinical Research Dean McGee Eye Institute Oklahoma City, Oklahoma YES CONNECT: OPENING DOORS vitreous traction, and safely place an IOL (either one-piece if the PC tear is focal and central or three-piece in the sulcus with or without optic capture). The other scenario in which surgeons often utilize this technique is when performing secondary IOL placement and exchanges (e.g., unhappy advanced-technology IOL patients, especially if a YAG has been performed), Dr. Riaz said. "In these cases, vitreous may be already in the AC, may be causing some of the pseudophakic unhappiness, or may prolapse anteriorly when trying to remove the IOL. Therefore, a pars plana approach can create a safe/clean AC for IOL removal/replacement, provide a more controlled surgical field during IOL replacement, improve long-term stability of the new IOL by making sure the optic/haptics are supported in a vitreous-free environment, and reduce vitreous incarceration around the haptics or AC structures that can lead to post- operative CME/retinal tears." He added that many anterior segment surgeons are shifting to a posterior approach thanks to a growing body of knowledge demonstrating safety and efficacy. "The only time I still do the 'traditional' anterior vitrectomy is if I'm doing [scleral-fixated] IOL surgery in a patient who has already been vit- rectomized but now has aphakia or a dislocated IOL," he said. "I've found, in these cases, there is often still some vitreous left near the IOL-iris, so the bimanual anterior vitrectomy approach works well here." Many cases where the need for vitrectomy arises can be managed by either the anteri- or or posterior approach, Dr. Baartman said. "Cases necessitating vitrectomy are usually vitreous prolapse from a ruptured capsular bag or damaged or absent zonular complex," he said. "Generally speaking, if vitreous is present- ing unexpectedly during an otherwise routine case, I favor the simplicity of a bimanual limbal approach to removing what is usually a limited amount of vitreous." Dr. Baartman gave the example of a poste- rior polar cataract where during cortex removal around the posterior plaque, a posterior capsu- lar opening is encountered. He said that many Pars plana anterior vitrectomy: an evolving practice continued on page 38 For this YES Connect column, we invited Brandon Baartman, MD, and Kamran Riaz, MD, to share their experiences and insights on pars plana approach anterior vitrectomy. As anterior segment surgeries become increasingly complex, many surgeons are incorporating this technique into their skillsets for situations where thorough vitreous removal is essential. In recent years, the term "middle segment surgery" has gained traction to describe anterior segment sur- geons who access the posterior chamber through the pars plana for secondary lens fixation and vitrectomy. Sessions on middle segment surgery are now regularly featured at national and international academic conferences and serve as valuable resources for those whose practices involve complex anterior segment surgery. It is im- portant to note that surgeons—both early-career and experienced—should always operate within the bounds of their training and comfort, seeking mentorship when undertaking these advanced procedures for the first time. —Brenton Finklea, MD YES Connect Guest Editor T he performance of a pars plana an- terior vitrectomy can be an essential skill in select circumstances. Brandon Baartman, MD, and Kamran Riaz, MD, discussed when this approach may best be utilized, benefits of the approach, and other nuances. Dr. Riaz said that the most common sce- nario to use anterior vitrectomy from the pars plana is following a PC tear with vitreous loss into the anterior chamber, which occurs during routine cataract surgery. "Traditionally, we would use the bimanual anterior vitrector through two paracenteses incisions," he said. "In recent years, many of us have shifted to using the anterior vitrector in these situations to enter the pars plana. The pars plana approach is preferred, in my opinion, because it allows the surgeon to cut the vitreous from behind the IOL- zonule complex, which allows the vitreous to fall back." He added that this allows the surgeon to clear the AC/pupil/capsular bag to create a stable anterior chamber environment, reduce

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