Eyeworld

38 | EYEWORLD | WINTER 2025 ATARACT C Relevant disclosures Baartman: None Riaz: None considering sutured lens fixation or intrascleral haptic fixation. "I would also consider a posterior approach beneficial when, in the example of an open bag IOL exchange, you can preempt vitreous loss by accessing the vitreous cavity prior to IOL re- moval and have more control," he said. "Bonus points for this approach are when you are using a trocar and are in need of IOP maintenance, you can use posterior infusion once the vitrecto- my is complete and keep the peri-limbal space free from a bulky AC maintainer." Dr. Riaz also finds that the anterior to posterior fluid flow is a benefit of the pars plana approach. It pulls vitreous posteriorly, away from the corneal wounds and allows the vitreous to naturally fall back into the posterior cavity, he said, which in turn helps to make sure the unwanted blurry vision or "pupil peaking," because of vitreous still present in the AC, doesn't occur. Another benefit, he said, is a stable anterior chamber. The infusion through the limbus or pars plana maintains a formed chamber, mini- mizing iris prolapse and wound stress. This also offers clearer visualization with less turbulence and less risk of corneal endo- thelial trauma compared to limbal vitrectomy because the vitrector isn't close to the cornea. Pars plana anterior vitrectomy also offers the advantage of long-term safety, Dr. Riaz said. It decreases the risk of retinal breaks, CME, and other vitreoretinal sequelae from vitreous incarceration. Finally, he said that one "bonus benefit" is it can get rid of floaters that many patients have that cause visual problems. Skills/techniques Dr. Riaz said the biggest skill needed is to be able to enter the pars plana safely and effective- ly. He thinks this is easier for younger surgeons who have done many pars plana injections for retinal pathology during training. He added that comfort with pars plana entry anatomy (3.5 mm posterior to the limbus in pseudophakic/apha- kic eyes) is also important. "Use a caliper and measurement; don't just 'eyeball' the 3.5 mm distance," he said. Surgeons should also plan to use a trocar- cannula system for safe access. "This is probably the biggest thing that makes surgeons hesitant," Dr. Riaz said. He uses a 23 g trocar but added times, this can be managed without vitreous loss, but if there is vitreous present in the an- terior chamber after lens placement, an ante- rior approach is sufficient. "For cases that are known to require an anterior vitrectomy, such as an open capsule IOL exchange or a dislocat- ed lens-bag complex in a patient without prior vitrectomy, I would favor a pars plana approach for more control and a more complete anterior vitrectomy," he said. Benefits of the pars plana approach Dr. Baartman noted several benefits to a pars plana vitrectomy for the anterior segment surgeon. "First, you're accessing the vitreous cavity directly, and the direction of travel of the vitreous during vitrectomy is posterior instead of anterior. I like the physiology of anterior infu- sion and posterior vitrectomy. Presumably, this would create less traction on a vitreous body still adherent to the retina." Another benefit he noted is a more com- plete vitrectomy, which may be preferred when continued from page 36 An eye undergoing pars plana anterior vitrectomy after ACIOL removal via superior scleral tunnel. An AC maintainer is present to maintain infusion, which can be moved posterior via the trocar (bottom right) during insertion of the secondary IOL. Source: Brandon Baartman, MD

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