Eyeworld

WINTER 2025 | EYEWORLD | 39 C Contact Baartman: brandon.baartman @vancethompsonvision.com Riaz: Kamran-Riaz@dmei.org eye with other instruments, he said, which will ensure the sclerotomy is complete. "It's also good practice to perform vitrec- tomy as you are entering and exiting the eye via the sclerotomy so as not to drag vitreous," he said. "A leaking sclerotomy is possible, even with a transconjunctival trocar, so ensure it's sealed before closing up the case to avoid hypo- tony or an inadvertent bleb." Dr. Baartman added that cases with vitreous loss are also known to have a higher risk of en- dophthalmitis. "If you're not sure, pass a suture to close the sclerotomy," he said. There's also always a potential risk of retinal detachment or choroidal hemorrhage in these complex eyes, so mind the red reflex during the case and always plan a dilated eye exam within the first week after the procedure. Dr. Riaz said to watch out for retinal breaks or detachment if the sclerotomy is misplaced too far posterior, or if vitreous traction is induced. You could also get iatrogenic lens or iris injury if the entry site is too anterior or if in- struments are misdirected, he said. If the trocar is not properly placed, there may be a risk of hypotony or wound leak. He added that eyes with compromised posterior segment status (like prior RD or vit- rectomy) may warrant extra caution and in rare cases, referral to a vitreoretinal colleague for a complete posterior vitrectomy. Dr. Riaz also noted the learning curve. "Sur- geons unfamiliar with pars plana anatomy or vitreoretinal maneuvers should practice before using it in a high-stress complication scenario," he said. "Many conferences now have dedicated wet labs so surgeons can learn these techniques quite easily." For cataract surgeons, pars plana ante- rior vitrectomy is a powerful tool to manage vitreous loss more safely and physiologically, Dr. Riaz said. "With the right tools and basic comfort in pars plana entry, it can improve vi- sualization, reduce traction, and ultimately lead to better IOL and retinal outcomes," he said. "I think all cataract surgeons should learn this skill because it is, in my opinion, a necessary skill for the modern anterior segment surgeon to master. We are having to use it for planned cases regu- larly and unplanned cases rarely." that 25 g and 27 g are available. He prefers the 23 g trocar because the tubing connects seam- lessly with his phaco machine, eliminating the need for a standalone vitrectomy machine. Placing the trocar is a "new skill" for vet- eran cataract surgeons, Dr. Riaz said, but more recently graduated surgeons have been placing trocars during residency, so they are comfort- able with the angled approach to ensure the trocar is placed safely and correctly. "Some sur- geons don't suture these incisions, but I always feel more comfortable suturing my sclerotomies, especially when I do an SFIOL surgery, because the last thing I want is hypotony, which can affect the IOL position, cause corneal edema, cause CME, etc." Dr. Riaz also noted that surgeons should re- view and be comfortable with vitrector settings for this approach: high cut rate and low aspira- tion to minimize vitreous traction for vitreous removal. He uses the "I/A cut" settings when removing cortex. An anterior chamber maintainer or infusion through the pars plana is key for chamber stabil- ity. Additionally, Dr. Riaz noted that triamcino- lone can be very helpful in confirming that all vitreous strands have been cleared before IOL placement. "A good rule is cut, don't pull. Al- ways cut vitreous strands rather than aspirating them out," he said. Always make an iridectomy (you can use the vitrector for this) when placing an IOL in the sulcus or SFIOL fixation to prevent pupillary block issues, Dr. Riaz added. To be able to utilize the pars plana tech- nique, Dr. Baartman said it's important to know the anatomy, which he said is measured at 3.5 mm posterior to the limbus, along with creation of a peritomy and suturing of the resultant sclerostomy if using a stab incision approach. "I prefer the use of a valved trocar, which if placed at the appropriate bevel can be used without the need for a suture," he said. Potential risks Dr. Baartman also offered some important tips to keep in mind. Anytime you access the pars plana via a sclerotomy, it's a good idea to aim your blade (or trocar) towards the center of the eye to create the incision. Make sure you visualize the tip of the trocar to ensure it is not covered by tissue before using it to access the

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