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Cover Focus | Mar/Apr 2024

Middle Segment Surgery

A unified approach to enhance patient outcomes through integrated expertise.

The term middle segment surgery (MSS) refers to the practice of tackling corneal and lens-based challenges via a pars plana approach, incorporating techniques such as intrascleral haptic fixation, sutured IOLs, and pars plana–assisted anterior vitrectomy. This approach not only embraces the surgical options available to surgeons but also aims to improve patient outcomes.


The division of labor has propelled the field of medicine, and ophthalmology in particular, forward. A relentless drive toward specialization enables physicians to dedicate more of their time to a narrower scope of issues, thereby cultivating experts with greater knowledge and proficiency in their specific areas of focus. The practice of ophthalmology is remarkably diverse, however, with variations across regions and individual surgeon preferences. In Europe, for example, it is not uncommon for a single ophthalmologist to perform both cataract and retina procedures.

The concept of MSS challenges us to reconsider the traditional dichotomy between anterior and posterior segment surgery. It suggests that, for certain complex procedures, patient outcomes can be significantly enhanced when managed by a surgeon skilled in both areas. This is not to diminish the value of collaboration between specialists but to highlight the benefits of a unified surgical approach for specific cases. Many European ophthalmologists are well-positioned to embrace MSS, whether independently or in collaborative settings.

The goal of integrating MSS into practice is not to prescribe a one-size-fits-all approach but to offer an additional strategy that can enhance patient care.

In an era when patient expectations about eye surgeries, including complex procedures, are exceedingly high, settling for anything less than optimal results is no longer acceptable. The goal of MSS is for a single, well-versed surgeon to manage these challenges. This includes conducting thorough preoperative assessments and imaging (eg, no-touch biometry and topography), executing surgery, and overseeing postoperative care.


As we look toward the future, the integration of MSS principles offers exciting possibilities. It speaks to the evolution of ophthalmology as a field that continually seeks to optimize patient care through both specialized expertise and integrated approaches. This evolution offers an opportunity to further enhance surgical outcomes and patient satisfaction by leveraging the full spectrum of our skills.

This cover series invites us to explore the potential of MSS within the diverse practice landscape of ophthalmology. It is an opportunity to reflect on how we can continue to push the boundaries of patient care by adapting and evolving our practices for the betterment of those we serve.

Cristos Ifantides, MD, MBA
  • Private practice, Tyson Eye, Cape Coral, Florida
  • Adjunct Assistant Professor, Sue Anschutz-Rodgers Eye Center, University of Colorado, Aurora, Colorado
  • Member, CRST Editorial Advisory Board
  • cristosmd@gmail.com; X (formerly Twitter) @GatorCristos; Instagram @cristosifantides
  • Financial disclosure: Consultant (Alcon, Johnson & Johnson Vision) Research funding (Bausch + Lomb, Johnson & Johnson Vision)