Eyeworld

58 | EYEWORLD | FALL 2025 C ORNEA Reference 1. Agarwal A, et al. Aberropia: a new refractive entity. J Cataract Refract Surg. 2007;33:1835–1836. said. The other way this can be treated is with a corneal transplant. Pinhole pupilloplasty Dr. Parker praised the development of the pinhole pupilloplasty technique by Dr. Agarw- al, which utilizes the idea that through a small aperture, a pinhole-sized opening, stray rays of light can be filtered out, only permitting directly straight, focused light to impact the retina. "It's an extremely simple, elegant way to solve a complex optical problem," he said. Dr. Parker noted that this technique has been slow to catch on, though he added that medicine is conservative, taking time to form a consensus on if a product or technique works. Dr. Agarwal stressed the usefulness of using a pinhole pupilloplasty procedure to help these patients, adding that David F. Chang, MD, helped him come up with the term. You can make the pupil a specific size, he said, and the pinhole blocks rays of light that are creating aberrations. Only the central ray of light will go through, and patients see better immediately. Another advantage of pinhole pupilloplasty is that not only does the patient have good dis- tance vision, but they see near without glasses. Dr. Agarwal said the pinhole pupilloplasty procedure reduces the need for corneal trans- plants, which are limited by the availability of donor tissue. He noted the millions of people worldwide waiting for a corneal donor and the backlog associated with corneal transplantation. While pinhole pupilloplasty might not work in every corneal transplant case, it can help avoid a transplant in many scenarios. Pinhole pupilloplasty also has fewer complications, the patient recovers immediately, and it has helped to neutralize the astigmatism, he said. Another advantage of this procedure is an anterior segment surgeon can perform the technique. Dr. Agarwal said that pinhole pupil- loplasty may also be indicated for keratoconus, pellucid marginal degeneration, corneal scars, post-DALK, post-PK, etc. One of the major benefits of the technique that he noted is that it neutralizes the astigma- tism/HOAs without needing a nomogram. Dr. Parker added that iris suturing is some- thing of an art, and it's not something everyone learns in training. Most general ophthalmolo- gists, and even some corneal specialists, don't do it or don't do much of it, so there is an initial hurdle to overcome, operating on a delicate part of the eye. Dr. Parker said there are drops that can constrict the pupil with pilocarpine. However, these can induce headaches, and he said he's not sure if they really mimic the effect you get with a pinhole pupilloplasty because with pin- hole pupilloplasty, you can titrate the size of the pupillary opening. Dr. Holladay also noted drops using pilocar- pine that can bring the pupil down to 1.0 mm or whatever size needed, based on the concen- tration of the drop. "The limitation with that is many times when you have a corneal scar, a penetrating keratoplasty, or irregularity in the cornea, that irregularity may be worse in the middle of the cornea," he said. "So when you bring the pupil down, the pupil is right on that area of the greatest irregularity. With pinhole pupilloplasty, you can take this pinhole gauge that we have, and move it around to differ- ent positions, and you find the one where the cornea is clear and doesn't have an irregularity. You can locate the pinhole wherever you want relative to the cornea, and with drops you can't do that." Surgeons may also choose to use a pinhole IOL to help patients with irregular astigmatism, Dr. Agarwal said. The IC-8 Apthera (Bausch + Lomb) offers the pinhole technology. Dr. Agarwal said this is another good option, but he prefers the pinhole pupilloplasty procedure due continued from page 57 The Holladay pinhole pupil gauge Source: Jack Holladay, MD

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