Eyeworld

FALL 2025 | EYEWORLD | 59 C Relevant disclosures Agarwal: None Holladay: None Parker: None Contact Agarwal: aehl19c@gmail.com Holladay: holladay@docholladay.com Parker: jack.parker@gmail.com to the ability to customize the location of the pinhole. "If the patient has a scar and I want to keep my pinhole pupil away from the scar, I can do this with pinhole pupilloplasty," he said. Additionally, he noted the lower cost of pinhole pupilloplasty and that it can be used for already pseudophakic patients. Pinhole pupilloplasty is also reversible. By doing a YAG laser, you can open the pinhole pupilloplasty or enlarge it if the patient complains of less illumination. The customizable size with pinhole pu- pilloplasty is a big benefit, Dr. Agarwal said, adding that Dr. Holladay's pinhole device has helped enable the ability for patients to choose the size pupil that will work for them. "You can't get a cornea to be as perfect as the original when you do a penetrating kera- toplasty, but if their lens is clear, if they have an intraocular lens, this little gauge allows us to put that in front of the patient, and depend- ing upon the amount of irregularity, you can find out which pinhole will give them the best vision," Dr. Holladay said. In someone who has a mild amount of ir- regularity, Dr. Holladay said they may get up to a 2.5-mm pupil and see 20/20. If someone has, for example, an injury from a piece of metal that hit the cornea with a bad irregularity, they may need a smaller pupil. They could end up with a 0.5, 1.0, or 1.5 mm, he said. "This little pinhole allows us to determine the size of the pinhole we want to achieve at surgery." Pinhole pupilloplasty is beginning to catch on, Dr. Agarwal said, noting that physicians in India, the U.S., Russia, Egypt, and other coun- tries are performing it. Dr. Holladay finds the technique to be more common internationally, though he predicted it will increase in frequency and in prevalence over time in the U.S. While he said it can also be used for corneal transplantation, he noted that the U.S. is less likely to have conditions like trachoma and oth- er diseases that may be more prevalent in other parts of the world. One of the limitations in using a pupil- loplasty, Dr. Holladay said, is that once you make the pupil 1.0 mm, your ability to see the peripheral retina goes away. "When we do nor- mal eye exams, the first thing we do is dilate the pupil up to 10 so we can see out in the periph- ery and make sure the patient has no retinal tears, holes, or anything that needs treatment, and once you make that pupil 1.0, all that goes away," he said. One scenario where he finds this being used the most is in someone who's had cataract sur- gery who has a clear lens but doesn't see well because the cornea is the limiting factor. These patients are prime candidates for pupilloplasty because you can locate the pupilloplasty where you want it and make it the size that you need, using the gauge for precision before you ever go to surgery, Dr. Holladay said. Dr. Parker noted that he wouldn't generally use pinhole pupilloplasty on phakic patients, though you could do it after or at the same time as cataract surgery. "There's a risk of damaging the patient's natural lens because you're sewing on top of it, and at some point, you'll have to reverse the pupilloplasty to fix that patient's cat- aract in the future." So it's better to remove the cataract before or at the time of pupilloplasty. The biggest fear that eye doctors have is visibility to the back of eye, Dr. Parker said. If you make the pupil smaller, you may not be able to dilate the patient anymore, and that could be a concern. However, he noted that modern fundus photography instruments help make this less of an issue. Kevin Miller, MD, EyeWorld Cataract Editorial Board member, shared how he goes "beyond the routine": "Many people read our electronic medical record (EMR) chart notes—fellow ophthalmologists, internists, other physicians, payers, even patients—after an office visit. To avoid confusion, we do not use any abbreviations or acronyms such as TFBUT (for tear film break-up time) anywhere in our notes. Instead, we spell everything out. Fortunately for us, our EMR has a customizable dictionary that allows us to automatically turn any abbreviation or acronym we have created into spelled-out text. This is especially useful when an abbreviation such as SLE can be interpreted two different ways, such as slit lamp examination or systemic lupus erythematosus." B E Y O ND T H E R O U T I N E

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