Corneal astigmatism may be regular or irregular variant. With regular variant, good visual acuity can be attained either by correction with glasses or surgically by performing astigmatic keratotomy. The irregular variant is difficult to correct with spectacles due to induced aberrations. Therefore, for such cases, other interventions like placing corneal inlays and pinhole intraocular lenses (IOLs) came into existence. Pinhole pupilloplasty (PPP) is a newer concept put forward to narrow down the pupillary aperture and achieve a pinhole kind of functionality, thereby benefitting patients suffering from higher order irregular corneal astigmatism.
A pinhole or a small aperture is created, thereby allowing passage of rays of light from the central aperture and blocking the rays emanating from the peripheral irregular cornea, so that the impact of higher order aberrations caused by irregular corneal astigmatism can be minimized. Another mechanism is the Stiles-Crawford effect of the first kind, according to which, an equal intensity of light entering near the centre of the pupil produces a
greater photoreceptor response compared with the light entering the eye near the edge of the pupil. Therefore, when the pupil narrows, more focused light enters the eye through the narrow aperture, producing a greater photoreceptor response.
Symptomatic iris defects (Congenital, Acquired, Iatrogenic, Traumatic)
To break PAS and angle apposition angle closure glaucoma whether primary, post trauma, plateau iris
syndrome, Urrets-Zavalia syndrome or long-standing silicone oil in the anterior chamber.
PPP can be done for cosmetic indication, especially in large colobomas.
In cases of floppy iris that is expected to adhere to the peripheral edge of graft causing peripheral anterior synechiae,
pupilloplasty is performed to tighten the iris preventing it from causing synechial adhesions that would increase the risk of angle closure and graft failure.
Written by: Dr. Soundari S – Regional Head – Clinical Services, Chennai
pupilloplasty cataract surgery
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