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Pinhole Pupilloplasty

Corneal astigmatism can be regular or irregular. With the regular variant, good visual acuity can be achieved either through glasses correction or surgically through astigmatic keratotomy. Because of induced aberrations, the irregular variant is difficult to correct with spectacles. As a result, other interventions such as placing corneal inlays and pinhole intraocular lenses (IOLs) became available for such cases. Pinhole pupilloplasty (PPP) is a newer concept that aims to narrow the pupillary aperture and achieve pinhole functionality, thereby benefiting patients with higher order irregular corneal astigmatism.

 

Principle

A pinhole or small aperture is created, allowing light rays from the central aperture to pass while blocking rays from the peripheral irregular cornea, reducing the impact of higher order aberrations caused by irregular corneal astigmatism. Another mechanism is the Stiles-Crawford effect, which states that an equal intensity of light entering the eye near the center of the pupil produces a greater photoreceptor response than light entering the eye near the edge of the pupil. As a result, when the pupil dilates, more focused light enters the eye through the narrow aperture, resulting in a greater photoreceptor response.

 

Procedure

  • 4 mL lidocaine hydrochloride (Xylocaine 2.0%) and 2 mL bupivacaine hydrochloride 0.5% peribulbar anaesthesia (Sensorcaine)
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  • Two paracenteses are performed, and a 10-0 polypropylene suture attached to the needle’s long arm is introduced into the anterior chamber.
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  • An anterior chamber maintainer or a trocar anterior chamber maintainer can be used to keep the anterior chamber open using an ophthalmic viscosurgical device or fluid infusion.
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  • Through the paracentesis, an end-opening forceps is inserted and the proximal iris leaflet is grasped. Suture needle is inserted into the proximal iris tissue.
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  • After being held with end-opening forceps, a 26-gauge needle is introduced from the opposite quadrant of the paracentesis and passed through the distal iris leaflet. The 10-0 needle’s tip is then passed through the barrel of the 26-gauge needle, which is then pulled out of the paracentesis. Together with the 26-gauge needle, the 10-0 needle exits the anterior chamber.
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  • A Sinskey hook is inserted into the paracentesis, and a suture loop is removed from the eye. The suture end is wrapped four times around the loop. Both suture ends are pulled, and the loop slides inside the eye, close to the edges of the iris tissue. The suture ends are then cut with micro scissors, and the procedure is repeated in the opposite quadrant to achieve the desired pupil configuration and shrink the pupil to pinhole size.

 

Indications

  • Functional or Optical: Symptomatic iris defects (Congenital, Acquired, Iatrogenic, Traumatic)
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  • Oppositional angle closure or PAS: To treat PAS and angle apposition angle closure glaucoma, whether primary, post-traumatic, plateau iris syndrome, Urrets-Zavalia syndrome, or long-standing silicone oil in the anterior chamber.
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  • Cosmesis: PPP can be performed for cosmetic reasons, particularly in large colobomas.
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  • Penetrating Keratoplasty: In cases where the iris is expected to adhere to the graft’s peripheral edge, causing peripheral anterior synechiae, pupilloplasty is performed to tighten the iris and prevent synechial adhesions, which would increase the risk of angle closure and graft failure.

 

Advantages

  • Faster and less difficult to perform than other pupilloplasty techniques – (Modified Siepser’s and McCanell method, which requires more than two passes from the anterior chamber, as well as additional iris tissue manipulation).
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  • Postoperative inflammation is reduced, and visual recovery is faster.
  • Effective in Urrets Zavalia syndrome, which is characterized by elevated IOP and persistent pupil dilation.
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  • Prevents secondary angle closure, inhibits mechanical blockage, and breaks the formation of peripheral anterior synechia.
  • Improves visual quality and depth of focus in patients with higher order corneal aberrations.
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  • Effective in certain cases of secondary angle closure as well as silicon oil-induced glaucoma.
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  • This method of reconstructing the pupil protects patients from glare, photophobia, and unfavorable images formed by light reflection.

 

Disadvantages

  • To examine the posterior segment, a limited dilation is used (In cases of retinal detachment, it is possible to YAG the iris and undo procedure if needed).
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  • Because of the risk of touching the crystalline lens during the procedure and the formation of cataracts, this procedure is best performed in pseudophakic eyes.

 

 
 
 
To get your eye examined, visit Accra Specialist Eye Hospital – Voted the Best Eye Hospital in Ghana. Visit Accra’s Finest Eyecare Facility today!  Our Services include are Laser Eye Surgeries, Micro Incision Cataract, Surgery (Phaco), Retina Surgeries, Phaco (Cataract), Gluacoma Surgeries, Cornea Surgery – Transplant, Oculoplastic Surgery and Child Eye Care Services.
 

 

We're an eye specialist hospital dedicated to providing the best care for you and your eyes. At Accra Specialist Eye Hospital, we are committed to delivering accessible and comprehensive eye care, to the highest possible standards. Our Expertise & Services Offered are Laser Eye Surgeries, Micro Incision Cataract, Surgery (Phaco), Retina Surgeries, Phaco (Cataract), Gluacoma Surgeries, Cornea Surgeru - Transplant , Oculoplastic Surgery and Child Eye Care Services. We're located at Tantra Hill - Accra.