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December 31, 2025
2 min read
Pinhole pupilloplasty is a surgical procedure that aims to narrow the pupil to pinhole size to impart greater depth of focus and neutralize associated higher-order aberrations.
Amar Agarwal
Following pinhole pupilloplasty (PPP), patients usually experience satisfactory vision under photopic and mesopic light condition, as documented in our series (Narang et al.). Recently, we encountered a few patients who experienced visual difficulty in poor illumination or during twilight or nighttime conditions. Under normal circumstances, the pupil dilates when dim illumination is encountered. However, after PPP, the pupil does not dilate enough to allow more light to enter the eye. The size of the pinhole achieved usually ranges from 1 mm to 2 mm. A study to determine the optimum pinhole pupil size suggested 1 mm or 1.5 mm provided the best visual correction to the patient with associated higher-order aberrations (Kumar et al.), with the optimum pinhole size being inversely proportional to the amount of higher-order aberrations present in the eye (optimum pinhole size is defined as the pinhole that provides best visual acuity to the patient as recorded with the Holladay pinhole device in the preoperative period) (Narang et al.). On the surgical front, an effort is made intraoperatively to achieve the optimum pupil size by incorporating a calibrated reticle in the eye piece of the microscope (Narang et al.).
Figure 1. YAG pupil enhancement in a clinical scenario. A case of RK with pseudophakia (A1). PPP performed in a case with RK marks to combat higher-order aberrations (A2). YAG enhancement done to address dim illumination following PPP (A3). A case with penetrating keratoplasty and associated higher-order aberrations (B1). PPP performed in the case with a PK graft (B2). YAG enhancement done (B3).
To overcome the issue of dim illumination under mesopic conditions, we performed YAG enhancement to enlarge the pupil size by ablating the part of the iris tissue that did not have a suture passing through it. Power was set at 3 mJ to 4 mJ with single burst mode and a spot size of 50 µm to 70 µm. The laser beam was focused on iris tissue along the pupil border as the aim was to ablate the iris tissue closest to the pupil edge. To maintain the concentric shape of the pupil, two shots were given, one on either side of the horizontal axis passing through the center of the pupil. Once the procedure was done, the patient was prescribed a low-dose steroid (loteprednol 0.5% eye drop) four times a day that was gradually tapered every 3 days. After YAG, patients were advised to follow up at day 1, day 7 and 1 month thereafter.
Priya Narang
In our ongoing series of 72 cases that underwent PPP to date, we had to enhance the pupil size with YAG laser in nine cases. After Nd:YAG ablation, these patients did not experience any decrease in photopic vision and were satisfied with mesopic vision.
When PPP is performed, the surgeon aims to achieve the optimum pupil size that would allow maximum visual potential for the patient. However, if patients complain of dim illumination, YAG laser can be employed to enhance pupil size. Performing a YAG enhancement serves as a functional method to improve the visual potential of patients undergoing PPP who experience decreased illumination during twilight hours or nighttime.
For more information:
Amar Agarwal, MS, FRCS, FRCOphth, director of Dr. Agarwal’s Eye Hospital and Eye Research Centre, is the author of several books, including Phaco Nightmares: Conquering Cataract Catastrophes, Bimanual Phaco: Mastering the Phakonit/MICS Technique, Dry Eye: A Practical Guide to Ocular Surface Disorders and Stem Cell Surgery and Presbyopia: A Surgical Textbook. He can be reached at aehl19c@gmail.com; website: www.dragarwal.com.
Priya Narang, MS, of Narang Eye Care & Laser Centre, Ahmedabad, India, can be reached at narangpriya19@gmail.com.
Sources/Disclosures
Source:
Healio Interviews
Reference:
- Kumar DA, et al. J Cataract Refract Surg. 2024;doi:10.1097/j.jcrs.0000000000001353.
- Narang P, et al. J Cataract Refract Surg. 2019;doi:10.1016/j.jcrs.2018.12.007.
- Narang P, et al. J Cataract Refract Surg. 2019;doi:10.1016/j.jcrs.2019.02.037.
- Narang P, et al. J Cataract Refract Surg. 2021;doi:10.1097/j.jcrs.0000000000000794.
- Narang P, et al. J Refract Surg. 2020;doi:10.3928/1081597X-20201008-01.
Disclosures:
The authors report no relevant financial disclosures.
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