No transplant, no stitches: The eye surgery giving patients a second chance at sight
In a country where the shortage of donor corneas often stands between a patient and restored vision, an innovative eye surgery developed in India is offering new hope.Known as Pinhole Pupilloplasty (PPP), the technique is changing the way ophthalmologists treat patients with severe corneal conditions, without the need for corneal transplants or lengthy recovery periods.Corneal transplants are required when the cornea, the clear, dome-shaped surface that covers the front of the eye, becomes damaged or diseased to the point where it affects vision or causes pain.advertisement
Injuries from trauma, infections (like herpes simplex or fungal keratitis), keratoconus etc., would need corneal transplants.Pioneered by Dr. Amar Agarwal, Chairman of Dr. Agarwals Eye Hospital, this groundbreaking procedure has not only found takers across India but is also gaining recognition on the global stage.In fact, the eye surgery earned Dr. Agarwal an international award at the ASCRS Film Festival in Los Angeles.
Dr. Amar Agarwal won an international award at the ASCRS Film Festival in Los Angeles.
The technique, now widely practiced in several countries, has been credited with restoring sight where traditional methods fall short."Some patients have very high astigmatism that cannot be corrected with usual methods, and toric intraocular lenses only work up to a certain level. This gave me the idea to create a pinhole effect in the pupil itself, which led to the first Pinhole Pupilloplasty," Dr. Agarwal told IndiaToday.in.advertisementA SIMPLER ALTERNATIVE TO CORNEAL TRANSPLANTIn traditional cases of corneal scarring, eye doctors often recommend a corneal transplant - a procedure that relies heavily on donor tissue, involves a long healing period, and carries the risk of graft rejection.The pinhole pupilloplasty method uses stitches to change the shape of the pupil without needing a donor cornea, and patients recover much faster compared to traditional surgery.The principle is simple: by reducing the size of the pupil to about 1-1.5 mm, similar to the tip of a pin, incoming light is focused more effectively onto the retina, bypassing irregularities in the cornea.
Pinhole surgery instead of regular corneal transplant (Image 1: pre-operation vision. Image 2: Post-operation eye)
The result? Sharper vision with reduced glare, especially for patients with complex eye issues like corneal scars, keratoconus, or radial keratotomy complications."With the pinhole technique, patients recover much faster, and long-term results are very promising. It removes the risks of rejection and prolonged medication associated with corneal transplantation," said Dr. Agarwal.WHAT MAKES THE PINHOLE TECHNIQUE UNIQUE?advertisementThe procedure uses very thin stitches to change the shape of the coloured part of the eye and make a small central opening (pupil). It may sound simple, but what makes it special is how precise and flexible it is.Unlike earlier surgical techniques such as the Modified Siepser's or McCannel methods, the pinhole pupilloplasty method requires fewer steps and causes less post-operative inflammation.It has distinct advantages in managing rare but difficult conditions like Urrets-Zavalia Syndrome (a fixed dilated pupil), silicon oil-induced glaucoma, and even cases of raised intraocular pressure where standard treatments fail.
The procedure uses very thin stitches to change the shape of the coloured part of the eye (pupil) and make a small central opening. ()
"It's quicker and simpler, and the pupil tightens enough to reduce glare and photophobia. It's particularly useful in patients with higher-order corneal aberrations. Plus, it's reversible. We can undo it with a YAG laser if necessary," explained Dr. Agarwal.WHO CAN BENEFIT FROM THE PROCEDURE?advertisementThe surgery is ideal for patients who:Have corneal tears that caused irregular astigmatismPreviously underwent corneal grafts and developed distorted visionHave permanent pupil dilation with glareAre living with keratoconus (conical cornea)Have had radial keratotomy in the past, an outdated refractive surgeryIt is also useful in situations where a pupil has lost its ability to constrict, causing overwhelming glare, or when the shape of the cornea is so irregular that glasses or contact lenses no longer help.AN AFFORDABLE OPTION FOR INDIA AND BEYONDFor India, where the gap between demand and availability of donor corneas remains stark, the pinhole pupilloplasty surgery has immense public health implications.
Estimates suggest that over 1 lakh corneal transplants are required annually in India, but only around 25,000 are performed due to limited donor supply. ()
Estimates suggest that over 1 lakh corneal transplants are required annually in India, but only around 25,000 are performed due to limited donor supply.'With Pinhole Pupilloplasty, we can avoid transplant in many cases,' Dr. Agarwal noted. 'It dramatically reduces the dependency on donor corneas and also cuts down the complications of transplant surgeries.'advertisementNotably, while pinhole intraocular lenses (IOLs) are an alternative used in high-income countries, they come with a steep price tag and fixed designs. PPP offers a more cost-effective, adaptable solution for patients in India and other low-resource settings.ARE THERE ANY RISKS?Like any intraocular procedure, the pinhole method is not without limitations.There's a small risk of the suture (stitch) coming close to the natural lens, which may result in cataract formation. To avoid this, it is typically performed in pseudophakic eyes, which means eyes in which the natural lens has already been replaced with an artificial one, such as after cataract surgery.One small downside is that it can be hard to check the outer part of the retina through such a tiny pupil. But with modern machines like Optos or Mirante, doctors can still get a clear and complete view without needing to enlarge the pupil.
Pinhole Pupilloplasty marks a shift in how eye diseases are approached. ()
advertisementPinhole Pupilloplasty marks a shift in how eye diseases are approached, especially in a country like India where healthcare resources are unevenly distributed. By eliminating the need for corneal grafts in certain cases and offering near-instant results, this procedure has the potential to democratize vision care."Knowing that this technique is helping people regain sight and confidence drives me to do what I love, to research, innovate, and impact lives with the gift of sight," Dr. Agarwal concluded.As awareness grows and training becomes more widespread, this homegrown innovation might well become a global standard in complex corneal care.
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