Optimum pinhole size determination in pinhole pupilloplasty for higher-order aberrations.

PURPOSE: To determine optimal pinhole size (OPS) and establish a relationship with visual acuity (VA) and RMS (root mean square) values in cases with higher-order aberrations (HOAs) undergoing pinhole pupilloplasty (PPP). SETTING: Private practice, India. DESIGN: Prospective, interventional study. METHODS: RMS value for 6-mm-diameter optical zone was determined by Scheimpflug imaging (Pentacam). Patients with RMS value >0.3 µm were included. Preoperatively, a hand-held pinhole gauge with varied apertures determined the OPS, and single-pass four-throw technique was used to perform pupilloplasty with Purkinje-1 reflex as a marker for centration. VA with OPS, correlation of RMS values with OPS and pupil size, and Strehl ratio were the main outcome measures. RESULTS: 29 eyes with HOAs were analyzed; all patients chose 1.0 or 1.5 mm as OPS. The mean preoperative and postoperative pupil size was 3.25 ± 0.81 mm and 1.8 ± 0.54 mm ( P = .000), respectively. Postoperative mean pupil size when compared with OPS denoted that 14 eyes had a difference of <0.1 mm, 8 eyes ranged from 0.2 to 0.45 mm, and 7 eyes had ≥0.6 mm (range from 0.6 to 1.8 mm) difference from OPS. Eyes with higher RMS values needed smaller pupil gauge to achieve better VA. Preoperatively, vision with OPS correlated well with preoperative 6-mm RMS HOAs ( r = 0.728; P = .00). Postoperative UDVA correlated well with VA measured with OPS ( r = 0.847; P = .00). The preoperative and postoperative mean Strehl ratio was 0.109 ± 0.07 and 0.195 ± 0.11 ( P = .001), respectively. CONCLUSIONS: Higher RMS values required a smaller pupil to achieve optimum VA. PPP can help achieve pinhole size in accordance with patient's optimum pinhole requirement.

Phacoemulsification, pinhole pupilloplasty, and pre-Descemet's endothelial keratoplasty for keratoconus with Fuchs' endothelial dystrophy.

The comorbidity of keratoconus with Fuchs' endothelial dystrophy with cataract is a rare clinical combination. We present an amalgamation of surgical techniques to manage the above clinical conditions and its complications in single setting. The modified triple procedure, namely, the phacoemulsification, pinhole pupilloplasty, and pre-Descemet's endothelial keratoplasty (PDEK) in the order of description is followed in single sitting. Lens removal by phacoemulsification, correction of irregular astigmatism by pinhole pupilloplasty (pinhole optics), and exchanging the endothelial layer for PDEK forms the main segments of the triple procedure. This combination of techniques may decrease the risk of multiple surgeries and its related complications. Moreover, it will allow the patient for faster visual rehabilitation by improving the uncorrected visual acuity and visual quality.

Pinhole pupilloplasty after previous radial keratotomy.

The multiple radial stromal deep corneal incisions placed in radial keratotomy (RK) lead to higher-order aberrations and pose a surgical challenge to performing any further corrective procedure on the cornea because of fear of inducing an incisional dehiscence. A method to perform pinhole pupilloplasty (PPP) in the setting of previous RK is presented. Application of pinhole optics by performing PPP leads to significant improvement in image quality and helps to optimize visual potential in post-RK cases.

Pinhole Pupilloplasty for Higher Order Aberrations: Assessment of Visual Quality and Depth of Focus.

PURPOSE: To evaluate visual quality and depth of focus under photopic and mesopic light conditions of patients treated with pinhole pupilloplasty (PPP) for corneal higher order aberrations. METHODS: This was a prospective, noncomparative, interventional series and PPP was performed with a single-pass four-throw procedure in 14 eyes of 14 patients. After PPP, patients were analyzed with the Clinical Trial Suite machine (M & S Technologies, Inc) that offers a standardized method of recording visual quality. The luminance levels of 85 and 3 cd/m2 were set for photopic and mesopic lighting conditions, respectively, and uncorrected and corrected distance visual acuity were recorded for distance (4 m), intermediate (66 cm), and near (44 cm). Low contrast acuity (LCA) at 10% and mesopic contrast sensitivity function (CSF) with glare on and off at four spatial frequencies of 1.5, 3, 6, and 12 cycles per degree (cpd) and defocus curve were assessed. RESULTS: Under photopic and mesopic conditions, a significant difference was observed postoperatively in uncorrected and corrected distance visual acuity for distance, intermediate, and near. The defocus curve demonstrated extended depth of focus that ranged from +1.50 to -2.50 diopters and LCA at 10% demonstrated significant improvement for all cases. For mesopic CSF, a significant improvement was noted at spatial frequencies of 3 and 6 cpd with glare on. With glare off, an improvement was seen at spatial frequencies of 1.5, 3, and 6 cpd, but not at 12 cpd. CONCLUSIONS: Early results demonstrate that PPP provides improved visual quality and extended depth of focus and can be a useful option in cases with higher order aberrations. [J Refract Surg. 2020;36(12):812-819.].

Application of Purkinje images for pinhole pupilloplasty and relevance to chord length mu.

PURPOSE: To evaluate the results of pinhole pupilloplasty in cases with high astigmatism and higher-order aberrations (HOAs). SETTING: Dr. Agarwal's Eye Hospital & Research Centre, Chennai. DESIGN: Case series. METHODS: Pinhole pupilloplasty was performed based on the Purkinje 1 (P1) images formed from the light source of a Lumera surgical microscope; the images served as a reference marker for centration. A single-pass 4-throw technique was used to achieve a pinhole pupil. The preoperative and postoperative pupil diameter, uncorrected (UDVA) and corrected (CDVA) distance visual acuities, simulated keratometry (K), and chord length mu (µ) were assessed, the latter using a Pentacam rotating Scheimpflug camera. RESULTS: Pinhole pupilloplasty was performed in 8 eyes (8 patients). There was a statistically significant reduction in the mean horizontal and vertical pupil diameters and in the mean pupil diameter from preoperatively to postoperatively (both P < .001). Although the improvement in UDVA was statistically significant (P < .001), the change in CDVA was not. The mean simulated K and mean chord length µ values were significantly lower postoperatively (P = .024 and P < .001, respectively). The reduction in pupil size was more apparent than the reduction in chord length µ. The correlation between the change in chord length µ and the change in pupil size was not significant (r = -0.067, P = .874). The pupil was well centered on the P1 images. No major adverse events or complications occurred postoperatively. CONCLUSION: Postoperative results showed a correlation between the improvement in visual acuity and the decrease in pupil size and chord length µ.

Dynamic tracking of Purkinje images for the comparison of pseudophakodonesis between in-the-bag and secondary fixated intraocular lenses.

PURPOSE: To compare the pseudophakodonesis of in-the-bag intraocular lens (IOL) and a secondary fixated IOL by tracking the Purkinje image IV. SETTING: Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, India. DESIGN: Prospective case series. METHODS: The IOL movement was recorded via slitlamp videography (DC3), streamed in video editor (Pinnacle), and evaluated by ImageJ analysis. The positional difference of Purkinje IV in relation to the stationary image Purkinje I at 3 random timeframes was measured. Pseudophakodonesis was quantified, compared, and correlated clinically. RESULTS: The study comprised 127 eyes that had posterior chamber IOLs (PC IOLs) (n = 50), anterior chamber IOLs (AC IOLs) (n = 20), iris-claw IOLs (n = 20), glued IOLs (n = 30), and sutured scleral-fixated IOLs (n = 7). The iris-claw IOL showed significant difference in Purkinje IV at various timeframes (P = .0418) whereas others showed no significant change. On comparison of the Purkinje IV difference, there was a significant difference between the PC IOL and the iris-claw IOL (P = .0001), the glued IOL and the iris-claw IOL (P = .0020), and the AC IOL and the iris-claw IOL (P = .0302). The iris-claw IOL showed significant exaggeration of the position of Purkinje IV (P = .0395) after saccade. Pseudophakodonesis seemed mild (difference < 0.5 mm) in the PC IOL (68%), glued IOL (53.3%), and AC IOL (50%); moderate in the scleral-fixated IOL (71.4%); and severe (≥ 1.0 mm) in the iris-claw IOL (55%). CONCLUSION: Positional difference in Purkinje IV was highest in iris-claw IOLs and lowest in PC IOLs.

Endoilluminator-assisted transcorneal illumination for Descemet membrane endothelial keratoplasty: enhanced intraoperative visualization of the graft in corneal decompensation secondary to pseudophakic bullous keratopathy.

UNLABELLED: Compromised visibility is problematic with Descemet membrane endothelial keratoplasty (DMEK), especially in the presence of corneal edema. Visibility may be enhanced by dehydrating the cornea preoperatively and by debriding the epithelium, staining the graft, and using a handheld slitlamp during surgery. Because the DMEK graft is transparent, thin, and flimsy, it is difficult to confirm the position, orientation, and morphology even with a clearer cornea. We describe a technique (endoilluminator-assisted DMEK) for identifying graft orientation and enhancing 3-dimensional depth perception within the anterior chamber of the graft. The technique uses oblique light from the endoilluminator for better visualization. Light reflexes from graft folds and edges aid further. This technique has the advantages of being able to visualize the entire graft even through hazy cornea, providing the surgeon with better comprehension of graft dynamics, morphology, orientation, and positioning. This leads to easier and faster surgery, potentially decreasing graft damage due to excessive fluidics and unnecessary manipulation. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.