Sometimes it is a small innovation in healthcare, re -immersing known procedures that keep hope of the revolution. It is in the second category that Pinhole Pupilloplastic (PPP) falls. After originally described in 2018, it was only recently proven to be a perhaps simple, low -cost alternative to corneal transplants.
AMAR AGARWAL, Chairman, dr. Agarwal’s Eye Hospitals, which first described the procedure in 2018, claims that it was only developed as a technique to repair astigmatism and abrasion. “For seven years we have been doing PPP to correct the high level of astigmatism – the condition where the cornea is cone. Since then, the technique will be picked up by eye surgeons,” he explains in Russia. Those who have already begun to perform the PPP procedure will only have to use the cornea for transplant situations, adds.
Pinhole Pupilloplastic | Photo Credit: Special Arrangement
How PPP works
PPP uses the principle of simple optics – control of the light that enters the eye to clarify the vision. The cornea is a transparent outer layer of the eye. It bends (attracts) light to help focus, and the pupil is a dark circular opening in the center of the iris. Its role, as well as the camera aperture, is to adjust the size to control how much light it enters into the eye. While corneal transplantation is trying to solve corneal damage, PPP is trying to restore vision by dealing with the pupil. In PPP, the pupil’s size is surgically reduced to 1.5 mm, blocking the peripheral vision and allows focused central rays inside the eye, ensuring that the image is clean and without distortion.
This can bring the patient back to almost 20/20 vision immediately after surgery, says Dr. Amar. For example, Subbalakshmi, a patient who traveled from Australia to perform a PPP procedure in Chennai, says the bandages were removed, three hours after surgery, could very well see. “I knew almost immediately that the sharpness of my vision improved significantly after surgery. If I were 5-6 on a visual scale before the operation, I went to 9.5 after the procedure,” he says.
Dr. AMAR AGARWAL examines the patient in his hospital photo credit: Thamodharan B
Amar, who summon another common metaphor to explain the scenario, says: “If you consider the cornea a front window and say it will disappear due to injury, or there is a tear, there is an opaque area, or the cornea is cone, which is what happens in astigmatism.
Satisfactory results
The team in the hospital even worked with an optics expert Jack T. Holladay to develop a pupil’s breakup, a tool used to measure the size of the pupil suitable for each patient.
“When we performed corneal transplantation, we found that not all patients regained good vision, some still had a number of problems – although they could see the visions were blurred,” Dr. Amar. “At that time, we said,” Hold on, why do we do transplantation in this case, will PPP work better? “When we began to see great results using PPP for these patients, it was clear that it was a viable alternative to corneal transplantation.” Since then, they have done 100 procedures and the results were satisfactory. On the other hand, corneal transplantation comes with chances of rejection, long healing, the need to use drugs for a longer period of time and see visual sharpness … In fact, no guarantee of vision recovery, ”he adds.
While children with corneal injuries are ideal candidates for advancement, they work on adults who also had tears of cornea or scars, in addition to injury. “In fact, if I have to choose between corneal transplantation and PPP, I will decide on others. Even if we do corneal transplants, we do the next PPP procedure to improve the chances of the patient to better see them,” Dr. Amar.
Not all people waiting for transplantation will benefit from PPP, explains Soundari S., regional manager, clinical services, Eye Hospital Dr. AGARWAL. Some people will still require corneal transplantation, but the use of PPP to those who benefit from this procedure will enable the redistributed donor cornea to be redistributed to those who need them. Given that more than 20 million people are waiting globally for a donor cornea, and there is a desperate shortage of cornea, any other technique that can restore vision, comes as a benefit to patients, says Dr. Amar.
Published – 23 July 2025 9:18
