Chennai-based Prof Dr Amar Agarwal, an ophthalmologist and chairman of Dr Agarwals Eye Hospital Group, has recently introduced an innovation called Pinhole Pupilloplasty (PPP), which offers a simple and highly effective alternative to corneal transplantation.
According to a press release, PPP is a promising solution to the global shortage of donor corneas that keeps millions visually impaired. In many cases where corneal transplantation is risky or impractical, PPP serves as a safe and effective alternative. The procedure can significantly improve vision in patients with corneal irregularities caused by conditions such as keratoconus, scarring, or higher-order aberrations, often eliminating the need for glasses or contact lenses.
PPP is a minimally invasive surgical procedure in which a small, custom-sized central opening (pinhole) is created in the iris to filter incoming light. This pinhole blocks out distorted peripheral rays and channels only the focused central rays, directing them precisely onto the retina, dramatically improving visual clarity in eyes with irregular corneas. Unlike corneal transplantation, which involves complex surgery, long healing time, and risk of rejection, PPP is a simple, quick-healing, low-risk, and effective alternative, states the release.
The procedure requires only basic surgical tools and does not rely on expensive equipment or donor tissue. Surgeons can perform it using standard ophthalmic instruments, making PPP highly scalable and accessible, even in low-resource settings. This means that eye care facilities around the world, regardless of infrastructure, can adopt the procedure quickly to address local cases of corneal blindness or visual distortion. The technique has already gained wide international acceptance and is being practiced by surgeons in countries such as Russia, Vietnam, and Egypt.
Agarwal, who developed Pinhole Pupilloplasty, is renowned for introducing several pathbreaking techniques in ophthalmology. His contributions include Phakonit (micro-incision cataract surgery), no-anesthesia cataract surgery, the glued intraocular lens (IOL), and the world’s first implantation of the mirror telescopic IOL. He was also a pioneer in Pre-Descemet’s Endothelial Keratoplasty (PDEK), which expanded the use of younger donor corneas for transplants. In recognition of his work on PPP, Agarwal received the ASCRS Film Festival Award in Los Angeles in May 2025.
Agarwal says, “Over 2 billion people worldwide live with visual impairment or blindness, and many of them will never receive a donor cornea. With the backlog of corneal blindness steadily increasing, Pinhole Pupilloplasty offers a timely, scalable, and practical alternative. We are proud to offer PPP as a meaningful solution to this pressing global health challenge. Especially in countries like India and across Africa, where affordable and accessible eye care is essential, this technique can truly make a difference. Our network of over 250 hospitals in India and abroad has already begun performing this procedure, and we are rapidly expanding its reach. We are also committed to training eye care professionals around the world to adopt and deliver this technique effectively.”
However, PPP is not a one-size-fits-all solution. The procedure is not suitable for eyes with central corneal opacities or progressive corneal diseases unless stability is ensured. Careful patient selection and preoperative assessment are essential to achieve the best outcomes.
