In this surgical case, Dr Amar Agarwal shares his brilliant, off-center, offset pinhole pupilloplasty technique for managing eyes with complex corneal pathology. While standard pupilloplasty often targets the anatomical center, this specific approach is dictated by a dense central corneal scar. Because the central cornea is opaque or highly irregular, a standard centered pupil would result in poor visual quality and light scattering. The key pearl is to strategically offset the 1.5 mm to stenopeic opening to a clearer portion of the mid-peripheral cornea. By utilizing the single-pass four-throw (SFT) pupilloplasty, we can precisely shift the aperture to align with a more transparent visual window. This maneuver effectively bypasses the central scar, utilizing the pinhole effect to provide the patient with a sharper, more functional image. Dr Agarwal demonstrates the intraocular suture maneuvers and the critical decision-making process required to determine the optimal location for the offset pupil to maximize the postoperative refractive outcome. And he narrates the video himself.
