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Year : 2022  |  Volume : 60  |  Issue : 1  |  Page : 63-65

A novel surgical approach in a blind eye for cosmesis and psychosocial well-being

Department of Pediatric Ophthalmology, Dr Agarwals Eye Hospital, Chennai, Tamil Nadu, India

Date of Submission25-Jul-2021
Date of Decision11-Nov-2021
Date of Acceptance06-Dec-2021
Date of Web Publication22-Mar-2022

Correspondence Address:
Dr. Manjula Jayakumar
Dr Agarwals Eye Hospital, 222, TTK Road, Chennai - 600 018, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_111_21

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Blind eyes are left unattended. They present with unsightly large exodeviation, corneal degenerative changes such as band-shaped keratopathy and mature cataract. These have cosmetic as well as functional implications. It is an obstacle to social life as well as securing employment and betterment of career options. We need to address these patients for psychosocial well-being. We propose a novel surgical approach to address the exodeviation with a distance near disparity as well as to obviate the leucocoria due to mature cataract as the patient did not want to continue pupil occluding cosmetic contact lens any further.

Keywords: Blind eye, pinhole pupilloplasty, strabismus surgerys

How to cite this article:
Jayakumar M, Agarwal A, Shukla V. A novel surgical approach in a blind eye for cosmesis and psychosocial well-being. TNOA J Ophthalmic Sci Res 2022;60:63-5

How to cite this URL:
Jayakumar M, Agarwal A, Shukla V. A novel surgical approach in a blind eye for cosmesis and psychosocial well-being. TNOA J Ophthalmic Sci Res [serial online] 2022 [cited 2022 Jun 29];60:63-5. Available from: https://www.tnoajosr.com/text.asp?2022/60/1/63/340337

  Introduction Top

Procedures done on a blind eye include enucleation, evisceration, and exenteration.[1] This is done on patients after severe eye injury, intraocular malignancies, endophthalmitis and panophthalmitis unresponsive to medical therapy, painful blind eye, and cosmetically disfigured eye. These destructive procedures done as a last resort are unwelcoming in most instances.[2] Blind eyes without any of these indications are seldom intervened and these eyes develop sensory exotropia, corneal band shaped keratopathy or other degenerative changes and complicated cataract with time. This leads to poor cosmesis and psychosocial issues especially in young adults. We present a novel surgical procedure for cosmesis in a young girl who developed blindness secondary to a long-standing closed funnel retinal detachment who presented with complicated cataract and a large sensory exotropia.

  Case Report Top

A 24-year-old female who had no perception of light in her left eye since childhood gave history of using prosthetic pupil occluding cosmetic contact lens for the past 9 years. She approached us for relieving the white reflex at pupil which will obviate her need to use the cosmetic contact lens and for alignment of her eyes. Her right eye was unremarkable and within normal limits. The left eye had early band-shaped keratopathy changes at the limbus at 3 and 9 o clock position. Anterior chamber was fairly quiet. Mature cataractous changes in the lens were noted with no fundus view. B scan revealed a closed funnel retinal detachment. A large sensory left exotropia was noted which measured 50 PD base in for distance and 35 PD base in for near on modified Krimsky test. Extraocular movements were full, free, and painless. We performed a combined strabismus surgery of a large recession of lateral rectus muscle 12 mm and a small resection of medial rectus muscle 5 mm under adjustables for correcting the sensory exotropia with distance near disparity along with single pass four throw pupilloplasty (SFT) to reduce the pupillary aperture size thereby obviating the cosmetically disfiguring white reflex in her left eye. The patient was also counseled on the need for future surgeries if there was a recurrence of strabismus or developed phacolytic glaucoma due to a leaking cataract. Postoperatively, her alignment was satisfactory and the white reflex was also obscured with good cosmesis. The preoperative picture for distance and near [Figure 1]a and [Figure 1]b and postoperative outcome at 2 months' follow-up [Figure 2] are depicted for comparison. The slit lamp picture [Figure 3] shows the pupillary slit apertures after SFT.
Figure 1: (a) Preoperative distance deviation at 6 m measuring 50 PD BI with leucocoria (b) Preoperative Near deviation at 33 cm measuring 30 PD BI with leucocoria

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Figure 2: Postoperative alignment which was cosmetically appropriate at both distance and near with absence of leucocoria

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Figure 3: Slitlamp picture of pupil with single pass four throw to obviate leucocoria

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  Discussion Top

The cosmetic and psychosocial implications of strabismus have been well analyzed by Keltner et al.[3],[4] Many aspects of patients' lives have been affected by it. They reported difficulty in self-image, securing employment, interpersonal relationships and school, work, sports were also affected. These issues intensified during teenage and adult years. David G. Hunter adds that strabismus not only has cosmetic implications and psychosocial aspects but it also limits a persons' ability to work, and hence, it is a true deformity.[5] There is loss of eye contact that makes it difficult to communicate with others as well as succeed in ones chosen career whether interface with public is needed or not. Strabismus surgery even in a blind eye needs to be considered as a reconstructive surgery which allows an individual to communicate normally with others and obtain employment. Blind eyes develop sensory exotropia. Sensory exotropia– a unilateral exodeviation–develops as a result of loss of vision or chronic poor vision in one eye. The reasons are multifactorial. Binocular rivalry with the eye having degraded image leads to disruption of vergence system and an active retinomotor divergence takes hold with a progressive exodeviation. A well-controlled exophoria can decompensate after loss of vision in one eye. Orbital dysmorphism or muscle anomalies predispose to exotropia when there is loss of vision in one eye. Our patient had a sensory exodeviation due to loss of vision in one eye which had a larger distance measurement but a smaller near measurement due to proximal or instrument convergence. Therefore we recessed the lateral rectus to a large extent, 12 mm from muscle insertion to control the distance deviation and performed a small Medial rectus muscle resection of 5 mm to correct the near deviation. The surgery was performed under adjustables to correct any unexpected postoperative results.[6] SFT pupilloplasty has been proposed by Amar Agarwal for pupillary reconstruction.[7] A single pass with 9-0 or 10-0 Prolene suture on a long arm needle is passed through iris tissue followed by creation of a loop with four throws around it that slides inside the eye. It has various indications-to reduce the size of pupillary aperture in traumatic mydriasis, in fixed mid dilated pupil in Urrets Zavalia syndrome[8] and to improve vision in patients with irregular astigmatism by creating a pinhole of 1.5 mm size,[9] treating angle closure glaucoma and plateau iris syndrome by pulling the iris tissue from the angle.[7] We have used this technique to abolish the leucocoria due to the white mature complicated cataract and thus relieving the patient of chronic cosmetic contact lens use which the patient did not want to continue any further. This is a novel surgical approach with strabismus correction in young patients' with blind eyes and leucocoria due to mature cataract as we need to restore confidence in them to lead normal lives.[10]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest

  References Top

Etebu EN, Adio AO. Indications for removal of the eye at a tertiary hospital in south-southern Nigeria. J Ophthalmol East Cent S Afr 2008;14:19-22.  Back to cited text no. 1
Eballé AO, Dohvoma VA, Koki G, Oumarou A, Bella AL, Mvogo CE. Indications for destructive eye surgeries at the yaounde gynaeco-obstetric and paediatric hospital. Clin Ophthalmol 2011;5:561-5.  Back to cited text no. 2
Keltner JL. Strabismus surgery in adults. Functional and psychosocial implications. Arch Ophthalmol 1994;112:599-600.  Back to cited text no. 3
Satterfield D, Keltner JL, Morrison TL. Psychosocial aspects of strabismus study. Arch Ophthalmol 1993;111:1100-5.  Back to cited text no. 4
Hunter DG. Benefits of strabismus surgery in patients with one blind eye. Arch Ophthalmol 1995;113:404.  Back to cited text no. 5
Bishop F, Doran RM. Adjustable and non-adjustable strabismus surgery: A retrospective case-matched study. Strabismus 2004;12:3-11.  Back to cited text no. 6
Narang P, Agarwal A, Kumar DA. Single-pass four-throw pupilloplasty for angle-closure glaucoma. Indian J Ophthalmol 2018;66:120-4.  Back to cited text no. 7
[PUBMED]  [Full text]  
Narang P, Agarwal A, Ashok Kumar D. Single-pass four-throw pupilloplasty for urrets-zavalia syndrome. Eur J Ophthalmol 2018;28:552-8.  Back to cited text no. 8
Narang P, Agarwal A, Ashok Kumar D, Agarwal A. Pinhole pupilloplasty: Small-aperture optics for higher-order corneal aberrations. J Cataract Refract Surg 2019;45:539-43.  Back to cited text no. 9
Oliveira BF, Bigolin S, Souza MB, Polati M. Sensorial strabismus: A study of 191 cases. Arq Bras Oftalmol 2006;69:71-4.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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