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BLOG: Corneal pockets are here to stay

ByJohn A. Hovanesian, MD, FACS

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In the cover story of this issue of OSN, we explore refractive surgery in the military. In this unique population, we see the most demanding work environment to put our refractive procedures to the test. Surely what works for a Navy SEAL will work for a civilian administrative assistant, banker or even eye surgeon. As we look at the demands of this unique population, the value of corneal pocket procedures becomes immediately apparent, and I believe this approach to modifying the cornea will only expand for the following reasons:

1. SMILE yields the fast recovery of LASIK with the desirable injury resistance and ocular surface kindness of PRK. A small pocket incision causes less damage and resulting ocular surface disease, according to a study published in Ophthalmology by Alexandre Denoyer. And with SMILE there’s no flap to injure or slip in the event of future injury. Furthermore, leaving the bulk of the anterior cornea unaltered by this surface incision preserves most of the mechanical integrity that prevents future ectasia. Corneal pockets offer the minimalist approach of PRK with the patient appeal of LASIK.

2. SMILE’s indications will expand. While currently approved only for myopia, which makes it an option for only about 20% of refractive candidates, approvals for astigmatism and hyperopia will surely come, allowing high levels of correction to be delivered safely.

3. Inlays are best placed in pockets. I believe the use of corneal inlays will continue to expand, and a corneal pocket appears to be the best way to secure these implants, based on studies and growing worldwide experience. Even in a patient with prior SMILE or LASIK, a pocket can be placed deep to the previous dissection plane to facilitate an inlay. Inlays offer patients a lifetime benefit of reading vision, even after future cataract surgery. And of course these inlay devices can be removed from a pocket with minimal risk of epithelial ingrowth in the rare event this is necessary.

So why did it take us refractive surgeons so long to start using corneal pockets? It’s because the first instrument approved for precise refractive correction was the excimer laser. When Ron Kurtz and Tibor Juhasz first conceived of the femtosecond laser for eye surgery in about 1992, they understood that the instrument could create lenticules for refractive correction. But rather than competing with the excimer laser, they chose a more direct path to FDA approval as a more precise substitute for a bladed microkeratome. Now, almost 20 years later, we are approaching the limits of excimer surgery, and newer treatments must be explored. While few of us refractive surgeons plan to sell our excimer lasers soon, it’s exciting to consider the possibilities that can be accomplished with a corneal pocket procedure.

Disclosure: Hovanesian reports he is a consultant to Zeiss.