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440                            <span class="date">Published <span itemprop="datePublished" content="2026-06-15T00:06:00">June 15, 2026</span></span>
441<div class="fullissuelink"><a href="/issue/may-june-2026">View Full Issue</a></div>                                                            <div class="departmentlink"><a href="/topic/cornea">Cornea</a></div>
442                            <h1 class="title" itemprop="name" id="art-title">Surgical Advances in Corneal Care: What ODs Need to Know Today&#8212;and Tomorrow</h1>
443                            <h3 class="subtitle" itemprop="abstract">A look at the evolving procedures, technologies and comanagement strategies transforming this space.</h3>
444                            <div class="author"><span itemprop="author" itemscope itemtype="http://schema.org/Person"><span itemprop="name" class="hidden">By Catlin Nalley, Contributing Writer</span></span>By Catlin Nalley, Contributing Writer</div>
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447                            <p> </p><style type="text/css"> p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; font: 60.5px Sabon} p.p2 {margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Sabon} p.p3 {margin: 0.0px 0.0px 0.0px 0.0px; text-indent: 9.0px; font: 10.0px Sabon} p.p4 {margin: 0.0px 0.0px 0.0px 0.0px; text-indent: 9.0px; font: 10.0px Sabon; min-height: 11.0px} p.p5 {margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Gotham; color: #33a26f} p.p6 {margin: 0.0px 0.0px 0.0px 18.0px; text-indent: -12.6px; font: 10.0px Sabon} p.p7 {margin: 0.0px 0.0px 0.0px 0.0px; font: 27.0px Sabon} p.p8 {margin: 0.0px 0.0px 0.0px 0.0px; font: 10.0px Sabon; min-height: 11.0px} p.p9 {margin: 0.0px 0.0px 2.1px 0.0px; line-height: 7.0px; font: 7.0px Gotham} span.s1 {letter-spacing: -0.1px} span.s2 {font: 10.0px 'Helvetica Neue'; letter-spacing: -0.1px} </style> <p>Co<span style="font-size: inherit;">rneal surgery is undergoing a period of rapid transformation. Procedures that once relied heavily on full-thickness transplantation are increasingly being replaced&#8212;or supplemented&#8212;by minimally invasive, tissue-sparing and highly targeted approaches designed to preserve native corneal architecture, accelerate recovery and improve long-term outcomes. At the same time, innovations in imaging, femtosecond laser technology, biologic therapies and additive tissue techniques are reshaping both refractive and therapeutic corneal care.</span></p><p>For ODs, these advances are more than surgical milestones; they are fundamentally changing when patients are referred, how they are counseled and what long-term comanagement looks like. Many of the newer procedures allow for earlier intervention, expanded candidacy and improved patient comfort, while also increasing the need for coordinated care between optometrists and corneal surgeons.</p><p>&#8220;Corneal surgery is really shifting toward being less invasive and more targeted,&#8221; notes Ranjani Panda, OD, who practices at Virginia Eye Consultants in Norfolk, VA. &#8220;Instead of transplants being our main option, we now have options that better match the specific disease and severity.&#8221; For example, Descemet stripping only (DSO) for Fuchs&#8217; dystrophy and corneal tissue addition keratoplasty (CTAK) and corneal allogenic intrastromal ring segments (CAIRS) for corneal ectasias &#8220;let us treat more selectively while preserving the patient&#8217;s own cornea,&#8221; she says. Even crosslinking is evolving, with the new epi-on option increasing patient comfort and recovery.</p><p>&#8220;Overall, this is positively affecting us as well as patients, who are having faster recoveries, less discomfort and fewer long-term risks, while still getting good visual outcomes,&#8221; she continues. &#8220;From a clinical standpoint, it gives us more flexibility to intervene earlier and more appropriately based on the individual patient.&#8221;</p><p>Experts interviewed for this article describe a field increasingly defined by personalization, minimally invasive intervention and biologically compatible tissue-based therapies. Corneal surgery is evolving rapidly, and optometrists play an increasingly central role in identifying candidates, counseling patients and managing outcomes.</p><h3><span style="color: #0070c0;"><b>Rise of Tissue-sparing and Minimally Invasive Surgery</b></span></h3><p>One of the clearest trends in corneal surgery is the movement away from traditional full-thickness transplantation whenever possible. Lamellar approaches, additive procedures and selective tissue replacement are allowing surgeons to target pathology more precisely while preserving healthy tissue.</p><p>For endothelial disease, this evolution has included DSO, also referred to as Descemet stripping without endothelial keratoplasty (DWEK). &#8220;Descemet stripping only is a less invasive way to manage Fuchs&#8217; compared to a corneal transplant, which used to be our only surgical option,&#8221; Dr. Panda says. &#8220;In this procedure, the central Descemet layer is stripped, which allows the surrounding endothelial cells to repopulate that area.&#8221; In the right patient, she says, it can be a great option that avoids a transplant altogether.</p><p>Patient selection remains critical for DSO &#8220;Appropriate candidates are patients with Fuchs&#8217; who have guttata limited to the central ~5mm with a clear peripheral cornea and an adequate endothelial cell count (around 1,000 cells/mm² or higher),&#8221; Dr. Panda explains, while emphasizing the importance of counseling patients that &#8220;this can be a less invasive alternative to a transplant, but visual recovery can take time, with some expected blur while the endothelium regrows.&#8221;</p><p>The advantages extend beyond avoiding donor tissue. &#8220;From a comanagement standpoint, it&#8217;s also reassuring that we don&#8217;t have to worry about issues such as graft rejection or dehiscence since there is no donor tissue involved,&#8221;
447 Dr. Panda says.</p><p>John Gelles, OD, director of Specialty Contact Lenses at the Cornea and Laser Eye Institute (CLEI) and CLEI Center for Keratoconus in Teaneck, NJ, notes that evolving surgical safety profiles are also changing referral timing. &#8220;We no longer have to wait until a Fuchs&#8217; patient is worse than 20/40 before intervening,&#8221; he says. &#8220;The procedures are safer, outcomes are excellent and patients don&#8217;t have to suffer.&#8221;</p><table class="fig" style="width: 480px; margin-bottom: 10px;"><tbody><tr><td><img src="/CMSImagesContent/2026/06/RCCL/0626_Nalley1.jpg" style="width: 479px; height: 639px;" class="fig-modal" alt="CTAK has the potential to induce significant keratometric flattening." /><br /></td></tr><tr><td><p><b>CTAK has the potential to induce significant keratometric flattening</b><b style="font-size: inherit;">. </b><span style="font-size: inherit;"><em>Photo:</em></span><em><b style="font-size: inherit;"> </b><span style="font-size: inherit;">Albert Cheung, MD.</span><b style="font-size: inherit;">&nbsp;</b></em><em style="font-size: inherit;">Click image to enlarge</em><span style="font-size: inherit;">.</span></p></td></tr></tbody></table><h3><span style="color: #0070c0;">Keratoconus and Corneal Ectastia: New Options Beyond Transplantation</span></h3><p>
447Advances in keratoconus management may represent one of the most significant areas of change in corneal surgery. Historically, patients with progressive ectasia who failed specialty lens management often progressed toward penetrating keratoplasty or deep anterior lamellar keratoplasty (DALK). Today, newer minimally invasive procedures are expanding options dramatically.</p><p>&#8220;Surgical management of keratoconus has evolved substantially toward tissue-sparing and lamellar techniques,&#8221; says Joseph Shovlin, OD, of Scranton, PA. Crosslinking remains foundational. Both Drs. Panda and Shovlin point to transepithelial, also referred to as epithelial-on or epi-on collagen crosslinking, as one of the most important recent developments.</p><p>&#8220;Historically, epi-on crosslinking was done off-label, but as of 2025 a specific system (Epioxa, Glaukos) is now FDA approved, making it the first approved epi-on option in the United States,&#8221; Dr. Panda says. &#8220;The main advantages are improved patient comfort and faster recovery. Outcomes are comparable to epi-off in many cases, although they can still be somewhat case-dependent.&#8221;</p><p>The approval of this system represented a significant milestone because earlier FDA-approved crosslinking protocols required epithelial removal. Epi-on approaches aim to improve comfort, reduce infection risk and shorten recovery while still stabilizing progressive ectasia. Research suggests epi-on approaches may produce somewhat less stromal stiffening than traditional epi-off methods, but newer oxygen-enhanced and accelerated pulsed protocols appear promising.</p><p>Dr. Gelles highlights another important practical implication of the newer approval. &#8220;The original FDA labeling for crosslinking was progressive keratoconus, which required documented progression before treatment could be covered,&#8221; he says. &#8220;The new labeling is for keratoconus&#8212;no mention of a progressive state&#8212;meaning treatment may occur at diagnosis rather than waiting to prove progression. This is impactful for young and high-risk patients.&#8221;</p><p>For optometrists, this potentially changes referral philosophy substantially, creating a preventative&#8212;not reactive&#8212;use of the treatment.</p><p>At the same time, additive stromal procedures are creating new treatment options for visual rehabilitation. &#8220;For keratoconus and other corneal ectasias, CTAK and CAIRS have been exciting developments,&#8221; Dr. Panda says. &#8220;These involve placing donor corneal tissue segments into the stroma to help reshape the cornea.&#8221;</p><p>CAIRS replaces synthetic PMMA ring segments with donor corneal tissue shaped to mimic intracorneal ring segments, potentially improving biocompatibility and reducing complications associated with synthetic implants. CTAK similarly uses allogenic donor tissue implanted into stromal channels or pockets to regularize the cornea and improve visual function.</p><p>CTAK is a minimally invasive anterior lamellar keratoplasty that uses sterilized allogenic donor stromal tissue that has been custom-shaped by a femto laser to augment the recipient&#8217;s cornea shape. The tissue is implanted into the anterior stroma via stromal channels or pockets to regularize the corneal shape and, in turn, improve visual function. Unlike traditional anterior lamellar keratoplasty, there is no tissue replacement&#8212;only tissue addition.</p><p>Dr. Gelles emphasizes that these procedures can help reduce patients&#8217; dependence on specialty contact lenses. &#8220;These minimally invasive procedures can help regularize the cornea and expand patients&#8217; correction options so they&#8217;re not 100% dependent on contact lenses,&#8221; he says. &#8220;Procedures like CTAK or topography-guided PRK can improve corneal shape and make patients more correctable in glasses or soft lenses.&#8221;</p><p>For optometrists, this requires looking beyond best-corrected acuity alone. &#8220;Optometrists often fixate on the fact that the patient&#8217;s visual acuity with medical contact lenses,&#8221; Dr. Gelles says. &#8220;But what about their count-fingers vision when they wear their glasses? CTAK addresses this to improve overall visual function.&#8221;</p><h3><span style="color: #0070c0;">
447Advances in Refractive Corneal Surgery</span></h3><p>Innovation is also accelerating on the refractive side of corneal surgery. Improvements in femtosecond laser technology, wavefront-guided treatments and ray-tracing platforms are allowing for increasingly customized procedures.</p><p>&#8220;In the refractive category, we&#8217;ve seen developments over the last couple of years,&#8221; Dr. Gelles says. &#8220;Zeiss&#8217;s VisuMax 800 now includes SMILE Pro with the ability to treat larger amounts of astigmatism, compensation for cyclotorsion, and the device runs faster&#8212;completing a SMILE cut in 10 seconds or a LASIK flap in five seconds. Unfortunately, there is still no hyperopic treatment in the US.&#8221;</p><p>Ray-tracing may represent one of the most significant developments in LASIK, with Alcon recently launching Wavelight plus, Dr. Gelles explains. &#8220;Treatment uses manifest refraction, plus the scan data collected from wavefront aberrometry, corneal tomography and biometry to create what they refer to as a digital clone, to then designing a custom ablation pattern. Again, there&#8217;s no hyperopic treatment.&#8221;</p><p>The goal is improved visual quality through increasingly individualized ablation profiles.</p><p>According to Dr. Gelles, many femto laser systems can create complex patterned cuts for procedures such as creating zig zag, mushroom or top hat-shaped cuts for penetrating keratoplasty and DALK. However, the newest systems are incorporating intraoperative OCT guidance to improve precision.</p><p>&#8220;One major innovation is the use of OCT guidance during corneal femto procedures,&#8221; he says. &#8220;The Ziemer Z8&#8217;s OCT allows the surgeon to see and guide the depth of cuts intraoperatively. This has been very helpful in CTAK for post-LASIK ectasia to ensure the channel depth is below the flap interface.&#8221;</p><p>Dr. Gelles also describes work involving femto-assisted DALK procedures designed to reduce perforation risk, using a combination of OCT guidance and surgical technique that avoids the use of big bubble technique.</p><p>Refractive tissue addition for presbyopia is also emerging. &#8220;Allotex is about to begin its phase 3 clinical trial for its presbyopia lenticle&#8212;a sterilized excimer-shaped allogenic stromal tissue about 2mm in diameter and 20µm in thickness, which is placed under a LASIK flap on the visual axis to induce spherical aberration to improve UCIVA and UCNVA.&#8221;<span style="font-size: 17px; font-weight: 900; color: #0070c0;"><br /></span></p><table class="fig" style="width: 480px; margin-bottom: 10px;"><tbody><tr><td><img src="/CMSImagesContent/2026/06/RCCL/0626_Nalley2.jpg" style="width: 479px; height: 99px;" alt="Visual improvement following the ray-tracing-guided ablation. The differential map shows the preoperative (middle) to postoperative (right) differences in point spread function and quality of vision." class="fig-modal" /><br /></td></tr><tr><td><em></em><p><b>Visual improvement following the ray-tracing-guided ablation. The differential map shows the preoperative (middle) to postoperative (right) differences in point spread function and quality of vision.<em> </em></b><em>Photo: Bobby Saenz, OD.<b>&nbsp;</b>Click image to enlarge</em>.</p></td></tr></tbody></table><p><span style="font-size: 17px; font-weight: 900; color: #0070c0;">Cell Therapy, Artificial Corneas and the Future<br /></span><span style="font-size: inherit;">Beyond current surgical techniques, some of the most intriguing developments involve regenerative medicine, endothelial cell therapy and bioengineered implants.</span></p><p>&#8220;Corneal endothelial cell therapies have opened a new frontier especially where there are shortages of viable tissue,&#8221; Dr. Shovlin says. &#8220;Pluripotent stem cell-based therapies are the latest option for endothelial diseases. Bioengineered implants and smart devices should soon be featured as an alternative to current lamellar procedures.</p><p>&#8220;Synthetic implants are under investigation along with several artificial corneas,&#8221; he continues. &#8220;CorNeat Vision has a CorNeat KPro device composed of a non-degradable synthetic biomimetic for artificial corneal transplantation.&#8221;</p><p>According to Dr. Gelles, hydrogel-like artificial endothelial implants have been successful and approved outside of the US. &#8220;EndoArt implants are providing an alternative to traditional EK, with a barrier like approach.&#8221;</p><p>One major area of investigation involves cultured endothelial cell injection therapy. &#8220;Aurion Biotech are culturing donor endothelial cells that can be injected is currently in Phase III of its endothelial cell therapy, a combination of donor endothelial cells and a rho-kinase inhibitor that is injected into the anterior chamber after stripping diseased endothelium,&#8221; Dr. Gelles says. &#8220;The idea is to restore endothelial function without requiring full donor tissue.&#8221;</p><p>Several studies, long-term data and Phase II data evaluating cultured endothelial cell therapies have demonstrated improvements in visual acuity, corneal clarity and endothelial function, particularly in bullous keratopathy and Fuchs&#8217; endothelial dystrophy. Dr. Gelles notes that this treatment has been used and approved by the PMDA in Japan since 2023.</p><p>&#8220;I am both intrigued and surprised by the advances made in artificial corneas,&#8221; Dr. Shovlin says. &#8220;It&#8217;s always been the holy grail but now we have options and they seem to improve greatly with every iteration.&#8221;</p><p>Meanwhile, new donor grafting procedures are expanding options for ocular surface disease and epithelial healing. &#8220;BrightMEM&#8212;a Descemet anterior membrane keratoplasty procedure&#8212;involves performing a superficial keratectomy and laying donor Descemet membrane onto exposed Bowman&#8217;s/anterior stromal layer to serve as a substrate to allow for epithelial healing,&#8221; Dr. Gelles says, while noting that this is being used in patients with partial limbal stem cell disease, as well as those with various forms of anterior corneal pathology.</p><p>Dr. Shovlin also points to newer allograft technologies for limbal stem cell deficiency and persistent epithelial defects. &#8220;BrightStar has the BrightMEM corneal allograft for a Bowman&#8217;s layer allograft consisting of confluent sheets of stem cells on Descemet&#8217;s membrane placed on the corneal defect,&#8221; he says.</p><table class="fig" style="width: 480px; margin-bottom: 10px;"><tbody><tr><td><img src="/CMSImagesContent/2026/06/RCCL/0626_Nalley3.jpg" style="width: 479px; height: 163px;" class="fig-modal" alt="This patient with complications from scleral lens overwear underwent CTAK, which provided 18.9D of flattening at the maximum point and a much more regular, central corneal shape. Vision improved from 20/400 uncorrected, 20/200 with manifest refraction and 20/50 with scleral lens 
447wear to 20/40 uncorrected, 20/25 with manifest refraction and 20/25 with soft contact lens wear. Complications from overwear resolved, as the patient was able to function without contact lenses, allowing for reduced wear time. Left to right map: post-op; pre-op; difference map showing changes in corneal shape." /><br /></td></tr><tr><td> <style type="text/css"> p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; font: 8.0px Gotham} </style> <p><b>This patient with complications from scleral lens overwear underwent CTAK, which provided 18.9D of flattening at the maximum point and a much more regular, central corneal shape. Vision improved from 20/400 uncorrected, 20/200 with manifest refraction and 20/50 with scleral lens wear to 20/40 uncorrected, 20/25 with manifest refraction and 20/25 with soft contact lens wear. Complications from overwear resolved, as the patient was able to function without contact lenses, allowing for reduced wear time. Left to right map: post-op; pre-op; difference map showing changes in corneal shape.</b><b style="font-size: inherit;">&nbsp;</b><span style="font-size: inherit;"><em>Photo: John Gelles, OD</em></span><b style="font-size: inherit;"><em>.</em>&nbsp;</b><em style="font-size: inherit;">Click image to enlarge.</em></p></td></tr></tbody></table><b></b><h3><b><span style="color: #0070c0;">The Expanding Role of Optometric Comanagement</span></b></h3><p>As procedures become safer and less invasive, the OD&#8217;s role in patient selection, counseling and postoperative care continues to grow.</p><p>&#8220;I would say our role in comanagement is definitely expanding,&#8221; Dr. Panda says. &#8220;We&#8217;re identifying candidates earlier, helping guide treatment discussions and taking on much of the postoperative care along with long-term monitoring. Overall, optometrists play an increasingly central role in patient selection and follow-up, which helps improve outcomes.&#8221;</p><p>Patient education has become especially important as online information and direct-to-patient marketing increase awareness of newer procedures. &#8220;The first step is to become familiar with the many options now available because if you don&#8217;t, your patients will,&#8221; Dr. Shovlin says.</p><p>Several experts emphasized the importance of understanding not only procedures themselves, but also which surgeons perform them and how they approach collaboration. &#8220;You want to work with a surgeon who wants to work with you,&#8221; Dr. Gelles advises. He encourages ODs to seek surgeons who communicate openly and welcome collaborative care. &#8220;Open communication is key, and the best comanagement relationship is with someone willing to give you their number and say, &#8216;Text or call me any time.&#8217;&#8221; he says.</p><p>At the same time, ODs must honestly assess their own comfort levels and clinical experience. &#8220;If you&#8217;re not comfortable managing something, tell the surgeon that,&#8221; Dr. Gelles says. &#8220;It is OK to refer some patients and co-manage others. You must know your limitations and work with a surgeon who understands your level of comfort and confidence and also can help foster your confidence in managing these procedures.&#8221;</p><p>Increasingly, successful outcomes depend on multidisciplinary management extending well beyond surgery alone. Dr. Gelles describes a recent case involving severe graft vs. host disease and corneal perforation that required coordination among multiple providers, including oncology, corneal specialists, ocular immunology and specialty contact lens management.</p><p>&#8220;The best outcomes happen when care is coordinated,&#8221; he emphasizes.</p><h3><span style="color: #0070c0;">Staying Ahead of the Game</span></h3><p>For practicing optometrists, staying current with emerging technologies is becoming increasingly important as innovation accelerates.</p><p>&#8220;We are uniquely positioned on the front-line to discuss these new options for corneal disease,&#8221; Dr. Shovlin says. &#8220;Attend educational presentations, discuss with colleagues what they have experienced and approach the specialists who perform the procedures and get their opinions as well.&#8221;</p><p>Dr. Panda similarly emphasizes the need for ongoing education. &#8220;
447The key to staying ahead is staying up to date on these advances so we can identify candidates earlier, have more informed conversations with our patients and ensure the best outcomes for them.&#8221;</p><p>The pace of development shows little sign of slowing. Investigational therapies involving biologics, gene therapy, mitochondrial transfer, monoclonal antibodies and neurotrophic treatments are already entering clinical research pipelines, which Dr. Gelles says &#8220;is going to be very interesting.&#8221;</p><p>The continued evolution of corneal surgery is changing not only how disease is treated, but also how optometrists approach corneal care more broadly. Procedures are becoming earlier, safer, more customized and increasingly collaborative.</p><p>&#8220;Stay tuned: the future is bright for corneal disease treatments,&#8221; Dr. Shovlin concludes. &#8220;Continue to remain curious enough to keep learning new and available options for our patients. For they depend on us to guide them through the process of treating their corneal disease.&#8221;&nbsp;</p><style type="text/css"> p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; font: 8.0px 'Gotham Light'} span.s1 {letter-spacing: 0.1px} </style><style type="text/css"> p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; font: 8.0px Gotham} </style>
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