Eyeworld

66 | EYEWORLD | SUMMER 2026 C ORNEA of the biomechanical stress forces, so the cornea becomes more regular. Just the simple redistri- bution can also make the corneal biomechanics stronger, she said. So, the chances of needing a corneal transplant may decrease. Another bene- fit of CAIRS is you can adjust it or reverse if the patient is unhappy. In terms of concerns and contraindications, Dr. Jacob said it's applicable for a large majority of the patients, but there may be some extreme cases, like very ectatic corneas, where it might not be a good option. In extremely ectatic cor- neas, which are too thin to crosslink, Dr. Jacob might still consider other procedures such as DALK. If there is a central scar over the visual axis, Dr. Jacob might also choose DALK instead of CAIRS. She added that in patients with auto- immune disorders, there may be some concern about implanting tissue in the cornea. Another point is that when you implant the tissue, you should not overstuff, she said. When starting out with this procedure, some may be inclined to try to make narrow tunnels and stuff a lot of tissue into them. But if you keep stretching, at a point, it will give way. Excessive stuffing and extremely narrow tunnels should be avoided, she said, and it's important that the segments fit comfortably within the tunnels. Looking forward There have been many publications from au- thors around the world on this, Dr. Jacob said, adding that there have been positive results in uncorrected and best corrected VA with CAIRS. She noted a study by Gerd Auffarth, MD, PhD, that is a meta-analysis of all studies that shows results have been good. 3 Dr. Jacob noted that CAIRS is being used in more than 40 countries worldwide. "It's surgery with a low risk and high reward." This can be used in young patients, since there are risks with keratoplasties and other procedures. "I think that's what has made CAIRS so popular," she said. Dr. Jacob advised surgeons who are in- terested in learning this technique to take a course or watch videos to learn more. The more important learning curve is in the planning, she said, adding that she has her own proprietary nomogram which she uses for custom shaping, and there are other nomograms available. At present, these procedures are gaining increasing interest worldwide, Dr. Kiliç said, but they are not yet universally adopted. "One of the main limiting factors is the requirement for a femtosecond laser, particularly for precise channel creation," she said. "The lack of access to this technology remains one of the most im- portant barriers to broader utilization." Although commercially available products such as KeraNatural (VisionGift) have simplified the process, Dr. Kiliç said it is important to note that surgeons also have the option to prepare allogenic tissue intraoperatively. But this ap- proach requires additional surgical skill, famil- iarity with tissue handling, and a certain level of adaptation within the operating room, often supported by dedicated training programs. "For surgeons who already have access to femtosecond laser platforms, the learning curve is relatively manageable," she said. Like Dr. Jacob, Dr. Kiliç pointed out the importance of surgical planning, adding that the Istanbul no- mogram is now widely recognized and has be- come one of the most practical and user-friend- ly nomograms in the field. Industry support also plays an important role in accelerating the learning process, she said. "Overall, while there are certain technologi- cal and educational barriers, the combination of standardized products, simplified nomograms, and increasing training opportunities is steadily improving accessibility and adoption," Dr. Kiliç said. One aspect that she is excited about is the potential to significantly reduce the need for keratoplasty in keratoconus patients. Inlay- based approaches, such as allogenic corneal implants, represent a less invasive, adjustable, and tissue-preserving alternative compared to procedures like DALK, she said. "We have already made remarkable prog- ress, but I think that this is only the beginning. With the accumulation of larger datasets and more refined analysis, we will be able to achieve more precise and predictable outcomes," Dr. Kiliç said. "Keratoconus is a highly heteroge- neous disease—each cornea is unique, and each patient may respond differently to the same treatment. This variability is one of the main challenges we still face today. However, as we improve our ability to predict these responses, I think these techniques could evolve toward a refractive, highly customized approach, ul- timately allowing us to provide better visual outcomes for a broader group of patients." continued from page 65 Relevant disclosures Jacob: Patent granted for special trephines and devices used to create these segments, patent granted for CAIRS segments and various types of shaped corneal segments; Beauty of Sight, Lions World Vision Institute, Madhu Instruments Kiliç: VisionGift Parker: None Contact Jacob: dr_soosanj@hotmail.com Kiliç: aylinkilicdr@gmail.com Parker: jack.parker@gmail.com

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