Eyeworld

62 | EYEWORLD | WINTER 2026 C ORNEA by Julie Schallhorn, MD Cornea Editor S ometimes a cornea clinic can feel a bit chaotic. Patients from the full spectrum of refractive surgery candidates to the monocular uveitis/glaucoma/corne- al edema/keratoprosthesis patients sit side by side, separated by the thin walls of the lanes. Recently in my clinic, one was a retired attorney weighing an extended depth of focus lens against a trifocal, and we sat discussing which would be better for her golf game. Two rooms down was a teen insured by MediCal (California's version of Medicaid) with anterior segment dysgenesis who recently had a retinal detachment in her good eye. Both visits mattered, but the finances of each were very different. Our field has always been pulled in two di- rections: refining vision that is already good and restoring vision that is gone. Both have been and will continue to be noble goals, but the reimbursement in our field for each has a wide divergence. A premium IOL upgrade is a simple out-of-pocket conversation, with the price set by the surgeon. The patient going blind from severe corneal or retinal disease often gets to us after months of prior authorizations, and the surgery that gives back their sight is among the least-rewarded hours of our week. This issue's Cornea articles sit squarely on that tension. Deborah S. Jacobs, MD, MSc, and Derek Louie, MSc, OD, discuss therapeutic contact lenses, which can now spare many patients from a transplant altogether. Dr. Jacobs thinks every patient with ectasia or irregular astig- matism should have a scleral lens trial before keratoplasty is decided. Yet, as Dr. Louie points out, most medical insurance doesn't cover these "medically necessary" lenses at all. Time and again, this results in a corneal transplant for a patient who would be functional without it if only insurance would cover the lens. The article on neurotrophic keratitis brings together Preeya K. Gupta, MD, Christopher J. Rapuano, MD, and Brandon Ayres, MD. They describe a growing set of treatments, from nerve growth factor to amniotic membrane to com- pounded insulin drops. They also describe what stands in the way. "The insurance companies aren't crazy about approving a super expensive drug over and over again," Dr. Gupta notes. However, it is exactly this high financial reward to drug makers that is driving innovation in this field. In the article on penetrating keratoplasty (PK), Stephen Armenti, MD, PhD, and Bennie Jeng, MD, explain that endothelial keratoplasty procedures have dominated in the U.S. for more than a decade, but PK is still by far the most common transplant worldwide. Indications are different, and although we are seeing less PK in the U.S., the physicians rightly point out that continuing this training for fellows is critical for the patients who must receive this care. With development of endothelial cell injections, I sus- pect we will continue to see increasing separa- tion in both finances and outcomes of receiving PK vs. endothelial treatments. What strikes me across these three articles is that we aren't short on new ideas. The science is moving fast. The valuation that society places on a physician's care for complex patients is where the deficit is growing. The valuation by patients placed on premium lenses demon- strates clearly the value of sight to patients, but insurers and Medicare do not see this, and unfortunately, it is in the physician's office they find space to make cuts. The challenges in achieving our goals Constance Okeke, MD, EyeWorld Glaucoma Editorial Board member, commented on new tools, techniques, and challenges in anterior segment surgery: "One of the biggest challenges is not simply learning new surgical techniques but successfully integrating them into clinical practice. Even the most promising innovation can struggle to gain traction without an efficient workflow that supports patient selection, staff training, scheduling, and surgical execution. Successful adoption requires mastering both the procedure and the process." to the MOON and BACK

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