{"id":13040,"date":"2026-09-15T06:24:50","date_gmt":"2026-09-15T04:24:50","guid":{"rendered":"https:\/\/keratoconuscenter.eu\/?p=13040"},"modified":"2026-09-15T06:25:03","modified_gmt":"2026-09-15T04:25:03","slug":"keratoconus-where-we-stand-london-2026","status":"publish","type":"post","link":"https:\/\/keratoconuscenter.eu\/en\/keratoconus-where-we-stand-london-2026\/","title":{"rendered":"Keratoconus: where we actually stand. Notes from the Keraring Global Users Group Meeting, London 2026"},"content":{"rendered":"

Keraring Global Users Group Meeting \u00b7 London, 13 September 2026<\/strong>
\nAlberto Bellone, MD, Ophthalmic Surgeon, Turin, Italy<\/em><\/p>\n

On 13 September I took part, as a panel member, in the Keraring Global Users Group Meeting in London, held at the Shangri-La The Shard. It is the international meeting devoted to the surgical treatment of keratoconus with intrastromal corneal ring segments. The photo report of the day is on my main website: Dr. Bellone at the Keraring Global Users Meeting 2026, London<\/a>.<\/p>\n

There were no lectures. A small group of surgeons from different countries sat around a table with an agenda built not on successes but on unresolved problems: three themes, ten questions, and nothing taken for granted. That format is rare at congresses, which is exactly why it is useful. This is a short account of where those answers currently stand.<\/p>\n

\"\"<\/p>\n

Combining treatments: rings, cross-linking, phakic lenses<\/h2>\n

Is there an optimal order? Honestly, not one that fits everyone, and the data agree. At one year, the three possible sequences (cross-linking first, rings first, or both in one session) show no statistically significant difference in residual astigmatism or corrected vision.<\/p>\n

That does not make the choice irrelevant; it moves the criterion. If the evidence does not dictate an order, the order is chosen on practical grounds and on the individual patient. The panel converged on this easily: sequence matters less than selection.<\/p>\n

One point drew full agreement, and it deserves to be stated plainly.<\/p>\n

Rings change the shape of the cornea. Cross-linking changes its time. They are not alternatives, and in a young patient with progressive disease, cross-linking is not optional.<\/p><\/blockquote>\n

As for the most predictable combination, predictability does not come from the combination itself but from each step having a defined entry criterion. First make the cornea regular, then make it stable, and only then correct the residual refractive error, possibly with a phakic lens. The logic is strict: a phakic lens corrects a refraction, not an irregular cornea. Implanted too early, it relocates the problem rather than solving it.<\/p>\n

Why some “perfect” cases underperform<\/h2>\n

This is where, in my view, the decisive part of the surgery is played out, and the panel gave it the most time.<\/p>\n

Keratoconus does not have a single shape. Topographic phenotype classifications distinguish central cones, symmetric patterns, and frankly asymmetric forms in which the ectatic zone is decentred. The question that discriminates is a single one: do the astigmatic axis and the axis of the main aberration coincide, or not?<\/p>\n

If they coincide, a symmetric implant can treat that cornea. If they do not, a symmetric implant flattens without regularising: it acts on the whole circumference and has no way of knowing where the asymmetry lies. Those eyes need asymmetric segments, of different arc length and thickness, placed on the two axes the cornea indicates. The published series supporting this are consistent with each other but still small, a few dozen eyes each. They point in a direction; they are not a settled nomogram.<\/p>\n

The panel also ran into a genuine limit of the field. We measure corneal shape well: curvature, thickness, elevation, aberrations. We measure corneal biomechanics far less well in routine practice, and the available instruments remain largely confined to research. When a case underperforms without an obvious geometric reason, we often lack the very measurement that would explain it.<\/p>\n

My own contribution was methodological: check the numbers nobody reads. After an implant it is normal for the summary indices to improve: mean curvature falls, astigmatism drops. But vision does not depend on averages; it depends on how the irregularity is distributed. Symmetry indices and higher-order aberrations can worsen while every headline number improves, and the patient sees poorly with a report that looks good.<\/p>\n

\"\"<\/p>\n

What explantation has taught us<\/h2>\n

In the textbooks, ring removal sits in the complications chapter, next to extrusion, migration and infection. The figures are reassuring: in high-volume centres the explantation rate runs between zero and just over one percent.<\/p>\n

But the published data say something else, often overlooked. Most explantations are not complications. They are elective, performed because the visual result is unsatisfactory: the segment is intact, the eye is quiet, and the segment is simply the wrong one for that cornea.<\/p>\n

The distinction has practical consequences. If removal is treated as a complication, it is avoided, and the patient waits. If it is treated as a correction, it is planned, and it is done early.<\/p>\n

Reversibility is the real strength of the technique. Unlike surgery that removes tissue, a ring implant destroys nothing: it adds an element within the corneal thickness. When it is removed, the cornea tends to return towards its previous state. That means two things at once: a wrong implant is not a final sentence, and the effect of a correct implant has to be maintained, because it is the ring that holds that shape, not a cure of the disease.<\/p>\n

Long-term biomechanical data remain thin, particularly in patients operated very young. What the literature does document are rare but real late events: spontaneous segment fracture years later without trauma, late extrusion, migration towards the incision. These are not reasons to abandon the technique, the incidence is low, but they are reason enough to treat long-term follow-up as part of the treatment rather than an optional extra. A patient operated at twenty has decades of surveillance ahead.<\/p>\n

The most interesting question on the programme was the last: what explanted cases reveal about how these implants actually work. The classical explanation says that adding volume at the periphery flattens the centre: more material, more effect. It describes central symmetric cones well and everything else poorly. What re-operated eyes suggest is different: a full-arc implant flattens a great deal and regularises little, while shorter segments, asymmetrically distributed and with less total material, can regularise considerably more. If that holds, the active part of the treatment is not only what you put in, but where you leave the gap, and geometry matters more than quantity. It is a working hypothesis, not a demonstrated conclusion, and it was discussed as such.<\/p>\n

What this means for a patient<\/h2>\n

If I had to reduce the evening to one sentence: the decisive part of this surgery does not happen in the operating room.<\/p>\n

Tunnel depth, cut precision, implant centration are problems the femtosecond laser has largely solved, and they separate one surgeon from another far less than they used to. What remains to be decided (how many segments, what arc length, what thickness, on which axes, and before or after cross-linking) is decided days earlier, at a screen, reading corneal maps. That is where a result is built or lost.<\/p>\n

So when surgery for keratoconus is proposed, it is reasonable to ask which examinations the implant geometry was chosen from, and not only which technology will be used in theatre.<\/p>\n

One last thing worth saying: many of the questions we put to ourselves in London still have no definitive answer. A field that meets to discuss its weak points rather than to display its best results is a field in good health.<\/p>\n

Further reading on this site: diagnosis and treatment of keratoconus<\/a>, corneal iontophoresis (transepithelial cross-linking)<\/a>, what is keratoconus<\/a>. To discuss your case: contacts<\/a>.<\/p>\n

Selected references<\/h3>\n
    \n
  1. Bonajmah H, Aljassar F, Taqi AA, AlSabah DH. Timing of corneal cross-linking in eyes undergoing intracorneal ring segments for keratoconus: same-day versus staged CXL: a systematic review and meta-analysis. Int Ophthalmol<\/em>. 2026;46:174. doi:10.1007\/s10792-026-04040-8<\/a><\/li>\n
  2. Coskunseven E, Jankov MR 2nd, Hafezi F, et al. Effect of treatment sequence in combined intrastromal corneal rings and corneal collagen crosslinking for keratoconus. J Cataract Refract Surg<\/em>. 2009;35(12):2084-2091. doi:10.1016\/j.jcrs.2009.07.008<\/a><\/li>\n
  3. El-Raggal TM. Sequential versus concurrent KERARINGS insertion and corneal collagen cross-linking for keratoconus. Br J Ophthalmol<\/em>. 2011;95(1):37-41. doi:10.1136\/bjo.2010.179580<\/a><\/li>\n
  4. Alfonso JF, Lisa C, Merayo-Lloves J, Fern\u00e1ndez-Vega Cueto L, Mont\u00e9s-Mic\u00f3 R. Intrastromal corneal ring segment implantation in paracentral keratoconus with coincident topographic and coma axis. J Cataract Refract Surg<\/em>. 2012;38(9):1576-1582. doi:10.1016\/j.jcrs.2012.05.031<\/a><\/li>\n
  5. Alfonso JF, Fern\u00e1ndez-Vega Cueto L, Baamonde B, et al. Inferior intrastromal corneal ring segments in paracentral keratoconus with no coincident topographic and coma axis. J Refract Surg<\/em>. 2013;29(4):266-272. doi:10.3928\/1081597X-20130318-06<\/a><\/li>\n
  6. Nassaralla BA, Soares JSB, Campos M. A randomized controlled trial of symmetric versus asymmetric intrastromal corneal ring segments for asymmetric keratoconus. Eur J Ophthalmol<\/em>. 2026;36(2):211-223. doi:10.1177\/11206721251372378<\/a><\/li>\n
  7. Hays Q, Kallel S, Garcin T, et al. Clinical evaluation of the effectiveness of asymmetric intrastromal corneal ring segments with progressive base width for management of keratoconus. J Cataract Refract Surg<\/em>. 2025;51(6):468-475. doi:10.1097\/j.jcrs.0000000000001629<\/a><\/li>\n
  8. Komninou MA, Seiler TG, Enzmann V. Corneal biomechanics and diagnostics: a review. Int Ophthalmol<\/em>. 2024;44(1):132. doi:10.1007\/s10792-024-03057-1<\/a><\/li>\n
  9. D’Oria F, Abdelghany AA, Ledo N, Barraquer RI, Alio JL. Incidence and reasons for intrastromal corneal ring segment explantation. Am J Ophthalmol<\/em>. 2021;222:351-358. doi:10.1016\/j.ajo.2020.09.041<\/a><\/li>\n
  10. Ferrer C, Ali\u00f3 JL, Monta\u00f1\u00e9s AU, et al. Causes of intrastromal corneal ring segment explantation: clinicopathologic correlation analysis. J Cataract Refract Surg<\/em>. 2010;36(6):970-977. doi:10.1016\/j.jcrs.2009.12.042<\/a><\/li>\n
  11. Al-Habboubi HF, Martinez-Osorio H, Maktabi AMY, et al. Long-term outcomes and causes of intrastromal corneal ring segment explantation in a tertiary eye hospital. Saudi J Ophthalmol<\/em>. 2022;36(1):64-69. doi:10.4103\/sjopt.sjopt_70_22<\/a><\/li>\n<\/ol>\n

    Disclosure.<\/strong> Participation in the meeting was by invitation from Mediphacos, which covered travel expenses. I have no financial interest in the company, no consultancy agreement, and received no speaker fee. I am a certified and reference ICL surgeon for STAAR Surgical, under an alliance agreement concluded in 2024.<\/p>\n

    This article is intended for general information and reports on an ongoing scientific discussion. It does not replace an eye examination: every case of keratoconus has its own characteristics and treatment must be assessed individually.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

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