Progress reframes keratoconus as SRR

Keratoconus care has become harder to describe in one sentence because the treatment menu is no longer just “cross-link early, transplant late.” A new review in *Progress in Retinal and Eye Research* tries to impose order on that expansion by grouping interventions under a simple sequence: stabilise the cornea, reshape it when useful, and replace tissue only when necessary. That matters because the field now includes not only corneal cross-linking and keratoplasty, but also tissue-adding and ring-based procedures designed to delay or avoid grafting. The review was highlighted this week by Japanese corneal surgeon @cornea_surgery, who said it frames keratoconus management around “SRR” — Stabilise, Reshape, Replace. ### Why does this framework matter if doctors already know the treatments? Keratoconus is a progressive corneal ectasia in which thinning and protrusion distort vision, and recent reviews have described a broader shift away from waiting for late disease before intervening. A 2025 clinical overview in *Ophthalmology Management* said cross-linking is now the “gold standard” for halting progression, while newer surgical options such as CAIRS and CTAK aim to improve vision without moving directly to transplant. (sciencedirect.com) The SRR model matters because it sorts those options by purpose rather than by novelty. In practical terms, “stabilise” centers on stopping progression, usually with corneal cross-linking; “reshape” covers methods intended to regularize the cornea and improve optical quality; and “replace” captures lamellar or full-thickness grafting for eyes that cannot be managed conservatively. That structure is consistent with recent keratoconus reviews emphasizing that progression assessment comes first and that surgery is no longer a single late-stage category. (ophthalmologymanagement.com) ### Where do cross-linking and CAIRS sit inside SRR? Corneal cross-linking fits the “stabilise” step because its main role is biomechanical arrest, not optical perfection. Reviews on PubMed and in the ophthalmic literature describe CXL as the treatment of choice for early or progressive keratoconus, including in younger patients and selected older patients with documented progression. CAIRS — corneal allogenic intrastromal ring segments — fits the “reshape” step because it adds donor corneal tissue within the stroma to flatten and regularize the cone. (sciencedirect.com) A 2025 professional overview described CAIRS as a minimally invasive, tissue-based reshaping option that can improve visual acuity and contact lens tolerance while potentially reducing the need for transplantation. (pubmed.ncbi.nlm.nih.gov) ### What changes when reshaping is treated as its own category? Recent keratoconus literature shows that reshaping is no longer limited to older synthetic ring segments. Reviews now discuss intracorneal ring segments, customized ablation-plus-cross-linking approaches, and tissue-addition strategies as distinct attempts to improve corneal optics while preserving native tissue. That matters because patients often need two different things at once: arrest of disease and better vision. (aop.org.uk) The SRR framing makes that split explicit. A patient may first need stabilization, then later reshaping for visual rehabilitation, without crossing immediately into graft territory. That is an inference from the treatment categories described in the review notice and supported by the broader keratoconus literature on sequencing combined procedures. (pubmed.ncbi.nlm.nih.gov) ### Does SRR push corneal transplantation later in the pathway? Corneal transplantation remains a standard option for advanced keratoconus, but recent reviews describe a sustained effort to reduce lifetime graft burden in a typically young patient population. The 2025 *Ophthalmology Management* article said many newer approaches are aimed at preventing or delaying the need for penetrating or lamellar keratoplasty. (x.com) The SRR model does not remove replacement surgery; it places it after attempts to preserve and optimize the native cornea when feasible. That ordering matches current literature describing keratoplasty as part of a broader ladder of care rather than the default endpoint once lenses fail. ### What should readers watch next? Progress in Retinal and Eye Research lists new review articles through its latest issue pages, and the keratoconus paper appears to be part of that current review stream. (ophthalmologymanagement.com) The next concrete step for readers is the full paper itself, which should show exactly how the author assigns specific procedures — including CXL, stromal augmentation and grafting — within the SRR sequence. (sciencedirect.com) (advancesinophthalmology.com)