Emerging technologies in corneal transplantation: innovations, challenges, and global implications

Abstract

Precision, reduction of rejection rates, and reduction of dependency on long-term immune suppression are being advanced by advancements in corneal transplantation (CT) using femtosecond laser-assisted keratoplasty (FLAK), Descemet membrane endothelial keratoplasty (DMEK), and Bowman layer transplantation (BLT). Also, technologies such as bioengineered tissues, CRISPR-Cas9 gene editing, and bioadhesives seek to enhance graft integration and survival in mechanisms to supply a global shortage of donor corneas, particularly in low-income countries with the greatest demand. Despite this, bioengineered corneas represent an alternative to traditional transplants that incur ethical and practical hurdles, including regulation, cost, and biases in resource allocation. The application of artificial intelligence (AI), in particular diagnosis and surgical planning, in ophthalmology in general, and especially in corneal disease management, has great promise. However, the 'black box' decision-making of AI, its biases, and lack of transparency could be barriers to accountability and consistent use in practice. The other obstacle is the high costs that discourage access to and availability of advanced technologies for many low- and middle-income countries (LMICs), whose healthcare infrastructures are also limited. To ensure these innovations can be integrated into mainstream corneal care, particularly serving the needs of underserved populations, we need to address these technological, economic, and ethical issues. However, these technologies require more clinical trials and policy considerations for their optimization for accessible, effective, global eye care.