Cornea: Digital Momentum
Summer 2026
by Ellen Stodola
Editorial Co-Director
There are many available technologies in the ophthalmologist’s toolkit for the corneal practice, according to Nandini Venkateswaran, MD. She mentioned the importance of having a topographer, adding that there are many great topographers on the market that help you really assess the anterior cornea.
“You also need a good tomographer, which is going to help you assess the posterior cornea, especially if you’re diagnosing corneal irregularities like ectasia or keratoconus,” she said. She added that epithelial thickness mapping and anterior segment OCT are useful. Dr. Venkateswaran said anterior segment OCT has become a nice tool for a variety of reasons, whether it’s looking at the depth of a corneal scar, the attachment of an endothelial keratoplasty graft (DMEK or DSAEK), or the degree of corneal thinning noted in a corneal ulcer. “Those are all the tools that I’m using in my practice that help me better diagnose and treat corneal diseases, and I use them often together.”
Dr. Venkateswaran said advanced corneal diagnostics and imaging devices can help paint a story. For example, if the topographer detects anterior corneal steepening, the tomographer and epithelial thickness mapping can be used together to confirm the diagnosis of keratoconus versus contact lens corneal warpage. Or if there are areas of flattening on topography, anterior segment OCT could potentially help characterize corneal lesions causing such flattening, such as Salzmann’s nodules or pterygia.
In terms of how frequently she’s using these technologies and if it’s for every patient diagnosis, Dr. Venkateswaran noted that often in her practice, a patient comes in already diagnosed with a condition, and she uses these technologies to confirm the diagnosis.
She will have certain diagnostic images taken before meeting with the patient so she can look at them clinically and assess what the imaging shows. Other times, she might suspect something and want additional tests.
In terms of a learning curve with anterior segment OCT, Dr. Venkateswaran said that all of these corneal technologies are easy to incorporate into practice. It can be helpful to speak to colleagues who use them to get a sense of certain layouts or printouts and which maps/displays to look at, as well as parameters that might be most helpful.
In general, Dr. Venkateswaran thinks the best approach to new technology is first to learn about it, then to see where it can play a role in your practice. It’s also a good idea to make sure your staff understands how to use the machines and to work with the company to get appropriate training.
While Dr. Venkateswaran is not using intraoperative OCT, she noted its utility when performing corneal transplants to check that an endothelial transplant is attached or to help understand corneal depth to achieve a successful big bubble for DALK.
When incorporating corneal imaging technologies into practice, Dr. Venkateswaran recommended starting with a tomographer and topographer and building up to adding more options.
Dr. Venkateswaran said it’s also nice to be able to hear about these technologies at meetings and from colleagues to really explore the best options for a physician and their practice before committing to implementing a new technology. It’s important to weigh if the return on investment is worth it, she said, adding that implementation can vary in different practice settings, for example from private practice to an academic setting.
Many of these OCT capabilities are incorporated into machines with other functionalities, so it’s not a huge footprint, but may require updating your machines.
Karolinne Rocha, MD, PhD, and Mitchell Weikert, MD, also discussed advanced imaging options in cornea, focusing on some of the newer technologies.
Dr. Rocha mentioned the OPMI LUMERA 700 (Zeiss), a surgical microscope with integrated intraoperative OCT imaging. She uses this technology for corneal transplants, lamellar and endothelial keratoplasty, and called it a “game changer.” It helps to show all the layers of the corneal graft in real time, so you can see if there are any folds or interface fluid. She added that there wasn’t much of a learning curve, it’s possible to adjust the focus, and you can turn the OCT on and off. She said it’s even useful in newer procedures, like CAIRS and CTAK.
Dr. Rocha also highlighted the ANTERION (Heidelberg Engineering), which combines corneal topography and tomography, epithelial mapping, high resolution anterior segment OCT, and biometry. This combining of different devices into one will help physicians do measurements quickly without moving patients, she said.
It also keeps track of ectasia progression. All the maps will show changes in keratometry and pachymetry over time, and it includes corneal wavefront analysis for complex cornea refractive cases. The photos are quick and easy, she said, adding that it can take around 65 images for topography in a few seconds with more than 16,000 data points over 8 mm. OCT is non-contact, so it’s easier for patients. The corneal data for the cataract evaluation app is derived from a 3 mm ring that is centered on the corneal vertex.
Dr. Rocha has been using the ANTERION for ICL sizing. You combine the high-resolution, swept-source OCT imaging of the anterior segment with artificial intelligence to help determine the sizes for ICLs and predicted vault.
In addition to measuring the biometry of the eye, it can give high-resolution imaging of the anterior segment. A lot of corneal topographers will measure the central 8–9 mm of the cornea, but Dr. Weikert said the ANTERION has a full scan diameter of more than 16 mm. You can get a nice cross-sectional image of the front of the eye that’s high resolution, which helps provide a clearer picture, he said.
There are other similar devices available, Dr. Weikert added, noting the CSO MS-39, a spectral domain OCT that measures the anterior segment and can do imaging of the anterior segment. It’s not a biometer, but it has dual functionalities—OCT and Placido rings.
“When you talk about these types of corneal imaging technologies, there are nuances of each one,” Dr. Weikert said. They provide high resolution and you can get detailed images of the cornea, the anterior chamber, the iris, the lens within the pupil, the corneal epithelium. “We can get our typical curvature data. We can get the anatomical dimensions of the front of the eye so we can look at the angle for glaucoma considerations. You can look at epithelial maps of the cornea.”
The issue with any of these OCT devices, Dr. Weikert said, is they can’t penetrate the iris. All the devices have ways to make assumptions and help them size for ICLs based on what they can image, but they’re not directly imaging the sulcus. Right now, that can only be done with ultrasound. When considering any gaps in the available technology, that’s the biggest, he said.
When you have the high-resolution images, it can help you manage corneal pathology, Dr. Weikert said. You can judge the extent of the depth, the density of corneal scars, some foreign bodies, and the intracorneal ring segments. Oculus is coming out with a Pentacam that will include OCT as well.
We’ve had OCT for a while now, Dr. Weikert said, but they were limited to the cornea and not the full anterior segment. “Now that these devices can image the anterior segment, they have become a lot more useful,” he said.
“… as these devices are out for longer periods of time and [in] more hands, the applications for them will start expanding.”
Mitchell Weikert, MD
“We were using corneal OCT to do things like judging scars, looking for irregularities, trying to measure or get a better estimation of what the refractive power of the cornea is because we can image the front and the back surface and thickness,” he continued. “But again, we were limited to the central 8 mm of the cornea. Now, we can get the whole answer. There’s potential there that we’re not tapping right now, but as these devices are out for longer periods of time and [in] more hands, the applications for them will start expanding.”
At the present time, in addition to using these devices for biometry and IOL calculations, Dr. Weikert said he’s using them after DMEK or DSAEK cases when he wants to check if it’s attached or to look for areas of detachment. He also likes to use the imaging to judge if a patient is a good candidate for PTK, adding that this technology has helped him locate entry points to remove a corneal inlay.
The technologies are fairly easy to learn and incorporate, but they can be a big investment. You need to look at everything you’re getting, he said, adding that it’s nice to be able to get combined applications, like a biometer with imaging.
Dr. Weikert said these devices are taking many scans and, in the case of ANTERION, taking a bunch of radial scans. “They’re taking cross sections of the front of the eye and putting those together to calculate the curvature of the cornea on the front of the eye, the curvature of the back of the cornea. With Placido rings, you’re reflecting it off the front surface of the eye, so you’re measuring the anterior curvature more directly (but you don’t get the back surface).”
Dr. Weikert mentioned the Eyestar 900 (Haag-Streit), which is also a biometer and OCT device. Whereas the ANTERION is pure OCT for measuring the curvature of the cornea, the Eyestar has some reflective spots to help with that, he said, adding that all these devices are a little different and all have ways of approaching things differently.
Often when these devices are first approved, their functionality may not be maximized. Applications are often added as they get into practice and are used more. As time goes on, we’ll be able to do more and more, he said.
In the future, Dr. Rocha said it will be important to have validation for technologies like this. “We’re so used to the IOLMaster [Zeiss] devices for IOL calculation, and we know they work and are precise,” she said. When transitioning to using a new technology, data and prospective studies become important to validate the new technology.
“I think physicians may fear a new device a little bit,” Dr. Rocha said. In the future, with validation, it will be much easier for patients, for technicians, and the workflow because all the measurements are in one place.
About the physicians
Karolinne Rocha, MD, PhD
Professor of Ophthalmology
Medical University of South Carolina
Storm Eye Institute
Charleston, South Carolina
Nandini Venkateswaran, MD
Cornea and Refractive Surgery Service
Massachusetts Eye and Ear
Lexington, Massachusetts
Mitchell Weikert, MD
Professor, Cullen Eye Institute
Baylor College of Medicine
Houston, Texas
Relevant disclosures
Rocha: None
Venkateswaran: None
Weikert: Alcon, Heidelberg Engineering, Zeiss
Contact
Rocha: karolinnemaia@gmail.com
Venkateswaran: nandini.venkat89@gmail.com
Weikert: mweikert@bcm.edu
