touchOPHTHALMOLOGY coverage from ESCRS 2025

Following his presentations at ESCRS 2025, one of the year’s most important meetings for surgical and refractive innovation, Dr Emilio Torres-Netto shares key updates on ELZA’s next-generation approaches to personalised keratoconus care.

In this Q&A, he discusses ELZA-PACE—the second-generation customised cross-linking technique designed to concentrate treatment precisely where the cornea is weakest—alongside the latest insights from the sub400 protocol for ultra-thin corneas and the role of ECO-CAIRS within a staged, individualised rehabilitation pathway.

Dr Torres-Netto shares the ELZA highlights from ESCRS 2025:

ELZA-PACE (Phototherapeutic keratectomy-assisted customized epi-on CXL) represents a second-generation evolution in corneal cross-linking. It uses an epithelial-map-guided PTK to selectively remove the epithelium over the cone while preserving it peripherally. This design establishes three overlapping gradients—of riboflavin concentration, oxygen availability, and UV fluence—that interact to focus cross-linking energy within the biomechanically weakest region of the cornea.

The result is targeted cone flattening and optical regularization without stromal ablation. In our prospective series of 165 eyes with up to 44 months of follow-up, ELZA-PACE reduced corneal asymmetry by up to 15 D and achieved 3–6 D of cone flattening on average, with marked reductions in higher-order aberrations and significant improvement in best-corrected visual acuity. Endothelial cell counts remained stable, confirming safety despite locally increased fluence.

The ELZA-sub400 protocol individualizes UV fluence according to stromal thickness, allowing safe and effective treatment of corneas as thin as 214 µm. The algorithm calculates the irradiation time required to maintain a ~70 µm un-cross-linked safety margin above the endothelium.

The second-generation sub400 increases total fluence from 5.4 to 10 J/cm² at 400 µm, achieving Dresden-like efficacy in a shorter procedure. One-year data show significant corneal stabilization, no endothelial decompensation, and a trend toward greater flattening with higher fluence. This approach ensures that even ultra-thin corneas—previously ineligible for standard CXL—can now be safely cross-linked.

ECO-CAIRS (Extracorporeal Corneal Allogenic Intrastromal Ring Segments) combines biomechanical and optical restoration. Allogenic corneal ring segments are cross-linked extracorporeally at ultra-high fluence before implantation, yielding stiff, transparent implants that reshape the cornea.When performed after stabilization with ELZA-PACE or sub400, ECO-CAIRS provides additional regularization and visual improvement in advanced ectasia. The staged combination of ELZA-PACE, ECO-CAIRS ± total cornea wave-front guided-PRK allows sequential biomechanical strengthening, shape correction, and refractive refinement—an individualized strategy for keratoconus rehabilitation.