Biomechanical stabilization of the keratoconic cornea: a review of current therapeutic strategies

Keratoconus is a progressive corneal ectatic disorder characterized by stromal thinning and biomechanical weakening of the cornea, leading to progressive corneal protrusion and visual impairment. Therapeutic strategies have evolved from visual correction toward approaches specifically targeting the biomechanical instability underlying disease progression. This review provides a biomechanical perspective on current and emerging strategies for the biomechanical stabilization of the keratoconic cornea. Conservative treatments based on contact lenses remain essential for visual rehabilitation but do not modify the underlying ectatic process. Corneal collagen crosslinking represents the reference treatment for progressive keratoconus, as it increases stromal stiffness through the formation of additional covalent bonds. However, its efficacy depends on treatment protocol, epithelial status, corneal thickness, and disease stage. Corneal implants, i.e., synthetic intracorneal ring segments and corneal allogenic intrastromal ring segments, provide stretch-induced geometric improvement of the corneal shape and, consequently, of visual acuity, although predictability remains limited. Combined approaches, such as ring implantation followed by cross-linking, aim to integrate corneal reshaping with intrinsic stromal reinforcement. Emerging approaches, including cell-based therapies, and implantation of stromal lenticule or tissue-engineered scaffolds, suggest a future shift toward a multimodal therapeutic strategy integrating biomechanical stabilization, restoration of stromal structure, and biological regeneration. Advancing keratoconus management will require objective biomechanical assessment and predictive modeling tools to guide individualized treatment planning and improve outcome predictability. Ultimately, future management should increasingly incorporate a biomechanical perspective, with interventions designed to modify the mechanical behavior of the ectatic cornea, arrest progression, and restore functional corneal integrity.