In the early 16th century, people’s clothing usually consisted of what they made themselves, wore used clothes or, if they were wealthy, could take an already existing pattern or design and have it tailored. For the commoner, if the pants were too loose you could cinch your belt tighter, too long and maybe you or your wife could hem them a bit. Then, around the end of the 16th and into the 17th century, some shops allowed you to come in and select the fabric, design, pattern and everything else for a piece of clothing from scratch, and after your measurements were taken, the material you picked was set aside and other customers were informed that it was already “spoken for” or, as they would say it back then, “bespoke.”

Now, it seems a lot of things are bespoke, from clothes (of course) to artisanal food and drink “experiences.” Also, as our corneal cover focus points out, even surgery is bespoke. However, rather than it being an effort to put on airs like someone who’s in search of bespoke birthday candles, a bespoke surgery actually has concrete benefits for the patient and the surgeon.

In the past, if a patient had a serious corneal problem, either in the anterior or the posterior, all roads usually led to penetrating keratoplasty. Though penetrating keratoplasty is an effective procedure, it leaves the patient with varying degrees of astigmatism, rejection issues and possibly the need for further surgeries. 

Now, however, surgeons can customize their intervention based on a patient's specific condition. 

As surgeons we spoke to for our update on corneal collagen cross-linking (pg. 46) attest, in some cases advanced keratoconus often meant a relentless march toward a penetrating keratoplasty and its attendant risks. But now, that march can be slowed or arrested in some patients. “We know that cross-linking is effective and that preventing the development of visually devastating keratoconus is a significant quality of life enhancer ... It’s very meaningful to that patient and family,” says Omaha’s Brandon Baartman, MD, in the article.

And, on the posterior side of the cornea, the strides made in endothelial transplants have been remarkable. The ability to preserve vital layers of the cornea while just replacing the endothelium has saved a lot of patients from having to go through the penetrating keratoplasty healing and follow-up process. 

However, as our feature on transplantation on page 58 points out, the “big gun” of penetrating keratoplasty is still there for certain patients who need its invasive—but effective—ability to restore a cornea to health. Sometimes, as the corneal surgeons in the article point out, if the scarring or corneal involvement is just too much, a penetrating keratoplasty can still save the day—and the stitching will be just as precise as that in your new suit from Savile Row.



— Walter Bethke
Editor in Chief


1. Bespoke. Accessed October 21, 2023.