Eyeworld

62 | EYEWORLD | FALL 2026 C ORNEA by Julie Schallhorn, MD Cornea Editor T alking to patients about the risks and benefits of a pro- cedure is our duty as surgeons, and I, like most surgeons, have a script that runs through my head each time I consent. New information, risks, and techniques force me to reevaluate these old scripts, and one that has been up for revision recently is what I tell patients about corneal crosslinking with the advent of epithelium-on with Epioxa (riboflavin 5´-phosphate ophthalmic solution, Glaukos). The arrival of epithelium-on crosslinking is a genuine refinement—same biological goal, gentler path. W. Barry Lee, MD, FACS, Parag Majmudar, MD, Rajesh Rajpal, MD, and Leyla Yavuz Saricay, MD, MSc, FEBO, all comment in this article. There are many potential benefits including a lower threshold for intervention. Delayed intervention risk, progression, and performing crosslinking earlier in the patient's journey may save them the burden of rigid contact lenses or invasive corneal procedures. At the same time, it's worth taking a look at the downsides of Epioxa—namely one downside: the price. We've seen this tension before. Oxervate (cenegermin-bkbj, Dompé) transformed how we treat neurotrophic keratitis. The anti-com- plement biologics for geographic atrophy slow progression modestly while carrying both a sub- stantial cost and real debate about how much vision they preserve. In each case we're asked the same question: How do we weigh a mean- ingful but partial advance against what it costs the patient and the system? Another article in the Cornea section of this issue—on the shift in blepharitis manage- ment toward mechanism-driven care—offers a quiet counterpoint. Kendall Donaldson, MD, MS, frames it well: Treatment should be "mechanism-driven, not label-driven," and with targeted options like lotilaner for Demodex, she describes "one of the rare cases where we've moved from management to a true targeted treatment." University of California, San Fran- cisco's own Gerami Seitzman, MD, cautions that lid scrubs applied to the wrong subtype "can further irritate the lids." Here precision arrived without a fortune attached. Stephen Pflugfelder, MD, also shares his thoughts in the article. What I keep coming back to is that the high price tags, for all the discomfort they cause at the point of care, are also what pull capital into our field. The prospect of premium reimburse- ment is exactly why so many startups have crowded into corneal and retinal disease—and why the pipeline behind these therapies is deep- er than it's ever been. The cost is real, and so is the innovation it finances. I remain in awe of how quickly our field advances—and mindful that part of our job now is deciding, honestly, what that progress is worth. Weighing all the factors in innovation Jonathan Rubenstein, MD, EyeWorld Cataract Editorial Board member, reflected on how ophthalmology is refining, combining, and reimagining modern care: "I [was thinking about] corneal transplanta- tion and how it has evolved over the past 30 years. The techniques have changed from a full penetrating keratoplasty to lamellar surgery. We used to have to perform a complete corneal transplant for any corneal conditions affecting visual acuity. Now we repair only the areas of the cornea that are abnormal. We can treat the surface with superficial keratectomy or excimer laser PTK. We also are now evolving into corneal epithelial cell culture and transplantation. We can treat the anterior stroma with anterior lamellar keratoplasty. We can treat deep stromal disease with deep anterior lamellar keratoplasty. Lastly, our approach to endothelial cell disease has completely changed over this time. In a patient with en- dothelial cell dysfunction or failure, we can replace the endothelium with DSEK, DMEK, or new emerging endothelial cell injection techniques." REFRESH. REFINE. REWIND.

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