Eyeworld

66 | EYEWORLD | FALL 2026 C ORNEA REWIND. REFRESH. REFINE. by Liz Hillman Editorial Co-Director About the physicians W. Barry Lee, MD, FACS Cornea Fellowship Director Eye Consultants of Atlanta Co-Medical Director Georgia Eye Bank Atlanta, Georgia Parag Majmudar, MD Professor of Ophthalmology Rush University Medical Center CEO Chicago Cornea Consultants Chicago, Illinois Rajesh K. Rajpal, MD Founder and Medical Director See Clearly Vision Group Clinical Professor of Ophthalmology George Washington University School of Medicine and Health Sciences Washington, D.C. Leyla Yavuz Saricay, MD, MSc, FEBO Assistant Professor of Ophthalmology Boston University Chobanian & Avedisian School of Medicine Boston Medical Center Instructor in Ophthalmology Harvard Medical School Boston Children's Hospital Boston, Massachusetts F or years, epithelium-on (epi-on) cross- linking protocols have been available outside the U.S., while an epithelium-off approach has been approved in the U.S. since 2016. Nearly a year ago, however, the FDA approved Epioxa HD/Epioxa (ribofla- vin 5´-phosphate ophthalmic solution, 0.239%/ riboflavin 5´-phosphate ophthalmic solution, 0.177%, Glaukos), described by the company as a "novel, bioactivated topical therapeutic catalyzed by supplemental oxygen and a UV light source" for an epithelium-on crosslinking approach. This past spring, the first commercial cases using Epioxa in the U.S. took place, and Glau- kos, which is the only company in the U.S. with an FDA-approved crosslinking procedure, believes so wholly in the benefits of the epithe- lium-on approach with Epioxa that it plans to discontinue commercial use of Photrexa Vis- cous/Photrexa (riboflavin 5´-phosphate in 20% dextran ophthalmic solution, 0.146%/riboflavin 5´-phosphate ophthalmic solution, 0.146%) used in the epithelium-off iLink procedure, making it available only for individual cases when it is considered medically necessary to treat the patient with an epi-off regimen. "I was the chief medical officer at Avedro [acquired by Glaukos in 2019] when we began the Epioxa clinical trials, so I am very proud to see this technology get approved and come to market," said Rajesh K. Rajpal, MD. "I think it's the right thing to do for patients. I think that having the opportunity to treat patients with greater comfort and less concern about risk will shift the field toward a more interventional ker- atoconus approach, with earlier detection and treatment of keratoconus." U.S. ophthalmologists who have used the Epioxa system in the "real world" are excited to share their insights and perspectives on this new option that they think will be safer for patients, facilitate faster healing, and could potentially stop progression of keratoconus sooner. "FDA approval of Epioxa is an important development because it may expand the range of available treatments for keratoconus. I think that an epithelium-on procedure will improve the overall patient experience and recovery time after crosslinking. For physicians who may have concerns about corneal healing or epithelial removal, improved patient experience with ep- ithelium-on crosslinking may encourage earlier intervention," Leyla Yavuz Saricay, MD, MSc, FEBO, said in an email to EyeWorld. Parag Majmudar, MD, who has been in- volved in epi-on crosslinking trials since 2010, thinks the approval of Epioxa is "long overdue." "Given its minimally invasive nature and strong safety record, many of us thought that regu- latory approval would eventually come, but U.S. physicians embrace epithelium-on crosslinking Dr. Saricay performs the first commercial Epioxa treatment at Boston Children's Hospital. Source: Leyla Yavuz Saricay, MD, MSc, FEBO, with permission from the patient Epi-on crosslinking pearl: develop trust When working with a pediatric patient, Dr. Saricay said it's important to develop a relationship with the child before treatment. "I ask my patients about music and movies during the evaluation, and on treatment day I continue to chat with them casually, so they hardly even notice when we start the crosslinking procedure. With this approach, I'm often able to treat children under topical rather than general anesthesia," she said. One pearl for adult patients, she added, is setting appropriate postop expectations to avoid disappointment. This procedure stops progression but doesn't necessarily improve their vision. "I also prefer to tell patients to ex- pect discomfort, then they can be pleasantly surprised if that doesn't happen," she said.

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