Eyeworld

68 | EYEWORLD | FALL 2026 C ORNEA Dr. Majmudar said treatment without the need for progression documentation will open the door for earlier keratoconus treatment, which could "help preserve better uncorrected and corrected visual acuity and potentially re- duce the need for specialty contact lenses later." "Over the past 16 years in various clini- cal trials, we treated many patients at earlier stages of disease and were able to maintain relatively normal corneal architecture because intervention occurred before significant struc- tural change," he said. "As epi-on crosslinking becomes more widely available, I expect we will see a shift toward earlier screening and inter- vention. As we identify very early disease, we may also find that the true prevalence of kerato- conus is higher than previously appreciated." Dr. Rajpal said that overall, crosslinking isn't being offered frequently enough for various reasons. "Only about 12% of newly diagnosed keratoconus patients were getting crosslinked," he said. Dr. Saricay hopes the excitement around Epioxa in the U.S. will increase kerato- conus awareness, potentially leading to earlier diagnoses and vision-preserving treatment. "In my experience, both keratoconus screen- ing and crosslinking treatment have been sig- nificantly underutilized, especially in the pediat- ric population. I still see many pediatric patients being referred with late-stage keratoconus when they are already blind in one eye and have mod- erate keratoconus in the other eye," she said, adding that she thinks epi-on crosslinking could lower barriers to treatment. "Comprehensive or pediatric ophthalmologists who may have been concerned about managing the potential com- plications of an epithelium-off procedure may likely be more comfortable performing Epioxa. … As more data become available on real-world outcomes and reimbursement trends of epithe- lium-on crosslinking, I think we'll see the pool of crosslinking providers broaden. I also think that with a more comfortable procedure, more surgeons will be able to perform crosslinking on young patients without general anesthesia, which could significantly expand access in pedi- atric cases." For practices that have not yet offered crosslinking but are considering it, Dr. Saricay said you have to think beyond the procedure itself. "Successfully integrating crosslinking requires a structured approach to keratoconus care, including screening, documentation, and follow-up protocols," she said. "Clinicians need to have an infrastructure in which they are prepared to receive referrals, and they need to understand payer requirements, the preauthori- zation process, and workflow logistics." Questions that remain Dr. Saricay said that clinical trial data suggests that Epioxa's epi-on treatment provides good results to a full range of keratoconus patients, but ongoing real-world data will be collected as more of these procedures are done commer- cially, helping determine if there are subsets of patients who would benefit the most from an epi-on procedure. "I think epithelium-on crosslinking may be particularly attractive for patients who would benefit from a more comfortable recovery and a potentially lower risk profile. Pediatric patients, individuals with Down syndrome, and those with collagen disorders are especially important populations to study. However, we still need real-world data to better understand outcomes in these groups. While the early results are en- couraging, the definition of the ideal candidate for epithelium-on crosslinking will continue to evolve as more long-term and subgroup-specific data become available." Dr. Rajpal said the Epioxa crosslinking procedure for post-LASIK ectasia is an area for additional research and real-world data, though he's confident it would be effective for these patients. When Glaukos' epi-off crosslinking was first approved in 2016, it was met with reimburse- ment challenges. Glaukos created a support network for providers and patients during that time to facilitate reimbursement for the continued from page 67 Epi-on crosslinking pearl: spread the word Dr. Rajpal said it's important to take the time to refresh your referral network about keratoconus (the need for screening, early detection, and importance of treatment tim- ing, as well as Epioxa's safety and efficacy). "It is important for referring doctors to un- derstand that Epioxa has been proven to be safe and effective in rigorous clinical trials and is the only FDA-approved epithelium-on treatment for keratoconus," he said.

• Cover