Eyeworld

FALL 2026 | EYEWORLD | 67 C In addition to not requiring removal of the epithelium, the label for Epioxa does not include keratoconus progression, like the prior epi-off procedure label did. "Without having progression in the label, I'm optimistic we can convey the medical necessity to payers that earlier treatment is paramount, without waiting for progression," Dr. Saricay said. Dr. Rajpal said the prior need for progression documentation (especially as it was required for reimbursement of the epithelium-off procedure in the past) was often the biggest hurdle and frustration. "… there is no other disease we treat where we wait for it to get worse before initiating treatment. The Epioxa label does not include progression, so I think that will be much less of a focus with the new procedure. Ultimately, I expect to see fewer financial barriers to treat- ment than in the past." W. Barry Lee, MD, FACS, feels the same way. "The new labeling makes much more sense and should allow us to treat more patients with the disease. This will have a major advantage for pediatric cases and those with early kerato- conus, as we can treat them much earlier in the disease course. This also affords treatment on more patients with thinner corneas," he wrote in an email to EyeWorld. it certainly took longer than anticipated," he said, adding that he thinks the availability of an epi-on procedure "represents a meaningful shift in how we approach keratoconus," potentially getting patients to receive treatment at earlier, less severe disease stages. First experiences and benefits Dr. Saricay performed her first Epioxa case on a young girl with keratoconus last spring. She said she only needed topical anesthesia. Through the spring and summer, she has completed multiple Epioxa cases and has other cases scheduled for the Epioxa treatment. Dr. Rajpal said the Epioxa procedure is appropriate for all keratoconus subtypes, offer- ing increased patient comfort, faster recovery, and reduced risk of complications compared to epithelium-off procedures. "The opportunity to treat thinner corneas (as thin as 325 µm) than we could previously will expand the range of eligible patients," he said. "I would suggest that patients who had significant pain in their first eye will be much more willing to undergo treatment with Epioxa for their second eye. I am most excited about the potential to treat early keratoconus because I think doctors will be more willing to treat early-stage disease in an eye that still has 20/20 or 20/25 vision when they don't have to remove the epithelium. It will be easier to make the decision to treat." continued on page 68 Severe bacterial ulcer as a result of epithelial-off crosslinking. The patient ultimately needed a keratoplasty due to the dense central scar. Source: W. Barry Lee, MD, FACS Epi-on crosslinking pearl: prepare Dr. Rajpal advised spending some time getting used to the nuances of the Boost Goggles, designed to supplement oxygen to the cornea, as they are a new element to the procedure. Learn how to secure the goggles to the face, measure oxygen levels, and un- derstand what to do if the oxygen levels fall below the required threshold, he said. In addition, he advised making changes slowly. "In our practice, we are initially main- taining the same protocols for antibiotics, anti-inflammatory medications, bandage contact lenses, and follow-up visits; over time we will decide what can be modified for Epioxa," he said.

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