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Case for Epithelium-Off Corneal Cross-linking.

William J Dupps^1,2,3

¹Department of Cornea and Refractive Surgery, Cole Eye Institute, Cleveland Clinic, Cleveland, OH.

|April 19, 2022

Summary

Epithelium removal in corneal cross-linking (CXL) for keratoconus may enhance treatment effectiveness, despite concerns about complications. Current evidence supports the standard epi-off protocol for stabilizing corneal ectatic disorders.

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Area of Science:

Ophthalmology
Corneal Surgery
Biomedical Engineering

Background:

Corneal cross-linking (CXL) is a treatment for keratoconus and other corneal ectatic disorders.
The necessity of epithelium removal (epi-off) versus epithelium-on (epi-on) CXL remains a subject of debate.
Epi-on CXL aims to minimize vision-threatening complications associated with epithelial debridement.

Purpose of the Study:

To evaluate the effectiveness of epi-off versus epi-on corneal cross-linking.
To review the current evidence regarding clinical outcomes and complications of both CXL protocols.
To provide a perspective on the standard of care for corneal ectatic disorders.

Main Methods:

Review of high-level evidence and clinical outcome metrics.
Analysis of data on topographic flattening and disease stabilization.
Assessment of complication rates, including infectious keratitis and vision loss.

Main Results:

Most evidence indicates that epi-off CXL leads to greater effectiveness in topographic flattening and disease stabilization.
High-quality evidence supporting a significant reduction in debridement-related complications for epi-on CXL is lacking.
The FDA-approved epi-off protocol remains the benchmark for safe and effective treatment.

Conclusions:

The epi-off protocol for corneal cross-linking is currently considered the standard for effective treatment of corneal ectatic diseases.
Further comparative effectiveness trials and long-term studies are needed to definitively establish the benefits of epi-on CXL.
Current evidence favors epi-off CXL for achieving optimal clinical outcomes in keratoconus management.