World Cornea Congress IX: Epi-on and accelerated crosslinking with Kenneth Beckman, MD

Kenneth Beckman, MD, discussed the latest advancements in epithelium-on (epi-on) corneal crosslinking, highlighting new accelerated protocols and innovative approaches to overcoming previous limitations in a presentation at the World Cornea Congress IX, held March 20 to 22, 2025, in Washington, DC.

Since its initial FDA approval in 2016, corneal crosslinking has played a critical role in slowing or halting keratoconus progression, noted Beckman, who is Director of Corneal Services at Comprehensive EyeCare of Central Ohio and a clinical assistant professor of ophthalmology at The Ohio State University. The conventional epithelium-off (epi-off) technique has demonstrated strong efficacy, however, may present challenges, including infection risk, scarring, delayed wound healing, and prolonged visual recovery, Beckman noted.

Epi-on crosslinking, which preserves the epithelium, is an attractive alternative, though it poses unique challenges in delivering adequate UV light, riboflavin, and oxygen to the cornea. “We have to get light to the cornea, we have to get oxygen to the cornea, and we have to get riboflavin into the cornea,” Beckman said. To address these limitations, Glaukos has developed an epi-on technique utilizing supplemental oxygen via a sealed mask to maintain over 90% oxygen concentration during treatment. Their clinical trials have shown promising results, with a 1.0-diopter difference between treated and control groups after 12 months, he noted. The company has submitted its findings to the FDA, with a PDUFA decision date of October 20, 2025.

Epion Therapeutics has taken a different approach, using a chemical reaction within the cornea to generate oxygen. Beckman explained that their proprietary riboflavin formulation includes an iodide molecule that converts toxic hydrogen peroxide byproducts into oxygen and water, enabling crosslinking without external oxygen supplementation. Phase 2 data indicate that over 80% of patients experienced stable or improved vision, with particularly strong results in those under 21, he said.

Additional emerging therapies include laser-assisted epi-on treatment from Glaukos and iVeena’s IVMED-80 eye drop, which enhances crosslinking by upregulating lysyl oxidase. “It’s really exciting to see what’s going to happen in the next year or so,” Beckman said, emphasizing the potential for safer, more efficient treatment options with faster recovery times.