Epi-on cross-linking is a form of corneal cross-linking in which the surface layer of the cornea, the epithelium, is left in place during treatment. The goal is the same as standard cross-linking: to strengthen the cornea and help slow or stop progression in keratoconus and corneal ectasia. The main appeal of epi-on CXL is a more comfortable recovery and a lower surface-healing burden than epi-off treatment.
To strengthen the cornea and help reduce the risk of progression in keratoconus and corneal ectasia, while preserving the surface epithelium during treatment.
Selected patients with progressive corneal ectasia, depending on corneal thickness, age, disease behavior, and the treatment goal.
Usually an outpatient procedure.
Less discomfort, less surface-healing stress, less infection risk, and typically faster visual recovery than epi-off CXL.
Epi-on cross-linking is designed to address the same underlying problem as standard cross-linking: a cornea that is becoming biomechanically weaker and progressively changing shape. In keratoconus and corneal ectasia, the cornea can thin and bulge, leading to worsening irregular astigmatism, blur, glare, and loss of visual quality. Cross-linking helps make the cornea more resistant to further deformation.
What makes epi-on different is not the goal, but the route. Instead of removing the epithelium first, the treatment keeps that surface layer intact and uses special strategies to get riboflavin and oxygen where they are needed. That makes the procedure more comfortable for many patients, but it also creates technical challenges that have historically made epi-on less effective than epi-off unless the protocol is carefully designed.
How It works
Your cornea is made largely of collagen – tightly organized protein fibers arranged in layers. In a healthy cornea, these fibers are well-bonded to one another, giving the cornea the structural integrity it needs to maintain its shape and focus light correctly onto the retina.
In keratoconus, some of these bonds between collagen fibers are weak or absent. Over time, without enough structural support, the cornea gradually bulges forward and thins – leading to increasing distortion of vision that glasses and standard contact lenses struggle to correct.
Cross-linking works by creating new covalent bonds between collagen fiber strands, effectively “locking” the corneal structure in place. After the procedure, the cornea is measurably stiffer and less prone to the deformation that drives keratoconus progression.
Compare
Comparison Parameters
Epi-on CXL
Transepitelial
Epi-off CXL
Standard / Dresden Protocol
Veja um vídeo de um procedimento CXL epi-on realizado com a lâmpada de fenda, mostrando como a nossa técnica avançada funciona num ambiente clínico.
Step-by-step guide
Knowing exactly what to expect can make a real difference in how comfortable you feel going into a procedure. Here is what a typical epi-on cross-linking experience looks like at ELZA Institute.
Arrival and preparation
You will be welcomed by our team and guided through the process. Once settled, anesthetic eye drops are applied to both numb the eye surface and keep you comfortable throughout.
Riboflavin application
Specially formulated riboflavin drops are applied to the eye at regular intervals over a soaking period. In the epi-on approach, these drops are designed to penetrate the intact epithelium and reach the corneal stroma below. This preparation phase is essential — it ensures the cornea is fully saturated with riboflavin before UV-A exposure begins.
UV-A light treatment
A precise, calibrated beam of UV-A light is directed at the cornea for a set period. This activates the riboflavin and initiates the cross-linking reaction within the corneal collagen. The light delivery is carefully monitored and controlled throughout.
Completion and aftercare
Once the treatment is complete, antibiotic and anti-inflammatory eye drops are applied. Depending on your individual case, a soft bandage contact lens may be placed on the eye to protect the surface and maximize comfort as the eye settles. The procedure itself typically takes between 60 and 90 minutes.
Before leaving the clinic, your eye will be examined and you will receive your prescription eye drops along with clear written instructions. Our team will confirm your follow-up appointment schedule before you go.
Embora o epi-on CXL tenha feito grandes progressos, o epi-off CXL continua a ser a opção de eleição para determinados casos.
O Protocolo de Dresden, o método epi-off original, continua a ser a ferramenta mais poderosa para o tratamento de formas avançadas e agressivas de ceratocone. Quando é necessária a maior resistência mecânica, o epi-off proporciona o suporte mais robusto.
A ELZA desenvolveu um protocolo epi-off de alta influência que reduz significativamente o tempo de tratamento sem sacrificar a eficácia. Utilizando até 7,5 J/cm² de luz UV, o nosso método de alta influência proporciona a mesma força mecânica que o protocolo padrão de 30 minutos de Dresden - mas em apenas um terço do tempo.
Embora o epi-on CXL ofereça muitas vantagens, especialmente em termos de recuperação mais rápida e menos riscos, o epi-off CXL continua a ser o tratamento de eleição em certos casos graves em que é necessária uma força mecânica máxima.
Na ELZA, estamos constantemente a aperfeiçoar as nossas técnicas para fornecer os tratamentos mais eficazes e personalizados. Quer utilize epi-on ou epi-off, o nosso objetivo é garantir que cada paciente recebe os melhores cuidados possíveis, adaptados às suas necessidades específicas.
Porquê nós?
Corneal cross-linking is a procedure where experience, precision, and individualized care make a significant difference in outcomes. Here is what distinguishes ELZA Institute.
Our team includes specialists who are internationally recognized for their work in keratoconus and corneal ectasia. Cross-linking is not a peripheral service for us — it is a core part of what we do, and our specialists have performed this procedure in very high volumes across a wide range of patient presentations.
Every patient undergoes a comprehensive corneal evaluation before any treatment decision is made. This includes high-resolution corneal tomography, pachymetry (corneal thickness mapping), and detailed wavefront analysis. We use this data to confirm the diagnosis, assess the rate of progression, and determine precisely which treatment — and which approach — is right for your cornea.
We regularly welcome patients from across Europe, the United States, the Middle East, and beyond. Our team includes English-speaking staff, and we can assist with planning your visit — from pre-travel diagnostics to coordinating follow-up care with your ophthalmologist at home.
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