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Absolutely not. We have been doing crosslinking with intact epithelium (called "epi-on") for nearly 5 years in the United States and still continue to do so. Many doctors around the world have now adopted "epi-on" crosslinking. Prominent ophthalmologists Dr. Roberto Pinelli in Italy, Dr. Aylin Ertan in Turkey, and Dr. Colin Chan in Australia, among others, have been seeing excellent results from epi-on crosslinking.

Perhaps you have heard an opinion from someone or your doctor that the epithelium must to be removed for crosslinking to work. Is that correct? Answer: No. Such opinion is probably based on a flawed laboratory study in pig eyes that concluded that riboflavin does not penetrate into the cornea through epithelium. Dr. Brian and colleagues published a letter to the editor pointing out the multiple flaws in the study (see link on navigation bar Presentations and Research Articles). Having earned a world-class reputation as a leader and pioneer in ophthalmology, Dr. Brian would not continue to do epi-on crosslinking if it didn't work! Please read his resume on Meet Dr. Brian page on this site and do and Google search on "Boxer Wachler" to learn more about him.

Why do some doctors say you need to remove the epithelium to have riboflavin penetrate? The reason that some doctors say riboflavin does not penetrate the cornea with intact epithelium is because they are using the wrong solution with the riboflavin for it to penetrate. They are using a very thick mixture of Dextran and Riboflavin that has a consistency similar to that of molasses. This molasses-like Dextran carrier holds onto Riboflavin so it can't penetrate through the epithlelium. The correct solution is CMC (carboxymethylcellulose) for the riboflavin that has the consistency of water. This thin mixture allows the riboflavin to penetrate through the cornea epithelium. This is the explanation for differing opinions. Wrong solution = wrong result. If you don't use the right engine oil in a race car, the car won't run well. The correct solution must be used for epi-on crosslinking.

Another vital component to making epi-on crosslinking work is to ALSO use preservatives in the eye drops. Millions of patients every year use various medicated eye drops (antibiotics drops, anti-inflammatory drops, glaucoma drops, etc) that are very fluid, like water, and they easily penetrate through epithelium - it's because of the preservative in them loosens the epithelial cell "tight junctions" (like opening the side gates on both sides of a house). Once the "side gates" are open, medications and, in this case Riboflavin, can easily penetrate through the epithelium and into the cornea. That's how epi-on crosslinking works. This is why eye doctors NEVER ask millions of patients to scrape off their epithelium when they prescribe millions of eye drop medications.

What are the risks of Epi-on and Epi-Off Crosslinking?

EPI-OFF CROSSLINKING: Epi-off crosslinking by definition is invasive. Your corneal epithelium is scraped off, like having a gigantic scratch on your eye which is painful and causes blurry vision during the healing phase. Complications of epi-off crosslinking can be quite serious too: corneal infections/ulcers, corneal infiltrates, corneal scarring, corneal haze, and delayed epithelium healing. These epi-off complications just came out from the U.S. Crosslinking Clinical Trial and from IROC in Switzerland at the 2009 American Academy of Ophthalmology Annual Meeting - Refractive Surgery Subspecialty Day. Cornea nerve damage from epi-off crosslinking takes 6 months to recover as reported by the University of Crete at the same meeting. Since epi-on crosslinking is non-invasive, we have never seen these complications. Additionally, epi-off crosslinking, while making the cornea stronger, does make the cornea thinner.

EPI-ON CROSSLINKING: Epi-on crosslinking on average maintains thickness or makes the cornea thicker (not thinner) while making it stronger.

If someone, including your eye doctor, tells you that epi-on crosslinking doesn't work and that the epithelium needs to be removed for crosslinking to be effective, simply refer them to this website page to read about the facts of corneal crosslinking. For more detailed information on the latest scientific studies and research, please click on Presentations and Research Articles section.

Keratoconus is the thinning and bulging of the cornea. Treatments include Intacs^®, C3-R^®, cornea collagen cross linking, and if keratoconus progresses to a serious level, cornea transplantation. Dr Brian Boxer Wachler is a specialist in keratoconus evaluation and treatment.

Dr. Brian Boxer Wachler of the Boxer Wachler Vision Institute is well known for his contribution to the ophthalmic industry and for his other eye care efforts. Dr Boxer Wachler has helped preserve or improve the vision of many patients. Dr. Boxer Wachler is often asked to lecture, both in the United States and abroad, about his advancements in LASIK and in the treatment of keratoconus. Dr. Boxer Wachler has his private practice in the Beverly Hills area of Los Angeles.