Improving outcomes for patients with keratoconus | Fall YPG recap

The Young Physicians Group (YPG) closed out 2025 with a packed virtual session focused on keratoconus management. Ophthalmology residents, fellows and early-career surgeons from across the country joined for an evening of case discussions, emerging evidence and surgical pearls.

Disclaimer: Medical information is not medical advice—read our disclaimer.

Crosslinking complication & amniotic membrane rescue

Robert Fantus, MD, FACS, Chief Division of Ophthalmology, Endeavor Health

Dr. Fantus opened with a striking case that underscored both the benefits and the risks of epi-off corneal crosslinking.

A 60-year-old man with advanced keratoconus underwent Dresden-protocol epi-off crosslinking. Although his initial recovery was unremarkable, he returned days later with severe pain, a persistent epithelial defect and multifocal stromal infiltrates. Initially, his findings were concerning for fungal keratitis; however, cultures later revealed MRSA keratitis.

Management included fortified topical antibiotics, topical antifungals, topical antivirals, IOP control, steroids and close monitoring. When the epithelial defect stalled and inflammation persisted, a self-retained amniotic membrane was used. The membrane accelerated re-epithelialization, reduced scarring and improved comfort, ultimately allowing the patient to recover to 20/25 with an RGP contact lens.

Key takeaways

• Epi-off crosslinking is effective, but not risk-free; infectious keratitis, although rare, can be vision-threatening.
• Multifocal infiltrates are often bacterial in post-PRK/CXL eyes, not necessarily fungal.
• Amniotic membrane can shorten healing time, calm inflammation and reduce scarring in refractory cases.
• Judicious case selection and rapid response to complications are essential.

The coming shift to epi-on crosslinking

Neel S. Vaidya, MD, MPH, MBA, Chicago Cornea Consultants & Rush University

Dr. Vaidya followed with a forward-looking overview of corneal crosslinking’s next era. For years, U.S. surgeons have relied almost exclusively on epi-off crosslinking. But two emerging platforms—one already FDA-approved—are poised to reshape clinical practice.

His central argument: epi-on crosslinking will likely replace epi-off as standard of care, mirroring international practice patterns.

Why the shift?

Removing the epithelium improves riboflavin penetration and oxygen diffusion, but also increases pain, healing time and infection risk. The below epi-on advances address these limitations in two different ways.

Epion Therapeutics — Phase 3 trial completed enrollment

• Uses a proprietary riboflavin designed to penetrate intact epithelium.
• Early data show homogeneous riboflavin saturation and meaningful improvement in best corrected vision—not just stabilization.
• Very low rates of adverse events across >2,200 treated eyes.
  

Glaukos Epioxa — FDA-approved in October 2025

• Uses supplemental oxygen delivered through “Boost Goggles” to drive a more efficient UV-riboflavin–oxygen reaction.
• Registration trials demonstrated significant reduction in Kmax at 6 and 12 months.
• Safety profile showed minimal haze, photophobia and no meaningful sight-threatening complications.
• Commercial rollout is expected mid-2026.

Practice implications

• Eliminates the need to document progression for treatment (per FDA labeling).
• Enables earlier intervention and potential bilateral same-day treatment.
• Safer postoperative course may expand access to populations disproportionately affected by keratoconus.

CAIRS as an alternative to Intacs

Aazim A. Siddiqui, MD, Solomon Eye

Dr. Siddiqui closed the meeting with an in-depth surgical walkthrough of corneal allogenic intrastromal ring segments (CAIRS), a technique that is rapidly replacing synthetic Intacs in many cornea practices.

Instead of inserting plastic segments, CAIRS uses shaped donor corneal tissue (KeraNatural) placed into femtosecond-created stromal channels to flatten steep axes, reshape the cone and improve visual quality.

Why is CAIRS gaining traction?

• Biocompatible with excellent integration
• Reduced risks of melt, extrusion and infection compared with synthetic rings
• Highly customizable arc lengths, thicknesses and profiles
• Reversible & adjustable; segments can be removed, exchanged or repositioned
• Compatible with sequential crosslinking for long-term stabilization

Dr. Siddiqui shared multiple surgical videos demonstrating channel dissection, segment insertion techniques and postoperative outcomes showing dramatic flattening—often 3 to 7 diopters—and improved best corrected acuity.

He recommended doing CAIRS first when vision is declining, then performing crosslinking 3 to 6 months later once shape improvements stabilize.

Looking ahead

The meeting closed with a group discussion on nomograms, manual vs. femtosecond channel creation, emerging planning tools and how to integrate CAIRS with topo-guided PRK or EVO ICL implantation. Eversight thanked Drs. Vaidya and Siddiqui for presenting their cases, with special recognition to Dr. Fantus for moderating.

The next YPG meeting date slated for March 2026. Share your interesting cases or questions in advance. We look forward to another interactive session.