ELZA epi-on cross-linking protocol shows comparable efficacy to 10-minute epi-off
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FRANKFURT, Germany — The ELZA epi-on corneal cross-linking protocol provides biomechanical stiffening comparable to epi-off CXL, without iontophoresis or additional oxygen, in the office at the slit lamp.
“The reason we all want a functioning and well-designed epi-on are clear. Besides the reason of reduced risk for infection, my personal aim is to move cross-linking out of the operating room into the doctor’s office,” Farhad Hafezi, MD, PhD, said at the ESCRS winter meeting.
The quest for a safe and effective epi-on technique has been ongoing. The first attempts failed, until the discovery of the crucial role of the combination of riboflavin and oxygen led to the development of supplemental oxygen methods and iontophoresis.
“The only drawback was, instead of having a very easy and straightforward technique, we had a bulky technique because you do not only need the patient and the cross-linking materials, you need an oxygen tank, and iontophoresis is quite fiddly. You might hurt the patient, you might lose suction, and riboflavin is everywhere,” Hafezi said.
Some years later, aiming for a simpler epi-on technique without the need for supplemental oxygen, Cosimo Mazzotta, MD, PhD, developed his high-fluence, accelerated, pulsed-light epi-on CXL procedure. However, iontophoresis was still needed.
During the pandemic, Hafezi and his group conducted intensive research, trying innumerable combinations of irradiation parameters and penetration enhancer formulations, finally achieving effective epi-on CXL with no need for additional oxygen or iontophoresis.
“It was like putting the pieces of a puzzle together. And the epi-on we have now only needs the patient, a slit lamp, light and drops,” Hafezi said.
Stress-strain measurements showed biomechanical effects similar to the 10-minute epi-off protocol, and anterior segment OCT revealed comparable demarcation line depth, ranging from 148 µm to 274 µm.
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Hafezi F, et al. Comparing the biomechanical effect and demarcation line depth of epi-on and accelerated epi-off CXL protocols. Presented at: ESCRS winter meeting; Feb. 15-18, 2024; Frankfurt, Germany.
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