(Epi-On) Crosslinking Without Epithelium Removal

Must the Corneal Epithelium Be Removed for Crosslinking to Work?

Absolutely not. We have been doing crosslinking with intact epithelium (called “epi-on”) since 2003 in the United States and still continue to do so. Many doctors around the world have now adopted this technique. Prominent ophthalmologists Dr. Roberto Pinelli in Italy and Dr. Colin Chan in Australia were personally taught Dr. Brian’s Holcomb C3-R® and are seeing excellent results. Dr. Brian received the 2010 Jules Stein Living Tribute Award for performing Holcomb C3-R® Crosslinking System on U.S. Bobsled Driver Steve Holcomb that helped restore his vision enabling him to win the Gold Medal in 2010 in Vancouver – this was the first Gold Medal for the United States in bobsled in 62 years.

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 the Holcomb C3-R® Crosslinking System if it didn’t work! Please read his resume on ‘Meet Dr. Brian’ page on this site and do and Google search on “brian 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 or honey. This molasses-like Dextran carrier holds onto Riboflavin so it can’t penetrate through the epithlelium. The correct riboflavin solution for the Holcomb C3-R® Crosslinking System is one that has the consistency of water. This thin mixture allows our proprietary Crosslinking Solution (that contains riboflavin and other compounds) to penetrate into the cornea WITHOUT DISRUPTING THE EPITHELIUM.

This is the explanation for differing opinions of the Holcomb C3-R® Crosslinking System. 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 Holcomb C3-R®. Also if the Holcomb C3-R® Crosslinking System didn’t work, then United States wouldn’t have it’s first Gold Medal in 4 Man Bobsled in 62 years! While your goal may not be to win a Gold Medal, imagine being able to confidently move ahead in your life to achieve your own goals.

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

RISKS OF EPI-OFF (CXL) 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 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. Another side effect is the significant vision fluctuations for the first 3 to 6 months of healing with epi-off crosslinking due to the extensive epithelium remodeling process that occurs after the epithelium grows back on the cornea surface.

Holcomb C3-R® is non-invasive – we have NEVER seen any of the above complications with it.

Watch Patients Describe That 1-Day Recovery vs. Very Painful and Long Recovery Following CXL


Dr. Brian’s Keratoconus Patient Experience YouTube Channel

To view videos from our “Keratoconus Patient Experience” YouTube Channel – simply click below.





Many out-of-town patients would like Dr. Brian to do a complimentary review of their medical records and make a preliminary determination of candidacy. This is useful before planning a trip to Beverly Hills.

Some people’s friends ask them, “Why are you thinking of traveling to Beverly Hills for your eye procedure?” They typically answer with, “I deserve the BEST and I want to go to the BEST doctor!”

These are the three easy steps for your complimentary chart review with Dr. Brian:

  • Along with your last 2 or 3 eye exams, please be sure to include a color copy of your corneal mapping. Color corneal mapping is a very important tool, along with your exam history, to determine your candidacy. The last 2 years of your total eye history will be used to make this preliminary determination.
  • Inside the envelope, please be sure to include a cover sheet with your name address, phone number and email address and the words, “Keratoconus Record Review”, so that we may optimize communication with you.
  • Enclose with your letter a copy of your records.

Mail to:

Boxer Wachler Vision Institute
Keratoconus Record Review
465 N. Roxbury Drive, Suite 902
Beverly Hills, CA 90210

Or you can scan your records and email them to info@boxerwachler.com.