Surgical Vision Correction Options for Keratoconus

How Keratoconus Treatment Works Today: Two Separate Goals

It helps to think of modern keratoconus treatment as addressing two different problems:

1. Disease progression — is the cornea continuing to thin and steepen over time? This is addressed with cross-linking (Epioxa).

2. Visual distortion — has keratoconus already created irregular astigmatism that glasses or standard contacts can't correct? This is addressed with a corrective procedure like Contoura topography-guided PRK or CTAK.

A patient can need just one of these, or both — and if both, the sequencing (which procedure first, or whether to combine them) depends on their individual cornea.

Step One — Stabilizing the Cornea with Epioxa

What Is Epioxa?

Epioxa is an FDA-approved epithelium-on ("epi-on") corneal cross-linking treatment, approved in October 2025 and commercially available in early 2026 — the first new FDA-approved cross-linking approach since Photrexa in 2016. It uses two riboflavin eye-drop formulations combined with an oxygen-delivery system (O2n™) and UV light activation (Boost Goggles®) to strengthen corneal collagen fibers and halt further steepening — without removing the corneal epithelium first, which traditional cross-linking requires.

Epi-On vs. Epi-Off Cross-Linking

Epi-off (traditional/Photrexa): epithelium removed → riboflavin drops → UV light → several days of healing and discomfort as the epithelium regrows

Epi-on (Epioxa): epithelium stays intact → oxygen-enriched riboflavin drops → UV light → minimal surface wound, generally faster, more comfortable recovery

Epioxa's approval was based on two Phase 3 randomized, double-masked clinical trials involving more than 400 patients.

Cross-linking of either type only stops progression — it does not reverse existing corneal irregularity or restore vision already lost. That's what step two addresses.

Step Two — Improving Vision and Corneal Irregularity

Contoura Topography-Guided PRK

Contoura is a laser procedure that uses detailed corneal topography mapping to guide a customized ablation pattern — selectively reshaping the cornea to flatten steep areas and smooth out irregular astigmatism. It's used for irregular corneas from several causes, including keratoconus, and is often combined with cross-linking to both stabilize the cornea and improve its optical surface — sometimes called the Athens Protocol when performed as a combined approach. Unlike a standard vision-correction laser treatment, Contoura in keratoconus is used for partial correction — reducing irregularity rather than eliminating a full glasses prescription.

CTAK (Corneal Tissue Addition Keratoplasty)

CTAK is a newer, less invasive alternative to a full corneal transplant. A customized, laser-shaped corneal tissue inlay — sourced from an eye bank and gamma-irradiated for sterility — is inserted into a channel created in the patient's own cornea using a femtosecond laser. The inlay reshapes and adds structural support to the keratoconic cornea, improving both corneal curvature and visual acuity. It's designed for patients with more significant corneal irregularity who have been told a transplant may eventually be needed, offering a way to improve vision and corneal shape while preserving the patient's own cornea.

How These Treatments Work Together

Contoura PRK and CTAK are both aimed at reducing corneal irregularity, and either can be combined with Epioxa cross-linking — performed before, after, or simultaneously, depending on the individual cornea and disease stage. Dr. Holzman determines sequencing based on corneal thickness, stability, and topography at the time of evaluation. In general:

If the priority is stopping active progression first, Epioxa is typically performed first, with a corrective procedure considered later once the cornea is confirmed stable.

If corneal shape is the more urgent issue and the disease is already stable, a corrective procedure may be considered without cross-linking, or combined with it in the same treatment window.

Am I a Candidate?

A candidacy evaluation typically includes corneal topography and pachymetry (thickness mapping) to determine:

• Whether keratoconus is actively progressing (favors Epioxa)

• How much irregular astigmatism is affecting vision quality (favors Contoura PRK and/or CTAK)

• Overall corneal thickness and shape, which determines which procedures are safely an option and in what order

Signs that typically prompt an evaluation: rapidly changing prescriptions, vision that isn't fully correctable with glasses, increased glare/light sensitivity, or a family history of keratoconus.

What to Expect: The Patient Journey

1. Evaluation — corneal topography, pachymetry, and a full exam to determine disease stage and which procedure(s) apply

2. Stabilization (if needed) — Epioxa treatment to halt progression

3. Vision correction (if needed) — Contoura PRK and/or CTAK to address irregularity, timed based on your individual case

4. Follow-up — monitoring to confirm stability and visual outcome

Benefits

• Modern keratoconus care can now address both disease progression and visual quality — not just one or the other

• Epioxa offers stabilization without removing the corneal epithelium

• CTAK offers many patients a way to avoid or delay a full corneal transplant

• Contoura PRK can meaningfully improve best-corrected vision in irregular corneas

Risks and Limitations

• Cross-linking (Epioxa) halts progression but does not reverse existing irregularity — a second procedure is often still needed for visual improvement

• Contoura PRK provides partial correction, not full elimination of a glasses prescription, and results vary by severity

• CTAK involves donor tissue placement and is a surgical procedure with its own recovery process

• Not every patient is a candidate for every combination — thickness, stability, and severity all factor into what's safely possible

• As with any newer procedure (Epioxa, CTAK), long-term real-world outcome data is still accumulating beyond clinical trial results

Frequently Asked Questions

Do I need more than one procedure for keratoconus?

It depends on your stage of disease. Some patients only need cross-linking (Epioxa) to stop progression. Others also need a corrective procedure like Contoura PRK or CTAK to improve vision already affected by corneal irregularity.

What's the difference between Epioxa and CTAK?

Epioxa is a cross-linking treatment that stops keratoconus from getting worse. CTAK is a separate, structural procedure that adds a corneal tissue inlay to reshape the cornea and improve vision that's already been affected.

Can Contoura PRK and cross-linking be done at the same time?

Yes — combining topography-guided PRK with cross-linking (sometimes called the Athens Protocol) is a well-established approach for stabilizing the cornea while also improving its optical surface. Whether it's done simultaneously or in stages depends on your individual cornea.

Is CTAK a corneal transplant?

No. CTAK adds a small, customized tissue inlay into a channel within your own cornea — it's designed as a less invasive alternative that can help some patients avoid or delay a full corneal transplant.

Will these procedures fully correct my vision?

Cross-linking is not intended to improve vision — only to stop progression. Contoura PRK and CTAK can meaningfully improve vision and reduce irregularity, but results vary based on the severity of your keratoconus, and neither guarantees glasses-free vision.

How do I know which combination is right for me?

A corneal evaluation with topography and thickness mapping is needed to determine disease stage and the safest, most effective sequence of treatment for your eyes.

Schedule a Keratoconus Consultation

Ready to find out which combination of treatments is right for you? Schedule a keratoconus evaluation with Dr. Holzman today.