This perspective essay examines disparities in access to corneal cross-linking (CXL) for keratoconus patients in the United States, focusing on the transition from the FDA-approved epithelium-off protocol (Photrexa/KXL) to the newly approved (2025) epithelium-on therapy Epioxa, and the implications of Photrexa's planned 2026 phase-out.
Epioxa's wholesale acquisition cost is $78,500; its short- and long-term efficacy (visual acuity, maximum keratometry) compared to Photrexa remains unproven. Photrexa's phase-out in 2026 will leave no FDA-approved epithelium-off CXL option in the US, risking worsened access disparities for underserved patients.
This is an expert perspective essay, not an original research study—conclusions are based on clinical experience and a literature review rather than new primary data. Long-term comparative efficacy data for Epioxa vs. Photrexa are not yet available.
Clinicians should be aware that as of 2026, Photrexa is being phased out and Epioxa (at $78,500 WAC) is the only FDA-approved CXL option in the US, with unconfirmed equivalence to epithelium-off CXL. Advocating for insurance coverage and access programs is critical, especially for underserved patients at risk of corneal transplant without treatment.
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