Riboflavin treatment has shown great results in some studies in strengthening the cornea of patients with keratoconus.  The treatment acts by increasing cross-linking within the cornea stroma with the application of ultraviolet light to the riboflavin solution.  In order for the treatment to be effective both the UV light and the riboflavin must be absorbed by the corneal stroma.  Above the stroma rests the epithelium, the upper layer of the cornea that sheds throughout the week.  Treating the epithelium with riboflavin and UV light is ineffective as it sheds itself regularly.  Additionally, the epithelium acts as a barrier to both the UV light and the riboflavin solution.

Studies show that without removal of the epithelium, both the UV light and the riboflavin are highly reduced and the effect of corneal cross-linking is also significantly reduced.  Additionally, some surgeons have expressed concern that by not removing the epithelium, the treatment is putting the patient at a higher risk for cataracts or macular damage since the riboflavin is less absorbed by the stroma and often a higher level of UV light is required if the epithelium is not removed.

Most ophthalmologists currently providing riboflavin treatment for corneal cross-linking are currently using an epithelium off method for maximum effectiveness.  Removing the epithelium results in a more uncomfortable recovery but maximizes the effectiveness of the treatment.

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