Study to Evaluate the Safety and Efficacy of Epi-on Corneal Cross-linking in Eyes With Progressive Keratoconus

Up to 275 study eyes with progressive keratoconus will be enrolled. Study eyes will be
randomized in a 2:1 ratio to receive CXL treatment or sham/control treatment.The primary
efficacy endpoint is a difference of ≥ 1 diopter between treatment groups in the mean change
in Kmax from baseline to Month 6.

Inclusion Criteria:

1. Be between 12 and 55 years of age, male or female, of any race;

2. Provide written informed consent and sign a HIPAA form. Subjects who are under the age
of 18 (or have not yet reached the age of majority per local regulations) will need to
sign an assent form as well as having a parent or legal guardian sign an informed
consent

3. Ability to read English or Spanish to complete the NEI-VFQ 25 questionnaire;

4. Willingness and ability to follow all instructions and comply with schedule for
follow-up visits;

5. For females capable of becoming pregnant, agree to have urine pregnancy testing
performed prior to randomization of each study eye and prior to treatment of a
cross-over eye; must not be lactating, and must agree to use a medically acceptable
form of birth control for at least one week prior to the randomization visit, one week
prior to treatment of a cross-over eye, and continue to use the method for one month
following the last treatment. Acceptable forms for birth control are spermicide with
barrier, oral contraceptive, injectable or implantable method of contraception,
transdermal contraceptive, intrauterine device, or surgical sterilization of partner.
For non-sexually active females, abstinence will be considered an acceptable form of
birth control. Women considered capable of becoming pregnant include all females who
have experienced menarche and have not experienced menopause (as defined by amenorrhea
for greater than 12 consecutive months) or have not undergone successful surgical
sterilization (e.g. hysterectomy, bilateral tubal ligation, or bilateral
oophorectomy);

6. Having topographic and clinical evidence of keratoconus defined as thefollowing:

- Axial topography consistent with keratoconus

- Maximum corneal curvature, as measured by Kmax of ≥ 47.00 D;

- Presence of central or inferior steepening on the Pentacam topography map

- Presence of one or more findings associated with keratoconus, such as

1. Fleischer ring

2. Vogt striae

3. Corneal thinning

4. Corneal scarring

5. Scissoring of the retinoscopic reflex

7. Having a diagnosis of progressive keratoconus, defined as one or more of the following
changes over a period of 18 months or less:

1. An increase of ≥ 1.00 D in Kmax or simK

2. An increase of ≥ 1.00 D in regular astigmatism on subjective manifest refraction

3. A myopic shift (towards greater negative sphere) of 0.50 D or more on subjective
manifest refraction or as evaluated by comparing eyeglass or contact lens
prescriptions to current subjective manifest refraction [NOTE: subjects with a
clear history of progression but without prior documentation may be screened and
followed for a period of time to confirm and document progression]

8. BSCVA of ≥ 1 letter and ≤ 85 letters on ETDRS chart

9. Contact Lens Wearers Only: Removal of contact lenses is required for a 1 week period
prior to the screening visit(s) and subject must agree to remain out of their contact
lenses from the time of treatment until the 1-month visit is completed. A contact lens
wearer is defined as someone who has worn contact lenses in the eye to be treated in
the last 30 days.

Exclusion Criteria:

1. Contraindications, sensitivity or known allergy to the use of the test article(s) or
their components;

2. If female, be pregnant, nursing or planning a pregnancy or have a positive urine
pregnancy test prior to the randomization or treatment of either eye or during the
course of the study;

3. Eyes classified as either normal, atypical normal, or keratoconus suspect on the
severity grading scheme;

4. A history of previous corneal surgery, limbal relaxing incision procedure, or
insertion of Intacs in the eye(s) to be treated;

5. Corneal pachymetry that is < 325 microns at the thinnest point measured by Pentacam in
the eye to be treated;

6. Eyes which are aphakic, or eyes which are pseudophakic and do not have a UV blocking
lens implanted;

7. Previous ocular condition (other than refractive error) in the eye to be treated that
may predispose the eye for future complications. For example:

- History of corneal disease (e.g., herpes simplex, herpes zoster keratitis,
corneal melt, corneal dystrophy, etc.);

- Clinically significant corneal scarring in the cross-linking treatment zone that
is not related to keratoconus or, in the Investigator's opinion, will interfere
with the cross-linking procedure;

8. A history of delayed epithelial healing in the eye to be treated or a current
condition that may interfere with or prolong epithelial healing;

9. Subjects with nystagmus or any other condition that would prevent a steady gaze during
the treatment or other diagnostic tests;

10. A history of previous corneal cross-linking treatment in the eye to be treated;

11. Have used an investigational drug or device within 30 days of screening or be
concurrently enrolled in another investigational drug or device trial within 30 days
of the study.