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It focuses on how TE-CXL compares with the standard epithelium-off cross-linking (S-CXL) and discusses recent improvements intended to make it more effective.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n Relevant studies were reviewed from PubMed and Google Scholar. The review focused on research about new riboflavin solutions, delivery techniques, ultraviolet-A (UV-A) light settings, oxygen supply methods, and recent new technologies designed to improve the results of TE-CXL.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n TE-CXL preserves the corneal epithelium, providing better patient comfort and fewer postoperative complications. However, its corneal stiffening effect is generally lower than S-CXL due to limited riboflavin penetration and UV photoactivation. Recent approaches, including chemical enhancers, iontophoresis-assisted delivery, optimized UV-A protocols, nanotechnology-based or ultrasound-assisted methods have demonstrated potential to improve biomechanical strengthening. In addition, theranostic-guided TE-CXL, which provides real-time monitoring of stromal riboflavin concentration and adaptive UV-A dosing, represents a promising advancement. Nevertheless, differences in treatment protocols and in oxygen and luminance parameters still lead to variability in clinical outcomes.<\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n TE-CXL is a promising and less invasive treatment for KC, offering better comfort and faster recovery. However, its long-term stability and biomechanical effect remain inferior to S-CXL. Future progress will depend on optimizing riboflavin and oxygen delivery, refining UV-A irradiation protocols, and validating newer technologies such as theranostic-guided CXL through large-scale clinical studies.<\/jats:p>\n <\/jats:sec>","DOI":"10.1007\/s10792-025-03928-1","type":"journal-article","created":{"date-parts":[[2026,1,10]],"date-time":"2026-01-10T04:38:03Z","timestamp":1768019883000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Transepithelial corneal cross-linking: a review"],"prefix":"10.1007","volume":"46","author":[{"given":"Wen","family":"Zhou","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sandeepani K.","family":"Subasinghe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesc March","family":"de Ribot","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kelechi C.","family":"Ogbuehi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"George J.","family":"Dias","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,1,10]]},"reference":[{"key":"3928_CR1","doi-asserted-by":"publisher","first-page":"1044","DOI":"10.1136\/bjo.2010.185868","volume":"95","author":"V Jhanji","year":"2011","unstructured":"Jhanji V, Sharma N, Vajpayee RB (2011) Management of keratoconus: current scenario. 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