Transient Reticular Cystic Corneal Epithelial Edema With Topical Netarsudil: A Case Series and Review

Crystalline keratopathy following long-term netarsudil therapy

Purpose

This case report highlights a possible association between netarsudil use and crystalline keratopathy.

Observations

Presented here is the case of a 72-year-old woman with primary open-angle glaucoma (POAG) who developed corneal crystalline keratopathy after taking netarsudil for 24 months. The patient's medical history was significant for dry eye syndrome, bilateral ptosis with surgical repair, and atopy (including asthma and various ocular and systemic allergies). The patient had previously undergone surgical repair for bilateral ptosis as well. During the interval between two routine visits, this patient experienced worsening vision with associated eye irritation. Further examination revealed crystal deposits on the anterior corneal surface in the left eye, the only eye undergoing netarsudil treatment.

Conclusions and importance

Long-term netarsudil use may be associated with crystalline keratopathy in the anterior stroma, with the potential to cause sight-threatening vision loss if located in the visual axis.

Reticular Bullous Epithelial Corneal Edema after Netarsudil Use for Elevated Intraocular Pressure with Concurrent Fuchs Endothelial Corneal Dystrophy: A Case Report

Introduction

We describe a case of reticular bullous corneal epithelial edema associated with the use of netarsudil ophthalmic solution (0.02%) for elevated intraocular pressure.

Case Presentation

A 74-year-old man with a complex ocular medical history, including Fuchs dystrophy and primary open-angle glaucoma, developed progressively worsening loss of vision 3 weeks following the initiation of topical netarsudil for increased intraocular pressure. Visual acuity in the left eye was counting fingers at 3 feet and intraocular pressure in the left eye was 7 mm Hg. A characteristic "honeycomb" pattern epitheliopathy was seen on ocular examination.

Conclusion

Reticular bullous epithelial corneal edema is an uncommon finding associated with netarsudil use, which can be overlooked in favor of corneal edema associated with Fuchs dystrophy. This is especially relevant given Fuchs dystrophy itself is a predisposing risk factor for netarsudil-induced reticular bullous corneal epithelial edema. Improvement of both the corneal edema and visual acuity should be expected after discontinuing netarsudil and undergoing superficial keratectomy.

ROCK inhibitors in ophthalmology: A critical review of the existing clinical evidence

Rho kinase (ROCK) inhibitors have emerged as a key therapeutic class of interest in ophthalmology over the last decade. Promising in vitro studies laid the foundations for the development of novel therapeutic agents that target the ROCK signalling pathway in ocular disease, with subsequent clinical trials supporting their use. Corneal endothelial disease, glaucoma, and vitreoretinal disease are the major pathologies in which ROCK inhibitors have been investigated to date. Ripasudil and netarsudil represent the current leaders in this pharmaceutical group, having been extensively validated and approved for use in glaucoma in some countries. Less substantial evidence exists for fasudil in ophthalmic use. ROCK inhibitors are also increasingly used in cultured endothelial cell grafting and as an adjunct to aid in endothelial cell migration and replication in Descemet's stripping procedures or Descemet's membrane injuries. This review has synthesised both established and emerging research to provide a practical guide to prescribing in this drug class. Drug efficacies, side effect profiles, and the demographic and clinical characteristics of appropriate drug candidates are discussed.

Reticular corneal epithelial edema with topical netarsudil

Rho-associated protein kinase inhibitor (ROCK) therapy for corneal endothelial dysfunction or damage other than glaucoma has been reported with few ocular side effects. We report reticular epithelial edema (REE) with netarsudil (0.02%) therapy in four cases with different clinical scenarios (three cases with corneal transplant and one case postcataract extraction). REE developed in all cases variably and cleared on cessation of netarsudil in three cases. One case was continued on netarsudil due to REE sparing the visual axis with no active ocular complaints. Partial clearance of stromal edema observed in all cases was correlated clinically to visual acuity considering existing comorbidities in an individual case.

Two pediatric cases of reticular corneal epithelial edema associated with netarsudil

Purpose

To report two pediatric cases of reticular corneal epithelial edema associated with the use of netarsudil ophthalmic solution 0.02%.

Observations

In Case 1, a six-year-old male with glaucoma following cataract surgery was treated with netarsudil for thirteen months and developed diffuse reticular corneal epithelial edema on post-operative day one after undergoing transscleral diode cyclophotocoagulation for persistently elevated intraocular pressures. In Case 2, a three-month-old male with bilateral ocular hypertension developed unilateral inferior reticular corneal epithelial edema five weeks after initiation of netarsudil, which had been discontinued in the fellow eye two weeks prior. In both cases, the reticular epithelial edema resolved following cessation of netarsudil.

Conclusions and Importance

Netarsudil-associated reticular corneal epithelial edema can occur in infants and young children.

Honeycomb epithelial oedema due to ripasudil: clinical, optical coherence tomography and histopathological correlation

A male in his 50s, who had undergone Descemet's stripping automated endothelial keratoplasty (DSAEK) for corneal oedema following irido-corneal-endothelial syndrome and glaucoma drainage device surgery for secondary glaucoma presented with gradual decreased vision. The patient was on ripasudil 0.4% for the past 4 months prior to the presentation. Honeycomb epithelial oedema was seen with vesicles and intraepithelial microcyst formation which were also noted on anterior segment optical coherence tomography (OCT) and histopathology, that co-related with the slit-lamp findings. The patient underwent repeat DSAEK and had a good outcome. While the clinical features and OCT findings have been reported earlier, the histopathological features have not been reported.

Management of endothelial disease without keratoplasty

PURPOSE OF REVIEW

Currently, the most widely used treatment for endothelial disease is endothelial replacement via endothelial keratoplasty. Increasingly selective techniques have allowed for increased safety and faster visual recovery. However, alternative treatment options that are lower in cost, require less surgical expertise, and rely less on tissue availability are needed. This review discusses established and emerging therapies for endothelial disease without keratoplasty.

RECENT FINDINGS

Regenerative therapies that have been successful include Descemet stripping only and Descemet membrane transplants. Rho-kinase inhibitors promote cell proliferation, adhesion, and migration and appear to have a role in these treatments and possibly in the prevention of endothelial disease. Cell-based therapies and the development of an artificial endothelial implant have also demonstrated promising results.

SUMMARY

There are numerous emerging treatments for endothelial disease that have proven successful. Advances in our understanding of disease pathogenesis on a cellular level will continue to expand possibilities for therapeutics.

Reticular epithelial edema after penetrating keratoplasty in a patient taking netarsudil

Netarsudil is a relatively new medication for the treatment of primary open-angle glaucoma and ocular hypertension. It has been associated with red eyes and burning after instillation. Reticular epitheliopathy is a relatively rare complication of netarsudil that has been described in patients with preexisting corneal edema. We report the case of a healthy 76-year-old woman who developed reticular epitheliopathy after full-thickness penetrating keratoplasty that completely resolved following discontinuation of the medication. In cases where netarsudil is initiated for treatment of glaucoma or, off-label, endothelial dysfunction, reticular epithelial edema should be considered in patients complaining of a decline in vision and severe pain.

Newer advances in medical management of glaucoma

The burden of irreversible vision loss from Glaucoma continues to rise. While the disease pathogenesis is not well understood, intraocular pressure (IOP) is the only modifiable risk factor identified to prevent glaucomatous vision loss. Medical management remains the first-line of treatment in most adult glaucomas and the evolution of medical therapy for glaucoma has followed an exponential curve. This review tracks the rapid development of new medications and drug delivery systems in the recent years. Introduction of Rho kinase inhibitors with an entirely new mechanism of action from that of the currently used anti glaucoma medications has been a significant milestone. Latanoprostene Bunod is a novel, single molecule which provides two active metabolites that work through two different pathways for reducing intra ocular pressure. Bimatoprost implants and travoprost punctum plugs attempt to ease chronic medication use in glaucoma patients. Nanotechnology is an evolving route of drug delivery. Role of cannabinoids in medical management of glaucoma remain equivocal. The relatively short term effect on IOP, the risks of developing tolerance and side effects impacting patients' neurocognitive health greatly outweigh the potential benefit. Research on Latrunculin B, Adenosine receptor agonists, Specific gene silencing and Stem cell therapy are poised to make an impact on glaucoma treatment. While there is some evidence to support the role of Brimonidine in neuroprotection, further research is needed to clarify the role of Memantine and Neurotrophins. Evidence for benefit from dietary supplementation with Alpha lipoic acid, Forskolin , and Ginko Biloba is limited.

Reticular epithelial corneal edema as a novel side-effect of Rho Kinase Inhibitors: An Indian scenario

Purpose

To describe clinical course, characteristics, and outcome of reticular epithelial corneal edema (RECE) occurring as a not-so-infrequent adverse effect of a novel drug, Rho-kinase inhibitors (ROCK-I)- netarsudil (0.02%) and ripasudil (0.4%).

Methods

This was a retrospective observational non-randomized study. In this study, 12 eyes of 11 patients presenting at a tertiary eye care center between April 2021 and September 2021 were included. All 12 eyes developed a distinctive honeycomb pattern of RECE after starting topical ROCK-I. All patients were subjected to detailed ophthalmic examinations.

Results

Eight patients were started on netarsudil (0.02%) and three on ripasudil (0.4%). Five eyes had a prior history of corneal edema. The remaining seven had the presence of ocular comorbidities predisposing to corneal edema. The average time for RECE occurrence was 25 days for netarsudil and 82 days for ripasudil. Visual acuity decreased in two eyes, remained unaffected in four eyes, and could not be quantified in four eyes due to preexisting profound visual impairment. Five eyes had symptoms of ocular surface discomfort associated with bullae. Symptoms and bullae resolved in all eyes in whom ROCK-I was stopped. The average time to resolution of RECE was 10 days for netarsudil and 25 days for ripasudil.

Conclusion

RECE after ROCK-I occurs with the use of both netarsudil and ripasudil, although the characteristics differ. The presence of corneal edema and endothelial decompensation seem to be a risk factor, and cautious use is warranted in these patients. Four clinical stages of RECE are described. ROCK-I act as a double-edged sword in patients with endothelial decompensation. Large-scale studies are required to know the exact incidence, pathophysiology, and long-term consequences of the aforementioned side-effect.

Case report: The use of netarsudil to improve corneal edema after laser peripheral iridotomy and Descemet's membrane endothelial keratoplasty

Purpose

To report a case in which netarsudil ophthalmic solution 0.02% improved refractory corneal edema after laser peripheral iridotomy (LPI) and Descemet's membrane endothelial keratoplasty (DMEK).

Observations

A 63-year-old female presented with decreased vision due to corneal edema secondary to iatrogenic endothelial cell loss from previous YAG and argon laser peripheral iridotomy. Initial treatment with topical sodium chloride 5% solution was unsuccessful in resolving the edema. As a result, topical netarsudil was initiated off-label. Improvement in corneal thickness and visual acuity was noted, but after a few months, the left eye decompensated with worsening edema. Cataract surgery with DMEK was performed. Surgery was prolonged and intraoperative floppy iris was encountered. Post-operatively, the patient's best-corrected visual acuity (VA) fluctuated between 20/30 to 20/70 with persistent corneal edema. The central corneal thickness (CCT) ranged from 758 to 779 three months after surgery. Topical netarsudil was started again off-label for cornea edema once nightly. Over the next two months, visual acuity and CCT improved to 20/25 and 650, respectively. Stabilization of visual acuity and cornea edema has been maintained for eight months after initiation of topical netarsudil.

Conclusions

Netarsudil, a commercially available rho-kinase inhibitor, may be an effective, non-invasive adjunctive therapy for refractory corneal edema. Our case demonstrates improvement in BCVA and CCT using topical netarsudil, which has been maintained without any vision threatening side effects.