Ripasudil Hydrochloride Hydrate in the Treatment of Glaucoma: Safety, Efficacy, and Patient Selection

The state of the art in secondary pharmacology and its impact on the safety of new medicines

Secondary pharmacology screening of investigational small-molecule drugs for potentially adverse off-target activities has become standard practice in pharmaceutical research and development, and regulatory agencies are increasingly requesting data on activity against targets with recognized adverse effect relationships. However, the screening strategies and target panels used by pharmaceutical companies may vary substantially. To help identify commonalities and differences, as well as to highlight opportunities for further optimization of secondary pharmacology assessment, we conducted a broad-ranging survey across 18 companies under the auspices of the DruSafe leadership group of the International Consortium for Innovation and Quality in Pharmaceutical Development. Based on our analysis of this survey and discussions and additional research within the group, we present here an overview of the current state of the art in secondary pharmacology screening. We discuss best practices, including additional safety-associated targets not covered by most current screening panels, and present approaches for interpreting and reporting off-target activities. We also provide an assessment of the safety impact of secondary pharmacology screening, and a perspective on opportunities and challenges in this rapidly developing field.

Investigation into the usefulness of cynomolgus monkeys with spontaneously elevated intraocular pressure as a model for glaucoma treatment research

Many glaucoma treatments focus on lowering intraocular pressure (IOP), with novel drugs continuing to be developed. One widely used model involves raising IOP by applying a laser to the trabecular iris angle (TIA) of cynomolgus monkeys to damage the trabecular meshwork. This model, however, presents challenges such as varying IOP values, potential trabecular meshwork damage, and risk of animal distress. This study investigated whether animals with naturally high IOP (>25 mmHg) could be used to effectively evaluate IOP-lowering drugs, thereby possibly replacing laser-induced models. Relationships between TIA size, IOP, and pupil diameter were also examined. Three representative IOP-lowering drugs (latanoprost, timolol, ripasudil) were administered, followed by multiple IOP measurements and assessment of corneal thickness, TIA, and pupil diameter via anterior segment optical coherence tomography (AS-OCT). There was a positive correlation was noted between IOP and corneal thickness before instillation, and a negative correlation between IOP and TIA before instillation. Our findings suggest animals with naturally high IOP could be beneficial for glaucoma research and development as a viable replacement for the laser-induced model and that measuring TIA using AS-OCT along with IOP yields a more detailed evaluation.

Rho-Kinase Inhibitors as Emerging Targets for Glaucoma Therapy

Glaucoma, the leading cause of irreversible blindness worldwide, is a chronic and progressive optic neuropathy characterized by damage to the optic and retinal nerve fiber layers, which can lead to permanent loss of peripheral or central vision. Reduction of intraocular pressure (IOP) is the only known modifiable risk factor for preventing and treating glaucoma. Rho kinase (ROCK) inhibitors are a new class of glaucoma drugs with a novel mechanism of action and good safety profile. They exert neuroprotective effects, act on the trabecular tissue, increase the outflow of aqueous humor, and reduce intraocular pressure. However, they also cause local adverse reactions, including common conjunctival congestion and subconjunctival bleeding; however, most are self-limiting and temporary. Netarsudil (0.02%), a ROCK inhibitor, relaxes the trabecular meshwork, increases the outflow of aqueous humor, reduces scleral venous pressure, and directly decreases IOP. Conjunctival congestion can be reduced if netarsudil is administered at night. The combination of these medications is always more effective than the single drug. Ripasudil (0.4%), another ROCK inhibitor, also lowers IOP; however, conjunctival hyperemia is the most common adverse drug reaction. The purpose of this review is to summarize the effects and adverse reactions of ROCK inhibitors in the experimental trial stage and in clinical treatment in recent years, providing suggestions for future clinical drug use, and research and development to reduce the side effects of these drugs, maximize the potential for reducing IOP, and improve the therapeutic effect.

Favorable effect of ripasudil use on surgical outcomes of microhook ab interno trabeculotomy

PURPOSE

We have previously demonstrated that prolonged use of glaucoma medications was associated with a poor surgical outcome of ab interno trabeculotomy (µTLO). Given that almost all types of glaucoma eye drop either enhance the drainage through the uveoscleral pathway or reduce aqueous humor production, we hypothesized that prolonged use of these medications might cause disuse atrophy of the conventional pathway. In contrast, ripasudil increases the conventional outflow and eventually shows a favorable outcome of µTLO. This study aimed to evaluate the effect of ripasudil use on µTLO outcomes.

METHOD

The medical charts of 218 patients who underwent µTLO were analyzed retrospectively. We compared the 1-year outcome between ripasudil users versus nonusers by using propensity score matching. We set the covariates as age, sex, glaucoma types, preoperative intraocular pressure (IOP), the mean deviation values of visual field tests, the presence or absence of concomitant cataract surgery, trabecular meshwork incision range, the presence or absence of any glaucoma medication except ripasudil and duration of glaucoma medical therapy. Success was defined as a postoperative IOP between 5 and 21 mmHg, a ≥ 20% IOP reduction from baseline, and no additional glaucoma surgery at postoperative 1 year.

RESULT

Fifty-seven patients each were allocated to the ripasudil users or nonusers. The 1-year success rates were 74% in ripasudil users and 51% in nonusers (p = 0.01). Kaplan‒Meier survival curves also showed that the ripasudil users had a higher survival distribution (p = 0.01).

CONCLUSION

The patients who took ripasudil showed a favorable 1-year outcome of µTLO.

Role of ripasudil as an adjunct treatment in the management of pseudoexfoliative glaucoma

Purpose

Ripasudil is a class of drug which alters the trabecular meshwork to increase the aqueous outflow and has been shown to be effective in pseudoexfoliative glaucoma (PXF G). This study aimed at assessing the efficacy and safety profile of ripasudil as an adjunct treatment in patients with PXF G at maximal tolerated antiglaucoma medications.

Methods

In this prospective, interventional study, 40 patients with PXF G were enrolled between May 2021 and Jan 2022. Ripasudil 0.4% was started as an adjunctive drug to the ongoing antiglaucoma medications. On follow-up visits at 1, 3, and 6 months, the visual acuity, intraocular pressure (IOP), anterior segment, and fundus findings were evaluated. The premedication and postmedication IOP values were compared by paired t-test, and a P-value <0.05 was considered statistically significant.

Results

Average age at recruitment was 60.02 ± 8.74 years. Baseline premedication IOP was 25.375 ± 3.276 mmHg. IOP reduction at 6 months was found to be statistically significant in all patients, with the maximal response being 24.13%. Also, 87.5% (35/40) of patients reached target IOP or even lower IOP at the end of study. There was no statistically significant association between the PXF grade and IOP. However, the grade of inferior iridocorneal angle pigmentation was found to be higher in eyes with elevated IOP (P < 0.05). Only three patients developed conjunctival hyperemia as an adverse reaction, which was mild and transient.

Conclusion

Ripasudil showed additional IOP-lowering effect with other antiglaucoma medications and exhibited no significant side effects.

Recent Advances of Ocular Drug Delivery Systems: Prominence of Ocular Implants for Chronic Eye Diseases

Chronic ocular diseases can seriously impact the eyes and could potentially result in blindness or serious vision loss. According to the most recent data from the WHO, there are more than 2 billion visually impaired people in the world. Therefore, it is pivotal to develop more sophisticated, long-acting drug delivery systems/devices to treat chronic eye conditions. This review covers several drug delivery nanocarriers that can control chronic eye disorders non-invasively. However, most of the developed nanocarriers are still in preclinical or clinical stages. Long-acting drug delivery systems, such as inserts and implants, constitute the majority of the clinically used methods for the treatment of chronic eye diseases due to their steady state release, persistent therapeutic activity, and ability to bypass most ocular barriers. However, implants are considered invasive drug delivery technologies, especially those that are nonbiodegradable. Furthermore, in vitro characterization approaches, although useful, are limited in mimicking or truly representing the in vivo environment. This review focuses on long-acting drug delivery systems (LADDS), particularly implantable drug delivery systems (IDDS), their formulation, methods of characterization, and clinical application for the treatment of eye diseases.

Circadian Fluctuation Changes in Intraocular Pressure Measured Using a Contact Lens Sensor in Patients with Glaucoma after the Adjunctive Administration of Ripasudil: A Prospective Study

Nocturnal and circadian intraocular pressure (IOP) fluctuations are important issues in glaucoma treatment. Ripasudil 0.4% eye drops, a new glaucoma medication, lowers IOP by increasing aqueous humor outflow through the trabecular meshwork. We aimed to compare differences between circadian IOP fluctuations measured using a contact lens sensor (CLS) before and after administering 0.4% ripasudil eye drops adjunctively to patients with primary open-angle glaucoma (POAG) and normal tension glaucoma (NTG). Patients with POAG (n = 1) and NTG (n = 5) underwent 24 h IOP monitoring with a CLS before and after administering ripasudil eye drops every 12 h (8 a.m., 8 p.m.) for 2 weeks without discontinuing currently used glaucoma medications. No vision-threatening adverse event occurred. The reduction in IOP fluctuation and the reduction in the SD of IOP in 24 h, awake time and sleep time did not reach statistical significance. The baseline office-hour IOP, which was measured using Goldmann applanation tonometry (GAT), ranged in the low teens, and the reduction in office-hour IOP also did not show a significant difference. Further study is necessary to evaluate whether the low baseline IOP with less IOP reduction relates to attenuated IOP fluctuation reduction.

Application and Study of ROCK Inhibitors in Pulmonary Fibrosis: Recent Developments and Future Perspectives

Rho-associated coiled-coil-containing kinases (ROCKs), serine/threonine protein kinases, were initially identified as downstream targets of the small GTP-binding protein Rho. Pulmonary fibrosis (PF) is a lethal disease with limited therapeutic options and a particularly poor prognosis. Interestingly, ROCK activation has been demonstrated in PF patients and in animal PF models, making it a promising target for PF treatment. Many ROCK inhibitors have been discovered, and four of these have been approved for clinical use; however, no ROCK inhibitors are approved for the treatment of PF patients. In this article, we describe ROCK signaling pathways and the structure-activity relationship, potency, selectivity, binding modes, pharmacokinetics (PKs), biological functions, and recently reported inhibitors of ROCKs in the context of PF. We will also focus our attention on the challenges to be addressed when targeting ROCKs and discuss the strategy of ROCK inhibitor use in the treatment of PF.

Rho-kinase inhibitor restores glomerular fatty acid metabolism in diabetic kidney disease

The small GTPase Rho and its effector Rho-kinase (ROCK) are activated in the diabetic kidney, and recent studies decade have demonstrated that ROCK signaling is an integral pathway in the progression of diabetic kidney disease. We previously identified the distinct role of ROCK1, an isoform of ROCK, in fatty acid metabolism in diabetic glomeruli. However, the effect of pharmacological intervention for ROCK1 is not clear. In the present study, we show that the inhibition of ROCK1 by Y-27632 and fasudil restores fatty acid oxidation in the glomeruli. Mechanistically, these compounds optimize fatty acid utilization and redox balance in mesangial cells via AMPK phosphorylation and the subsequent induction of PGC-1α. A further in vivo study showed that the inhibition of ROCK1 suppressed the downregulation of the fatty acid oxidation-related gene expression in glomeruli and mitochondrial fragmentation in the mesangial cells of db/db mice. These observations indicate that ROCK1 could be a promising therapeutic target for diabetic kidney disease through a mechanism that improves glomerular fatty acid metabolism.

Early Postoperative Effect of Ripasudil Hydrochloride After Trabeculectomy on Secondary Glaucoma: A Randomized Controlled Trial

Purpose:

To evaluate the effect of Rho-associated kinase inhibitor (ripasudil hydrochloride hydrate; ripasudil) eye drops on postoperative intraocular pressure (IOP) after trabeculectomy in eyes with uveitic glaucoma.

Design:

This was a prospective, observational, controlled, and randomized study.

Methods:

Sixteen eyes of 16 patients with uveitic glaucoma who underwent trabeculectomy without mitomycin C were randomly treated without ripasudil (8 eyes) and with ripasudil (8 eyes). Postoperative IOP and surgical outcomes 3 months after surgery were compared between the two groups.

Results:

No patient discontinued treatment due to the lack of efficacy or adverse effects of ripasudil during the 3-month study period in the ripasudil group. The mean IOP (mmHg) in the control and ripasudil groups were 42.5 ± 9.8 mmHg /43.9 ± 11.7 mmHg (p = 0.82) at baseline, 14.3 ± 4.9 mmHg /9.0 ± 3.7 mmHg (p = 0.04) at 1 week, 16.3 ± 4.2 mmHg /10.6 ± 3.0 mmHg (p = 0.01) at 1 month, and 16.0 ± 3.4 mmHg /12.5 ± 2.3 mmHg (p = 0.04) at 3 months. The number of laser suture lysis procedures (2.0 ± 0.5 vs 0.4 ± 0.7), the rate of bleb revision by needling (50.0% vs 0.0%), and the mean number of antiglaucoma medications (1.6 ± 1.5 vs. 0.1 ± 0.3) after trabeculectomy were higher in the control group than in the ripasudil group (all p < 0.05). A multivariate analysis showed that the IOP reduction rate at 3 months after surgery was associated with the use of ripasudil and baseline IOP (all p < 0.05).

Conclusion:

This study demonstrated the therapeutic efficacy, safety, and tolerability of ripasudil for 3 months postoperatively. Ripasudil may effectively reduce postoperative IOP and increase the success rate of trabeculectomy in patients with uveitic glaucoma.

The Piezo1 ion channel in glaucoma: a new perspective on mechanical stress

Glaucomatous optic nerve damage caused by pathological intraocular pressure elevation is irreversible, and its course is often difficult to control. This group of eye diseases is closely related to biomechanics, and the correlation between glaucoma pathogenesis and mechanical stimulation has been studied in recent decades. The nonselective cation channel Piezo1, the most important known mechanical stress sensor, is a transmembrane protein widely expressed in various cell types. Piezo1 has been detected throughout the eye, and the close relationship between Piezo1 and glaucoma is being confirmed. Pathological changes in glaucoma occur in both the anterior and posterior segments of the eye, and it is of great interest for researchers to determine whether Piezo1 plays a role in these changes and how it functions. The elucidation of the mechanisms of Piezo1 action in nonocular tissues and the reported roles of similar mechanically activated ion channels in glaucoma will provide an appropriate basis for further investigation. From a new perspective, this review provides a detailed description of the current progress in elucidating the role of Piezo1 in glaucoma, including relevant questions and assumptions, the remaining challenging research directions and mechanism-related therapeutic potential.

Cardiac Hypertrophy May Be a Risk Factor for the Development and Severity of Glaucoma

The purpose of this study was to examine the relationship between glaucoma and cardiac abnormalities. We evaluated 581 patients with open-angle glaucoma (285 men and 296 women) and 595 individuals without glaucoma (273 men and 322 women). All of the participants underwent visual field testing using a Humphrey Visual Field Analyzer (30-2 program), an electrocardiogram (ECG), and blood pressure measurement. We examined the ECG abnormalities and other factors (age, intraocular pressure (IOP) and systemic hypertension) involved in the development and severity of glaucoma. Logistic regression analyses revealed significant correlations of glaucoma with IOP (OR = 1.43; 95% CI: 1.36−1.51; p < 0.00001), atrial fibrillation (OR = 2.02; 95% CI: 1.01−4.04; p = 0.04), left ventricular hypertrophy (LVH) (OR = 2.21; 95% CI: 1.15−4.25; p = 0.02), and bradycardia (OR = 2.19; 95% CI: 1.25−4.70; p = 0.02). Regression analyses revealed significant correlations of the mean deviation of the visual field with age (t = −6.22; 95% CI: −0.15, −0.08; p < 0.00001), IOP (t = −6.47; 95% CI: −0.42, −0.23; p < 0.00001), and LVH (t = −2.15; 95% CI: −3.36, −0.29; p = 0.02). Atrial fibrillation, LVH and bradycardia may decrease the cerebral blood flow, and may also affect the ocular blood flow. Cardiac abnormalities may be associated with the development and severity of glaucoma.

ANGPTL7 is transcriptionally regulated by SP1 and modulates glucocorticoid-induced cross-linked actin networks in trabecular meshwork cells via the RhoA/ROCK pathway

Glaucoma is one of the leading causes of worldwide irreversible blindness. Lowering elevated intraocular pressure (IOP) is currently the only effective approach for controlling the progress of glaucoma. Angiopoietin-like 7 (ANGPTL7) takes a key part in elevated outflow resistance of aqueous humor in dysfunctional trabecular meshwork (TM), along with the formation of cross-linked actin networks (CLANs), leading to high IOP. In this study, we explored the role of the ANGPTL7 signaling pathway in CLAN formation. We detected the expression of ANGPTL7 in cultured primary TM cells treated with dexamethasone (DEX) and ethanol as a control using qRT-PCR and western blotting. Actin filaments were revealed by phalloidin staining. ANGPTL7 short hairpin RNA (shRNA) was applied to TM cells to examine the effect of ANGPTL7 on DEX-induced CLAN formation. Western blotting was used to assess the effect of ANGPTL7 on the RhoA/Rho-associated kinase (Rho-kinase/ROCK) signaling pathway. Bioinformatics, dual-luciferase reporter assays, and chromatin immunoprecipitation were employed to identify the transcription factors of ANGPTL7. Transcription factor specificity protein 1 (SP1) overexpression and silencing were performed to determine their roles in the modulation of ANGPTL7 expression. We found DEX-induced ANGPTL7 expression and stress fiber rearrangement in TM cells. ANGPTL7 knockdown effectively inhibited the formation of CLANs. Moreover, it was involved in the regulation of the RhoA/ROCK signaling pathway, further affecting DEX-induced CLAN formation. SP1 was identified as a transcription factor of ANGPTL7 which regulated ANGPTL7 level to mediate CLAN formation through the RhoA/ROCK signaling pathway. This study contributes to revealing the molecular mechanisms of ANGPTL7 in CLAN formation, which is involved in TM dysfunction and glaucoma pathogenesis.

Topical Medication Therapy for Glaucoma and Ocular Hypertension

Glaucoma is one of the most common causes of blindness, thus seriously affecting people’s health and quality of life. The topical medical therapy is as the first line treatment in the management of glaucoma since it is inexpensive, convenient, effective, and safe. This review summarizes and compares extensive clinical trials on the topical medications for the treatment of glaucoma, including topical monotherapy agents, topical fixed-combination agents, topical non-fixed combination agents, and their composition, mechanism of action, efficacy, and adverse effects, which will provide reference for optimal choice of clinical medication. Fixed-combination therapeutics offer greater efficacy, reliable security, clinical compliance, and tolerance than non-fixed combination agents and monotherapy agents, which will become a prefer option for the treatment of glaucoma. Meanwhile, we also discuss new trends in the field of new fixed combinations of medications, which may better control IOP and treat glaucoma.

Drugs for the treatment of glaucoma: Targets, structure-activity relationships and clinical research

Glaucoma is the third leading cause of blindness and impairment of vision worldwide, after refractive errors and cataracts. According to the survey, the number of people with glaucoma is more than 76 million, with projections increasing to 112 million by 2040. With the coming of an aging society, the number of people suffering from glaucoma will increase day by day. Glaucoma is a heterogeneous disease characterized by damage to the head of the optic nerve and visual field. High intraocular pressure is a major risk and cause of glaucoma optic neuropathy. Therefore, drug lowering intraocular pressure therapy is still the first-line therapy in clinical practice. Here, the targets, structure-activity relationship, and clinical progress of drugs for the treatment of glaucoma are reviewed.

The ROCK Inhibitor Ripasudil Shows an Endothelial Protective Effect in Patients With Low Corneal Endothelial Cell Density After Cataract Surgery

Purpose

In the field of regenerative medicine, Rho kinase inhibitors (ROCK inhibitors) show a protective effect on the corneal endothelium and promote effective healing in acute surgical wounds. In this study, we investigated the effectiveness of eyedrops containing ripasudil, a ROCK inhibitor approved in Japan for therapeutic use for glaucoma.

Methods

In this retrospective observational study, 13 glaucoma patients (16 eyes) were treated with 0.4% ripasudil eyedrops twice a day after cataract surgery. The control group comprised 13 patients (17 eyes). The averaged corneal endothelial cell density from one central and four paracentral points was <1500/mm2 (range, 527 to 1439/mm2).

Results

The mean rate of increase in the thinnest corneal thickness one week after surgery was 1.25% in the ripasudil group, which was significantly lower than the 5.97% increase observed in the control group (P = 0.0037). The mean endothelial cell density loss 90 to 120 days after surgery, excluding bullous keratopathy patients for whom measurements were not possible was -4.5% in the ripasudil group, which was significantly lower than in control group (14.1%; P = 0.0003).

Conclusions

The results suggest that ripasudil may help maintain corneal endothelial functional integrity and reduce cell loss after cataract surgery in patients with low corneal endothelial cell density, suggesting that it may be more broadly useful for protection of the corneal endothelium after intraocular surgery.

Translational Relevance

The clinically approved ROCK inhibitor ripasudil formulated as an eye drop for glaucoma has a corneal endothelial protective effect in cataract surgery for patients with low corneal endothelial cell density.

Netarsudil: A new ophthalmic drug in the treatment of chronic primary open angle glaucoma and ocular hypertension

BACKGROUND

Vision impairment remains a major health problem worldwide. Elevated intraocular pressure is a prime risk factor for blindness in the elderly. Netarsudil is a Rho-associated protein kinase (ROCK) inhibitor, which also inhibits norepinephrine transport. This narrative review summarizes the properties and clinical significance of netarsudil, a promising drug in topical glaucoma therapy.

METHODS

We searched PubMed, Medline and Scopus databases using relevant keywords to retrieve information on the physicochemical properties, formulation, mechanism of action, clinical pharmacokinetics, dose and toxicity of netarsudil.

RESULTS

Netarsudil showed promising effects in lowering the elevated intraocular pressure by two mechanisms. The US FDA approved netarsudil for clinical use in 2017 under the trademark of Rhopressa^® while European Medicines Agency approved Rhokiinsa^® in 2019. This drug is available as a 0.02% ophthalmic solution for once-daily topical application.

CONCLUSION

The discovery of netarsudil is a breakthrough in the therapy of glaucoma with proven efficacy in a wide range of eye pressures and is well tolerated in cases with ocular hypertension and chronic glaucoma.

Articular Chondrocyte Phenotype Regulation through the Cytoskeleton and the Signaling Processes That Originate from or Converge on the Cytoskeleton: Towards a Novel Understanding of the Intersection between Actin Dynamics and Chondrogenic Function

Numerous studies have assembled a complex picture, in which extracellular stimuli and intracellular signaling pathways modulate the chondrocyte phenotype. Because many diseases are mechanobiology-related, this review asked to what extent phenotype regulators control chondrocyte function through the cytoskeleton and cytoskeleton-regulating signaling processes. Such information would generate leverage for advanced articular cartilage repair. Serial passaging, pro-inflammatory cytokine signaling (TNF-α, IL-1α, IL-1β, IL-6, and IL-8), growth factors (TGF-α), and osteoarthritis not only induce dedifferentiation but also converge on RhoA/ROCK/Rac1/mDia1/mDia2/Cdc42 to promote actin polymerization/crosslinking for stress fiber (SF) formation. SF formation takes center stage in phenotype control, as both SF formation and SOX9 phosphorylation for COL2 expression are ROCK activity-dependent. Explaining how it is molecularly possible that dedifferentiation induces low COL2 expression but high SF formation, this review theorized that, in chondrocyte SOX9, phosphorylation by ROCK might effectively be sidelined in favor of other SF-promoting ROCK substrates, based on a differential ROCK affinity. In turn, actin depolymerization for redifferentiation would “free-up” ROCK to increase COL2 expression. Moreover, the actin cytoskeleton regulates COL1 expression, modulates COL2/aggrecan fragment generation, and mediates a fibrogenic/catabolic expression profile, highlighting that actin dynamics-regulating processes decisively control the chondrocyte phenotype. This suggests modulating the balance between actin polymerization/depolymerization for therapeutically controlling the chondrocyte phenotype.

[Rho kinase inhibitors as new local therapy option in primary open angle glaucoma]

BACKGROUND

In 2014 in Japan and 2017 in the USA, the Rho-kinase inhibitors were approved as a new antiglaucomatous substance group and will now be launched in Europe.

OBJECTIVE

On this occasion the current state of knowledge on Rho-kinase inhibitors is presented.

METHODS

In intensive search in PubMed the relevant experimental and clinical literature on the Rho-kinase inhibitors ripasudil and netarsudil and the combination of netarsudil and latanoprost were selected and compiled for this review.

RESULTS

The intraocular pressure lowering efficacy of ripasudil and netarsudil is in the range of the beta blocker timolol and the prostaglandin analogue latanoprost. In the fixed combination netarsudil/latanoprost the intraocular pressure reduction is greater than that of the single components and reaches a target pressure of below 15 mm Hg in 32%. Conjunctival hyperemia with 53-65% is the most common local side effect. Systemic side effects are very rare and so far there are no contraindications.

CONCLUSION

The Rho-kinase inhibitors are an interesting new introduction for glaucoma therapy, as each new pressure-lowering therapy represents an additional chance to reach the individually defined target pressure level in a glaucoma patient with local therapy; however, many of the pleiotropic effects associated with Rho-kinase inhibitors have so far only been found experimentally and will require clinical confirmation in the future.