Netarsudil-Associated Reticular Corneal Epithelial Edema

To document a rare adverse effect of Netarsudil 0.02%, a Rho-associated kinase (ROCK) inhibitor, in a patient undergoing topical treatment for corneal edema due to Fuchs endothelial corneal dystrophy (FECD).

This case report underscores the importance of monitoring for potential side effects of ROCK inhibitors and provides insight into their role in the medical management of endothelial dysfunction.

Eye Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE. 

A 62-year-old woman was referred for worsening vision in her left eye. On presentation, best-corrected visual acuity (BCVA) was 20/30 in the right eye and 20/400 in the left eye. Intraocular pressure (IOP) measured 16 mmHg in the right eye and 18 mmHg in the left eye. Slit-lamp examination revealed 1+ guttae with a clear cornea in the right eye, while the left eye showed 2+ guttae, microcytic edema, and 2+ Descemet’s folds. Additionally, 1+ nuclear sclerosis was present in both eyes. Specular microscopy revealed confluent guttae with polymegathism and pleomorphism in both eyes. The patient has diabetes but showed no signs of diabetic retinopathy in either eye. Based on evidence suggesting its potential to promote corneal endothelial cell regeneration in patients with FECD, Netarsudil 0.02% was initiated in the left eye once daily at bedtime. After two weeks of treatment, corneal edema significantly decreased, and BCVA improved to 20/30. The condition remained stable for two months, but the patient later presented with significant vision deterioration (BCVA 20/400) due to the development of reticular corneal epithelial edema with a honeycombed pattern. As a result, Netarsudil was discontinued, and the patient was advised to follow up closely.

ROCK inhibitors, such as Netarsudil, provide a promising non-surgical option for treating corneal edema by promoting endothelial cell regeneration, reducing edema, and potentially delaying the need for corneal transplantation. Research indicates that Netarsudil can effectively reduce corneal edema and enhance BCVA, leading to improved visual function and overall quality of life. While generally well tolerated, common side effects include conjunctival hyperemia, corneal verticillata, and conjunctival hemorrhage. A rare but notable side effect is reticular corneal epithelial edema, which may temporarily worsen vision. Further research is needed to identify at-risk patients and understand the underlying mechanisms of this adverse effect.