Netarsudil-associated epithelial keratopathy

Abstract

Purpose: To report 2 cases with a novel finding of bullous epithelial keratopathy associated with netarsudil use.

Observations: A 72-year-old man with history of primary open angle glaucoma was started on netarsudil daily in both eyes for uncontrolled intraocular pressures despite treatment with latanoprost, brimonidine, and dorzolamide-timolol. One month later he presented with bilateral conjunctival hyperemia, predominantly inferior corneal epithelial bullae, and keratic precipitates without hypopyon. Netarsudil was discontinued, and the patient was started on topical steroids. One week later, the hyperemia and corneal edema had resolved while many small keratic precipitates persisted.A 29-year-old man with history of rubella-associated glaucoma and chronic postoperative inflammation on prednisolone was started on netarsudil in his left eye only for elevated intraocular pressures despite latanoprost, brimonidine, and dorzolamide-timolol. Two months later, he complained of eye pain and decreased vision since starting netarsudil. Examination revealed mild hyperemia and inferior corneal epithelial bullae without keratic precipitates. Netarsudil was discontinued, and two weeks later, conjunctival injection resolved and cornea cleared.

Conclusions and importance: Netarsudil ophthalmic solution 0.02% (Rhopressa) is a rho-kinase inhibitor recently approved for lowering intraocular pressure in open-angle glaucoma or ocular hypertension. As netarsudil continues to be increasingly used, physicians and patients need to be aware of this new possible adverse effect.

Keywords: Drug reaction; Glaucoma; Keratopathy; Netarsudil; Rho-kinase inhibitors.

Fig. 1

Patient 1 (A) External photos 1 month after initiating netarsudil ophthalmic solution 0.02% daily in both eyes show severe bilateral conjunctival hyperemia (B) Slit lamp photographs of the right and left eyes demonstrate predominantly inferior epithelial haze and bullous changes on the corneal epithelium, as well as large keratic precipitates. Trace cells were present in the anterior chamber bilaterally. (C) Slit lamp photographs of the right and left eyes 1 week after netarsudil was stopped and prednisolone acetate was started shows resolution of the bullae, improvement in hyperemia, and decrease in keratic precipitates.

Fig. 2

Patient 2 (A) Slit lamp photographs of the left eye on downgaze and right gaze 2 months after initiating netarsudil ophthalmic solution 0.02% shows mild conjunctival injection, and inferior corneal epithelial haze and bullous changes. (B) Slit lamp photographs 2 weeks after netarsudil was stopped shows resolution of conjunctival injection and corneal haze.