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

Abstract

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.

Keywords: Corneal edema; DMEK; LPI; Netarsudil; Rho-kinase inhibitors.

Fig. 1

A) Superior microcystic and stromal edema extending to the visual axis in the left eye. B) Microcystic edema progressed to stromal edema with Descemet's folds in the left eye as endothelial cell loss continued.

Fig. 2

Specular microscopy showed regular endothelial cells OD with a count of 2151. No cells could be visualized OS due to the corneal edema.

Fig. 3

A) Persistent stromal edema several weeks after successful re-bubbling of the inferior DMEK graft. B) Interval improvement of cornea edema two months after topical netarsudil.