Netarsudil-associated reticular corneal epithelial edema

Abstract

Purpose: To describe 8 cases of reversible reticular corneal epithelial edema of the cornea that developed after use of the topical Rho-kinase inhibitor netarsudil.

Methods: This is a retrospective chart review case series of 8 patients treated with netarsudil at an academic medical center.

Observations: Patients had predisposing corneal conditions including penetrating keratoplasty, corneal decompensation after trabeculectomy-associated endophthalmitis, congenital glaucoma with Haab striae, aphakic bullous keratopathy, history of Ahmed valve and silicone oil, and Fuchs endothelial corneal dystrophy undergoing Descemet stripping only. One patient did not have clear predisposing corneal disease other than low endothelial cell density and a history of trabeculectomy. All patients developed reticular corneal epithelial edema, which appeared as collections of moderate sized superficial epithelial bullae arranged in a reticular pattern resembling a honeycomb. Most developed these changes within weeks of initiating netarsudil, but unique to this series are 2 cases in which netarsudil was tolerated by the cornea for months before developing reticular corneal epithelial edema after diode laser cyclophotocoagulation. In cases which underwent anterior segment optical coherence tomography, the imaging demonstrated that the corneal stroma was not edematous, and the reticular corneal epithelial edema involved both host and donor corneal epithelium in cases of penetrating keratoplasty. This fully resolved in all cases upon cessation of netarsudil, and this series is the first to document resolution via a pattern in which the individual bullae become smaller and more widely spaced apart.

Conclusion: Netarsudil can cause a reversible reticular corneal epithelial edema.

Keywords: Corneal edema; Honeycomb edema; Netarsudil; Reticular edema; Rhopressa.

Fig. 1

Row 1: Slit lamp photographs under diffuse illumination (left) and retroillumination (middle) of reticular corneal epithelial edema in the right eye of the patient in case 1, 16 months after starting netarsudil. One week after stopping netarsudil, the bullae had begun to appear smaller and more widely spaced apart (right). Fig. 1, row 2: Slit lamp photographs under diffuse illumination (left) and cobalt blue light (middle) of reticular corneal epithelial edema in the right eye of the patient in case 2, 6 months after starting netarsudil and 1 day after diode laser cyclophotocoagulation. One week after stopping netarsudil, the bullae had nearly completely resolved (right). Fig. 1, row 3: Slit lamp photographs under diffuse illumination (left) and cobalt blue light (middle) of reticular corneal epithelial edema in the left eye of the patient in case 3, 2 months after starting netarsudil. Two months after stopping netarsudil, the bullae had nearly completely resolved (right). Fig. 1, row 4: Anterior segment optical coherence tomography (left) demonstrates superficial epithelial edema in the right eye of the patient in case 4, following 6 months of netarsudil treatment. Slit lamp photograph (right) shows near resolution of the corneal edema, 1 week after stopping netarsudil. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

Fig. 2

Top: Slit lamp photographs under diffuse illumination (top left) and cobalt blue light (top right) of reticular corneal epithelial edema in the right eye of the patient in case 5, 3 months after starting netarsudil. Anterior segment optical coherence tomography (row 2) demonstrates superficial epithelial edema in both host and donor cornea. Fig. 2, bottom left: Slit lamp photograph of reticular corneal epithelial edema in the left eye of the patient in case 6, 1 month after starting netarsudil. Fig. 2, bottom right: Slit lamp photographs under diffuse illumination (top) and retroillumination (bottom) of reticularcorneal epithelial edema in the left eye of the patient in case 7, one day after combined diode laser cyclophotocoagulation, explant of Ahmed valve, and silicone oil granuloma excision. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

Fig. 3

Slit lamp photographs under diffuse illumination of the cornea in the left eye of the patient in case 8. One day after Descemet stripping only (DSO) and before starting netarsudil, Descemet folds were present without reticular corneal epithelial edema (top). One week after DSO and three days after starting netarsudil, reticular corneal epithelial edema developed (middle). One month after DSO, the bullae became smaller and more widely spaced apart (bottom).