Reticular Epithelial Edema in a Postkeratoplasty Eye Due to Ripasudil.

Abstract

A 34-year-old female underwent phacoemulsification with Descemet stripping endothelial keratoplasty (Supplementary Digital Content, Fig. 1A, B, http://links.lww.com/APJO/ A132) under a failed previous therapeutic penetrating keratoplasty. The visual acuity was restored to 20/50. At 2 years postoperative period, she developed raised intraocular pressure of 30 mm Hg despite being on 2 antiglaucoma medications, and hence ripasudil was initiated as an additional antiglaucoma medication. The endothelial cell density was 920 cells/mm.1Figure 1: Slitlamp image (A) and anterior segment optical coherence tomography (B) illustrating reticular edema in superficial cornea after 4 months of ripasudil use.Her intraocular pressure at 1 month of starting ripasudil was 12 mm Hg. Subsequently, 3 months later, she presented with counting finger vision, honeycomb edema in the superficial cornea (Fig. 1). Ripasudil was discontinued and 1 month later, although the epithelial net-like pattern disappeared, the graft was diffusely edematous and failed to recover the clarity until a follow-up of 3 months (Supplementary Digital Content, Fig. 1C, D, http://links.lww.com/APJO/A132) when repeat endothe-lial keratoplasty was planned. Rho kinase inhibitors have gained popularity in the management of glaucoma and corneal endothelial diseases.2 Ripasudil and netarsudil are Rho kinase inhibitors approved for clinical use. Reticular bullous epithelial edema has been reported with the use of 0.02% netarsudil, which improves in some eyes after the medication is discontinued.1 In our patient, similar pattern of edema was noted with 0.4% ripasudil after 4 months of treatment, which failed to resolve on discontinuing ripasudil. The reticular epithelial edema during ripasudil treatment should be distinguished from graft rejection. The medication should be stopped promptly if cornea edema is noted. The likelihood of nonclearance of edema should be explained to the patients.