Two pediatric cases of reticular corneal epithelial edema associated with netarsudil

Topical Netarsudil in Childhood Glaucoma: A Systematic Review

PURPOSE

To evaluate the effectiveness and safety of topical netarsudil 0.02% in managing childhood glaucoma.

METHODS

A literature search in the electronic databases of PubMed CENTRAL, Google Scholar, EMBASE, the Register of Controlled Trials, and Ovid MEDLINE from January 2017 to August 2023 using one or a combination of the following terms: "netarsudil," "rhopressa," "Rho-kinase," "pediatric glaucoma," "childhood glaucoma," "intraocular pressure" was conducted.

RESULTS

Eight publications (four retrospective studies, one prospective study, and three case reports) were identified evaluating the outcomes of topical netarsudil in childhood glaucoma. Six publications were conducted in the United States, and two publications were conducted in India. Studies included a heterogeneous cohort of primary and secondary childhood glaucoma with a variable range of follow-up (1 week-26 months). The mean IOP reduction after the initiation of topical netarsudil 0.02% in childhood glaucoma patients varies from 0.8 ± 13.2 to 12.0 ± 0.0 mmHg. The most common ocular adverse event was conjunctival hyperemia, seen in 27 out of 82 eyes (32.9%), followed by corneal honeycombing/reticular epithelial edema, seen in 13 out of 82 eyes (15.9%).

CONCLUSION

Limited literature is currently available on using topical netarsudil in childhood glaucoma. However, in children with refractory glaucoma on maximum topical medications, netarsudil may serve as an adjunctive treatment option, potentially delaying the need for further surgical interventions in some patients. Careful corneal examination is needed before and after initiation of netarsudil treatment for early detection of corneal adverse events that may compromise the vision.

Drug- and Cell-Type-Specific Effects of ROCK Inhibitors as a Potential Cause of Reticular Corneal Epithelial Edema

Rho-associated kinase (ROCK) inhibitors have gained popularity as novel treatment options in the management of glaucoma and corneal endothelial disorders. Among the various ocular side effects, reticular corneal epithelial edema has been most frequently reported, mainly after treatment with netarsudil. To explain the potential mechanisms, we comparatively analyzed the effects of ripasudil and netarsudil on corneal endothelial and epithelial function in vitro. Primary human corneal endothelial and epithelial cells were incubated with netarsudil dihydrochloride and ripasudil hydrochloride dihydrate for up to 7 days. Gene and protein expression analyses were performed by real-time PCR and immunocytochemistry. Functional assays assessed the cell migration, proliferation, viability, Na+/K+-ATPase activity, transcellular electrical resistance, and FITC-dextran permeability. Reticular bullous corneal epithelial edema was observed in a patient following netarsudil 0.02%/latanoprost 0.005% ophthalmic solution (Roclanda®) for elevated intraocular pressure. In the subsequent laboratory analyses, both netarsudil and ripasudil were found to improve the corneal endothelial pump and barrier function, but they showed differential effects on corneal epithelial cells. Whereas ripasudil improved the epithelial barrier function by upregulating major components of the tight and adherens junctions and reducing paracellular permeability, netarsudil had no or even adverse effects on the epithelial barrier properties by downregulating the expression levels of cell-junction-associated genes. The expression changes normalized after discontinuation of ROCK inhibitors. The findings support the concept that ROCK inhibitors can act as a double-edged sword by having beneficial effects on corneal endothelial cells and adverse effects on epithelial cells.

Ocular effects of Rho kinase (ROCK) inhibition: a systematic review

Topical therapies targeting Rho-associated protein kinase (ROCK) signalling, including netarsudil (Rhopressa®) and ripasudil (Glanatec®), have become widely adopted as part of standard clinical practice to lower intraocular pressure (IOP) in patients with ocular hypertension or glaucoma. Given the pleiotropic roles of ROCK signalling, ROCK inhibition has the potential to cause unintended ocular side effects beyond IOP lowering in other substructures of the eye, both beneficial and deleterious. Additional experience and observation of patients treated with this class of medications have uncovered both new side effects not reported in the initial clinical trials, as well as potential benefits that have inspired off-label uses and that have been the topic of numerous clinical studies, case series, case reports, and translational studies. Here, we performed a comprehensive systematic review and identified 170 studies describing ocular effects of ROCK inhibition. In addition to describing well-established ocular effects associated with inhibition of ROCK signalling, such as conjunctival hyperaemia, corneal verticillata, and reticular corneal epithelial oedema, we also highlight other effects, such as corneal haemorrhages, changes in corneal contour, anterior subcapsular opacities, contact dermatitis, punctal stenosis, and eyelid wound dehiscence, which have been described in case series and case reports. Finally, we evaluated studies describing potential novel applications of ROCK inhibition for treating disorders affecting the cornea, the retina, and the optic nerve, finding strong evidence in support of a beneficial effect of ROCK inhibitors on corneal oedema due to corneal endothelial cell dysfunction. The other potential applications require further research.

ROCK Inhibitors in Corneal Diseases and Glaucoma-A Comprehensive Review of These Emerging Drugs

Rho kinase (ROCK) inhibitors have gained significant attention as emerging novel treatment options in the field of ophthalmology in recent years. The evidence supporting their efficacy in glaucoma and corneal pathology includes both in vitro and clinical studies. Among the available options, ripasudil and netarsudil have emerged as the leading ROCK inhibitors, and some countries have approved these therapeutic options as treatments for glaucoma. Various dosing regimens have been studied, including monotherapy and combination therapy, especially for patients with secondary glaucoma who are already on multiple medications. Another rising application of ROCK inhibitors includes their use as an adjunct in surgical procedures such as Descemetorhexis Without Endothelial Keratoplasty (DWEK), Descemet Stripping Only (DSO) to accelerate visual recovery, glaucoma surgeries to reduce scarring process and allow better intraocular pressure (IOP) control, or after complicated anterior segment surgery to treat corneal oedema. This article provides a comprehensive overview of the existing literature in the field, offering recommendations for prescribing ROCK inhibitors and also discussing patient selection, drug efficacy, and possible adverse effects.