Topical Rho kinase inhibitor (Ripasudil) rescue in failing corneal grafts: A case series on a novel application of topical ROCK inhibitors

This retrospective case series analyzed the medical records of five patients who presented with nonresolving corneal edema due to failing corneal grafts post corneal graft rejections. Three patients were post penetrating keratoplasty (PK), and two patients were post endothelial keratoplasty. All the patients presented with graft rejection within an average of 6–12 months of initial transplant and had no associated ocular comorbidities. There was no improvement after receiving the standard of care treatment consisting of oral and topical steroids, and the patients developed persistent corneal graft edema. These patients were being considered for a repeat keratoplasty procedure. Topical Ripasudil (ROCK Inhibitor) 0.4% four times a day was started for all these patients in the interim period, while they continued on maintenance topical corticosteroids, as an academic endeavor to assess its possible efficacy in reducing corneal edema. The primary outcome measure was improvement in graft clarity. The secondary outcome measures were improvement in uncorrected visual acuity and reduction of corneal edema as measured by the central corneal thickness. All five patients showed reduction in corneal edema, graft clearing, and an improvement in visual acuity preventing the need of regrafts over 3 months after initiation of topical Ripasudil. We acknowledge that specular microscopy could not be performed due to poor baseline clarity, and this limits objective assessment of endothelial changes. Therefore, these findings may be interpreted as preliminary and hypothesis-generating. The regenerative action of ROCK inhibitors on corneal endothelium may have a role in the management of graft rejections. The peripheral endothelial cell reservoir in these patients could have a potential in clearing chronic edema due to graft rejections.