Ripasudil-induced Edema in Grafted Eyes, Differentials, and Its Variance from Netarsudil-induced Edema

To describe characteristics, clinical course, and outcome of reticular epithelial corneal edema (RECE) occurring as an adverse effect of novel rho-kinase inhibitor (ROCK-I) ripasudil in eyes with corneal grafts. Retrospective case series at a tertiary eye care center of patients developing a distinctive pattern of RECE seen clinically and on anterior segment optical coherence tomography after initiation of novel topical ripasudil (0.4%). Three grafted eyes of three patients who were started postoperatively on topical ripasudil for intraocular pressure control developed a characteristic RECE. All patients were started on ROCK-I between June 2024 and August 2024. Vision was not affected in these patients. In the first patient, bullae spared the visual axis; the second patient’s affected eye was preexisting poor seeing with glaucomatous cupping, and the third patient had a failed opaque graft. In all patients, ROCK-I was stopped, and the bullae resolved completely. ROCK-induced reticular edema occurs more frequently than previously thought. RECE after ROCK-I occurs with the use of ripasudil as well as netarsudil. Although bullae are reversible on discontinuing ROCK-Is, cautious use is warranted in patients with preexisting corneal edema and endothelial decompensation. Large-scale studies are required to know the exact incidence and pathophysiology of the mentioned side effect.