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Last Month’s Blink

Netarsudil-Associated Reticular Bullous Epithelial Edema

Written by Arash M. Davanian, DO, Glaucoma Center of Texas, Dallas, and Eric Brown, MD, PhD, Vanderbilt Eye Institute, Nashville, Tenn. Photo by Garvin Munn, Vanderbilt Eye Institute.

An 86-year-old woman with primary open-angle glaucoma presented to the clinic for an IOP check. She had presented one month earlier for decreased VA from 20/30 to 20/200 and was found to have microcystic corneal edema and IOP of 33 mm Hg in the left eye for which she was started on netarsudil .02% drops.

At the one-month follow-up, IOP in her left eye had improved to 26 mm Hg and VA was stable at 20/200. On exam of the left eye, she was found to have 1+ conjunctival injection and reticular bullous epithelial edema inferiorly consistent with netarsudil use (Fig. 2). The fellow eye did not have corneal edema (Fig. 1), and VA was unchanged at 20/200 secondary to advanced age-related mac­ular degeneration. Netarsudil was stopped, and the patient was placed on pilocarpine instead. On six-week follow-up, her edema had resolved and her IOP was 15 mm Hg in the left eye.

Reticular bullous epithelial edema and con­junctival hyperemia have been described in patients using netarsudil, a Rho kinase inhibitor.¹ Reticular bullous epithelial edema has been seen in those who have a history of corneal edema, as in our patient. The epithelial bullae typically disappear within four to six weeks of stopping the drop.² Unlike the other characteristic signs of netarsudil use, such as cornea verticillata or conjunctival hyperemia, this adverse effect is often visually significant.^2,3

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1 Rao VP, Epstein DL. BioDrugs. 2007;21(3):167-177.

2 Tran JA et al. Am J Ophthalmol Case Rep. 2022;25:101287.

3 Wisely CE et al. Am J Ophthalmol. 2020;217:20-26.

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