SUCCESSFUL TREATMENT OF CHRONIC PSEUDOPHAKIC BULLOUS KERATOPATHY WITH FOCAL CORNEAL OEDEMA USING ROCLANDA (LATANOPROST/NETARSUDIL) ONCE DAILY, AVOIDING ENDOTHELIAL KERATOPLASTY

To present a case of chronic pseudophakic bullous keratopathy with focal corneal oedema that responded well to once-daily Roclanda (a combination of latanoprost and the Rho Kinase Inhibitor (RKI) netarsudil), thereby avoiding the need for endothelial keratoplasty.

Keywords: corneal oedema, bullous keratopathy, pseudophakia, Rho kinase inhibitor.

James Paget University Hospital NHS Foundation Trust, United Kingdom.

A 60-year-old Caucasian male presented in July 2023 with a several-month history of discomfort and grittiness in the right eye (RE), which had worsened in recent weeks. His surgical history included RE pseudophakia, Fuchs heterochromic iridocyclitis (quiescent), Bell’s palsy, floaterectomy, partial macular-off retinal detachment repair, laser capsulotomy, and equivocal optic neuritis.

Visual acuity (VA) in the RE was 6/30 unaided, improving to 6/9.5 with pinhole. Right conjunctival injection and inferior punctate epithelial erosions (PEEs) were observed, and the patient was initially managed with lubricants for possible exposure keratopathy secondary to Bell’s palsy. By August 2023, his VA was 6/24 unaided, improving to 6/9.5 with pinhole, and he was treated with hypertonic saline for endothelial attrition and inferior corneal oedema with microbullae.

In April 2024, he was diagnosed with pseudophakic bullous keratopathy with focal corneal oedema in the RE, though his VA was 6/6 with glasses. Given his excellent vision, he was advised to continue hypertonic saline and lubricants rather than undergo endothelial keratoplasty.

By September 2024, he presented with acute worsening of RE pain and tearing; VA was 6/30 unaided, improving to 6/15 with pinhole, with findings of mild conjunctival congestion, stromal oedema, and bullae. A bandage contact lens was applied, and previous treatments were continued.

Several days later, worsening corneal oedema with involvement of the visual axis was noted. Roclanda (latanoprost/netarsudil) eye drops, administered once daily, were initiated to attempt to improve endothelial function, avoiding keratoplasty, along with levofloxacin drops.

Within a month, the patient demonstrated a good response to the Rho kinase inhibitor, with a reduction in corneal oedema and improved visual acuity. His VA was 6/7.5 with glasses and 6/6 with pinhole. The characteristic “ROCKopathy” appearance developed in his right cornea but has remained stable. The mechanism of improvement may be due to healthy endothelial cell migration promoted by Rho kinase inhibition.

Once-daily RKI treatment with Roclanda can effectively reduce corneal oedema and improve visual outcomes in chronic pseudophakic bullous keratopathy with focal oedema, potentially avoiding the need for endothelial keratoplasty. The development of stable “ROCKopathy” appears to be a manageable side effect.