Netarsudil-Induced Corneal Flattening in a Child with Secondary Open-Angle Glaucoma

We report a case of a child with secondary open-angle glaucoma who developed 6.5 diopters (D) of corneal flattening upon the addition of Rhopressa (0.02% netarsudil dimesylate solution) eye drops to a preexisting treatment regimen of timolol and latanoprost. This change in corneal power reversed after netarsudil, a rho-kinase inhibitor, was discontinued and replaced with Vyzulta (0.024% latanoprostene bunod ophthalmic solution). The 4-year-old female patient presented with bilateral secondary open-angle glaucoma from Paired Box 6 (PAX6)-related aniridia, aphakia, and persistent fetal vasculature. She was started on netarsudil to treat elevated intraocular pressure (IOP) in her right eye, which was not adequately controlled by latanoprost and timolol. Over 4 months, she developed 6.5D of corneal flattening in her right eye. Netarsudil was stopped and the corneal flattening reversed. There is evidence to support the ability of rho kinase inhibitors to increase the healing of the corneal endothelium in addition to their intended IOP-lowering effects. Rho kinase inhibitors may increase cell proliferation and adhesion within the corneal endothelium, hence decreasing apoptosis and promoting cell preservation. If there was an excess of cell proliferation; however, this might induce stromal cells to abnormally secrete enzymes or proteins, such as TGFβ-induced proteins. This could result in corneal fibrosis, thereby flattening the cornea. Further investigation is required to explore this phenomenon and elucidate its mechanism of action. Corneal flattening may be considered as a potential side effect of the use of netarsudil, particularly in young pediatric patients.