Rho-kinase (ROCK) Inhibitor-Associated Corneal Epithelial Edema

Rho-kinase inhibitor–associated corneal epithelial edema is a temporary swelling of the surface layer (epithelium) of the cornea that appears after using ROCK-inhibitor glaucoma drops such as netarsudil or ripasudil. The swelling makes tiny, clear blisters that line up in a net-like or honeycomb pattern, and this pattern is usually easy to see with a slit-lamp exam. The problem is drug-related and usually reversible when the drop is stopped. PMC+1PubMedAAO

ROCK-inhibitor drops change how cells on the eye’s front surface and in the drainage tissue behave. In some people, the surface corneal cells react strongly, and fluid collects between the epithelial cells, forming many small cysts that look like a honeycomb. This reaction happens more easily in eyes that already have a stressed or previously operated cornea, but it can also happen in otherwise healthy corneas. The exact mechanism is still being studied. EyeWikiPMC

The honeycomb pattern may appear within days to weeks of starting the drop, sometimes as early as 5–7 days. Vision becomes blurred, the eye may feel irritated, and bright lights may bother the eye. In most reports, stopping the ROCK-inhibitor makes the pattern fade over days to a few weeks. EyeWikiPMC

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Types

1. By medication

• Netarsudil-associated reticular epithelial edema. Most published reports use this name when the pattern follows netarsudil. PMCPubMed

• Ripasudil-associated reticular epithelial edema. The same pattern has been seen with ripasudil. PMCLippincott Journals

2. By distribution on the cornea

• Central-dominant (blisters mainly in the visual axis).

• Peripheral-dominant (more obvious in the periphery; sometimes over a graft edge).

• Limbus-to-limbus (diffuse across the cornea). These variations are all reported in case series and images. The National Medical Journal of India

3. By timing

• Acute (days to a couple of weeks after starting the drop).

• Subacute (several weeks after starting or after eye surgery while on the drop). PMCLippincott Journals

4. By clinical setting

• On a previously compromised cornea (e.g., after DSAEK/DMEK/PK, after tube shunt, in Fuchs dystrophy).

• On a clinically “normal” cornea (no obvious prior disease; rarer but reported). PMCThe National Medical Journal of India

5. By age group

• Adult cases (most reports).

• Pediatric cases (rare; described with netarsudil and even congenital glaucoma). ScienceDirectLippincott Journals

6. By severity

• Mild (fine reticular microcysts, minimal symptoms).

• Moderate (clear honeycomb with blur and glare).

• Severe (bullous epithelial edema with marked blur and discomfort). PubMed

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Causes

Each item explains what the cause is and why it matters.

1. Starting netarsudil — The most common trigger; the pattern often shows within days to weeks after beginning therapy. PMC

2. Starting ripasudil — The same pattern has been documented with ripasudil use. PMC

3. Pre-existing corneal edema or decompensation — A swollen cornea is more vulnerable to epithelial cyst formation. EyeWiki

4. Prior corneal transplant (DMEK/DSAEK/PK) — Altered endothelial function and graft-host junctions can predispose to epithelial fluid pockets. PMC

5. Fuchs endothelial corneal dystrophy — Endothelial pump weakness raises the chance of epithelial swelling once the drug is added. The National Medical Journal of India

6. Glaucoma drainage devices or filtering surgery history — Surgical eyes are often more surface-fragile and can show honeycombing.

7. Recent cataract surgery while on netarsudil — Post-operative changes plus the drop have preceded new-onset honeycombing. Lippincott Journals

8. Congenital glaucoma with Haab’s striae — Pediatric corneas with old breaks in Descemet’s membrane may react with reticular edema. Lippincott Journals

9. Uveitis or ocular surface inflammation history — Inflammation may lower the threshold for epithelial fluid accumulation. EyeWiki

10. Older age — Aging endothelium is less resilient, so epithelial edema appears more easily once the drug is started. The National Medical Journal of India

11. Multiple topical medications — Polypharmacy and preservatives can stress the epithelium and amplify the reaction. (Case series frequently note complex regimens alongside ROCK inhibitors.) Lippincott Journals

12. High drop frequency — More frequent dosing can increase epithelial exposure and the chance of cystic change. (Inferred from dose-response experience in case reports.) PMC

13. Compromised tear film — Dry, unstable tears make the epithelium more fragile and prone to blistering patterns once stressed. (Supportive clinical reasoning consistent with case images.) Lippincott Journals

14. Post-laser procedures (e.g., LPI) where netarsudil was used — Honeycomb edema has been reported in the post-procedure period on therapy. ScienceDirect

15. Endothelial disorders beyond Fuchs (ICE syndrome, prior endothelial injury) — Weak pump function increases epithelial fluid pockets after ROCK-I exposure. PMC

16. Recent cyclodestructive procedures — Eyes after cyclophotocoagulation have been listed among at-risk settings in reviews. MDPI

17. Contact lens wear on top of a compromised cornea — Added hypoxia/mechanical stress can worsen epithelial responses to drops. (Clinical inference aligned with surface-stress mechanisms described in reviews.) PMC

18. Epithelial basement membrane changes — Subtle basement membrane irregularities may trap fluid into a reticular pattern under drug influence. (Suggested by confocal/histology figures in case reports.)

19. Prior lamellar interface abnormalities — Edges and interfaces from lamellar surgery can alter local fluid handling and favor localized honeycombing.

20. Idiosyncratic epithelial sensitivity — Some otherwise healthy corneas develop the pattern shortly after starting therapy and clear after stopping, suggesting an individual drug reaction. The National Medical Journal of India

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Symptoms

1. Blurred vision — Vision looks foggy because the surface is swollen and uneven. EyeWiki

2. Halos and glare — Light scatters on the bumpy, blistered surface.

3. Reduced contrast — Fine detail is harder to see because the optical surface is rough.

4. Fluctuating vision — Blur may change through the day as the epithelial fluid shifts.

5. Photophobia — Bright light feels harsh on a stressed corneal surface.

6. Foreign-body sensation — The tiny blisters make the eye feel gritty.

7. Mild pain or soreness — Surface swelling can be uncomfortable, especially with larger bullae. EyeWiki

8. Tearing — The eye waters more due to surface irritation.

9. Redness — Conjunctival vessels can be more visible during the reaction. EyeWiki

10. Worsening with prolonged reading or screen time — Staring lowers blinking and dries the surface, worsening blur.

11. Temporary improvement after lubricants — A wet film can briefly smooth optical quality.

12. More blur in low light — Larger pupils magnify optical scatter from surface irregularity.

13. Contact lens intolerance — The bumpy surface reduces lens comfort.

14. Ghosting or double edges — Multiple reflections form over the blistered grid.

15. Sudden improvement after stopping the drop — Symptoms usually fade as the honeycomb pattern resolves. The National Medical Journal of India

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Diagnostic tests

A. Physical examination 

1. History focused on new glaucoma drops — Asking “When did you start netarsudil or ripasudil?” is critical because timing often links directly to onset. EyeWiki

2. Visual acuity testing — Measures how much vision the surface swelling is reducing.

3. External inspection — Looks for redness, tearing, and lid squeezing that signal irritation.

4. Slit-lamp biomicroscopy — The key exam that shows the reticular or honeycomb epithelial cysts and distinguishes them from uniform microcysts of pressure-related edema. The National Medical Journal of India

5. Dilated fundus exam (when needed) — Ensures the blur is not from a retinal problem.

B. Manual/in-office tests 

1. Tonometry (Goldmann/iCare) — Confirms that intraocular pressure is not elevated; the honeycomb pattern often appears even with normal IOP, which helps separate it from pressure-driven epithelial edema. The National Medical Journal of India
2. Pachymetry — Measures corneal thickness; edema can increase central thickness and track improvement after stopping the drop.
3. Gonioscopy — Reviews the drainage angle if the eye also has glaucoma, guiding overall therapy decisions while the ROCK-I is held.
4. Corneal sensation testing (Cochet-Bonnet) — Checks surface nerve function; reduced sensation can worsen surface healing and comfort.
5. Refraction — Quantifies irregular astigmatism caused by the bumpy epithelium.

C. Lab/pathological tests 

1. Impression cytology — Gently lifts cells from the surface to look for abnormal epithelial changes when the diagnosis is uncertain. (Shown in case figures of honeycomb edema workups.)
2. Corneal scraping with culture/PCR (HSV/adenovirus) when infection is suspected — Rules out viral keratitis that can also blur vision and alter the epithelium.
3. Tear inflammatory markers (e.g., MMP-9) or osmolarity — Helps document surface inflammation that may worsen epithelial fragility.
4. Histopathology of debrided bullae (rarely) — If tissue is removed during care, microscopy can confirm intra-epithelial cystic change. (Reported in honeycomb edema case write-ups.)

D. Electrodiagnostic tests 

1. Visual evoked potential (VEP) — Checks that the optic nerve and brain pathways conduct signals normally if the blur seems disproportionate to corneal findings.
2. ) Electroretinogram (ERG) — Rules out retinal dysfunction when the clinical picture is confusing.
   (These tests are not routine for honeycomb edema; they are safety checks in atypical cases.)

E. Imaging tests 

1. Anterior segment OCT (AS-OCT) — Shows small, bright cystic spaces limited to the epithelium and documents their resolution over time. EyeWiki
2. In vivo confocal microscopy — Gives “cell-level” images of the epithelium and can visualize the cystic pattern directly. (Provided in published case figures.)
3. Specular microscopy — Evaluates endothelial cell health and density, which helps explain why a given eye is more prone to epithelial swelling. PMC
4. Corneal topography/tomography — Maps the surface shape and thickness to quantify irregularity and to follow improvement after the drop is stopped.

Non-pharmacological treatments (therapies & other measures)

These are supportive steps your doctor may use in addition to stopping the ROCK inhibitor. Each item lists its description, purpose, and simple mechanism.

1. Immediate drug holiday (stop the ROCK inhibitor)
   What: Pause netarsudil/ripasudil after your doctor confirms REE.
   Purpose: Remove the trigger.
   How it helps: Once the drop is out of the picture, the corneal surface can re-equilibrate and the honeycomb blisters gradually flatten. This is the core treatment. EyeWiki

2. Switch to alternative glaucoma therapy (non-ROCK)
   What: Replace with other pressure-lowering drops or procedures (see “Drug treatments”).
   Purpose: Keep eye pressure controlled without the offending class.
   How: Uses different pathways (β-blockers, α-agonists, prostaglandin analogs, CAIs, laser) so the epithelium can recover while IOP stays safe. EyeWiki

3. Observation with close follow-up
   What: Frequent slit-lamp checks and photos/OCT.
   Purpose: Ensure edema is resolving and vision is recovering.
   How: REE is typically reversible over weeks; monitoring confirms the trend. EyeWiki

4. Protective glasses and light management
   What: Sunglasses, anti-glare lenses, adjusting screen brightness.
   Purpose: Reduce glare and halos from surface microblisters.
   How: Decreases scatter of light until the epithelium smooths out.

5. Avoid eye rubbing
   Purpose: Prevents mechanical stress that can worsen epithelial microcysts.
   How: Keeps the fragile surface from shearing while it heals.

6. Humidified air and blink hygiene
   Purpose: Improve surface moisture for comfort.
   How: Humidity and conscious blinking stabilize the tear film covering the irregular epithelium.

7. Warm compresses (short, gentle)
   Purpose: Soothe eyelids and improve meibum quality.
   How: A steadier lipid layer reduces tear evaporation over the rough surface.

8. Screen-time breaks (20-20-20 rule)
   Purpose: Reduce evaporative dryness that amplifies blur.
   How: Frequent breaks maintain tear film on a bumpy epithelium.

9. Nighttime eye shield
   Purpose: Prevents inadvertent rubbing during sleep.
   How: Physical barrier while the surface recovers.

10. Temporary activity modification
    Purpose: Pause contact lens wear or dusty/hot environments.
    How: Limits friction and desiccation until the surface smooths.

11. Bandage contact lens (BCL)
    What: A soft, highly oxygen-permeable lens applied in clinic.
    Purpose: Pain relief if bullae are tender; protects healing epithelium.
    How: The lens splints the surface, reducing friction from blinking. (Often paired with prophylactic antibiotic.)

12. Punctal occlusion (temporary plugs)
    Purpose: Keep more tears on the eye for comfort.
    How: Slows drainage so the tear film cushions the irregular epithelium longer.

13. Hypertonic saline as a measure in clinic
    Purpose: Quick test dose to reduce epithelial microcyst fluid for comfort.
    How: Draws water out of the surface layer by osmosis (ongoing use covered under “Drug treatments”). EyeWiki

14. Patient education with “return precautions”
    Purpose: Spot red-flag symptoms (worsening pain, sudden blur) early.
    How: Ensures prompt reassessment if healing stalls.

15. Treat underlying endothelial disease
    Purpose: Fix the root predisposition to surface edema.
    How: Optimizing the “corneal pump” (medical/surgical) removes the tendency for water to collect in epithelium. Lippincott Journals

16. Peri-operative planning in surgical eyes
    Purpose: Avoid or delay ROCK inhibitors right after corneal surgery if possible.
    How: Lowers the chance of surface edema in a freshly operated cornea. PMC

17. Gentle eyelid hygiene
    Purpose: Reduce inflammatory load from blepharitis that can worsen surface symptoms.
    How: Warm water and diluted baby-shampoo/specific lid cleansers keep margins clean.

18. Cold lubricating gel packs (brief)
    Purpose: Relieve irritation in acute phases.
    How: Cooling temporarily reduces nerve hyper-sensitivity.

19. Scleral lens (later, if needed)
    Purpose: For persistent surface irregularity after recovery.
    How: A fluid reservoir under the lens optically smooths the cornea for better vision.

20. Psychological reassurance
    Purpose: Reduce anxiety about the unusual “honeycomb” look.
    How: Emphasize the high likelihood of reversal once the drug is stopped. EyeWiki

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Drug treatments

Important: Medication plans must be individualized by your ophthalmologist. Doses below are common starting points, not prescriptions.

1. Stop the offending ROCK inhibitor (netarsudil/ripasudil)
   Class: ROCK inhibitor (the trigger).
   Dose/Time: Discontinue immediately once REE is diagnosed.
   Purpose: Core treatment; removes the cause.
   Mechanism: Allows epithelial fluid pockets to resolve.
   Side effects: None from stopping; eye pressure must be controlled by alternatives. EyeWiki

2. Sodium chloride 5% hypertonic drops
   Class: Hyperosmotic.
   Dose/Time: 1 drop q.i.d.; can add q2–3h as needed.
   Purpose: Symptom relief; helps microcysts dehydrate.
   Mechanism: Draws water out of the epithelium.
   Side effects: Temporary sting; mild redness. EyeWiki

3. Sodium chloride 5% ointment (night)
   Class: Hyperosmotic ointment.
   Dose/Time: h.s. (bedtime).
   Purpose: Overnight comfort; reduces morning blur.
   Mechanism: Sustained osmotic effect.
   Side effects: Temporary blur after application. EyeWiki

4. Preservative-free lubricating drops (e.g., carboxymethylcellulose, hyaluronate)
   Class: Tear substitutes.
   Dose/Time: q.i.d.–q2h.
   Purpose: Cushion the rough surface, reduce friction.
   Mechanism: Forms a smooth, protective tear film.
   Side effects: Rare allergy/blur.

5. Loteprednol 0.5% (short course, taper)
   Class: Soft topical corticosteroid.
   Dose/Time: q.i.d. × 1–2 weeks, then taper per doctor.
   Purpose: Quieten surface inflammation reported in some cases; speed comfort.
   Mechanism: Down-regulates inflammatory mediators around fragile epithelium.
   Side effects: Possible IOP rise, cataract with prolonged use—thus short course only, with IOP checks. EyeWiki

6. Timolol 0.5%
   Class: β-blocker (IOP-lowering alternative).
   Dose/Time: b.i.d.
   Purpose: Maintain pressure control without ROCK inhibitor.
   Mechanism: Reduces aqueous humor production.
   Side effects: Fatigue, bradycardia, bronchospasm in susceptible patients.

7. Brimonidine 0.2%
   Class: α2-agonist.
   Dose/Time: t.i.d.
   Purpose: Additional IOP control.
   Mechanism: Lowers aqueous production, increases uveoscleral outflow.
   Side effects: Allergy, dry mouth, fatigue.

8. Latanoprost 0.005% (night)
   Class: Prostaglandin analog.
   Dose/Time: q.h.s.
   Purpose: Strong nightly IOP control.
   Mechanism: Increases uveoscleral outflow.
   Side effects: Lash growth, iris darkening; caution if cystoid macular edema risk.

9. Dorzolamide 2%
   Class: Topical carbonic anhydrase inhibitor.
   Dose/Time: t.i.d.
   Purpose: Pressure-lowering substitution or add-on.
   Mechanism: Reduces aqueous production.
   Side effects/caution: Can worsen corneal edema in endothelial failure—use with care and monitoring.

10. Acetazolamide 250 mg oral
    Class: Systemic carbonic anhydrase inhibitor.
    Dose/Time: 250 mg b.i.d.–q.i.d. short term if pressure spikes.
    Purpose: Temporary IOP control while the cornea recovers and the drop regimen is adjusted.
    Mechanism: Systemic reduction of aqueous production.
    Side effects: Tingling, fatigue, kidney stone risk, sulfa allergy caution.

Notes: Short antibiotic prophylaxis (e.g., moxifloxacin 0.5% q.i.d.) may be used only if a bandage contact lens is placed or if there is an epithelial defect—this is not routine for REE itself.

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Dietary molecular supplements

These do not treat REE directly. They can support the tear film and epithelial recovery. Discuss with your clinician, especially if pregnant or on blood thinners.

1. Omega-3 (EPA+DHA 1,000–2,000 mg/day)
   Function: Anti-inflammatory tear-film support; improves meibum quality.
   Mechanism: Resolves surface inflammation and reduces evaporative dryness.

2. Vitamin A (retinol 2,500–5,000 IU/day; avoid excess/pregnancy)
   Function: Epithelial maturation and goblet-cell health.
   Mechanism: Supports mucin production and barrier integrity.

3. Vitamin C (500–1,000 mg/day)
   Function: Collagen cross-linking and antioxidant support.
   Mechanism: Aids stromal/epithelial repair.

4. Vitamin D3 (1,000–2,000 IU/day; tailor to level)
   Function: Immune modulation; dry-eye symptom reduction in deficiency.
   Mechanism: Down-regulates pro-inflammatory cytokines.

5. Zinc (10–25 mg/day, with copper if long-term)
   Function: Co-factor for epithelial enzymes and antioxidant defense.
   Mechanism: Supports DNA repair and keratinization.

6. Lutein (10 mg/day) + Zeaxanthin (2 mg/day)
   Function: Ocular antioxidants; may reduce light sensitivity and oxidative stress.
   Mechanism: Quench free radicals in ocular tissues.

7. N-acetylcysteine (600–1,200 mg/day)
   Function: Mucolytic/antioxidant; helpful in filamentary keratitis and tear-film instability.
   Mechanism: Replenishes glutathione; reduces mucus viscosity.

8. Curcumin (500–1,000 mg/day with piperine)
   Function: Systemic anti-inflammatory support.
   Mechanism: NF-κB pathway modulation.

9. Coenzyme Q10 (100–200 mg/day)
   Function: Mitochondrial support for healing tissues.
   Mechanism: Electron transport/antioxidant role.

10. Hyaluronic acid (120–240 mg/day oral)
    Function: Hydration support that may complement topical hyaluronate drops.
    Mechanism: Binds water; supports extracellular matrix.

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Regenerative/biologic or immune-modulating” therapies

These are for selected cases with persistent surface fragility (e.g., recurrent erosions or neurotrophic tendencies) after the ROCK inhibitor is stopped. Many are off-label for REE; use only under specialist care.

1. Autologous serum tears (20–50%)
   Dose: 1 drop q.i.d.–q2h per protocol.
   Function: Delivers growth factors (EGF, TGF-β, vitamin A).
   Mechanism: Promotes epithelial migration/adhesion on a compromised surface.

2. Platelet-rich plasma (PRP) tears
   Dose: Typically q.i.d.–q6x/day.
   Function: High platelet-derived growth factor content.
   Mechanism: Stimulates epithelial healing and reduces pain.

3. Cenegermin 0.002% (nerve growth factor)
   Dose: q6h (6×/day) for 8 weeks.
   Function: For neurotrophic epithelium; can stabilize a poorly healing surface.
   Mechanism: Regenerates corneal nerves and improves epithelial trophic support.

4. Matrix-regenerating agent (RGTA®, e.g., Cacicol—region-dependent)
   Dose: As per local protocol (often 1 drop every 2–3 days, limited course).
   Function: Rebuilds heparan-sulfate scaffolding for cell adhesion.
   Mechanism: Protects growth factors in the wound micro-environment.

5. Topical cyclosporine A 0.05–0.1%
   Dose: b.i.d.
   Function: Immune modulation for chronic surface inflammation/dryness that delays healing.
   Mechanism: Inhibits T-cell–mediated cytokines; increases goblet cells.

6. Amniotic-membrane–derived drops (where available) or short in-office AMT
   Dose: Drops q.i.d. (region-dependent); AMT: single application (see Surgeries).
   Function: Anti-inflammatory and pro-healing biological matrix.
   Mechanism: Provides heavy-chain hyaluronan/pentraxin 3 complex and growth factors to speed re-epithelialization.

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Procedures/surgeries (when and why)

1. Bandage contact lens (BCL)
   Procedure: In-clinic placement of a high-oxygen soft lens; may add prophylactic antibiotic.
   Why: Pain relief if epithelial bullae are tender; reduces blink friction to help healing.

2. Amniotic membrane transplantation (AMT)
   Procedure: A cryopreserved or dehydrated membrane is placed on the cornea (sutured or device-mounted).
   Why: Biological dressing that reduces inflammation and promotes epithelialization in stubborn defects.

3. Temporary partial tarsorrhaphy
   Procedure: Partially sewing eyelids together at the corner (usually lateral) to reduce exposure; reversible.
   Why: Protects a fragile surface that keeps breaking down.

4. Endothelial keratoplasty (DMEK/DSAEK)
   Procedure: Replaces the failing corneal pump layer with a donor endothelial graft.
   Why: If an underlying endothelial disease is the driver of recurrent surface edema, restoring pump function eliminates the tendency for epithelial fluid pockets. Lippincott Journals

5. Penetrating keratoplasty (PK)
   Procedure: Full-thickness corneal transplant (rarely needed for REE itself).
   Why: Reserved for severe, irreversible corneal disease when vision cannot be restored otherwise.

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Prevention tips

1. Screen for corneal risk (endothelial disease, recent surgery) before starting a ROCK inhibitor. EyeWiki

2. Start cautiously and review within 1–2 weeks of initiation.

3. Educate patients to report new glare, halos, or sudden blur right away.

4. Avoid ROCK inhibitors immediately after corneal surgery when possible, especially in grafted or edematous corneas. PMC

5. Use preservative-free tears alongside any glaucoma regimen that irritates the surface.

6. Control eyelid disease (blepharitis/meibomian dysfunction) to keep the surface calmer.

7. Limit contact lens wear during initiation and any surface complaints.

8. Protect from trauma/UV (sunglasses; no rubbing).

9. Coordinate with the surgeon when pressure control is needed around surgery—choose alternatives first if the cornea is vulnerable.

10. Document baseline corneal status (slit-lamp photos, AS-OCT/specular if indicated) for comparison.

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When to see a doctor urgently

• Sudden blur or halos, especially within days–weeks after starting netarsudil/ripasudil.

• Pain, light sensitivity, or a gritty “bubble” feeling.

• Worsening redness or discharge.

• After corneal or glaucoma surgery if any of the above appear.
  REE often resolves after stopping the drop, but an ophthalmologist must confirm the diagnosis, manage eye pressure safely, and monitor recovery. EyeWiki

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Foods to favor—and to limit

Eat more of:

1. Fatty fish (salmon, sardines) for omega-3s.

2. Leafy greens (spinach, kale) for lutein/zeaxanthin.

3. Citrus & berries for vitamin C.

4. Orange/yellow produce (carrots, sweet potatoes) for vitamin A precursors.

5. Nuts & seeds (walnuts, flax, chia) for healthy fats.

6. Eggs (yolks contain lutein/zeaxanthin).

7. Legumes for zinc and plant protein.

8. Olive oil for anti-inflammatory monounsaturates.

9. Water—steady hydration.

10. Yogurt/kefir—protein and micronutrients that support healing.

Limit/avoid:

1. Excess alcohol (dehydrates and inflames).

2. Smoking (oxidative stress; delays healing).

3. Very salty foods (fluid shifts may worsen morning puffiness).

4. Ultra-processed snacks high in refined oils/sugars.

5. Over-the-counter redness drops with vasoconstrictors (surface rebound).

6. Heavily perfumed aerosols near the face (irritate eyes).

7. Hot, dusty environments without eye protection.

8. Prolonged screen sessions without breaks.

9. Contact lenses during active symptoms.

10. Unsupervised herbal eye drops (unknown preservatives/contaminants).

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FAQs

1. What exactly is “reticular epithelial edema”?
   A rare ROCK-inhibitor side effect where tiny, net-like blisters form in the corneal surface, creating blur and glare. It looks honeycomb-like under the microscope. PubMed

2. Which drops can cause it?
   Mostly netarsudil; ripasudil has also been implicated. Reports suggest it occurs more often and resolves faster with netarsudil than with ripasudil, but both drugs can do it. PMC

3. How soon can it happen?
   As early as 5 days to about 1–2 weeks after starting therapy in some cases. EyeWikiScienceDirect

4. Does it go away?
   Usually yes, after stopping the ROCK inhibitor; many cases improve within weeks. EyeWiki

5. Is my cornea permanently damaged?
   In most reports, no permanent damage once the drop is stopped and the eye heals. Your doctor will confirm recovery. PubMed

6. Why me?
   It’s more likely if your cornea was already stressed (e.g., after surgery or with endothelial disease), though it can occur in otherwise normal corneas. EyeWikiPMC

7. Is it allergic? contagious?
   No—this is a drug effect on corneal fluid balance, not an infection or a classic allergy.

8. Can I restart the ROCK inhibitor later?
   Sometimes a careful re-challenge fails (edema returns). If pressure control is needed, doctors usually choose a different class. Lippincott Journals

9. What does the eye exam show?
   A honeycomb/reticular bullous pattern in the epithelium; AS-OCT can document the microcysts but diagnosis is clinical. EyeWiki

10. Is this related to cornea verticillata?
    Different. Cornea verticillata (whorl-like deposits) is another known netarsudil effect; REE is fluid blisters, not deposits. Dove Medical Press

11. Could this be from endothelial problems?
    Evidence suggests endothelial weakness increases risk, and improving endothelial function can improve REE—even if the ROCK inhibitor continues. Lippincott Journals

12. What else treats it besides stopping the drop?
    Hypertonic saline and short, mild steroids may help symptoms; mainstay is discontinuation and pressure control by alternatives. EyeWiki

13. How common is it?
    It’s uncommon, recognized mainly through case reports and small series since netarsudil entered practice. PubMed+1

14. Can ripasudil also do this?
    Yes—REE has been reported with ripasudil as well, though patterns and frequency may differ. PMC

15. I had a corneal transplant—am I at special risk?
    Yes; post-keratoplasty eyes have multiple reports of REE after netarsudil. Your surgeon will usually avoid this class or watch you very closely. PMC

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

The article is written by Team RxHarun and reviewed by the Rx Editorial Board Members

Last Updated: August 24, 2025.