Punctal Stenosis Associated with Topical Netarsudil Use

Purpose: To report a series of patients who developed punctal stenosis secondary to the use of topical netarsudil 0.02% for treatment of glaucoma. Design: Case series. Participants: Patients using topical netarsudil for management of glaucoma and noted to have punctal stenosis ipsilateral to the eye(s) being treated with netarsudil were included. Methods: Each enrolled patient's chart was reviewed, and alternative causes of punctal stenosis were sought. Photographs were obtained to document punctal stenosis for some patients. Main Outcome Measures: Presence of punctal stenosis after topical netarsudil use and resolution of punctal stenosis after cessation of therapy. Results: Sixteen patients had punctal stenosis; 13 developed unilateral punctal stenosis while using netarsudil unilaterally, and 3 patients developed bilateral punctal stenosis with bilateral use. Time from initiation of netarsudil to recognition of symptoms or documentation of punctal stenosis ranged from 2 to 35 months (median, 12; mean, 14.0 +/- 8.7 months). Thirteen patients endorsed tearing, but 2 had no symptoms. Ectropion was seen in 1 eye. Corneal verticillata was noted in 14 patients (87.5%). In 8 cases, netarsudil was discontinued, and the punctal stenosis was reversed, with resolution of associated symptoms. Conclusions: Netarsudil use can lead to the development of reversible punctal stenosis. This inflammation-mediated stenosis may cause tearing and associated symptoms and may be of sufficient severity to necessitate discontinuation of treatment. In this case series, all patients who discontinued treatment had reversal of their punctal stenosis and associated symptoms. (C) 2022 by the American Academy of Ophthalmology