Addressing Glaucoma and Corneal Disease: A Comprehensive Review of Rho Kinase (ROCK) Inhibitors


Glaucoma and corneal diseases pose significant challenges in the field of ophthalmology, often requiring medical therapy as the primary mode of treatment. These conditions affect millions of individuals worldwide, and effective management is crucial to prevent vision loss and maintain eye health.

One of the primary concerns in glaucoma management is the prevalence of polypharmacy, where patients often require multiple medications to control intraocular pressure (IOP).

Additionally, many of the current medications have systemic side effects, and there is a growing recognition that intensifying medical therapy may have diminishing returns while increasing clinical and economic burdens. This has led to an ongoing need for innovative and more efficient treatment approaches.

In recent years, Rho kinase (ROCK) inhibitors have emerged as a promising therapeutic option for both glaucoma and corneal diseases.

These inhibitors have gained significant attention for their potential to address the limitations of existing treatments and open new avenues for patient care. The ROCK signaling cascade is a ubiquitous pathway in the human body, regulating various cellular processes, including replication, proliferation, and apoptosis.

In the eye, ROCK plays a vital role in regulating the physiological properties of the trabecular meshwork and corneal endothelium, making it a potential therapeutic target.

This comprehensive review explores the current state of knowledge on ROCK inhibitors, focusing on the two FDA-approved molecules, ripasudil and netarsudil. It aims to provide evidence-based recommendations for prescribing these drugs, including insights into patient selection, efficacy, and potential adverse effects.

Understanding the Role of ROCK Inhibitors

The Rho kinase (ROCK) signaling cascade is involved in the regulation of cellular functions and has widespread implications in health and disease. In the eye, ROCK plays a critical role in maintaining the balance of aqueous humor outflow and controlling corneal endothelial cell function.

For glaucoma management, ROCK inhibitors offer a novel approach to modulate the trabecular meshwork, potentially reducing intraocular pressure. In addition to their potential benefits in glaucoma, ROCK inhibitors have shown promise in the treatment of corneal endothelial diseases by promoting corneal endothelial cell regeneration and functional recovery.

Laboratory studies have indicated that these inhibitors enhance cellular attachment and proliferation of cultured endothelial cells, improve wound healing on ex vivo corneas, and facilitate cell cycle progression from the G1 to S phase. By inhibiting actinomyosin contraction through the inhibition of the Rho kinase signaling cascade, ROCK inhibitors serve a niche in current anterior segment surgeries and novel techniques like Descemetorhexis Without Endothelial Keratoplasty (DWEK).

FDA-Approved ROCK Inhibitors

Three commercially available ROCK inhibitors have gained attention in the ophthalmological community: ripasudil (Glanatec®), netarsudil (Rhopressa®), and fasudil.

Ripasudil has been used in Japan for the treatment of ocular hypertension and glaucoma since September 2014 and has more recently gained approval for use in the United Kingdom.

Netarsudil, on the other hand, has been employed for glaucoma treatment in the United States since late 2017 and received approval for use in Europe in November 2021.

Fasudil, although not initially developed for ophthalmological purposes, was first approved in Japan in 1995 for the treatment of cerebral vasospasms caused by subarachnoid hemorrhage and is now utilized in ophthalmology for the treatment of diabetic macular edema (DME).

Beyond these approved drugs, there are two additional ROCK inhibitors in various stages of development. SNJ-1656 is currently in phase II trials for controlling intraocular pressure (IOP), while Y-27632 is in a pre-clinical phase for use in corneal endothelial diseases. These ongoing research and development efforts signify the expanding interest in the therapeutic potential of ROCK inhibitors.

Acceptance and Utilization

Despite the promise of ROCK inhibitors in ophthalmology, there are variable levels of acceptance among healthcare professionals worldwide, and these drugs are still far from being routinely used in ophthalmological practice. This reluctance may stem from a variety of factors, including concerns about safety, efficacy, and the need for further clinical data to establish the full scope of their potential applications.

Evidence-Based Recommendations

To better understand the potential benefits and safety of ROCK inhibitors for both approved and off-label uses, it is essential to evaluate the existing literature and provide evidence-based recommendations for their prescription.

Patient Selection:

  • Glaucoma Patients: Consider using ROCK inhibitors as a primary or adjunctive therapy in glaucoma management, especially in patients with suboptimal IOP control on traditional medications.
  • Corneal Disease Patients: Assess the potential benefits of ROCK inhibitors in corneal endothelial diseases, particularly for patients with compromised corneal endothelium function.


  • Glaucoma Management: Evaluate the efficacy of ROCK inhibitors in lowering IOP and their potential to reduce the need for multiple medications in patients with glaucoma. Consider their role in preventing disease progression.
  • Corneal Endothelial Disease: Explore the ability of ROCK inhibitors to promote corneal endothelial cell regeneration and functional recovery, potentially reducing the need for invasive surgical procedures.

Adverse Effects:

  • Systemic Side Effects: Be aware of potential systemic side effects associated with ROCK inhibitors, such as ocular hyperemia and conjunctival hemorrhage, and discuss these risks with patients.
  • Patient Monitoring: Implement regular patient monitoring to detect adverse effects and assess the overall response to treatment.

Future Directions:

  • Clinical Trials: Encourage and participate in ongoing clinical trials to expand the evidence base for the safety and efficacy of ROCK inhibitors in various ophthalmological conditions.
  • Education and Training: Promote education and training within the ophthalmological community to increase awareness and familiarity with ROCK inhibitors.


Rho kinase (ROCK) inhibitors represent a promising and evolving therapeutic option for addressing glaucoma and corneal diseases. While these drugs have shown significant potential, there is still room for further research and clinical data to establish their safety and efficacy definitively. As the utilization of ROCK inhibitors continues to grow among ophthalmologists globally, a comprehensive understanding of their potential benefits and risks is crucial.

This review has aimed to provide an evidence-based foundation for the prescription of ROCK inhibitors, discussing patient selection, efficacy, and adverse effects, with a particular focus on FDA-approved molecules, ripasudil and netarsudil. It is through continued research, clinical trials, and the collective efforts of the ophthalmological community that these innovative treatments will find their place in routine practice, ultimately improving the lives of patients with glaucoma and corneal diseases.

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