CLINICAL SCIENCE Descemetorhexis Without Grafting for Fuchs Endothelial Dystrophy—Supplementation With Topical Ripasudil Gregory Moloney, MBBS, BSc (Med), MMed, FRANZCO,*† Constantinos Petsoglou, MBBS, MMed, FRANZCO,*† Matthew Ball, MBBS, FRANZCO,*† Yves Kerdraon, MBBS, BSc (Med), MBiomedE, FRANZCO,*† Roland Höllhumer, MBChB, MMed, FC Ophth (SA),* Natasha Spiteri, MD, FRCOphth,* Simone Beheregaray, MD, PhD,* Judith Hampson, BPharm, MHA,* Mario D’Souza, MSc, PhD,† and Raj N. Devasahayam, BApp Sci*†‡ Purpose: To report the safety and efficacy of descemetorhexis without grafting as a primary intervention in Fuchs dystrophy, and the use of a ROCK inhibitor, ripasudil as a salvage agent in failing cases. Methods: Twelve eyes of 11 patients underwent central descemeto- rhexis not exceeding 4 mm. All had Fuchs dystrophy–producing visual symptoms, requesting intervention. Exclusion criteria were a peripheral endothelial cell count ,1000 and central edema. Corneal clearance and visual parameters were recorded monthly until corneal clearance was observed, then at intervals of 6 months. Cases failing to clear by month 2 were considered for salvage treatment. This consisted of treatment with 1 of 2 formulations of Rho-associated kinase inhibitor eye drops. Endothelial keratoplasty was planned as the final salvage procedure in unsuccessful cases. Results: Nine of 12 eyes cleared spontaneously between 2 and 6 months. One eye failed to clear by month 5 and topical Y-27632 was administered, without success. Endothelial keratoplasty was per- formed. In 2 eyes, healing stalled at 3 and 2 months. In both cases, topical ripasudil administered 6 times a day for 2 weeks resulted in complete corneal clearance. In cases achieving corneal clearance, best spectacle corrected visual acuity improved from a mean of 0.26 to 0.125 (logMAR) with subjective improvement in quality of vision. Conclusions: In Fuchs dystrophy with visual degradation due to central guttae, descemetorhexis without grafting is a viable pro- cedure for visual rehabilitation. Careful patient selection is required, but the advent of topical ripasudil as a salvage agent suggests that a broader application of the surgery may be possible. Further study into the use of this agent is now needed. Key Words: Fuchs dystrophy, Descemetorhexis, ripasudil (Cornea 2017;36:642–648) S urgical management of Fuchs endothelial corneal dystro- phy (FECD) continues to advance at a rapid pace. Transition to lamellar surgery is now evolving into a search for more minimally invasive techniques. Several centers, including our own, have reported success with graftless procedures as a primary intervention. 1–8 This calls into question the need for endothelial transplantation in every case of symptomatic Fuchs dystrophy and invites the possibility of more inventive use of available tissue for transplantation. In addition, medical therapies for the condi- tion are the subject of intense research. Notable among these is the use of topical Rho-associated kinase (ROCK) inhibitors to aid in corneal clearance. 9–16 ROCK is a serine/threonine kinase and an important downstream effector of Rho guanosine triphosphatase, playing a critical role in regulation of contractile tone of smooth muscle tissues. 15 Its inhibition as a potential effector of corneal endothelial healing has been pioneered in recent years by Kinoshita et al. Ripasudil hydrochloride hydrate (Glanatec ophthalmic solution 0.4%, Kowa Co Ltd., Nagoya, Japan) is a topical, selective ROCK 1 and 2 inhibitor, which has recently come to the market in Japan for treatment of glaucoma and ocular hypertension. Its safety in phase III clinical trials for ocular hypertension has been demonstrated, as has its ability to accelerate corneal endothelial healing in rabbit models. No adverse alteration of endothelial cell morphology was reported in phase I human trials. 9,15,16 Its use for acceleration of corneal endothelial healing is currently off label. We recently reported our experience of spontaneous corneal clearance after primary descemetorhexis in Fuchs dystrophy. 1 Clearance was observed by 1 month with improvement in best-corrected vision from 20/40 to 20/20. Subjectively, the patient reported satisfaction with the pro- cedure and resolution of blur and debilitating glare. There have also been recent reports of mixed or poor results illustrating the potential for failure of this technique. 17–19 Received for publication December 30, 2016; revision received February 2, 2017; accepted February 21, 2017. Published online ahead of print April 14, 2017. From the *Discipline of Ophthalmology, Sydney Medical School, The University of Sydney, Sydney, Australia; †Sydney Eye Hospital, Sydney, Australia; and ‡Lions NSW Eye Bank, OTDS (Organ and Tissue Donation Service), Sydney, Australia. The authors have no funding or conflicts of interest to disclose. Reprints: Gregory Moloney, MBBS, BSc (Med), MMed, FRANZCO, Mosman Eye Centre, 1A Effingham St, Mosman, NSW 2088, Australia (e-mail: gregorymoloney@yahoo.com.au). Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. 642 | www.corneajrnl.com Cornea  Volume 36, Number 6, June 2017 Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.