Ripasudil’s paradox: bullous keratopathy with honeycomb twist

We present a case of a male patient in his mid-50s who presented with bullous keratopathy secondary to an anterior chamber intraocular lens, complicated by superimposed honeycomb keratopathy while on ripasudil 0.4%. The bullous keratopathy was characterised by generalised microcystic epithelial oedema, alongside more centrally located, variable-sized macrocystic epithelial oedema with a honeycomb appearance. Discontinuation of ripasudil resulted in the resolution of the honeycomb keratopathy, although with the persistence of pre-existing microcystic corneal oedema. This case highlights the complexity of ripasudil's effects on corneal endothelium, showing a paradoxical response. Timely identification of ripasudil-induced keratopathy is crucial, particularly in cases when it is started elsewhere, emphasising the necessity for vigilant monitoring and management strategies.