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Purpose: This case report highlights a possible association between netarsudil use and crystalline keratopathy. Observations: Presented here is the case of a 72-year-old woman with primary open-angle glaucoma (POAG) who developed corneal crystalline keratopathy after taking netarsudil for 24 months. The patient's medical history was significant for dry eye syndrome, bilateral ptosis with surgical repair, and atopy (including asthma and various ocular and systemic allergies). The patient had previously undergone surgical repair for bilateral ptosis as well. During the interval between two routine visits, this patient experienced worsening vision with associated eye irritation. Further examination revealed crystal deposits on the anterior corneal surface in the left eye, the only eye undergoing netarsudil treatment. Conclusions and importance: Long-term netarsudil use may be associated with crystalline keratopathy in the anterior stroma, with the potential to cause sight-threatening vision loss if located in the visual axis.

Purpose: To provide the first report of effective use of bilateral XEN Gel Stent implantation using an ab externo open-conjunctival approach designed to improve bleb function and meet the uniquely low intraocular pressure requirements of a Japanese patient with normal-tension glaucoma refractory to topical medical therapy. Observations: A 54-year-old phakic Japanese woman with severe normal-tension glaucoma on maximally tolerated medical therapy of four topical agents presented with above-goal intraocular pressures and new medication intolerances. She underwent bilateral ab externo open-conjunctival XEN Gel Stent implantation with tenectomy and sub-Tenon's injection of 40μg of mitomycin-C, which resulted in reduction of intraocular pressures by 41.2 and 28.6% to 10 and 10 mmHg in the right and left eyes, respectively at the most recent visit. Postoperatively, a diffuse filtering bleb with good morphology developed in both eyes. The procedure has so far allowed for complete cessation of all four topical medications for up to eight months following surgery without any serious complications. Conclusions: This case illustrates the potential of Xen Gel Stent implantation through an ab externo, open-conjunctival approach to be an effective, simple alternative to trabeculectomy to meet the unique low-pressure requirements of normal-tension glaucoma patients with practical and safety benefits of a micro-invasive approach.