This study prospectively evaluated the use of ripasudil, a rho kinase inhibitor, in patients undergoing Descemet’s stripping only (DSO) without an endothelial graft for Fuch’s endothelial dystrophy (FED). Patients with dense central guttae limited to the central 5mm of the cornea and central corneal stromal oedema were included in the study. Patients were required to have a clear peripheral cornea with an endothelial cell density (ECD) of greater than 1000 cells/mm2. Patients underwent DSO with or without cataract surgery. They were categorised into group 1, who received ripasudil postoperatively, and group 2 who did not. The primary end points were change in corneal thickness, ECD and the number of weeks after surgery for vision to improve to 20/40 or greater between the two groups. Group 1 patients were assigned to topical ripasudil 0.4% four times a day for two months. All patients were followed up monthly for the first six months and then at nine and 12 months after surgery. ECD and pachymetry were evaluated at each postoperative visit. All patients used sodium chloride 5% ointment at bedtime for the first two months after surgery. Eighteen eyes of 18 patients were enrolled, with 10 patients assigned to the no ripasudil (observation) group and eight patients assigned to the ripasudil group after DSO. Patients who underwent DSO with ripasudil recovered vision more quickly (4.6 vs. 6.5 weeks, p<0.01). In addition, the ripasudil group had a statistically significantly higher average ECD at three, six and 12 months. The patients in the DSO observation group had a 10% decrease in peripheral ECD when comparing counts before surgery with counts 12 months after surgery (p<0.05). In the DSO ripasudil group, there was no significant difference between peripheral ECD at preoperative baseline versus 12 months after surgery. The lack of decrease in the peripheral ECD in this group may support the concept of endothelial cell proliferation, as opposed to endothelial cell migration in the DSO group. The authors suggest that DSO with ripasudil should be considered for early disease while reserving Descemet membrane endothelial keratoplasty (DMEK) for more advanced disease states. They recommend more trials to identify the correct dosage and duration of treatment with ripasudil as it will be a cheaper less complex alternative to endothelial keratoplasty with no risk of graft rejection.