Synthetic scleral reinforcement materials: I. Development and in vivo tissue biocompatibility response

Evaluation of new robust silk fibroin hydrogels for posterior scleral reinforcement in rabbits

Background: Currently, there is no ideal material available for posterior scleral reinforcement (PSR) to prevent the progression of high myopia. In this study, we investigated robust regenerated silk fibroin (RSF) hydrogels as potential grafts for PSR in animal experiments to evaluate their safety and biological reactions. Methods: PSR surgery was performed on the right eye of twenty-eight adult New Zealand white rabbits, with the left eye serving as a self-control. Ten rabbits were observed for 3 months, while 18 rabbits were observed for 6 months. The rabbits were evaluated using intraocular pressure (IOP), anterior segment and fundus photography, A- and B-ultrasound, optical coherence tomography (OCT), histology, and biomechanical tests. Results: No complications such as significant IOP fluctuation, anterior chamber inflammation, vitreous opacity, retinal lesion, infection, or material exposure were observed. Furthermore, no evidence of pathological changes in the optic nerve and retina, or structural abnormalities on OCT, were found. The RSF grafts were appropriately located at the posterior sclera and enclosed in fibrous capsules. The scleral thickness and collagen fiber content of the treated eyes increased after surgery. The ultimate stress of the reinforced sclera increased by 30.7%, and the elastic modulus increased by 33.0% compared to those of the control eyes at 6 months after surgery. Conclusion: Robust RSF hydrogels exhibited good biocompatibility and promoted the formation of fibrous capsules at the posterior sclera in vivo. The biomechanical properties of the reinforced sclera were strengthened. These findings suggest that RSF hydrogel is a potential material for PSR.

Intrascleral outflow after deep sclerectomy with absorbable and non-absorbable implants in the rabbit eye

BACKGROUND

The purpose of the study is an analysis of intrascleral drainage vessels formed in rabbits' eyes after non-penetrating deep sclerectomy (NPDS) with absorbable and non-absorbable implants, and comparison to eyes in which surgery was performed without implanted material.

MATERIAL/METHODS

NPDS was carried out in 12 rabbits, with implantation of non-absorbable methacrylic hydrogel (N=10 eyes) or absorbable cross-linked sodium hyaluronate (N=6 eyes), or without any implant (N=8 eyes). All the animals were euthanized 1 year after surgery. Twenty-one eyeballs were prepared for light microscopy and 3 were prepared for transmission electron microscope (TEM) analysis. Aqueous humour pathways were stained with ferritin in 6 eyeballs.

RESULTS

By light microscopy, small vessels adjacent to the areas of scarring were the most common abnormality. Vessel density was significantly higher in operated sclera compared to normal, healthy tissue, regardless of the type of implant used. The average vessel densities were 2.18±1.48 vessels/mm2 in non-implanted sclera, 2.34±1.69 vessels/mm2 in eyes with absorbable implants, and 3.64±1.78 vessels/mm2 in eyes with non-absorbable implants. Analysis of iron distribution in ferritin-injected eyes showed a positive reaction inside new aqueous draining vessels in all groups. TEM analysis showed that the ultrastructure of new vessels matched the features of the small veins.

CONCLUSIONS

Aqueous outflow after NPDS can be achieved through the newly formed network of small intrascleral veins. Use of non-absorbable implants significantly increases vessel density in the sclera adjacent to implanted material compared to eyes in which absorbable implants or no implants were used.

A NiTi alloy-based cuff for external banding valvuloplasty: a six-week follow-up study in pigs

OBJECTIVE

The study aimed to test a Nitinol(®)-based vein cuff model for external banding valvuloplasty.

METHOD

In 12 adult minipigs, the vena jugularis externa was covered for 42 days by a cuff with an inner diameter adapted to the outer vein diameter in supine position. By changing from supine into prone position hypostatically vein dilation was induced to simulate varicose vein dilation. Cuff position and the inner diameter of the vein lumen under the cuff were examined by computer tomography scanning. Also, histological analysis of the vein wall within the cuff was performed.

RESULTS

The preset tubular shape of the cuff and the cuff position did not change in both prone and supine position, but due to fibrosis the luminal vein diameter within the cuff was decreased (P < 0.01) already after 21 days.

CONCLUSION

A foreign body response resulted in a fibrous capsule covering the cuff which might limit cuff functionality.

Development, characterization, and validation of porous carbonated hydroxyapatite bone cement

Carbonated hydroxyapatite (CHA) bone cement is capable of self-setting and forming structures similar to mineralized bone. Conventional CHA leaves little room for new bone formation and delays remodeling. The purposes of this study were to develop porous CHA (PCHA) bone cement and to investigate its physicochemical properties, biocompatibility, biodegradation, and in vivo bone repair potential. Vesicants were added to modify CHA, and the solidification time, porosity, and pore size of the PCHA cements were examined. The cytotoxicity and bone repair potential of PCHA were tested in a rabbit bone defect model and assessed by x-ray, histological examination, and mechanical testing. The porosity of the modified PCHA was 36%; 90.23% of the pores were greater than 70 mum, with a calcium/phosphate ratio of 1.64 and a solidification time of 15 minutes. The PCHA did not affect bone cell growth in vitro, and the degrading time of the PCHA was two and four times faster in vitro and in vivo when compared to CHA. In the bone defect model, the amount of new bone formation in the PCHA-treated group was eight times greater than that of the CHA group; the compressive strength of the PCHA setting was relatively weak in the first weeks but increased significantly at 8 to 16 weeks compared to the CHA group. The PCHA has stable physicochemical properties and excellent biocompatibility; it degrades faster than CHA, provides more porous spaces for new bone ingrowths, and may be a new form of bone cement for the management of bone defects.

Histological biocompatibility of new, non-absorbable glaucoma deep sclerectomy implant

We performed this study to compare the intrascleral biocompatibility of three materials: non-absorbable hydrogel contact lens polymer, non-absorbable silicone rubber, and absorbable cross-linked sodium hyaluronate. Intrascleral implantation of three different materials was performed in 13 healthy, pigmented rabbits. Implants of methacrylic hydrogel, silicone rubber, and cross-linked sodium hyaluronate were implanted in 10, 8, and 8 eyes, respectively. The animals were euthanized at 7, 30, 180, and 360 days post implantation. The eyes were enucleated and immediately fixed in 10% buffered formalin. Semithin sections were cut and stained with hematoxylin-eosin. Light microscope analysis of the specimens was performed. The least severe inflammatory reaction was observed with cross-linked sodium hyaluronate implants. The number of inflammatory cells in proximity to methacrylic hydrogel and silicone implants at all periods of follow up was similar. The thickest fibrous capsule was observed with silicone implants (average, 28.38 +/- 11.17 microm). This area was thinner with methacrylic hydrogel implants (average, 14.90 +/- 5.57 microm) and was thinnest around sodium hyaluronate implants (average, 7.21 +/- 2.33 microm). For each type of implant, the wall on the conjunctival side of the fibrous capsule was significantly thicker than the wall on the choiroidal side. The space between the implant, scleral flap, and bed was filled soon after surgery with connective tissue rich in vessels. In our study, cross-linked sodium hyaluronate had the highest intrascleral biocompatibility. Although the inflammatory responses of the sclera to methacrylic hydrogel and silicone rubber were similar in nature, a thicker fibrous capsule was generated around silicone implants.

Tissue reactions evoked by porous and plane surfaces made out of silicon and titanium

Square-shaped silicon or titanium implants with plane or porous surfaces surrounded by a rim of silicone were implanted in the rat abdominal wall for evaluation of the tissue response after one, six, or 12 weeks. Cell damage was identified as increased membrane permeability using fluorescence microscopy by injection of propidium iodide prior to the killing of the rats. Capsule thickness and immunohistochemical quantification of macrophages were used as a further measure of the foreign-body reaction. There were no significant differences in capsular cell densities for macrophages, total cells (macrophages, fibroblasts, and other cells), or necrotic cells at the different time points for the four surfaces studied. However, significant differences in the kinetics of the response were found between plane surfaces compared with porous ones. Both types of plane surfaces developed a significant increase in capsule thickness over time in contrast to the porous implants. Porous silicon displayed a significant decrease in total cells in the reactive capsule over time. Furthermore, porous silicon and titanium surfaces displayed a significant decrease in total cell numbers at the implant interface between six and 12 weeks. The present study demonstrated that implanted silicon elicited soft-tissue reactions comparable to that of titanium.

Expanded polytetrafluoroethylene reinforcement material in glaucoma drain surgery

PURPOSE

To determine whether a synthetic material, expanded polytetrafluoroethylene (E-PTFE), can be used successfully as a reinforcement material over the tubes of glaucoma drainage implants.

METHODS

Patches of E-PTFE were sutured over the tubes of Baerveldt glaucoma drains implanted in the eyes of New Zealand white rabbits. Two material thicknesses were tested: 0.5 mm in four eyes and 0.25 mm in five eyes. Rabbit donor scleral patches were used in five eyes as the control. Total ocular health and intraocular pressure were monitored every 2 weeks after the procedure. Six months after implantation, the eyes were harvested and analyzed histologically.

RESULTS

Two of the four eyes that received 0.5-mm thick E-PTFE patches showed some conjunctival melting over the anterior corners of the material close to the limbus. All five eyes that received 0.25-mm thick E-PTFE patches showed a healthy cellular wound healing response and no conjunctival melting. Cellular infiltration and collagen deposition in the E-PTFE materials showed integration of the patch material into the surrounding tissue. In the control eyes, marked thinning and resorption of the donor sclera immediately above the drainage tube was noted.

CONCLUSION

Thin (0.25 mm) E-PTFE patches were well tolerated in all rabbit eyes tested. Thin E-PTFE should be investigated further as a functional alternative to donor sclera for reinforcement in glaucoma drain surgery.

Biocompatibility response to modified Baerveldt glaucoma drains

Glaucoma implants are designed to increase fluid outflow from the eye in order to decrease intraocular pressure and prevent damage to the optic nerve. The implant consists of a silicone tube that is inserted into the anterior chamber at one end and is attached at the other end to a silicone plate that is sutured to the outside of the globe beneath the conjunctiva. The glaucoma "implant" becomes a "drain" over the first 3 to 6 postoperative weeks as the silicone plate is enclosed by a fibrous capsule that allows a space to form into which fluid can drain and from which fluid can be absorbed by the surrounding tissues. Ideally, the size and thickness of the capsule (the filtering bleb) that surrounds the plate is such that the amount of fluid that passes through the capsule is identical to the amount of fluid produced by the eye at an intraocular pressure of 8 to 14 mmHg. The most common long-term complication of these implants is failure of the filtering bleb 2 to 4 years after surgery due to the formation of a thick fibrous capsule around the device. Micromovement of the smooth drainage plate against the scleral surface may be integral to the mechanism of glaucoma implant failure by stimulating low-level activation of the wound healing response, increased collagen scar formation, and increased fibrous capsule thickness. To test this hypothesis, we modified seven Baerveldt implants by adding porous cellular ingrowth material to the posterior surface of the drainage plate. Seven modified and five unmodified implants were placed in adult rabbit eyes. After 6 months, we found that the fibrous capsule around the modified implants was significantly thinner than the capsule surrounding the unmodified implants (p < 0.05), particularly on the surface between the porous ingrowth material and the sclera (p < 0.05). Although type I collagen predominated in the fibrous capsules around both types of implants, the amount of type III collagen in the capsules around the modified implants was significantly less than the amount around the unmodified implants (p < 0.05). We believe that these data suggest a reduction in the wound healing response to the modified implants, with greater stability of capsule thickness. Long-term studies are needed to verify that the stability of the capsules around the modified implants persists over a period of years, in which case this type of modification may prove useful in prolonging the functional life of these devices in the surgical treatment of glaucoma.

e-PTFE as scleral buckling episcleral implants: an experimental and histopathologic study

To investigate the effects of focal implantation of expanded polytetrafluoroethylene (e-PTFE) episcleral implants (i.e., explants or exoplants) on surrounding ocular tissues, an experimental and histopathological study was performed. Twenty-seven Fauve de Bourgogne rabbits eyes were implanted for a period of 3-11 months with oval-shaped e-PTFE episcleral implants. A newly formed capsule constantly encased the implants. Affected by the only two severe complications observed, 2 eyes had an endocapsular acute inflammation and could not be included in the study. Finally, 25 eyes were studied histopathologically. Neither intrusion nor extrusion of episcleral implants was observed. Other changes were related to implant characteristics. The inner surface of the capsule was often covered with numerous giant cells attesting to a foreign-body granuloma developed against the irregular outline of the episcleral implants. The porosity of the material was closely related to its surface irregularity, and also allowed its colonization by a fibrovascular and inflammatory tissue mainly in its peripheral layers. Under episcleral implants, sclera was both thinned and invaginated. Expanded PTFE hydrophobia was the other factor that might have suscitated granuloma. These microscopic changes are in contrast with an overall good apparent experimental tolerance to the material. However, additional studies on the long term behavior of this material would be helpful.

Novel synthetic meshwork for glaucoma treatment. I. Design and preliminary in vitro and in vivo evaluation of various expanded poly(tetrafluoroethylene) materials

A novel drainage implant for glaucoma filtering surgery (MESH) is proposed. After various expanded poly(tetrafluoroethylene) (e-PFTE) materials were evaluated, the feasibility and the short-term safety of the technique were assessed in this first pilot study in the rabbit. The porous structure and the in vitro resistance to aqueous flow of seven different e-PTFE membranes (5-80 microm average pore size) were compared. Eight Dutch pigmented rabbits were implanted with the T-shaped MESH implants made from either 20- or 50-microm average pore size e-PTFE membranes. Clinical examination, intraocular pressure (IOP) measurements, and histology analyses were performed over a period of 3 months. The contralateral nonoperated eyes served as controls. MESH implantation took less than 7 min. No postoperative hypotony, migration, or extrusion of the implant and no intraocular inflammation or infection occurred. A significant IOP reduction in the implanted eyes was obtained past postoperative day 21 with the 20-microm material implant. The drainage efficacy was correlated with the degree of colonization of the porous materials and the inner spacing of the implant as observed by histology. With a filtering patency 3 times longer than conventional trabeculectomy and laser sclerectomy, MESH surgery is a promising technique for glaucoma treatment. Further studies are underway to enhance the device efficacy and understand the mechanism of filtration.

Thickness of fibrous capsule after implantation of hydroxyapatite in subcutaneous tissue in rats

The present study evaluates in rats the histomorphometrical thickness of fibrous capsules that surround hydroxyapatite (HA) disks after implantation. HA disks were implanted into the subcutaneous tissue of 79 rats for 1 day to 20 months. Decalcified histological sections stained with hematoxylin and eosin were examined. Fibrous capsule thickness (FCT) was measured using an objective micrometer. On the fourteenth day, primary fibrous capsules formed around implants. From that time point FCT increased with time of implantation. Within a given sample, FCT differed from one portion of the fibrous capsule to another, depending on which site faced the disks. FCT was thickest at the upper and lower portions of the disks, thinner at the lateral portions, and thinnest at the upper and lower ring-shaped portions. Two possible explanations for the above findings are discussed in this paper: (1) The area of contact between disk and tissue differs. (2) Chemical stimulation of implanted material caused by demineralization and remineralization may result from the varying thicknesses of fibrous capsules. FCT from upper and lower portions of HA disks increased by over 200% in the first 10 months and steadily increased about 20% over the next 10 months. Many studies have concluded that HA is useful for reconstructive surgery, so the long-term effects of FCT need further study.

Comparison of novel synthetic materials with traditional methods to repair exposed abdominal wall fascial defects

Repair of large abdominal wall defects is a challenge, particularly when full-thickness tissue loss prohibits coverage of the fascial repair. Two novel synthetic materials (TMS-1 and TMS-2) have been shown to be better accepted than expanded polytetrafluoroethylene (Gore-Tex), and polypropylene (Marlex) in the closure of clean and contaminated fascial wounds that are immediately covered by skin/soft tissue. Therefore, 1-cm2 abdominal wall defects were created in each of the four quadrants of rat groups. Gore-Tex, Marlex, and TMS-1 or TMS-2 were used to repair three defects, the fourth being primarily closed. To ensure that each repair remained exposed, skin edges were sutured to underlying muscle. Additional animal groups underwent the same protocol; however, peritonitis was induced at surgery using a fecal inoculum technique. Animals were sacrificed 2 weeks later, at which time a blinded observer assessed the surface area and severity of adhesions. In clean wounds, the surface area of formed adhesions was less (p < .004) after primary closure than each synthetic material; among the synthetics, TMS-2 caused significantly (p < .01) less extensive adhesions than Marlex. In addition, the severity of adhesions to TMS-2 was comparable to that of defects closed primarily, and less severe (p < .02) than those formed to Gore-Tex and Marlex. In animals with peritonitis, primary closure caused less extensive (p < .03) adhesions than Marlex and Gore-Tex and significantly (p < .002) less severe adhesions than Marlex, Gore-Tex, and TMS-2. However, the severity of adhesions formed to TMS-1 repairs proved comparable to primarily closed wounds. These experiments reaffirm the tenet that, whenever possible, abdominal wounds should undergo primary fascial closure. When soft tissue coverage over the repair cannot be achieved, TMS-2 is well tolerated in clean wounds. However, the superiority of TMS-1 over the other synthetic materials in contaminated wounds suggests it may also ultimately prove to be of clinical utility.

Synthetic scleral reinforcement materials. III. Changes in surface and bulk physical properties

Changes in the physical properties of polymer materials during implantation in the biological environment can directly affect the ultimate performance of the polymer and/or device. We implanted four types of extraocular bands (porous, solid, composite, and patched) made from 11 types of materials in rabbit eyes and examined the changes in the physical strength and polymer structure of the implanted bands in terms of tensile strength measurements, creep analysis, and attenuated total internal reflectance--Fourier transform infrared spectroscopy (ATR-FTIR) at intervals up to 18 months after implantation. Most of the materials showed increases in tensile strength over the first 6 months in situ in the rabbit eye, followed by significant decreases between 6 and 18 months. Polymer bands that had been implanted for 18 months generally exhibited less creep behavior than unimplanted controls; for most of the bands, creep values ranged from 0% to 10% of the original length. ATR-FTIR of the solid bands and surface coatings showed protein deposition on all of the materials examined, with silicone materials and coatings least affected. Thirty-degree ATR-FTIR scans detected significant changes in the polymer structure for two of the band types: one solid (polyether urethane) and one porous (porous polyacrylate). In general, expanded polytetrafluoroethylene was the most stable in terms of tensile strength and creep. The least stable bands (composite bands made with porous polyurethane) were those that had undergone hydrolytic and/or oxidative degradation and chain scission of the polymer or alteration of the bond between the two materials making up the composite. These changes in physical properties and polymer structure observed after 18 months of implantation support the idea that polymer implant materials should be followed closely over several years in vivo to determine their suitability prior to use in humans.

Long-term observation of subcutaneous tissue reaction to synthetic auditory ossicle (Apaceram) in rats

The present study evaluates histological characteristics of the soft tissue response to long-term implantation of Apaceram discs composed of dense hydroxyapatite in rats. Discs were implanted into the subcutaneous tissue of 76 rats for six to 20 months. Decalcified histological sections stained with haematoxylin and eosin (H & E) and Mallory's azan were examined. Different cell types surrounding implants were counted. The greatest proportion of macrophages was found at six months (13.5 per cent). This proportion gradually decreased to four per cent at 20 months. Small numbers of lymphocytes and foreign body giant cells were observed in every group, but neither neutrophils nor osteogenesis were observed in any specimens. Results of the present study and previous related studies indicate that despite reappearance of a small number of macrophages six months after implantation, Apaceram is useful for reconstructive surgery.

Effect of forms of collagen linked to polyurethane on endothelial cell growth

Collagen has been widely coated or grafted onto polymer surfaces to improve the biocompatibility of materials. To better support the growth of endothelial cells on polyurethane (PU), collagen was grafted to the carboxyl group enriched PU through 1,2-bis(2,3-epoxypropoxy)ethane linking. Our results demonstrated that collagen in various conditions may result in different forms being grafted to the PU substrate, which subsequently affected the growth of endothelial cells. Collagen predialyzed against physiological phosphate buffered saline (PBS) could be reconstituted into native type fibrils with a bigger diameter at 37 degrees C than could collagen neutralized by titration with NaOH. At low temperature, titrated collagen formed floss-like fibrils packed in a ball with cobblestone-like morphology. The amount of collagen grafted was related to the condition of the collagen used, which in consequence affected the diameter of the collagen fibril formed and the growth of endothelial cells. In conclusion, reconstituted collagen fibrils formed from collagen in PBS at 37 degrees C grafted in the highest amounts to an epoxy-PU substrate and that optimally supported the growth of endothelial cells. Such prepared materials may be potentially good vascular bioprosthetic materials and may provide a wide range of biological applications.

Synthetic scleral reinforcement materials. II. Collagen types in the fibrous capsule

Attainment of a steady state in fibrous-capsule formation around a polymeric implant is indicative of minimization of the foreign-body response, and is characterized by thin capsule walls, few macrophages, and the replacement of type III collagen with type I collagen within the capsular matrix. We implanted four general types of extraocular band materials (porous, solid, composite, and patched) in rabbit eyes, and examined the proportions of types III and I collagen in the surrounding fibrous-capsule walls at intervals after surgery. Immunohistochemical analysis showed that 18 months after implantation of the band materials, the capsules adjacent to the porous-material surfaces had virtually no type III collagen remaining, while the solid-surface-material capsules still contained more than trace amounts (greater than 5%). In that the bands were implanted around the outside of the globe, which provides a dynamic environment in constant motion, it may be that the cellular ingrowth permitted by the porous materials increased the stability of the implants, thereby lessening the foreign body response and allowing the collagen replacement characteristic of the steady state to be completed. In contrast the solid-surface implants, which had little cellular ingrowth, may have continued to undergo sufficient micromovement within the capsule walls to sustain a low-level activation of the wound-healing response, resulting in thicker capsule walls and residual type III collagen a year and a half after implantation surgery.

Evaluation of a novel synthetic material for closure of large abdominal wall defects

BACKGROUND

This study was undertaken to compare the efficacy of a novel synthetic material (TMS-1) with polytetrafluoroethylene, polypropylene, and primary closure of experimentally fashioned clean and contaminated abdominal wounds.

METHODS

One square centimeter full-thickness abdominal wall defects were created in each of the four abdominal quadrants of anesthetized rats (n = 6). Patches of polytetrafluoroethylene, polypropylene, and a polyurethane-polypropylene composite material (TMS-1) were used to repair three of these defects; the fourth was primarily closed. A second group of rats (n = 9) underwent the same operative protocol; however, peritonitis was induced at the time of operation by using the fecal inoculation technique. Animals were killed 2 to 3 weeks later, and surface area and severity of formed adhesions were assessed.

RESULTS

By all methods of assessment, primary closure proved significantly superior to all other methods of closure in clean and contaminated conditions. The three synthetic materials were equally matched for surface area involved in adhesion formation. When compared with the other synthetic materials, TMS-1 was associated with significantly milder adhesions in uninfected (p < 0.002) and in infected (p < 0.002) conditions.

CONCLUSIONS

The clear superiority of TMS-1 over other nonabsorbable synthetic materials shown in this pilot study warrants further investigation relative to its use to close large abdominal wall defects.