Inhibitory effects of salmosin, a disintegrin, on posterior capsular opacification in vitro and in vivo

Posterior Capsule Opacification: A Review of Experimental Studies

Posterior capsule opacification (PCO) is the most common complication of cataract surgery. It causes a gradual deterioration of visual acuity, which would otherwise improve after a successful procedure. Despite recent advances in ophthalmology, this complication has not been eradicated, and the incidence of PCO can be as high as 10%. This article reviews the literature concerning the pathomechanism of PCO and examines the biochemical pathways involved in its formation and methods to prevent this complication. We also review the reported tests performed in cell cultures under laboratory conditions and in experimental animal models and in ex vivo human lens capsules. Finally, we describe research involving human eyes in the clinical setting and pharmacological methods that may reduce the frequency of PCO. Due to the multifactorial etiology of PCO, in vitro studies make it possible to assess the factors contributing to its complications and search for new therapeutic targets. Not all pathways involved in cell proliferation, migration, and contraction of the lens capsule are reproducible in laboratory conditions; moreover, PCO in humans and laboratory animals may be additionally stimulated by various degrees of postoperative reactions depending on the course of surgery. Therefore, further studies are necessary.

Fibronectin has multifunctional roles in posterior capsular opacification (PCO)

Fibrotic posterior capsular opacification (PCO), one of the major complications of cataract surgery, occurs when lens epithelial cells (LCs) left behind post cataract surgery (PCS) undergo epithelial to mesenchymal transition, migrate into the optical axis and produce opaque scar tissue. LCs left behind PCS robustly produce fibronectin, although its roles in fibrotic PCO are not known. In order to determine the function of fibronectin in PCO pathogenesis, we created mice lacking the fibronectin gene (FN conditional knock out -FNcKO) from the lens. While animals from this line have normal lenses, upon lens fiber cell removal which models cataract surgery, FNcKO LCs exhibit a greatly attenuated fibrotic response from 3 days PCS onward as assessed by a reduction in surgery-induced cell proliferation, and fibrotic extracellular matrix (ECM) production and deposition. This is correlated with less upregulation of Transforming Growth Factor β (TGFβ) and integrin signaling in FNcKO LCs PCS concomitant with sustained Bone Morphogenetic Protein (BMP) signaling and elevation of the epithelial cell marker E cadherin. Although the initial fibrotic response of FNcKO LCs was qualitatively normal at 48 h PCS as measured by the upregulation of fibrotic marker protein αSMA, RNA sequencing revealed that the fibrotic response was already quantitatively attenuated at this time, as measured by the upregulation of mRNAs encoding molecules that control, and are controlled by, TGFβ signaling, including many known markers of fibrosis. Most notably, gremlin-1, a known regulator of TGFβ superfamily signaling, was upregulated sharply in WT LCs PCS, while this response was attenuated in FNcKO LCs. As exogenous administration of either active TGFβ1 or gremlin-1 to FNcKO lens capsular bags rescued the attenuated fibrotic response of fibronectin null LCs PCS including the loss of SMAD2/3 phosphorylation, this suggests that fibronectin plays multifunctional roles in fibrotic PCO development.

Evaluation of laser capsule polishing for prevention of posterior capsule opacification in a human ex vivo model

PURPOSE

To evaluate the efficacy of a laser photolysis (LP) system in preventing posterior capsule opacification (PCO) in a human ex vivo PCO model.

SETTING

Ars Ophthalmica Study Center, Department of Ophthalmology, General Hospital Linz, Medical Faculty of Johannes Kepler University, Linz, Austria, and the Department of Ophthalmology, Ludwig-Maximillians-University, Munich, Germany.

DESIGN

Prospective randomized controlled laboratory trial.

METHODS

Open sky extracapsular cataract extraction following implantation of a capsular tension ring (CTR) into the capsular bag was performed in 28 human donor eyes. Donor eyes received LP treatment of the capsular bag fornix and the anterior capsule for 180 or 360 degrees, whereas the contralateral eyes served as a control group. Lens epithelial cell (LEC) growth onto the posterior capsule was determined objectively during 3 months of organ culture incubation.

RESULTS

The mean interval until a complete monolayer of LECs on the posterior capsule had formed was 8.2 days ± 1.2 (SD) for control eyes and 9.4 days ± 1.1 for eyes with 180-degree LP treatment (P = .042). Eyes with 360-degree treatment showed no sign of LEC growth or migration onto the posterior capsule during the entire observation period. Transmission light microscopy revealed many residual LECs on the anterior lens capsule of untreated areas, whereas no evidence of remaining LEC in areas treated with LP was found.

CONCLUSIONS

This study demonstrates complete and sustained PCO prevention by a prototype LP system in a capsular tension ring-based human ex vivo model. Laser capsule polishing has the potential to serve as a successful surgical strategy for PCO prevention.

FINANCIAL DISCLOSURE

The authors have no proprietary or financial interest in any of the materials or equipment mentioned in this study.

Nanofiber-based hydrogels with extracellular matrix-based synthetic peptides for the prevention of capsular opacification

Nanofiber-based hydrogels (nanogels) with different, covalently bound peptides were used as an extracellular environment for lens epithelial cells (LECs) in order to modulate the capsular opacification (CO) response after lens surgery in a porcine eye model. Lenses were divided into 15 groups (n = 4 per group), the lens content was removed and the empty capsules were refilled with nanogel without peptides and nanogels with 13 combinations of 5 different peptides: two laminin-derived, two fibronectin-derived, and one collagen IV-derived peptide representing cell adhesion motifs. A control group of 4 lenses was refilled with hyaluronan. After refilling, lenses were extracted from the porcine eye and cultured for three weeks. LECs were assessed for morphology and alpha smooth muscle actin (αSMA) expression using confocal laser scanning microscopy. Compared to hyaluronan controls, lenses filled with nanogel had less CO formation, indicated by a lower αSMA expression (P = 0.004). Microscopy showed differences in morphological cell response within the nanogel refilled groups. αSMA expression in these groups was highest in lenses refilled with nanogel without peptides (9.54 ± 11.29%). Overall, LEC transformation is reduced by the presence of nanogels and the response is improved even further by incorporation of extracellular matrix peptides representing adhesion motifs. Thus, nanomaterials targeting biological pathways, in our case interactions with integrin signaling, are a promising avenue toward reduction of CO. Further research is needed to optimize nanogel-peptide combinations that fully prevent CO.

Prevention of posterior capsular opacification

Posterior capsular opacification (PCO) is a common complication of cataract surgery. The development of PCO is due to a combination of the processes of proliferation, migration, and transdifferentiation of residual lens epithelial cells (LECs) on the lens capsule. In the past decades, various forms of PCO prevention have been examined, including adjustments of techniques and intraocular lens materials, pharmacological treatments, and prevention by interfering with biological processes in LECs. The only method so far that seems effective is the implantation of an intraocular lens with sharp edged optics to mechanically prevent PCO formation. In this review, current knowledge of the prevention of PCO will be described. We illustrate the biological pathways underlying PCO formation and the various approaches to interfere with the biological processes to prevent PCO. In this type of prevention, the use of nanotechnological advances can play a role.

The intraocular lens: challenges in the prevention and therapy of infectious endophthalmitis and posterior capsular opacification

Cataract is the leading cause of visual impairment worldwide. In the UK, some 30% of the population over 65 years of age have visually impairing cataract. Importantly, 88% of those with treatable visual impairment from cataract are not in contact with any ocular healthcare service, representing a major potential healthcare need [1]. In the USA, it has been estimated that 17.2% of the population (approximately 20.5 million) over 40 years of age have cataract in either eye and by 2020, this number is expected to rise to 30.1 million. Currently, cataract is responsible for 60% of Medicare costs associated with vision [2]. Furthermore, as the populations of industrialized countries such as the UK and the USA continue to age, the costs associated with treatment of cataract can only be expected to increase. Consequently, the development of the intraocular lens to replace the cataractous lens and the advances in intraocular lens design and implantation represent a major development in cataract treatment. However, despite such advances, cataract surgery is not without complications, such as postoperative infectious endophthalmitis, a rare but potentially devastating condition, and posterior capsular opacification, a less serious but much more common problem. This review will examine the epidemiology of cataracts, the polymeric construction of intraocular lenses implanted during cataract surgery and the complications of postoperative infectious endophthalmitis and posterior capsular opacification with regard to therapeutic interventions and prophylactic strategies. Advances in biomaterial design and function will be discussed as novel approaches to prevent such postoperative complications.

Cytoskeletal drugs prevent posterior capsular opacification in human lens capsule in vitro

BACKGROUND

To determine whether the cytoskeletal drugs H-7 and Latrunculin B (LAT-B) inhibit posterior capsular opacification (PCO) in the cultured human lens capsular bag.

METHODS

Following extracapsular cataract (lens) extraction in human donor eyes, the capsular bag was prepared and cultured by standard techniques. Forty-eight capsular bags were studied, of which 13 were treated with H-7 (50, 100 or 300 μM), 12 with 1% BSS (vehicle of H-7), 11 with LAT-B (2, 5 or 10 μM), and 12 with 0.25% DMSO (vehicle of LAT-B). Forty out of the 48 capsular bags were from paired eyes of 20 donors, with one bag being treated with H-7/LAT-B and the other with BSS/DMSO for each pair, including 20 for the H-7-BSS protocol and 20 for the LAT-B-DMSO protocol. The medium with the cytoskeletal drug/vehicle was replaced every 3-4 days for 4 weeks. PCO was assessed daily using inverted phase-contrast microscopy, and scored on a 4-point scale.

RESULTS

In all cultures with BSS or DMSO, residual lens epithelial cells (LECs) on the anterior capsule migrated to and proliferated on the posterior capsule by 3-7 days, and apparent LEC growth on the posterior capsule with severe capsular wrinkling (PCO Grade 3) was seen by 2-3 weeks. When treated continuously with H-7 or LAT-B, the migration and proliferation of LECs and the capsular wrinkling were inhibited in a dose-dependent manner, with the inhibition being complete (PCO Grade 0) in the 300 μM H-7 (n = 8, p < 0.001) or 10 μM LAT-B culture (n = 3, p = 0.002).

CONCLUSION

H-7 and LAT-B dose-dependently inhibited PCO formation in the cultured human lens capsular bags, suggesting that cytoskeletal drugs might prevent PCO formation after surgery in the human eye.

Effect of H-7 on secondary cataract after phacoemulsification in the live rabbit eye

PURPOSE

This study is aimed to determine if the serine-threonine kinase inhibitor H-7 inhibits secondary cataract after phacoemulsification in the live rabbit eye.

METHODS

Eighteen rabbits underwent extracapsular lens extraction by phacoemulsification in 1 eye. The eye was treated with intravitreal H-7 (300 or 1,200 μM; n = 6 or 5) or balanced salt solution (BSS) (n = 7) immediately after the surgery and twice weekly for 10 weeks. Each eye received slit lamp biomicroscopy once a week, during which posterior capsule opacification (PCO) was evaluated. The eye was then enucleated and the lens capsule was prepared, fixed, and imaged. PCO was evaluated again on the isolated lens capsule under a phase microscope. Soemmering's ring area (SRA) and the entire lens capsule area were measured from capsule images on a computer and the percentage of SRA (PSRA) in the entire capsule area was calculated. Wet weight of the capsule (WW) was determined on a balance.

RESULTS

No significant difference in PCO was observed in any comparison. No significant differences in SRA, PSRA, and WW were observed between the 300 μM H-7-treated eye and the BSS-treated eye. However, SRA, PSRA, and WW in the 1,200 μM H-7-treated eye were significantly smaller than those in the BSS-treated eye [28.3 ± 16.2 vs. 61.4 ± 8.86 mm(2) (P = 0.001), 33% ± 20% vs. 65% ± 15% (P = 0.01), and 65.6 ± 27.9 vs. 127.0 ±37.3 mg (P = 0.01)].

CONCLUSIONS

Intravitreal H-7 (1,200 μM) significantly inhibits Soemmering's ring formation in the live rabbit eye, suggesting that agents that inhibit the actomyosin system in cells may prevent secondary cataract after phacoemulsification.

Integrins in lens development and disease

Integrins are the major cell surface receptors for proteins in the extracellular matrix. These receptors form major cell signaling centers that are bidirectional, communicating messages between the cell and its environment. They are a large receptor family, with members well-known to regulate cellular processes essential to both development and disease. In this review we examine the literature regarding integrins in the lens. Here we cover integrin function in lens cell differentiation, in the development of the lens and in protection of the lens epithelial cell phenotype. In addition, we analyze the role of integrins in the progression of lens fibrotic diseases, focusing particularly on integrin regulation of TGFbeta signaling pathways in posterior capsule opacification (PCO) and anterior subcapsular cataract (ASC).

Conditional deletion of beta1-integrin from the developing lens leads to loss of the lens epithelial phenotype

Beta1-integrins are cell surface receptors that participate in sensing the cell's external environment. We used the Cre-lox system to delete beta1-integrin in all lens cells as the lens vesicle transitions into the lens. Adult mice lacking beta1-integrin in the lens are microphthalmic due to apoptosis of the lens epithelium and neonatal disintegration of the lens fibers. The first morphological alterations in beta1-integrin null lenses are seen at 16.5 dpc when the epithelium becomes disorganized and begins to upregulate the fiber cell markers beta- and gamma-crystallins, the transcription factors cMaf and Prox1 and downregulate Pax6 levels demonstrating that beta1-integrin is essential to maintain the lens epithelial phenotype. Furthermore, beta1-integrin null lens epithelial cells upregulate the expression of alpha-smooth muscle actin and nuclear Smad4 and downregulate Smad6 suggesting that beta1-integrin may brake TGFbeta family signaling leading to epithelial-mesenchymal transitions in the lens. In contrast, beta1-integrin null lens epithelial cells show increased E-cadherin immunoreactivity which supports the proposed role of beta1-integrins in mediating complete EMT in response to TGFbeta family members. Thus, beta1-integrin is required to maintain the lens epithelial phenotype and block inappropriate activation of some aspects of the lens fiber cell differentiation program.

Extracellular matrix and integrin signaling in lens development and cataract

During development of the vertebrate lens there are dynamic interactions between the extracellular matrix (ECM) of the lens capsule and lens cells. Disruption of the ECM causes perturbation of lens development and cataract. Similarly, changes in cell signaling can result in abnormal ECM and cataract. Integrins are key mediators of ECM signals and recent studies have documented distinct repertoires of integrin expression during lens development, and in anterior subcapsular cataract (ASC) and posterior caspsule opacification (PCO). Increasingly, studies are being directed to investigating the signaling pathways that integrins modulate and have identified Src, focal adhesion kinase (FAK) and integrin-linked kinase (ILK) as downstream kinases that mediate proliferation, differentiation and morphological changes in the lens during development and cataract formation.

Development of an accommodating intra-ocular lens--in vitro prevention of re-growth of pig and rabbit lens capsule epithelial cells

Cataract surgery is routinely performed to replace the clouded lens by a rigid polymeric intra-ocular lens unable to accommodate. By implanting a silicone gel into an intact capsular bag the accommodating properties of the natural lens can be maintained or enhanced. The implantation success of accommodating lenses is hampered by the occurrence of capsular opacification (PCO) due to lens epithelial cell (LEC) growth. In order to prevent LEC proliferation, a treatment regime using actinomycin D, cycloheximide and water was developed. The effectiveness of treatment was analyzed using an in vitro, MTT-based cell culture system and an ex vivo pig eye model in which the implanted lens-in-the-bag is cultured as a whole. LEC were exposed to treatment solutions for 5 min, then the cells were allowed to recover and to re-colonize the substratum. MTT conversion by cells was transiently inhibited by cycloheximide dissolved in water and by water alone. Exposure to actinomycin D resulted in a lasting inhibition of MTT conversion and consequently cell proliferation. These in vitro data could not be fully reproduced in the ex vivo pig eye model due to essential differences between both models. Treatment with actinomycin D containing solutions, however, resulted in a nearly complete absence of cells on the capsular wall. The pig eye model is a promising approach to further evaluate the effects of peri-surgical treatment during the accommodating intra-ocular lens implantation.

Evaluation of the effects of hydrodissection with antimitotics using a rabbit model of Soemmering's ring formation

BACKGROUND

Regeneration/proliferation of lens material within the capsular bag still is the most frequent complication after cataract surgery. We aimed to evaluate the effects of hydrodissection with low doses of antimitotics on the overall regeneration/proliferation of lens material in rabbit eyes, using a model allowing the lens material to be confined to the equatorial region of the capsular bag, facilitating its quantification.

METHODS

Twelve albino rabbits underwent bilateral phacoemulsification. Their eyes were randomized to receive 0.4 cc of balanced salt solution, 5-fluorouracil (12.5 mg/mL) or mitomycin C (0.1 mg/mL) during hydrodissection. They were left aphakic, so the capsulorhexis would fuse with the posterior capsule postoperatively. After 4 weeks, killing/enucleation was performed. Regeneration/proliferation of lens material within the equatorial capsular bag (Soemmering's ring) was graded from the Miyake-Apple view (0-4). Its area was also calculated (microm(2)) from direct measurements performed on histological sections.

RESULTS

The capsulorhexis margin fused with the peripheral posterior capsule, so the central posterior capsule remained clear. There was no significant difference among the groups (Kruskal-Wallis test) regarding Soemmering's ring gross grading (P = 0.511), number of lens epithelial cell layers lining the inner surface of the capsular bag (P = 0.310) and Soemmering's ring microscopic cross-sectional area (P = 0.638).

CONCLUSIONS

The effect of different solutions on after-cataract should be assessed in terms of overall regeneration/proliferation of lens material within the capsular bag, in addition to posterior capsule opacification. When administered in low doses during hydrodissection, 5-fluorouracil and mitomycin C did not show a significant inhibitory effect on after-cataract formation in rabbit eyes.

Efficacy of various drugs in the prevention of posterior capsule opacification: experimental study of rabbit eyes

PURPOSE

To assess the efficacy of various drugs in the prevention of posterior capsule opacification (PCO) in a closed capsular bag technique.

SETTING

Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida, USA.

METHODS

Lens material was removed using phacoaspiration or phacoemulsification through a microcapsulorhexis according to the hardness of the crystalline lens correlated with the weight and age of the rabbits. A mixture of an ophthalmic viscosurgical device (sodium hyaluronate 1.4% [SHA]) and a drug was injected into the empty capsular bag, allowed to remain inside for 3 minutes, and removed. The capsular bag was rinsed with balanced salt solution (BSS) and refilled with SHA. In a group of rabbits, the capsulorhexis was sealed with a minicapsulorhexis valve (MCV). Rabbits were treated with 1 of the following: SHA (control), BSS, mitomycin-C (MMC, 0.2 mg/mL), ethylenediaminetetraacetic acid (EDTA) (10 mM and 15 mM), 5-fluorouracil (5-FU, 33 mg/mL), acetic acid (3%, 0.3%, and 0.003%), and distilled water.

RESULTS

Upon completion of the study, the control and treated eyes had PCO and new lens material (not residual). Anterior capsule proliferation was observed in eyes treated with 5-FU. The order of PCO appearance (earliest to latest) was as follows: 15 mM EDTA, SHA, MMC, acetic acid 0.3%, acetic acid 3%, BSS, distilled water (small animals; no MCV), acetic acid 0.003%, 5-FU, 10 mM EDTA, and distilled water (large animals; MCV). The earliest appearance was day 1 postoperatively and the latest, day 47.

CONCLUSIONS

Distilled water and 10 mM EDTA treatments were the most efficient in retarding the appearance of PCO.

Effect of extracellular matrix on proliferation and differentiation of porcine lens epithelial cells

BACKGROUND

Proliferation and differentiation of lens epithelial cells (LECs) are important mechanisms of secondary cataract formation. After extracapsular cataract extraction the extracellular matrix (ECM) around the remaining LECs is altered compared with the intact lens. This study investigated the effects of different ECMs on cell proliferation and alpha-smooth muscle actin (alpha-SMA) expression, a marker for myofibroblasts, in cultured porcine LECs.

METHODS

Porcine LECs were cultured for 3 days (cell proliferation assay) or 4 days (alpha-SMA expression) on wells and glass cover slips, respectively, coated with laminin, fibronectin, type I collagen or type IV collagen. LECs cultured on uncoated wells or cover slips served as control. Proliferative response was measured by [(3)H]-thymidine incorporation into DNA. alpha-SMA was detected immunocytochemically with a mouse monoclonal antibody, and the relative numbers of alpha-SMA-positive cells were calculated. Statistical analysis was performed using Student's unpaired t-test.

RESULTS

Cell proliferation was significantly increased by coating with fibronectin (10,320.5+/-6,073 counts per minute; p<0.0001) (mean +/- SD), type I collagen (12,507.3+/-3,914.2 CPM; p<0.0001) and type IV collagen (9,591.4+/-4,088 CPM; p<0.0001) compared with control (1,876.5+/-998 CPM), whereas coating with laminin had no effect (1,760.8+/-812.6 CPM; p=0.7271). The ratio of alpha-SMA-positive LECs cultured on uncoated cover slips for a period of 4 days was 12.2+/-3.51%. This ratio was significantly increased by coating with fibronectin (24.3+/-4.56%; p=0.0001) and type I collagen (21.2+/-8.48%; p=0.0142). Coating with laminin (9.8+/-3.67%; p=0.1682) and type IV collagen (9.0+/-7.09 %; p=0.2491) slightly decreased alpha-SMA expression, but this effect was not statistically significant.

CONCLUSIONS

Fibronectin and type I collagen stimulated both cell proliferation and alpha-SMA expression in cultured porcine LECs. Because fibronectin and type I collagen are not normally present in the adult lens, their possible introduction into the lens capsule after cataract surgery may play a critical role in the development of posterior capsule opacification.

17Beta-estradiol confers a protective effect against transforming growth factor-beta2-induced cataracts in female but not male lenses

Transforming growth factor-beta2 (TGF-beta2) induces anterior subcapsular cataracts, with a marked increase in cytoskeletal and extracellular matrix proteins, such as alpha-smooth muscle actin (alphaSMA). It has been shown that 17beta-estradiol (E2) can prevent TGF-beta2-induced cataracts in lenses from ovariectomized female rats. The purpose of the current study was to extend this finding by testing whether E2 can prevent TGF-beta2-induced cataracts and inhibit the induction of alphaSMA gene expression in normal male and normal, non-ovariectomized female rats.Sex-specific differences were observed in 17-week-old rat lenses incubated in 0.15 ng ml(-1) TGF-beta2 and in 10(-8)M E2 plus TGF-beta2. TGF-beta2 induced approximately twice as many anterior subcapsular plaques and 1.5 times the level of alphaSMA transcripts in male lenses compared to female lenses. Notably, E2 inhibited plaque formation and the induction of alphaSMA transcripts in female rat lenses but not in male rat lenses. E2 also inhibited the induction of alphaSMA in TGF-beta2-incubated lenses from ovariectomized female rats.E2 prevented lens opacification and the induction of alphaSMA gene expression in female, but not male, lenses. This sex-specific difference may have implications for studies on the therapeutic use of estradiol for treatment of secondary cataract.

Expression of CD18, CD49b, CD49c and CD49e on lens anterior capsules in human cataracts

PURPOSE

To examine the lens epithelial cells obtained from the anterior lens capsules removed during cataract surgery and detect various subclasses of the cell surface adhesion molecules known as integrins.

METHODS

The circular sections of anterior capsules with attached lens epithelial cells (LECs) were obtained during cataract surgery from 28 patients. The lens capsules were immunohistochemically stained.

RESULTS

CD49b CD49c, CD49e, and CD18 were detected in varying degrees in specimens obtained from human cataractous lenses. The positive percentages were 33, 75, 33, and 20%, respectively. The most striking feature was the increasing staining profiles towards the edges of the capsules (away from the central part of the lens capsules) for CD49c, suggesting that the LECs showed higher immunoreactivity for this antibody. The immunoreactivity for CD49b and CD49e was weaker. This was absent for CD18 in the central part of the lens capsules.

CONCLUSION

The positive expression of antibodies suggests that specific integrin subunits were expressed in LECs of human cataracts. These results suggest that lens epithelial cells expressing CD49b, CD49c, CD49e, and CD18 might be precursors in the process of anterior lens epithelial cell (A cell) adhesion, and hence play a role in anterior capsule opacification or in subsequent migration and a possible role in posterior capsule opacification.