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Gade S, Glover K, Mishra D, Sharma S, Guy O, Donnelly RF, Vora LK, Thakur RRS. Hollow microneedles for ocular drug delivery. J Control Release 2024; 371:43-66. [PMID: 38735395 DOI: 10.1016/j.jconrel.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 05/14/2024]
Abstract
Microneedles (MNs) are micron-sized needles, typically <2 mm in length, arranged either as an array or as single needle. These MNs offer a minimally invasive approach to ocular drug delivery due to their micron size (reducing tissue damage compared to that of hypodermic needles) and overcoming significant barriers in drug administration. While various types of MNs have been extensively researched, significant progress has been made in the use of hollow MNs (HMNs) for ocular drug delivery, specifically through suprachoroidal injections. The suprachoroidal space, situated between the sclera and choroid, has been targeted using optical coherence tomography-guided injections of HMNs for the treatment of uveitis. Unlike other MNs, HMNs can deliver larger volumes of formulations to the eye. This review primarily focuses on the use of HMNs in ocular drug delivery and explores their ocular anatomy and the distribution of formulations following potential HMN administration routes. Additionally, this review focuses on the influence of formulation characteristics (e.g., solution viscosity, particle size), HMN properties (e.g., bore or lumen diameter, MN length), and routes of administration (e.g., periocular transscleral, suprachoroidal, intravitreal) on the ocular distribution of drugs. Overall, this paper highlights the distinctive properties of HMNs, which make them a promising technology for improving drug delivery efficiency, precision, and patient outcomes in the treatment of ocular diseases.
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Affiliation(s)
- Shilpkala Gade
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, Belfast, UK
| | - Katie Glover
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, Belfast, UK
| | - Deepakkumar Mishra
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, Belfast, UK
| | - Sanjiv Sharma
- College of Engineering, Swansea University, Swansea, UK; Pharmacology and Therapeutics, University of Liverpool, UK
| | - Owen Guy
- Department of Chemistry, School of Engineering and Applied Sciences, Faculty of Science and Engineering, Swansea University, Swansea SA2 8PP, UK
| | - Ryan F Donnelly
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, Belfast, UK
| | - Lalitkumar K Vora
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, Belfast, UK.
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Mulkutkar M, Damani M, Sawarkar S. Polymeric microneedles for the eye: An overview of advances and ocular applications for minimally invasive drug delivery. Eur J Pharm Biopharm 2024; 197:114209. [PMID: 38336234 DOI: 10.1016/j.ejpb.2024.114209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 01/29/2024] [Accepted: 02/02/2024] [Indexed: 02/12/2024]
Abstract
Ocular drug delivery is challenging due to the presence of tissue barriers and clearance mechanisms. Most widely used topical formulations need frequent application because of poor permeability, short retention, and low bioavailability. Invasive intraocular injections and implants that deliver drugs at the target site are associated with infections, inflammation, and even vision loss post-use. These gaps can be addressed by a delivery platform that can efficiently deliver drug with minimal tissue damage. Microneedles were introduced as a delivery platform for overcoming dermal barriers with minimal tissue damage. After the successful clinical transition of microneedles in the transdermal drug delivery, they are now being extensively studied for ocular applications. The attributes of minimally invasive application and the capability to deliver a wide range of therapeutics make microneedles an attractive candidate for ocular drug delivery. The current manuscript provides a detailed overview of the recent advancements in the field of microneedles for ocular use. This paper reviews research focusing on polymeric microneedles and their pharmaceutical and biopharmaceutical properties. A brief discussion about their clinical translation and regulatory concerns is also covered. The multitude of research articles supports the fact that microneedles are a potential, minimally invasive drug delivery platform for ophthalmic use.
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Affiliation(s)
- Madhura Mulkutkar
- Department of Pharmaceutics, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, University of Mumbai, Mumbai, India
| | - Mansi Damani
- Department of Pharmaceutics, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, University of Mumbai, Mumbai, India
| | - Sujata Sawarkar
- Department of Pharmaceutics, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, University of Mumbai, Mumbai, India.
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3
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Chiang B, Jang K, Goldberg J, Myung D. Design and ex vivo development of a suprachoroidal spacer implant to treat glaucoma. RESEARCH SQUARE 2024:rs.3.rs-3895533. [PMID: 38352508 PMCID: PMC10862960 DOI: 10.21203/rs.3.rs-3895533/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Glaucoma is a leading cause of visual impairment and blindness in the United States and worldwide. Elevated intraocular pressure (IOP) has been identified as the only modifiable risk factor in glaucoma, and there exists a need for a glaucoma procedure that is safe, efficacious, and can be performed in the outpatient clinic setting. Suprachoroidal expansion has been explored as a method to lower IOP previously. The purpose of this work was to design a monolithic hydrogel implant that would not clear or degrade to potentially achieve long term (possibly permanent) IOP reduction. Here, we developed and showed ex vivo testing of a novel photo-crosslinked polyethylene glycol (PEG) suprachoroidal spacer implant delivered via a custom-designed injector system. We optimized the composition, shape, and mechanics of the implant to be suitable for implantation with the suprachoroidal space. We developed a microneedle injector system to deliver this implant. We showed precise control over implant location and volume occupied within the suprachoroidal space. Further preclinical testing is needed to demonstrate efficacy.
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Ansari M, Kulkarni YA, Singh K. Advanced Technologies of Drug Delivery to the Posterior Eye Segment Targeting Angiogenesis and Ocular Cancer. Crit Rev Ther Drug Carrier Syst 2024; 41:85-124. [PMID: 37824419 DOI: 10.1615/critrevtherdrugcarriersyst.2023045298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Retinoblastoma (RB), a childhood retinal cancer is caused due to RB1 gene mutation which affects the child below 5 years of age. Angiogenesis has been proven its role in RB metastasis due to the presence of vascular endothelial growth factor (VEGF) in RB cells. Therefore, exploring angiogenic pathway by inhibiting VEGF in treating RB would pave the way for future treatment. In preclinical studies, anti-VEGF molecule have shown their efficacy in treating RB. However, treatment requires recurrent intra-vitreal injections causing various side effects along with patient nonadherence. As a result, delivery of anti-VEGF agent to retina requires an ocular delivery system that can transport it in a non-invasive manner to achieve patient compliance. Moreover, development of these type of systems are challenging due to the complicated physiological barriers of eye. Adopting a non-invasive or minimally invasive approach for delivery of anti-VEGF agents would not only address the bioavailability issues but also improve patient adherence to therapy overcoming the side effects associated with invasive approach. The present review focuses on the eye cancer, angiogenesis and various novel ocular drug delivery systems that can facilitate inhibition of VEGF in the posterior eye segment by overcoming the eye barriers.
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Affiliation(s)
- Mudassir Ansari
- Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKM's NMIMS, Mumbai 400056, India
| | - Yogesh A Kulkarni
- Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKM's NMIMS, Mumbai 400056, India
| | - Kavita Singh
- Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKM's NMIMS, Mumbai 400056, India
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5
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Wu KY, Akbar D, Giunta M, Kalevar A, Tran SD. Hydrogels in Ophthalmology: Novel Strategies for Overcoming Therapeutic Challenges. MATERIALS (BASEL, SWITZERLAND) 2023; 17:86. [PMID: 38203940 PMCID: PMC10780040 DOI: 10.3390/ma17010086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/19/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024]
Abstract
The human eye's intricate anatomical and physiological design necessitates tailored approaches for managing ocular diseases. Recent advancements in ophthalmology underscore the potential of hydrogels as a versatile therapeutic tool, owing to their biocompatibility, adaptability, and customizability. This review offers an exploration of hydrogel applications in ophthalmology over the past five years. Emphasis is placed on their role in optimized drug delivery for the posterior segment and advancements in intraocular lens technology. Hydrogels demonstrate the capacity for targeted, controlled, and sustained drug release in the posterior segment of the eye, potentially minimizing invasive interventions and enhancing patient outcomes. Furthermore, in intraocular lens domains, hydrogels showcase potential in post-operative drug delivery, disease sensing, and improved biocompatibility. However, while their promise is immense, most hydrogel-based studies remain preclinical, necessitating rigorous clinical evaluations. Patient-specific factors, potential complications, and the current nascent stage of research should inform their clinical application. In essence, the incorporation of hydrogels into ocular therapeutics represents a seminal convergence of material science and medicine, heralding advancements in patient-centric care within ophthalmology.
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Affiliation(s)
- Kevin Y. Wu
- Department of Surgery, Division of Ophthalmology, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada; (K.Y.W.)
| | - Dania Akbar
- Department of Human Biology, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Michel Giunta
- Department of Surgery, Division of Ophthalmology, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada; (K.Y.W.)
| | - Ananda Kalevar
- Department of Surgery, Division of Ophthalmology, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada; (K.Y.W.)
| | - Simon D. Tran
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC H3A 1G1, Canada
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Das N, Chaurasia S, Singh RP. A review of emerging tyrosine kinase inhibitors as durable treatment of neovascular age-related macular degeneration. Expert Opin Emerg Drugs 2023; 28:203-211. [PMID: 37796039 DOI: 10.1080/14728214.2023.2259790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 09/13/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION Current treatment for age-related macular degeneration poses a large burden on patients and the inability of patients to adhere to this immense burden can lead to worse visual outcomes. Novel treatments have been proposed to extend treatment intervals and reduce visit burden. AREAS COVERED This review article summarizes phase I and phase II clinical trials of tyrosine kinase inhibitors as durable treatment options for patient with neovascular age-related macular degeneration. EXPERT OPINION Tyrosine kinase inhibitors have shown substantial promise in reducing treatment burden while maintaining visual acuity and anatomic outcomes with favorable safety profiles. Several platforms have shown positive outcomes in initial trials and are currently moving toward phase III clinical trials.
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Affiliation(s)
- Nikhil Das
- Center for Ophthalmic Bioinformatics, Cleveland Clinic Cole Eye Institute, Cleveland, OH, USA
| | - Sameer Chaurasia
- Department of Ophthalmology, Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Rishi P Singh
- Center for Ophthalmic Bioinformatics, Cleveland Clinic Cole Eye Institute, Cleveland, OH, USA
- Cleveland Clinic Martin Hospitals, Cleveland Clinic Florida, Stuart, FL, USA
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Zhang S, Yang L, Liu J, Li H, Hong S, Hong L. Microneedle systems: cell, exosome, and nucleic acid based strategies. Biomater Sci 2023; 11:7018-7033. [PMID: 37779477 DOI: 10.1039/d3bm01103h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Cells, exosomes, and nucleic acids play crucial roles in biomedical engineering, holding substantial clinical potential. However, their utility is often hindered by various drawbacks, including cellular immunogenicity, and instability of exosomes and nucleic acids. In recent years, microneedle (MN) technology has revolutionized drug delivery by offering minimal invasiveness and remarkable versatility. MN has emerged as an ideal platform for the extraction, storage, and delivery of these biological components. This review presents a comprehensive overview of the historical progression and recent advances in the field of MN. Specifically, it highlights the current applications of cell-, exosome-, and nucleic acid-based MN systems, while presenting prevailing research challenges. Additionally, the review provides insights into the prospects of MN in this area, aiming to provide new ideas for researchers and facilitate the clinical translation of MN technology.
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Affiliation(s)
- Shufei Zhang
- Department of Obstetrics and Gynecology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, People's Republic of China.
| | - Lian Yang
- Department of Obstetrics and Gynecology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, People's Republic of China.
| | - Jianfeng Liu
- Department of Obstetrics and Gynecology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, People's Republic of China.
| | - Hanyue Li
- Department of Obstetrics and Gynecology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, People's Republic of China.
| | - Shasha Hong
- Department of Obstetrics and Gynecology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, People's Republic of China.
| | - Li Hong
- Department of Obstetrics and Gynecology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, People's Republic of China.
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Wu KY, Fujioka JK, Gholamian T, Zaharia M, Tran SD. Suprachoroidal Injection: A Novel Approach for Targeted Drug Delivery. Pharmaceuticals (Basel) 2023; 16:1241. [PMID: 37765048 PMCID: PMC10535603 DOI: 10.3390/ph16091241] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 09/29/2023] Open
Abstract
Treating posterior segment and retinal diseases poses challenges due to the complex structures in the eye that act as robust barriers, limiting medication delivery and bioavailability. This necessitates frequent dosing, typically via eye drops or intravitreal injections, to manage diseases, often leading to side effects with long-term use. Suprachoroidal injection is a novel approach for targeted drug delivery to the posterior segment. The suprachoroidal space is the region between the sclera and the choroid and provides a potential route for minimally invasive medication delivery. Through a more targeted delivery to the posterior segment, this method offers advantages over other routes of administration, such as higher drug concentrations, increased bioavailability, and prolonged duration of action. Additionally, this approach minimizes the risk of corticosteroid-related adverse events such as cataracts and intraocular pressure elevation via compartmentalization. This review focuses on preclinical and clinical studies published between 2019 and 2023, highlighting the potential of suprachoroidal injection in treating a variety of posterior segment diseases. However, to fully harness its potential, more research is needed to address current challenges and limitations, such as the need for technological advancements, refinement of injection techniques, and consideration of cost and accessibility factors. Future studies exploring its use in conjunction with biotech products, gene therapies, and cell-based therapies can lead to personalized treatments that can revolutionize the field of ophthalmology.
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Affiliation(s)
- Kevin Y. Wu
- Department of Surgery, Division of Ophthalmology, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada; (K.Y.W.)
| | - Jamie K. Fujioka
- Faculty of Medicine, Queen’s University, Kingston, ON K7L 3N6, Canada
| | - Tara Gholamian
- Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada
| | - Marian Zaharia
- Department of Surgery, Division of Ophthalmology, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada; (K.Y.W.)
| | - Simon D. Tran
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC H3A 1G1, Canada
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Sahel DK, Vora LK, Saraswat A, Sharma S, Monpara J, D'Souza AA, Mishra D, Tryphena KP, Kawakita S, Khan S, Azhar M, Khatri DK, Patel K, Singh Thakur RR. CRISPR/Cas9 Genome Editing for Tissue-Specific In Vivo Targeting: Nanomaterials and Translational Perspective. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2023; 10:e2207512. [PMID: 37166046 PMCID: PMC10323670 DOI: 10.1002/advs.202207512] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 04/15/2023] [Indexed: 05/12/2023]
Abstract
Clustered randomly interspaced short palindromic repeats (CRISPRs) and its associated endonuclease protein, i.e., Cas9, have been discovered as an immune system in bacteria and archaea; nevertheless, they are now being adopted as mainstream biotechnological/molecular scissors that can modulate ample genetic and nongenetic diseases via insertion/deletion, epigenome editing, messenger RNA editing, CRISPR interference, etc. Many Food and Drug Administration-approved and ongoing clinical trials on CRISPR adopt ex vivo strategies, wherein the gene editing is performed ex vivo, followed by reimplantation to the patients. However, the in vivo delivery of the CRISPR components is still under preclinical surveillance. This review has summarized the nonviral nanodelivery strategies for gene editing using CRISPR/Cas9 and its recent advancements, strategic points of view, challenges, and future aspects for tissue-specific in vivo delivery of CRISPR/Cas9 components using nanomaterials.
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Affiliation(s)
- Deepak Kumar Sahel
- Department of PharmacyBirla Institute of Technology and Science‐PilaniBITS‐Pilani, Vidya ViharPilaniRajasthan333031India
| | - Lalitkumar K. Vora
- School of PharmacyQueen's University Belfast97 Lisburn RoadBelfastBT9 7BLUK
| | - Aishwarya Saraswat
- College of Pharmacy & Health SciencesSt. John's UniversityQueensNY11439USA
| | - Saurabh Sharma
- Terasaki Institute for Biomedical InnovationLos AngelesCA90064USA
| | - Jasmin Monpara
- Department of Pharmaceutical SciencesUniversity of SciencesPhiladelphiaPA19104USA
| | - Anisha A. D'Souza
- Graduate School of Pharmaceutical Sciences and School of PharmacyDuquesne UniversityPittsburghPA15282USA
| | - Deepakkumar Mishra
- School of PharmacyQueen's University Belfast97 Lisburn RoadBelfastBT9 7BLUK
| | - Kamatham Pushpa Tryphena
- Molecular and Cellular Neuroscience LabDepartment of Pharmacology and ToxicologyNational Institute of Pharmaceutical Education and Research (NIPER)‐HyderabadTelangana500037India
| | - Satoru Kawakita
- Department of Biomedical EngineeringUniversity of CaliforniaDavisCA95616USA
| | - Shahid Khan
- Terasaki Institute for Biomedical InnovationLos AngelesCA90064USA
| | - Mohd Azhar
- Research and Development Tata Medical and Diagnostics LimitedMumbaiMaharashtra400001India
| | - Dharmendra Kumar Khatri
- Molecular and Cellular Neuroscience LabDepartment of Pharmacology and ToxicologyNational Institute of Pharmaceutical Education and Research (NIPER)‐HyderabadTelangana500037India
| | - Ketan Patel
- College of Pharmacy & Health SciencesSt. John's UniversityQueensNY11439USA
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Rotenstreich Y, Sher I, Lawrence M, Mangelus M, Ingerman A, Barak Y. A Novel Device for Suprachoroidal Drug Delivery to Retina: Evaluation in Nonhuman Primates. Transl Vis Sci Technol 2023; 12:3. [PMID: 37289173 PMCID: PMC10257339 DOI: 10.1167/tvst.12.6.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/04/2023] [Indexed: 06/09/2023] Open
Abstract
Purpose Evaluation of distribution and tolerance of suprachoroidal injection of indocyanine green (ICG) in nonhuman primates (NHPs) using a novel suprachoroidal (SC) delivery technology. Methods Three live and three euthanized African green monkeys were injected with 150 or 200 µL ICG/eye into the SC space of both eyes, 2.5 mm posterior to the limbus in the inferior quadrant, utilizing a novel SC injector. Eyes were analyzed by imaging of scleral flatmounts. Live animals were observed for 24 hours for general health. Ophthalmic evaluation included slit-lamp biomicroscopy, tonometry, fundus imaging, confocal laser ophthalmoscopy, and spectral-domain optical coherence tomography (SD-OCT) before and at 10 minutes and 1, 3, and 24 hours post-injection. Results SC dosing was successfully performed in all eyes. Infrared fundus imaging demonstrated ICG distribution throughout the posterior segment, reaching the macula within 24 hours post-injection. No inflammation, intravitreal penetration, SC blebs, retinal detachment, or hemorrhages were detected. No significant changes were observed in retinal thickness by SD-OCT (P = 0.267, ANOVA). A mild, statistically insignificant elevation in intraocular pressure was observed within 10 minutes post-injection (mean ± standard error: 7.28 ± 5.09 mmHg; P = 0.061) and was spontaneously resolved within the first hour after dosing. Conclusions Suprachoroidal injection of 150 to 200 µL ICG dye was successfully performed and well tolerated in NHP eyes, with rapid distribution into the macular region and throughout the posterior pole. Translational Relevance This novel SC drug delivery system may potentially provide safe and effective delivery of therapeutics to the posterior pole region in humans.
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Affiliation(s)
- Ygal Rotenstreich
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Ifat Sher
- The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- TELEM Rubin Excellence in Biomedical Research Program, Sheba Medical Center, Tel Hashomer, Israel
| | | | | | | | - Yoreh Barak
- Department of Ophthalmology, Rambam Health Care Campus, Haifa, Israel
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Hammadi S, Tzoumas N, Ferrara M, Meschede IP, Lo K, Harris C, Lako M, Steel DH. Bruch's Membrane: A Key Consideration with Complement-Based Therapies for Age-Related Macular Degeneration. J Clin Med 2023; 12:2870. [PMID: 37109207 PMCID: PMC10145879 DOI: 10.3390/jcm12082870] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 03/29/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
The complement system is crucial for immune surveillance, providing the body's first line of defence against pathogens. However, an imbalance in its regulators can lead to inappropriate overactivation, resulting in diseases such as age-related macular degeneration (AMD), a leading cause of irreversible blindness globally affecting around 200 million people. Complement activation in AMD is believed to begin in the choriocapillaris, but it also plays a critical role in the subretinal and retinal pigment epithelium (RPE) spaces. Bruch's membrane (BrM) acts as a barrier between the retina/RPE and choroid, hindering complement protein diffusion. This impediment increases with age and AMD, leading to compartmentalisation of complement activation. In this review, we comprehensively examine the structure and function of BrM, including its age-related changes visible through in vivo imaging, and the consequences of complement dysfunction on AMD pathogenesis. We also explore the potential and limitations of various delivery routes (systemic, intravitreal, subretinal, and suprachoroidal) for safe and effective delivery of conventional and gene therapy-based complement inhibitors to treat AMD. Further research is needed to understand the diffusion of complement proteins across BrM and optimise therapeutic delivery to the retina.
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Affiliation(s)
- Sarah Hammadi
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Nikolaos Tzoumas
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
- Sunderland Eye Infirmary, Queen Alexandra Rd., Sunderland SR2 9H, UK
| | | | - Ingrid Porpino Meschede
- Gyroscope Therapeutics Limited, a Novartis Company, Rolling Stock Yard, 6th Floor, 188 York Way, London N7 9AS, UK
| | - Katharina Lo
- Gyroscope Therapeutics Limited, a Novartis Company, Rolling Stock Yard, 6th Floor, 188 York Way, London N7 9AS, UK
| | - Claire Harris
- Gyroscope Therapeutics Limited, a Novartis Company, Rolling Stock Yard, 6th Floor, 188 York Way, London N7 9AS, UK
- Clinical and Translational Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Majlinda Lako
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - David H. Steel
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
- Sunderland Eye Infirmary, Queen Alexandra Rd., Sunderland SR2 9H, UK
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12
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Hao H, He B, Yu B, Yang J, Xing X, Liu W. Suprachoroidal injection of polyzwitterion hydrogel for treating glaucoma. BIOMATERIALS ADVANCES 2022; 142:213162. [PMID: 36279749 DOI: 10.1016/j.bioadv.2022.213162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 09/24/2022] [Accepted: 10/15/2022] [Indexed: 06/16/2023]
Abstract
Glaucoma is the primary cause of irreversible blindness worldwide. The current treatments are primarily based on drug usage or surgical operation to reduce intraocular pressure (IOP). However, it is expensive and requires patients to insist on taking the medicine for a long time. The suprachoroidal space (SCS) is the space between the choroid and the sclera, which forms part of the uveovortex pathway in the circulation of aqueous humor. So far, it is still challenging to realize the injection of hydrogels into the SCS with long-term duration. In this work, an in situ-forming polyzwitterionic polycarboxybetaine hydrogel is designed and injected to expand SCS to increase the drainage of aqueous humor from the eye via the uveovortex pathway, thus reducing IOP for at least 6 weeks, while commercial hyaluronic acid hydrogel can only last for about 4 weeks. The clinical ophthalmological safety assessment examination shows that the treatment of polyzwitterion hydrogel is well-tolerated that leads to minimal inflammatory reaction, and histopathology assessment demonstrates that the SCS is expanded after injection of the hydrogel. Further analysis of ultrasound biomicroscopy reveals that there is a strong correlation between IOP reduction and SCS expansion. In short, the polyzwitterion hydrogel developed in this work can prolong the period of IOP reduction by expanding SCS, thus treating ocular hypertension and glaucoma without resorting to drugs or regular surgery.
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Affiliation(s)
- Huijie Hao
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China
| | - Binbin He
- School of Materials Science and Engineering, Tianjin Key Laboratory of Composite and Functional Materials, Tianjin University, Tianjin 300350, China
| | - Bo Yu
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China
| | - Jianhai Yang
- School of Materials Science and Engineering, Tianjin Key Laboratory of Composite and Functional Materials, Tianjin University, Tianjin 300350, China.
| | - Xiaoli Xing
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China.
| | - Wenguang Liu
- School of Materials Science and Engineering, Tianjin Key Laboratory of Composite and Functional Materials, Tianjin University, Tianjin 300350, China
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13
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Suprachoroidal delivery enables targeting, localization and durability of small molecule suspensions. J Control Release 2022; 349:1045-1051. [PMID: 35868358 DOI: 10.1016/j.jconrel.2022.05.061] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 05/30/2022] [Indexed: 11/20/2022]
Abstract
Drug delivery to the suprachoroidal space (SCS®) has become a clinical reality after the 2021 FDA approval of CLS-TA, a triamcinolone acetonide injectable suspension for suprachoroidal use (XIPERE®), administered via a microneedle-based device, the SCS Microinjector®. Suprachoroidal (SC) delivery facilitates targeting, compartmentalization, and durability of small molecule suspensions, thereby potentially addressing some of the efficacy, safety, and treatment burden limitations of current retinal therapies. Herein, the design features of the SCS Microinjector are reviewed, along with the biomechanics of SC drug delivery. Also presented are preclinical evaluations of SC small molecule suspensions from 4 different therapeutic classes (plasma kallikrein inhibitor, receptor tyrosine kinase inhibitor, corticosteroid, complement factor D inhibitor), highlighting their potential for durability, targeted compartmentalization, and acceptable safety profiles following microinjector-based SC delivery. The clinical evaluations of the safety, tolerability and efficacy of SC delivered triamcinolone further supports potential of SC small molecule suspensions as a clinically viable strategy for the treatment of chorioretinal diseases. Also highlighted are current limitations, key pharmacological considerations, and future opportunities to optimize the SC microinjector platform for safe, effective, and potentially long-acting drug delivery for the treatment of chorioretinal disorders.
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Tabl AA, Elsayed MA, Tabl MA. Suprachoroidal triamcinolone acetonide injection: a novel therapy for serous retinal detachment due to Vogt-Koyanagi Harada disease. Eur J Ophthalmol 2022; 32:3482-3488. [PMID: 35266801 DOI: 10.1177/11206721221085420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To assess the efficacy and safety of Suprachoroidal triamcinolone acetonide injection [SCTA] as an adjunctive therapy in management of Vogt-Koyanagi Harada [VKH] serous retinal detachment. DESIGN Prospective parallel group study. PARTICIPANTS 12 eyes of 6 patients with bilateral multiple serous retinal detachment of VKH in acute phase on systemic steroids. METHODS Each patient was received single SCTA injection (SCTA group, n = 6 eyes) and the other non-injected eye (Standard treatment group, n = 6 eyes), patients were followed for 1, 3, and 6 months to assess changes in best corrected visual acuity [BCVA], central foveal thickness [CFT] and intraocular pressure [IOP] between both groups. MAIN OUTCOME MEASURES The primary end point was changes in BCVA from baseline till 6th months follow-up. Secondary end points were changes in CFT and IOP from baseline to 6 months of follow-up. RESULTS BCVA at one and three months was significantly better in eyes received SCTA than in non-injected eyes (p-value = 0.026 for each). CFT at one and three months was significantly higher in non-injected eyes than in eyes received SCTA (p-value = 0.028 for each). IOP showed no significant differences between both groups. CONCLUSIONS SCTA is an effective adjuvant treatment for VKH serous retinal detachment, without any serious ocular adverse effects or increase in IOP and causing significant reduction in CFT and rapid improvement in BCVA when combined with oral steroids.
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Affiliation(s)
- Ahmed Abdelshafy Tabl
- Department of Ophthalmology, Faculty of Medicine, 68817Benha University, Farid Nada st Benha, 13512, Egypt
| | - Mohamed Anany Elsayed
- Department of Ophthalmology, Faculty of Medicine, 68817Benha University, Farid Nada st Benha, 13512, Egypt
| | - Marwa Abdelshafy Tabl
- Department of Ophthalmology, Faculty of Medicine, 68817Benha University, Farid Nada st Benha, 13512, Egypt
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15
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Verma A, Bacci T, Sarraf D, Freund KB, Sadda SR. Vortex Vein Imaging: What Can It Tell Us? Clin Ophthalmol 2021; 15:3321-3331. [PMID: 34408390 PMCID: PMC8364369 DOI: 10.2147/opth.s324245] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/23/2021] [Indexed: 11/23/2022] Open
Abstract
This review article summarizes the patho-anatomy of the vortex veins, the major drainage channels for the choroid, and describes the various pathways of diseases associated with vortex vein abnormalities. This report also details the technical advancements to image the vortex veins, such as ultra-widefield indocyanine green angiography, which are critical to elucidate the importance of the vortices in various retino-choroidal disorders. Future applications of these advanced imaging systems to better understand the role of the vortex veins in health and disease are also discussed.
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Affiliation(s)
- Aditya Verma
- Doheny Eye Institute, Los Angeles, CA, USA.,Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Tommaso Bacci
- Vitreous Retina Macula Consultants of New York, New York, NY, USA.,Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY, USA
| | - David Sarraf
- Stein Eye Institute, David Geffen School of Medicine at University of California, Los Angeles, CA, 90095, USA
| | - K Bailey Freund
- Vitreous Retina Macula Consultants of New York, New York, NY, USA.,Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY, USA
| | - SriniVas R Sadda
- Doheny Eye Institute, Los Angeles, CA, USA.,Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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16
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Tharmatt A, Malhotra D, Sharma H, Bedi N. Pharmaceutical Perspective in Wearable Drug Delivery Systems. Assay Drug Dev Technol 2021; 19:386-401. [PMID: 34339259 DOI: 10.1089/adt.2021.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Humans have been dealing with health problems for millions of years. Normal health services need well-trained personnel and high-cost diagnostic tests, which forces patients to go to hospitals if medical treatment is required. To address this, prototype testing has been carried out into the wearable drug delivery health care perspectives. Researchers have devised a wide variety of formulations for the treatment of various diseases at home by performing real-time monitoring of different routes of drug administration such as ocular, transdermal, intraoral, intracochlear, and several more. A comprehensive review of the different types of wearable drug delivery systems with respect to their manufacturing, mechanism of action and specifications has been done. In the pharmaceutical context, these devices are technologically well-equipped interfaces for diverse physicochemical signals. Above mentioned information with a broader perspective has also been discussed in this article. Several wearable drug delivery systems have been introduced in the market in recent years. But a lot of testing needs to be conducted to address the numerous obstacles before the wearable devices are successfully launched in the market.
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Affiliation(s)
- Abhay Tharmatt
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, India
| | - Danish Malhotra
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, India
| | - Hamayal Sharma
- Department of Pharmacy, Birla Institute of Technology and Science (BITS) Pilani, Pilani, India
| | - Neena Bedi
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, India
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17
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Naftali Ben Haim L, Moisseiev E. Drug Delivery via the Suprachoroidal Space for the Treatment of Retinal Diseases. Pharmaceutics 2021; 13:pharmaceutics13070967. [PMID: 34206925 PMCID: PMC8309112 DOI: 10.3390/pharmaceutics13070967] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 06/18/2021] [Accepted: 06/22/2021] [Indexed: 02/06/2023] Open
Abstract
The suprachoroidal space (SCS), a potential space between the sclera and choroid, is becoming an applicable method to deliver therapeutics to the back of the eye. In recent years, a vast amount of research in the field has been carried out, with new discoveries in different areas of interest, such as imaging, drug delivery methods, pharmacokinetics, pharmacotherapies in preclinical and clinical trials and advanced therapies. The SCS can be visualized via advanced techniques of optical coherence tomography (OCT) in eyes with different pathologies, and even in healthy eyes. Drugs can be delivered easily and safely via hollow microneedles fitted to the length of the approximate thickness of the sclera. SCS injections were found to reach greater baseline concentrations in the target layers compared to intravitreal (IVT) injection, while agent clearance was faster with highly aqueous soluble molecules. Clinical trials with SCS injection of triamcinolone acetonide (TA) were executed with promising findings for patients with noninfectious uveitis (NIU), NIU implicated with macular edema and diabetic macular edema (DME). Gene therapy is evolving rapidly with viral and non-viral vectors that were found to be safe and efficient in preclinical trials. Here, we review these novel different aspects and new developments in clinical treatment of the posterior segment of the eye.
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Affiliation(s)
- Liron Naftali Ben Haim
- Department of Ophthalmology, Meir Medical Center, Kfar Saba, 59 Tshernichovsky St., Kfar Saba 4428164, Israel;
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Correspondence: ; Tel.: +972-97471527; Fax: +972-97472427
| | - Elad Moisseiev
- Department of Ophthalmology, Meir Medical Center, Kfar Saba, 59 Tshernichovsky St., Kfar Saba 4428164, Israel;
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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18
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Peptidomimetics Therapeutics for Retinal Disease. Biomolecules 2021; 11:biom11030339. [PMID: 33668179 PMCID: PMC7995992 DOI: 10.3390/biom11030339] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/11/2021] [Accepted: 02/20/2021] [Indexed: 12/28/2022] Open
Abstract
Ocular disorders originating in the retina can result in a partial or total loss of vision, making drug delivery to the retina of vital importance. However, effectively delivering drugs to the retina remains a challenge for ophthalmologists due to various anatomical and physicochemical barriers in the eye. This review introduces diverse administration routes and the accordant pharmacokinetic profiles of ocular drugs to aid in the development of safe and efficient drug delivery systems to the retina with a focus on peptidomimetics as a growing class of retinal drugs, which have great therapeutic potential and a high degree of specificity. We also discuss the pharmacokinetic profiles of small molecule drugs due to their structural similarity to small peptidomimetics. Lastly, various formulation strategies are suggested to overcome pharmacokinetic hurdles such as solubility, retention time, enzymatic degradation, tissue targeting, and membrane permeability. This knowledge can be used to help design ocular delivery platforms for peptidomimetics, not only for the treatment of various retinal diseases, but also for the selection of potential peptidomimetic drug targets.
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19
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Wan CR, Muya L, Kansara V, Ciulla TA. Suprachoroidal Delivery of Small Molecules, Nanoparticles, Gene and Cell Therapies for Ocular Diseases. Pharmaceutics 2021; 13:pharmaceutics13020288. [PMID: 33671815 PMCID: PMC7926337 DOI: 10.3390/pharmaceutics13020288] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 02/06/2023] Open
Abstract
Suprachoroidal drug delivery technology has advanced rapidly and emerged as a promising administration route for a variety of therapeutic candidates, in order to target multiple ocular diseases, ranging from neovascular age-related macular degeneration to choroidal melanoma. This review summarizes the latest preclinical and clinical progress in suprachoroidal delivery of therapeutic agents, including small molecule suspensions, polymeric entrapped small molecules, gene therapy (viral and nonviral nanoparticles), viral nanoparticle conjugates (VNCs), and cell therapy. Formulation customization is critical in achieving favorable pharmacokinetics, and sustained drug release profiles have been repeatedly observed for multiple small molecule suspensions and polymeric formulations. Novel therapeutic agents such as viral and nonviral gene therapy, as well as VNCs, have demonstrated promise in animal studies. Several of these suprachoroidally-administered therapies have been assessed in clinical trials, including small molecule suspensions of triamcinolone acetonide and axitinib, viral vector RGX-314 for gene therapy, and VNC AU-011. With continued drug delivery research and optimization, coupled with customized drug formulations, suprachoroidal drug delivery may address large unmet therapeutic needs in ophthalmology, targeting affected tissues with novel therapies for efficacy benefits, compartmentalizing therapies away from unaffected tissues for safety benefits, and achieving durability to relieve the treatment burden noted with current agents.
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20
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Hancock SE, Wan CR, Fisher NE, Andino RV, Ciulla TA. Biomechanics of suprachoroidal drug delivery: From benchtop to clinical investigation in ocular therapies. Expert Opin Drug Deliv 2021; 18:777-788. [PMID: 33393391 DOI: 10.1080/17425247.2021.1867532] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION As research in suprachoroidal drug delivery advances, and therapeutic candidates, ranging from small molecule suspensions to gene therapy, progress through clinical trials, an understanding of suprachoroidal space (SCS) biomechanics assumes increasing importance.Areas covered:Numerous anatomic features play an important role in therapeutic access to the SCS. Methods of access include a catheter, a standard hypodermic needle, and a microinjector with microneedle. Physical and fluidic properties of injectates into the SCS, such as volume, viscosity, particle size, osmotic pressure, and ionic charge of formulation can impact the spread and extent of opening of the SCS. Pharmacokinetic data of several small molecule suspensions yielded favorable ocular distribution and pharmacokinetic profiles. Phase 2 and 3 clinical trials have been completed with a suprachoroidally injected corticosteroid; results and information on procedural details with the microinjector are discussed. EXPERT OPINION Suprachoroidal drug delivery has been demonstrated to be a reliable and consistent drug delivery method for targeted treatment of retinal and choroidal disorders to potentially maximize efficacy, while compartmentalizing therapies away from the unaffected tissues to potentially enhance safety. These delivery attributes, along with fluid transport properties and formula customization for pharmacological agents, may allow for more tailored treatment of diseases affecting chorio-retinal tissues.
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21
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Sher I, Bubis E, Ketter-Katz H, Goldberg Z, Saeed R, Rotenstreich Y. Efficacy and safety of injecting increasing volumes into the extravascular spaces of the choroid using a blunt adjustable depth injector. Int Ophthalmol 2020; 40:2865-2874. [PMID: 32617801 DOI: 10.1007/s10792-020-01471-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/20/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE To evaluate the efficacy and safety of injecting increasing volumes into the extravascular spaces of the choroid (EVSC) in rabbit eyes in vivo using a blunt adjustable depth injector. METHODS Indocyanine green (ICG) was injected in the superior-temporal quadrant, 2 mm posterior to the limbus at increasing volumes (0.1-0.3 ml) into the EVSC of New Zealand rabbit eyes in vivo. Intraocular pressure (IOP) measurements, spectral domain optical coherence tomography (SD-OCT), fundus imaging and histology analysis were performed to assess the safety and efficacy of the injection. RESULTS Volumes up to 0.3 ml were administered consistently. ICG injection was successfully monitored in vivo using infrared fundus imaging and SD-OCT. ICG was detected across the EVSC compartment, reaching the retinal pigment epithelium, optic nerve head and visual streak. Injection of 0.3 ml yielded maximal dye distribution with a coverage area of 61.8% ± 6.7% (mean ± standard error, SE) of the posterior segment. Maximal IOP elevation was recorded 5 min following injection of 0.2 and 0.3 ml ICG (+ 20.0 mmHg, + 19.4 mmHg, respectively). Twenty minutes post-injection, the IOP was < 15 mmHg in all injection volumes. No retinal detachment or hemorrhages were detected in any of the injected eyes. CONCLUSIONS This study demonstrates consistent and safe delivery of large volumes within the EVSC using a blunt adjustable depth injector that distributes the dye over 60% of the retinal surface. This injection system may offer a minimally invasive and easy way to deliver large volumes of pharmaceuticals into the posterior segment.
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Affiliation(s)
- Ifat Sher
- Goldschleger Eye Institute, Sheba Medical Center, 52621, Tel-Hashomer, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ettel Bubis
- Goldschleger Eye Institute, Sheba Medical Center, 52621, Tel-Hashomer, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadas Ketter-Katz
- Goldschleger Eye Institute, Sheba Medical Center, 52621, Tel-Hashomer, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zehavit Goldberg
- Goldschleger Eye Institute, Sheba Medical Center, 52621, Tel-Hashomer, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rawan Saeed
- Goldschleger Eye Institute, Sheba Medical Center, 52621, Tel-Hashomer, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ygal Rotenstreich
- Goldschleger Eye Institute, Sheba Medical Center, 52621, Tel-Hashomer, Israel. .,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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22
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Jung JH, Chiang B, Grossniklaus HE, Prausnitz MR. Ocular drug delivery targeted by iontophoresis in the suprachoroidal space using a microneedle. J Control Release 2018; 277:14-22. [PMID: 29505807 DOI: 10.1016/j.jconrel.2018.03.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/23/2018] [Accepted: 03/01/2018] [Indexed: 11/19/2022]
Abstract
Treatment of many posterior-segment ocular indications would benefit from improved targeting of drug delivery to the back of the eye. Here, we propose the use of iontophoresis to direct delivery of negatively charged nanoparticles through the suprachoroidal space (SCS) toward the posterior pole of the eye. Injection of nanoparticles into the SCS of the rabbit eye ex vivo without iontophoresis led to a nanoparticle distribution mostly localized at the site of injection near the limbus and <15% of nanoparticles delivered to the most posterior region of SCS (>9 mm from the limbus). Iontophoresis using a novel microneedle-based device increased posterior targeting with >30% of nanoparticles in the most posterior region of SCS. Posterior targeting increased with increasing iontophoresis current and increasing application time up to 3 min, but further increasing to 5 min was not better, probably due to the observed collapse of the SCS within 5 min after injection ex vivo. Reversing the direction of iontophoretic flow inhibited posterior targeting, with just ~5% of nanoparticles reaching the most posterior region of SCS. In the rabbit eye in vivo, iontophoresis at 0.14 mA for 3 min after injection of a 100 μL suspension of nanoparticles resulted in ~30% of nanoparticles delivered to the most posterior region of the SCS, which was consistent with ex vivo findings. The procedure was well tolerated, with only mild, transient tissue effects at the site of injection. We conclude that iontophoresis in the SCS using a microneedle has promise as a method to target ocular drug delivery within the eye, especially toward the posterior pole.
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Affiliation(s)
- Jae Hwan Jung
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Bryce Chiang
- Wallace H. Coulter Department of Biomedical Engineering at Georgia Tech and Emory University, Georgia Institute of Technology, Atlanta, GA 30332, USA; Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Hans E Grossniklaus
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Mark R Prausnitz
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA; Wallace H. Coulter Department of Biomedical Engineering at Georgia Tech and Emory University, Georgia Institute of Technology, Atlanta, GA 30332, USA.
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Peynshaert K, Devoldere J, De Smedt SC, Remaut K. In vitro and ex vivo models to study drug delivery barriers in the posterior segment of the eye. Adv Drug Deliv Rev 2018; 126:44-57. [PMID: 28939376 DOI: 10.1016/j.addr.2017.09.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 07/18/2017] [Accepted: 09/08/2017] [Indexed: 12/18/2022]
Abstract
Many ocular disorders leading to blindness could benefit from efficient delivery of therapeutics to the retina. However, despite extensive research into drug delivery vehicles and administration techniques, efficacy remains limited because of the many static and dynamic barriers present in the eye. Comprehension of the various barriers and especially how to overcome them can improve our ability to estimate the potential of existent drug delivery vectors and support the design of new ones. To this end, this review gives an overview of the most important ocular barriers for each administration route to the back of the eye. For each barrier, its biological composition and its role as an obstacle towards macromolecules, nanoparticles and viral vectors will be discussed; special attention will be paid to the influence of size, charge and lipophilicity of drug(s) (carrier) on their ability to overcome each barrier. Finally, the most significant available in vitro and ex vivo methods and models to test the potential of a therapeutic to cross each barrier are listed.
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24
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Huang D, Chen YS, Rupenthal ID. Overcoming ocular drug delivery barriers through the use of physical forces. Adv Drug Deliv Rev 2018; 126:96-112. [PMID: 28916492 DOI: 10.1016/j.addr.2017.09.008] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 06/30/2017] [Accepted: 09/08/2017] [Indexed: 12/25/2022]
Abstract
Overcoming the physiological barriers in the eye remains a key obstacle in the field of ocular drug delivery. While ocular barriers naturally have a protective function, they also limit drug entry into the eye. Various pharmaceutical strategies, such as novel formulations and physical force-based techniques, have been investigated to weaken these barriers and transport therapeutic agents effectively to both the anterior and the posterior segments of the eye. This review summarizes and discusses the recent research progress in the field of ocular drug delivery with a focus on the application of physical methods, including electrical fields, sonophoresis, and microneedles, which can enhance penetration efficiency by transiently disrupting the ocular barriers in a minimally or non-invasive manner.
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25
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Chiang B, Jung JH, Prausnitz MR. The suprachoroidal space as a route of administration to the posterior segment of the eye. Adv Drug Deliv Rev 2018; 126:58-66. [PMID: 29545195 DOI: 10.1016/j.addr.2018.03.001] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 03/05/2018] [Accepted: 03/08/2018] [Indexed: 02/06/2023]
Abstract
The suprachoroidal space (SCS) is a potential space between the sclera and choroid that traverses the circumference of the posterior segment of the eye. The SCS is an attractive site for drug delivery because it targets the choroid, retinal pigment epithelium, and retina with high bioavailability, while maintaining low levels elsewhere in the eye. Indeed, phase III clinical trials are investigating the safety and efficacy of SCS drug delivery. Here, we review the anatomy and physiology of the SCS; methods to access the SCS; kinetics of SCS drug delivery; strategies to target within the SCS; current and potential clinical indications; and the safety and efficacy of this approach in preclinical animal studies and clinical trials.
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27
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Chiang B, Wang K, Ethier CR, Prausnitz MR. Clearance Kinetics and Clearance Routes of Molecules From the Suprachoroidal Space After Microneedle Injection. Invest Ophthalmol Vis Sci 2017; 58:545-554. [PMID: 28125841 PMCID: PMC5283080 DOI: 10.1167/iovs.16-20679] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Purpose To determine clearance kinetics and routes of clearance of molecules from the suprachoroidal space (SCS) of live New Zealand White rabbits. Methods Suprachoroidal space collapse rate and pressure changes after microneedle injection into SCS were determined. Fluorescent fundus images were acquired to determine clearance rates of molecules ranging in size from 332 Da to 2 MDa. Microneedle injections of fluorescein were performed, and samples were taken from various sites over time to determine amount of fluorescein exiting the eye. Clearance transport was modeled theoretically and compared with experimental data. Results After injection, pressures in SCS and vitreous humor spiked and returned to baseline within 20 minutes; there was no difference between these two pressures. Suprachoroidal space collapse occurred within 40 minutes. One hour after fluorescein injection, 46% of fluorescein was still present in the eye, 15% had transported across sclera, 6% had been cleared by choroidal vasculature, and 4% had exited via leakage pathways. Characteristic clearance time increased in proportion with molecular radius, but total clearance of 2 MDa FITC-dextran was significantly slower (21 days) than smaller molecules. These data generally agreed with predictions from a theoretical model of molecular transport. Conclusions Guided by experimental data in the context of model predictions, molecular clearance from SCS occurred in three regimes: (1) on a time scale of approximately 10 minutes, fluid and molecules exited SCS by diffusion into sclera and choroid, and by pressure-driven reflux via transscleral leakage sites; (2) in approximately 1 hour, molecules cleared from choroid by blood flow; and (3) in 1 to 10 hours, molecules cleared from sclera by diffusion and convection.
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Affiliation(s)
- Bryce Chiang
- Wallace H. Coulter Department of Biomedical Engineering at Georgia Tech and Emory University, Georgia Institute of Technology, Atlanta, Georgia, United States
| | - Ke Wang
- Wallace H. Coulter Department of Biomedical Engineering at Georgia Tech and Emory University, Georgia Institute of Technology, Atlanta, Georgia, United States
| | - C Ross Ethier
- Wallace H. Coulter Department of Biomedical Engineering at Georgia Tech and Emory University, Georgia Institute of Technology, Atlanta, Georgia, United States
| | - Mark R Prausnitz
- Wallace H. Coulter Department of Biomedical Engineering at Georgia Tech and Emory University, Georgia Institute of Technology, Atlanta, Georgia, United States 2School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, Georgia, United States
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28
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Chiang B, Venugopal N, Grossniklaus HE, Jung JH, Edelhauser HF, Prausnitz MR. Thickness and Closure Kinetics of the Suprachoroidal Space Following Microneedle Injection of Liquid Formulations. Invest Ophthalmol Vis Sci 2017; 58:555-564. [PMID: 28125842 PMCID: PMC5283084 DOI: 10.1167/iovs.16-20377] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Purpose To determine the effect of injection volume and formulation of a microneedle injection into the suprachoroidal space (SCS) on SCS thickness and closure kinetics. Methods Microneedle injections containing 25 to 150 μL Hanks' balanced salt solution (HBSS) were performed in the rabbit SCS ex vivo. Distribution of SCS thickness was measured by ultrasonography and three-dimensional (3D) cryo-reconstruction. Microneedle injections were performed in the rabbit SCS in vivo using HBSS, Discovisc, and 1% to 5% carboxymethyl cellulose (CMC) in HBSS. Ultrasonography was used to track SCS thickness over time. Results Increasing HBSS injection volume increased the area of expanded SCS, but did not increase SCS thickness ex vivo. With SCS injections in vivo, the SCS initially expanded to thicknesses of 0.43 ± 0.06 mm with HBSS, 1.5 ± 0.4 mm with Discovisc, and 0.69 to 2.1 mm with 1% to 5% CMC. After injection with HBSS, Discovisc, and 1% CMC solution, the SCS collapsed to baseline with time constants of 19 minutes, 6 hours, and 2.4 days, respectively. In contrast, injections with 3% to 5% CMC solution resulted in SCS expansion to 2.3 to 2.8 mm over the course of 2.8 to 9.1 hours, after which the SCS collapsed to baseline with time constants of 4.5 to 9.2 days. Conclusions With low-viscosity formulations, SCS expands to a thickness that remains roughly constant, independent of the volume of fluid injected. Increasing injection fluid viscosity significantly increased SCS thickness. Expansion of the SCS is hypothesized to be controlled by a balance between the viscous forces of the liquid formulation and the resistive biomechanical forces of the tissue.
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Affiliation(s)
- Bryce Chiang
- Wallace H. Coulter Department of Biomedical Engineering at Georgia Tech and Emory University, Georgia Institute of Technology, Atlanta, Georgia, United States
| | - Nitin Venugopal
- H. Milton Stewart School of Industrial & Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, United States
| | | | - Jae Hwan Jung
- School of Chemical & Biomolecular Engineering, Georgia Institute of Technology, Atlanta, Georgia, United States
| | | | - Mark R Prausnitz
- Wallace H. Coulter Department of Biomedical Engineering at Georgia Tech and Emory University, Georgia Institute of Technology, Atlanta, Georgia, United States 4School of Chemical & Biomolecular Engineering, Georgia Institute of Technology, Atlanta, Georgia, United States
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29
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Del Amo EM, Rimpelä AK, Heikkinen E, Kari OK, Ramsay E, Lajunen T, Schmitt M, Pelkonen L, Bhattacharya M, Richardson D, Subrizi A, Turunen T, Reinisalo M, Itkonen J, Toropainen E, Casteleijn M, Kidron H, Antopolsky M, Vellonen KS, Ruponen M, Urtti A. Pharmacokinetic aspects of retinal drug delivery. Prog Retin Eye Res 2016; 57:134-185. [PMID: 28028001 DOI: 10.1016/j.preteyeres.2016.12.001] [Citation(s) in RCA: 398] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/25/2016] [Accepted: 12/01/2016] [Indexed: 12/14/2022]
Abstract
Drug delivery to the posterior eye segment is an important challenge in ophthalmology, because many diseases affect the retina and choroid leading to impaired vision or blindness. Currently, intravitreal injections are the method of choice to administer drugs to the retina, but this approach is applicable only in selected cases (e.g. anti-VEGF antibodies and soluble receptors). There are two basic approaches that can be adopted to improve retinal drug delivery: prolonged and/or retina targeted delivery of intravitreal drugs and use of other routes of drug administration, such as periocular, suprachoroidal, sub-retinal, systemic, or topical. Properties of the administration route, drug and delivery system determine the efficacy and safety of these approaches. Pharmacokinetic and pharmacodynamic factors determine the required dosing rates and doses that are needed for drug action. In addition, tolerability factors limit the use of many materials in ocular drug delivery. This review article provides a critical discussion of retinal drug delivery, particularly from the pharmacokinetic point of view. This article does not include an extensive review of drug delivery technologies, because they have already been reviewed several times recently. Instead, we aim to provide a systematic and quantitative view on the pharmacokinetic factors in drug delivery to the posterior eye segment. This review is based on the literature and unpublished data from the authors' laboratory.
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Affiliation(s)
- Eva M Del Amo
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Anna-Kaisa Rimpelä
- Centre for Drug Research, Division of Pharmaceutical Biosciences, University of Helsinki, Helsinki, Finland
| | - Emma Heikkinen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Otto K Kari
- Centre for Drug Research, Division of Pharmaceutical Biosciences, University of Helsinki, Helsinki, Finland
| | - Eva Ramsay
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Tatu Lajunen
- Centre for Drug Research, Division of Pharmaceutical Biosciences, University of Helsinki, Helsinki, Finland
| | - Mechthild Schmitt
- Centre for Drug Research, Division of Pharmaceutical Biosciences, University of Helsinki, Helsinki, Finland
| | - Laura Pelkonen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Madhushree Bhattacharya
- Centre for Drug Research, Division of Pharmaceutical Biosciences, University of Helsinki, Helsinki, Finland
| | - Dominique Richardson
- Centre for Drug Research, Division of Pharmaceutical Biosciences, University of Helsinki, Helsinki, Finland
| | - Astrid Subrizi
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Tiina Turunen
- Centre for Drug Research, Division of Pharmaceutical Biosciences, University of Helsinki, Helsinki, Finland
| | - Mika Reinisalo
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Jaakko Itkonen
- Centre for Drug Research, Division of Pharmaceutical Biosciences, University of Helsinki, Helsinki, Finland
| | - Elisa Toropainen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Marco Casteleijn
- Centre for Drug Research, Division of Pharmaceutical Biosciences, University of Helsinki, Helsinki, Finland
| | - Heidi Kidron
- Centre for Drug Research, Division of Pharmaceutical Biosciences, University of Helsinki, Helsinki, Finland
| | - Maxim Antopolsky
- Centre for Drug Research, Division of Pharmaceutical Biosciences, University of Helsinki, Helsinki, Finland
| | | | - Marika Ruponen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Arto Urtti
- Centre for Drug Research, Division of Pharmaceutical Biosciences, University of Helsinki, Helsinki, Finland; School of Pharmacy, University of Eastern Finland, Kuopio, Finland.
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30
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Chiang B, Venugopal N, Edelhauser HF, Prausnitz MR. Distribution of particles, small molecules and polymeric formulation excipients in the suprachoroidal space after microneedle injection. Exp Eye Res 2016; 153:101-109. [PMID: 27742547 DOI: 10.1016/j.exer.2016.10.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/25/2016] [Accepted: 10/10/2016] [Indexed: 11/19/2022]
Abstract
The purpose of this work was to determine the effect of injection volume, formulation composition, and time on circumferential spread of particles, small molecules, and polymeric formulation excipients in the suprachoroidal space (SCS) after microneedle injection into New Zealand White rabbit eyes ex vivo and in vivo. Microneedle injections of 25-150 μL Hank's Balanced Salt Solution (HBSS) containing 0.2 μm red-fluorescent particles and a model small molecule (fluorescein) were performed in rabbit eyes ex vivo, and visualized via flat mount. Particles with diameters of 0.02-2 μm were co-injected into SCS in vivo with fluorescein or a polymeric formulation excipient: fluorescein isothiocyanate (FITC)-labeled Discovisc or FITC-labeled carboxymethyl cellulose (CMC). Fluorescent fundus images were acquired over time to determine area of particle, fluorescein, and polymeric formulation excipient spread, as well as their co-localization. We found that fluorescein covered a significantly larger area than co-injected particles when suspended in HBSS, and that this difference was present from 3 min post-injection onwards. We further showed that there was no difference in initial area covered by FITC-Discovisc and particles; the transport time (i.e., the time until the FITC-Discovisc and particle area began dissociating) was 2 d. There was also no difference in initial area covered by FITC-CMC and particles; the transport time in FITC-CMC was 4 d. We also found that particle size (20 nm-2 μm) had no effect on spreading area when delivered in HBSS or Discovisc. We conclude that (i) the area of particle spread in SCS during injection generally increased with increasing injection volume, was unaffected by particle size, and was significantly less than the area of fluorescein spread, (ii) particles suspended in low-viscosity HBSS formulation were entrapped in the SCS after injection, whereas fluorescein was not and (iii) particles co-injected with viscous polymeric formulation excipients co-localized near the site of injection in the SCS, continued to co-localize while spreading over larger areas for 2-4 days, and then no longer co-localized as the polymeric formulation excipients were cleared within 1-3 weeks and the particles remained largely in place. These data suggest that particles encounter greater barriers to flow in SCS compared to molecules and that co-localization of particles and polymeric formulation excipients allows spreading over larger areas of the SCS until the particles and excipients dissociate.
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Affiliation(s)
- Bryce Chiang
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, United States
| | - Nitin Venugopal
- H. Milton Stewart School of Industrial & Systems Engineering, Georgia Institute of Technology, Atlanta, GA, United States
| | | | - Mark R Prausnitz
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, United States; School of Chemical & Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA, United States.
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31
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Thakur Singh RR, Tekko I, McAvoy K, McMillan H, Jones D, Donnelly RF. Minimally invasive microneedles for ocular drug delivery. Expert Opin Drug Deliv 2016; 14:525-537. [DOI: 10.1080/17425247.2016.1218460] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Raghu Raj Thakur Singh
- School of Pharmacy, Queen’s University Belfast, Medical Biology Centre, Belfast, Northern Ireland, UK
| | - Ismaiel Tekko
- School of Pharmacy, Queen’s University Belfast, Medical Biology Centre, Belfast, Northern Ireland, UK
| | - Kathryn McAvoy
- School of Pharmacy, Queen’s University Belfast, Medical Biology Centre, Belfast, Northern Ireland, UK
| | - Hannah McMillan
- School of Pharmacy, Queen’s University Belfast, Medical Biology Centre, Belfast, Northern Ireland, UK
| | - David Jones
- School of Pharmacy, Queen’s University Belfast, Medical Biology Centre, Belfast, Northern Ireland, UK
| | - Ryan F. Donnelly
- School of Pharmacy, Queen’s University Belfast, Medical Biology Centre, Belfast, Northern Ireland, UK
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32
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Lajunen T, Nurmi R, Kontturi L, Viitala L, Yliperttula M, Murtomäki L, Urtti A. Light activated liposomes: Functionality and prospects in ocular drug delivery. J Control Release 2016; 244:157-166. [PMID: 27565215 DOI: 10.1016/j.jconrel.2016.08.024] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 08/08/2016] [Accepted: 08/21/2016] [Indexed: 12/17/2022]
Abstract
Ocular drug delivery, especially to the retina and choroid, is a major challenge in drug development. Liposome technology may be useful in ophthalmology in enabling new routes of delivery, prolongation of drug action and intracellular drug delivery, but drug release from the liposomes should be controlled. For that purpose, light activation may be an approach to release drug at specified time and site in the eye. Technical advances have been made in the field of light activated drug release, particularly indocyanine green loaded liposomes are a promising approach with safe materials and effective light triggered release of small and large molecules. This review discusses the liposomal drug delivery with light activated systems in the context of ophthalmic drug delivery challenges.
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Affiliation(s)
- Tatu Lajunen
- Centre for Drug Research, Division of Pharmaceutical Biosciences, University of Helsinki, Viikinkaari 5 E, 00790 Helsinki, Finland
| | - Riikka Nurmi
- Centre for Drug Research, Division of Pharmaceutical Biosciences, University of Helsinki, Viikinkaari 5 E, 00790 Helsinki, Finland
| | - Leena Kontturi
- Centre for Drug Research, Division of Pharmaceutical Biosciences, University of Helsinki, Viikinkaari 5 E, 00790 Helsinki, Finland; Department of Pharmaceutics, University of Utrecht, Utrecht, The Netherlands
| | - Lauri Viitala
- Department of Chemistry, Aalto University, Espoo, Finland
| | - Marjo Yliperttula
- Centre for Drug Research, Division of Pharmaceutical Biosciences, University of Helsinki, Viikinkaari 5 E, 00790 Helsinki, Finland; Department of Pharmaceutical Sciences, University of Padova, Padova, Italy
| | | | - Arto Urtti
- Centre for Drug Research, Division of Pharmaceutical Biosciences, University of Helsinki, Viikinkaari 5 E, 00790 Helsinki, Finland; School of Pharmacy, University of Eastern Finland, 70211 Kuopio, Finland.
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