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Pascual Carrasco Á, Espadas García I, Ramírez López A, Selva Otaolaurruchi J. [Translated article] Syringes for intraocular administration: A systematic review. FARMACIA HOSPITALARIA 2024; 48:T133-T140. [PMID: 38705829 DOI: 10.1016/j.farma.2024.04.011] [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: 01/31/2024] [Accepted: 01/31/2024] [Indexed: 05/07/2024] Open
Abstract
OBJECTIVE The off-label use in clinical practice of non-approved syringes for intravitreal drug administration has resulted in the detection of silicone oil drops in the vitreous of some patients. This situation derives from the lack of approved syringes for intraocular use in the Spanish market. The aim of this work is to review the use of syringes for intraocular administration, as well as to search for alternatives that meet the legal requirements for these unmet needs. METHOD A systematic review was performed following the PRISMA 2020 guidelines by searching PubMed with the descriptors: (silicone) AND (syringes) AND ((intraocular) OR (intravitreal)) and filtering all existing publications from January 2006 to December 2023, including all those articles dealing with silicone oil release in intravitreal injections and analysing the possible consequences. RESULTS Sixty-eight results were found, 23 of which were excluded because they did not deal with the subject under study, leaving a total of 45 articles for the systematic review. These were classified according to the conclusions obtained in 4 groups: the adverse reactions produced by silicone; the administration technique; the physicochemical aspects of silicone release; and the characteristics of the medical device. After reviewing the current manufacturers and technical data sheets of commercialised syringes, the existing syringes for this use have been collected, finding 2 that will probably be commercialised in Spain at the beginning of 2024: Zero Residual™ 0.2 ml SiO-free and VitreJect® Ophthalmic. CONCLUSIONS From the results obtained, it can be interpreted that the use of syringes and needles with silicone for intravitreal use is a concern for health professionals due to the implications and consequences that may arise in patients, the most important being adverse reactions, so it is necessary to have silicone-free syringes on the market that are specific for intraocular use. Safety and legality in the use of intraocular syringes and needles is essential to guarantee ocular integrity and patient health.
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Affiliation(s)
| | | | - Ana Ramírez López
- Servicio de Farmacia, Hospital General Universitario Doctor Balmis, Alicante, Spain
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Pascual Carrasco Á, Espadas García I, Ramírez López A, Selva Otaolaurruchi J. Syringes for intraocular administration: Systematic review. FARMACIA HOSPITALARIA 2024; 48:133-140. [PMID: 38556370 DOI: 10.1016/j.farma.2024.01.008] [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: 01/31/2024] [Accepted: 01/31/2024] [Indexed: 04/02/2024] Open
Abstract
OBJECTIVE The off-label use in clinical practice of non-approved syringes for intravitreal drug administration has resulted in the detection of silicone oil drops in the vitreous of some patients. This situation derives from the lack of approved syringes for intraocular use in the Spanish market. The aim of this work is to review the use of syringes for intraocular administration, as well as to search for alternatives that meet the legal requirements for these unmet needs. METHOD A systematic review was performed following the PRISMA 2020 Guidelines by searching PubMed with the descriptors: "silicone" AND "syringes" AND ("intraocular" OR "intravitreal") and filtering all existing publications from January 2006 to December 2023, including all those articles dealing with silicone oil release in intravitreal injections and analysing the possible consequences. RESULTS Sixty-eight results were found, 23 of which were excluded because they did not deal with the subject under study, leaving a total of 45 articles for the systematic review. These were classified according to the conclusions obtained in 4 groups: the adverse reactions produced by silicone, the administration technique, the physicochemical aspects of silicone release, and the characteristics of the medical device. After reviewing the current manufacturers and technical data sheets of commercialized syringes, the existing syringes for this use have been collected, finding two that will probably be commercialized in Spain at the beginning of 2024: Zero Residual™ 0.2 ml SiO-free and VitreJect® Ophthalmic. CONCLUSIONS From the results obtained, it can be interpreted that the use of syringes and needles with silicone for intravitreal use is a concern for health professionals due to the implications and consequences that may arise in patients, the most important being adverse reactions, so it is necessary to have silicone-free syringes on the market that are specific for intraocular use. Safety and legality in the use of intraocular syringes and needles is essential to guarantee ocular integrity and patient health.
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Affiliation(s)
| | - Isabel Espadas García
- Servicio de Farmacia, Hospital General Universitario Doctor Balmis, Alicante, España
| | - Ana Ramírez López
- Servicio de Farmacia, Hospital General Universitario Doctor Balmis, Alicante, España
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Jørstad ØK, Foss S, Gjølberg TT, Mester S, Nyquist-Andersen M, Sivertsen MS, Fossum D, Gleditsch E, Moe MC, Andersen JT. Pharmaceutical compounding and storage of faricimab in a syringe for intravitreal injection do not impair stability and bi-specific binding properties. Int J Retina Vitreous 2023; 9:65. [PMID: 37936232 PMCID: PMC10631190 DOI: 10.1186/s40942-023-00507-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/26/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Intravitreal injection (IVI) of antibody biologics is a key treatment approach in ophthalmology. Pharmaceutical compounding and storage of prefilled syringes for IVI must take place without impairing the structure and function of the biologics. This study investigated the effect of withdrawing and storing the therapeutic antibody faricimab (Vabysmo, Roche, Basel, Switzerland) in the Zero Residual silicone oil-free, 0.2-mL syringe (SJJ Solutions, The Hague, the Netherlands). METHODS To assess the effect of syringe withdrawal on faricimab, we compared samples from syringes prepared at day 0 with samples taken directly from faricimab vials. To assess the effect of syringe storage on faricimab, we kept prefilled syringes in the dark at 4 oC for 7, 14, or 37 days and compared samples from these syringes with day 0. We measured protein concentration (with spectrophotometry), stability and integrity (with sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE), size-exclusion chromatography (SEC), and melting temperature (Tm)), as well as binding of faricimab to its cognate antigens: vascular endothelial growth factor A (VEGF-A) and angiopoietin-2 (Ang-2) (with enzyme-linked immunosorbent assay (ELISA)). RESULTS Faricimab migrated in line with its expected molecular mass under both reducing and non-reducing conditions for all time points when analyzed with SDS-PAGE, without any sign of degradation products or aggregation. The SEC elution profiles were identical for all time points. There were slight variations in Tm for different time points compared to day 0 but without consistent relationship with storage time. ELISA did not detect differences in VEGF-A or Ang-2 binding between time points, and faricimab did not bind the neonatal Fc receptor. CONCLUSIONS Withdrawal and storage of faricimab in syringes for up to day 37 did not impair the structure and bi-specific binding properties of the therapeutic antibody.
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Affiliation(s)
| | - Stian Foss
- Department of Pharmacology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Precision Immunotherapy Alliance (PRIMA), University of Oslo, Oslo, Norway
| | - Torleif Tollefsrud Gjølberg
- Department of Pharmacology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Precision Immunotherapy Alliance (PRIMA), University of Oslo, Oslo, Norway
| | - Simone Mester
- Department of Pharmacology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Precision Immunotherapy Alliance (PRIMA), University of Oslo, Oslo, Norway
| | - Mari Nyquist-Andersen
- Department of Pharmacology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Precision Immunotherapy Alliance (PRIMA), University of Oslo, Oslo, Norway
| | | | - Dag Fossum
- The Hospital Pharmacy Oslo, Ullevål, Norway
| | | | - Morten Carstens Moe
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jan Terje Andersen
- Department of Pharmacology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Precision Immunotherapy Alliance (PRIMA), University of Oslo, Oslo, Norway
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Vitharana S, Stillahn JM, Katayama DS, Henry CS, Manning MC. Application of Formulation Principles to Stability Issues Encountered During Processing, Manufacturing, and Storage of Drug Substance and Drug Product Protein Therapeutics. J Pharm Sci 2023; 112:2724-2751. [PMID: 37572779 DOI: 10.1016/j.xphs.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 07/24/2023] [Accepted: 08/07/2023] [Indexed: 08/14/2023]
Abstract
The field of formulation and stabilization of protein therapeutics has become rather extensive. However, most of the focus has been on stabilization of the final drug product. Yet, proteins experience stress and degradation through the manufacturing process, starting with fermentaition. This review describes how formulation principles can be applied to stabilize biopharmaceutical proteins during bioprocessing and manufacturing, considering each unit operation involved in prepration of the drug substance. In addition, the impact of the container on stabilty is discussed as well.
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Affiliation(s)
| | - Joshua M Stillahn
- Legacy BioDesign LLC, Johnstown, CO 80534, USA; Department of Chemistry, Colorado State University, Fort Collins, CO 80523, USA
| | | | - Charles S Henry
- Department of Chemistry, Colorado State University, Fort Collins, CO 80523, USA
| | - Mark Cornell Manning
- Legacy BioDesign LLC, Johnstown, CO 80534, USA; Department of Chemistry, Colorado State University, Fort Collins, CO 80523, USA.
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Iqball S, Beck DK, Devarajan G, Khoo CP, O’Connor DM, Ellis S, Guzman E, Mitrophanous KA, Lad Y. Lentiviral delivered aflibercept OXB-203 for treatment of neovascular AMD. Mol Ther Methods Clin Dev 2023; 30:350-366. [PMID: 37637380 PMCID: PMC10448334 DOI: 10.1016/j.omtm.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 07/12/2023] [Indexed: 08/29/2023]
Abstract
Neovascular age-related macular degeneration (nAMD) is a leading cause of blindness in the aging population, with vascular endothelial growth factor (VEGF) playing a key role. Treatment with recombinant anti-VEGFs is the current standard of care; however, it is only effective for 1-2 months at a time and requires re-administration. Gene therapy could pave the way for stable, long-term expression of therapeutic anti-VEGF with a single dose, reducing the frequency of treatment and potentially improving clinical outcomes. As such, we have developed OXB-203, a lentiviral-based gene therapy encoding the anti-VEGF protein aflibercept. Aflibercept derived from OXB-203 exhibited comparable in vitro binding characteristics to VEGF as recombinant aflibercept. Furthermore, its biological potency was demonstrated by the equivalent inhibition of VEGF-induced human umbilical vein endothelial cell (HUVEC) proliferation and tubule formation as recombinant aflibercept. In a rat choroidal neovascularization (CNV) model of nAMD, a single subretinal administration of OXB-203 reduced laser-induced CNV lesion areas analogous to an intravitreal bolus of recombinant aflibercept. Finally, in a head-to-head comparative study, aflibercept derived from OXB-203 was shown to be expressed at significantly higher levels in ocular tissues than from an AAV8-aflibercept vector following a single subretinal delivery to rats. These findings support the therapeutic potential of OXB-203 for the management of nAMD.
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Affiliation(s)
- Sharifah Iqball
- Oxford Biomedica (UK) Ltd., Windrush Court, Transport Way, OX4 6LT Oxford, UK
| | - Daniel K. Beck
- Oxford Biomedica (UK) Ltd., Windrush Court, Transport Way, OX4 6LT Oxford, UK
| | - Gayathri Devarajan
- Oxford Biomedica (UK) Ltd., Windrush Court, Transport Way, OX4 6LT Oxford, UK
| | - Cheen P. Khoo
- Oxford Biomedica (UK) Ltd., Windrush Court, Transport Way, OX4 6LT Oxford, UK
| | - Deirdre M. O’Connor
- Oxford Biomedica (UK) Ltd., Windrush Court, Transport Way, OX4 6LT Oxford, UK
| | - Scott Ellis
- Oxford Biomedica (UK) Ltd., Windrush Court, Transport Way, OX4 6LT Oxford, UK
| | - Efrain Guzman
- Oxford Biomedica (UK) Ltd., Windrush Court, Transport Way, OX4 6LT Oxford, UK
| | | | - Yatish Lad
- Oxford Biomedica (UK) Ltd., Windrush Court, Transport Way, OX4 6LT Oxford, UK
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Louis AM, Ali AM, Patel SB, Fan KC, Rahman EZ, Pearce WA, Trejo Corona S, Villanueva Boone C, Yu HJ, Wykoff CC. Impact of Prefilled Syringes and Masking on Postintravitreal Injection Endophthalmitis. JOURNAL OF VITREORETINAL DISEASES 2023; 7:382-388. [PMID: 37706081 PMCID: PMC10496810 DOI: 10.1177/24741264231191339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Purpose: To compare rates of endophthalmitis (1) following intravitreal injection of antivascular endothelial growth factor therapies with glass-vial preparation (GVP) vs prefilled syringes (PFS) and (2) before and after masking protocols were implemented. Methods: Medical records within a multicenter retina practice in Houston, Texas, from January 2015 to August 2021 were retrospectively reviewed. The primary outcome was rate of endophthalmitis after intravitreal injection. Results: A total of 307 349 injections were performed during the study period and 101 cases of endophthalmitis were identified (0.033%). PFS use was associated with a decreased risk of endophthalmitis (relative risk [RR], 0.320; 95% CI, 0.198-0.518, P < .001); 54 cases of endophthalmitis occurred in the GVP group of aflibercept and ranibizumab (0.052%) compared with 24 in the PFS group (0.017%). There was no difference in the endophthalmitis rates with or without universal masking (RR, 0.953; 95% CI 0.616-1.473, P = .91). Discussion: PFS use was associated with a significant reduction in the rate of endophthalmitis while the use of surgical face masks did not appear to significantly impact the rate of endophthalmitis.
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Affiliation(s)
- Abigail M. Louis
- McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Amna M. Ali
- McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Sagar B. Patel
- Retina Consultants of Texas, Retina Consultants of America, Bellaire, TX, USA
- Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
| | - Kenneth C. Fan
- Retina Consultants of Texas, Retina Consultants of America, Bellaire, TX, USA
- Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
| | - Effie Z. Rahman
- Retina Consultants of Texas, Retina Consultants of America, Bellaire, TX, USA
- Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
| | - William A. Pearce
- Retina Consultants of Texas, Retina Consultants of America, Bellaire, TX, USA
- Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
| | | | | | - Hannah J. Yu
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Charles C. Wykoff
- Retina Consultants of Texas, Retina Consultants of America, Bellaire, TX, USA
- Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
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Physicochemical and Biological Stability Assessment of SB11 (Ranibizumab Biosimilar) Under Ambient and In-Use Storage for Intravitreal Administration. Ophthalmol Ther 2023; 12:985-998. [PMID: 36607595 PMCID: PMC10011347 DOI: 10.1007/s40123-022-00645-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/21/2022] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION SB11 (Byooviz™) is a ranibizumab biosimilar that acts as a vascular endothelial growth factor (VEGF)-A inhibitor. Stability data for unopened SB11 vials at room temperature are limited and no data are available for SB11 withdrawn into syringes (in-use) for intravitreal administration. METHODS SB11 stability was assessed in two different settings: unopened vials stored at 30 ± 2 °C/65 ± 5% relative humidity (RH) for 2 months, and in-use SB11 withdrawn into syringes stored at 5 ± 3 °C for 98 days and then 25 ± 2 °C/60 ± 5% RH for 24 h. The product was stored in the absence of light, and the experimental design followed International Conference on Harmonization and European Medicines Agency requirements for stability evaluation of biological products. Analysis included visual appearance (color, clarity, and presence of visible particles), pH, protein concentration (A280) and purity (size-exclusion high-pressure liquid chromatography, capillary electrophoresis-sodium dodecyl sulfate, imaged capillary isoelectric focusing), biological activity (VEGF binding and neutralization), and safety (sub-visible particulates). RESULTS Except for charge variants in unopened vials at room temperature after 1 month by US standards, all results met the stability acceptance criteria (US and EU) for both unopened vials and for in-use SB11. There were no major changes in terms of physicochemical stability, biological activity and sub-visible particulates. CONCLUSION SB11 was stable for longer periods and at higher temperatures than what is stated in the labels of the reference product (Lucentis) and SB11. The physicochemical properties, biological activity, and sub-visible particulates of SB11 in both tested settings (unopened vials at room temperature and in-use product withdrawn into syringes) were maintained under the described storage periods. This information can help to avoid unnecessary delays in patient treatment without any loss in quality and biological activity, lower the workload of health care providers and reduce costs associated with drug waste.
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Bae SS, Koenigstein D, Weaver T, Merkur A, Albiani D, Pakzad-Vaezi K, Kirker A. Incidence of ocular hypertension after anti-VEGF injections: examining the effect of drug filtration and silicone-free syringes. CANADIAN JOURNAL OF OPHTHALMOLOGY 2023; 58:66-72. [PMID: 34331870 DOI: 10.1016/j.jcjo.2021.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/25/2021] [Accepted: 06/30/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To examine the difference in incidence of ocular hypertension (OHT) following the introduction of filtered anti-vascular endothelial growth factor (anti-VEGF) medication in silicone-free syringes. DESIGN Retrospective cohort study. METHODS A retrospective review of consecutive treatment-naive patients receiving intravitreal anti-VEGF injections in a group practice was performed. Data from the cohort receiving nonfiltered anti-VEGF in insulin syringes (IS group) was collected from June 2015. Data from the cohort receiving filtered anti-VEGF in silicone-free syringes (SFS group) was collected from June 2019. Follow up data were collected at 1 year. Exclusion criteria included prior anti-VEGF treatment, known glaucoma or diagnosis of glaucoma suspect before anti-VEGF treatment, neovascular glaucoma, steroid use, or vitrectomy during follow-up. Primary outcome was the cumulative incidence of intraocular pressure (IOP) > 21 mmHg and IOP ≥ 30 mm Hg at any follow-up visit. The use of IOP lowering therapy was also recorded. RESULTS The mean age (71 ± 13 years), mean number of injections (9.6 ± 2.7), and median follow-up time (392 ± 57 days) were similar between groups. The incidence of IOP ≥ 21 mm Hg was 34% (34/100) in the IS group and 15% (15/100) in the SFS group (p = 0.025). The incidence of IOP ≥ 30 mm Hg was 8% (8/100) in the IS group and 0% (0/100) in the SFS group (p =0.004). The incidence of IOP-lowering therapy was 13% in the IS group and 0% in the SFS group (p =0.0002). CONCLUSION The incidence of OHT and treatment with IOP-lowering therapy significantly decreased after the introduction of filtered anti-VEGF medication and silicone-free syringes.
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Affiliation(s)
- Steven S Bae
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - Dvir Koenigstein
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - Travers Weaver
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - Andrew Merkur
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - David Albiani
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - Kaivon Pakzad-Vaezi
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC
| | - Andrew Kirker
- From the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, BC..
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Hertzberg SNW, Jørstad ØK, Petrovski BÉ, Bragadottir R, Steffensen LA, Moe MC, Burger EA, Petrovski G. Transition from Laser to Intravitreal Injections for Diabetic Retinopathy: Hospital Utilization and Costs from an Extended Healthcare Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12603. [PMID: 36231903 PMCID: PMC9564656 DOI: 10.3390/ijerph191912603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 06/16/2023]
Abstract
PURPOSE To describe the trends in hospital utilization and economic outcomes associated with the transition from laser to intravitreal injection (IVI) therapy for diabetic retinopathy (DR) at Oslo University Hospital (OUH), which provides the largest retina service in Norway. METHODS This descriptive study analyzed hospital administrative data and determined the average utilization and treatment proportions of laser therapy, IVIs and vitrectomy for each patient per year. The Chi-square test was used to compare resource use between treatment groups. From an extended healthcare perspective, the annual cost per patient was calculated using Norwegian tariff data from 2020 and the National Medication Price Registry for patients seen between 2010 and 2018. Bootstrapping was performed to generate 95% confidence intervals for the cost per patient per year. RESULTS Among the 1838 (41% female) patients treated for DR between 2005 and 2018, OUH provided on average 1.09 laser treatments per DR patient and 0.54 vitrectomies per DR patient in 2005, whose utilization declined to 0.54 and 0.05 treatments per DR patient, respectively, by 2018. Laser treatments declined from 64% to 10%, while vitrectomies declined from 32% to 1%. In contrast, IVI treatments increased from 4.5% to 89% of the total share, representing an average increase, from 0.08 injections per patient in 2005 to 4.73 injections per patient in 2018. Both the increasing number of DR patients and the shift in the type of treatment increased the economic costs of treating DR from a total of EUR 0.605 million (EUR 2935 per patient) in 2010 to EUR 2.240 million (EUR 3665 per patient) in 2018, with IVIs contributing considerably to these costs. CONCLUSIONS Despite the decline in the use of vitrectomies, the transition from laser to IVI therapy for DR increased the healthcare resource utilization and economic costs of its treatment over the observed time. A main cost driver was the need for long-term IVIs, in addition to the drug cost itself. Trade-offs can be achieved through effective alternative IVI delivery or appropriate drug choice that balances patient needs with the economic burden of treating DR.
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Affiliation(s)
| | - Øystein K. Jørstad
- Department of Ophthalmology, Oslo University Hospital, 0450 Oslo, Norway
| | - Beáta Éva Petrovski
- Center for Eye Research, Department of Ophthalmology, Institute for Clinical Medicine, University of Oslo, 0450 Oslo, Norway
| | - Ragnheidur Bragadottir
- Center for Eye Research, Department of Ophthalmology, Institute for Clinical Medicine, University of Oslo, 0450 Oslo, Norway
- Department of Ophthalmology, Oslo University Hospital, 0450 Oslo, Norway
| | | | - Morten Carstens Moe
- Center for Eye Research, Department of Ophthalmology, Institute for Clinical Medicine, University of Oslo, 0450 Oslo, Norway
- Department of Ophthalmology, Oslo University Hospital, 0450 Oslo, Norway
| | - Emily A. Burger
- Department of Health Management and Health Economics, University of Oslo, 0317 Oslo, Norway
- Center for Health Decision Science, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA
| | - Goran Petrovski
- Center for Eye Research, Department of Ophthalmology, Institute for Clinical Medicine, University of Oslo, 0450 Oslo, Norway
- Department of Ophthalmology, Oslo University Hospital, 0450 Oslo, Norway
- Department of Ophthalmology, University of Split School of Medicine and University Hospital Centre, 21000 Split, Croatia
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Uludag G, Hassan M, Matsumiya W, Pham BH, Chea S, Trong Tuong Than N, Doan HL, Akhavanrezayat A, Halim MS, Do DV, Nguyen QD. Efficacy and safety of intravitreal anti-VEGF therapy in diabetic retinopathy: what we have learned and what should we learn further? Expert Opin Biol Ther 2022; 22:1275-1291. [PMID: 35818801 PMCID: PMC10863998 DOI: 10.1080/14712598.2022.2100694] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 07/08/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Diabetic retinopathy (DR) is one of the most frequent microvascular complications of diabetes that can lead to blindness. Laser treatment has been the gold standard treatment for diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR) for many years. Recently, the role of vascular endothelial growth factor (VEGF) has been established in the pathogenesis of DR, and the use of intravitreal anti-VEGF therapy has gained popularity for the management of DR. AREAS COVERED This review includes a brief overview of the efficacy and safety of currently available (bevacizumab, ranibizumab, and aflibercept) and potential future (brolucizumab, faricimab, and KSI-301) anti-VEGF agents in patients with DR based mainly on publicly available data from phase 1, 2 and 3 clinical trials. EXPERT OPINION Clinical trials investigating the efficacy of intravitreal bevacizumab, ranibizumab, and aflibercept injections demonstrated favorable functional and anatomical outcomes in patients with DME. Moreover, the use of these anti-VEGF agents showed a significant improvement in the severity of DR. Recent clinical research for future anti-VEGF molecules aims to provide higher target-protein binding affinity and prolonged therapeutic effect. Brolucizumab, faricimab, and KSI-301 are three novel anti-VEGF agents that demonstrate promising data for the management of DME and potentially DR.
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Affiliation(s)
- Gunay Uludag
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Muhammad Hassan
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Wataru Matsumiya
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
- Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Brandon Huy Pham
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
- Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami, Miami, FL, USA
| | - Sophaktra Chea
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | | | - Hien Luong Doan
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | | | - Muhammad Sohail Halim
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
- Ocular Imaging Research and Reading Center, Sunnyvale, CA, USA
| | - Diana V Do
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
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Gjølberg TT, Lode HE, Melo GB, Mester S, Probst C, Sivertsen MS, Jørstad ØK, Andersen JT, Moe MC. A Silicone Oil-Free Syringe Tailored for Intravitreal Injection of Biologics. FRONTIERS IN OPHTHALMOLOGY 2022; 2:882013. [PMID: 38983507 PMCID: PMC11182194 DOI: 10.3389/fopht.2022.882013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/31/2022] [Indexed: 07/11/2024]
Abstract
Intravitreal injections (IVI) of biologics targeting vascular endothelial growth factor (anti-VEGF) led to a paradigm shift in the management and prognosis of prevalent retinal conditions. Yet, IVI are typically performed with syringes that are neither developed nor approved for this purpose. Notably, syringes lubricated with silicone oil (SiO) are extensively used despite multiple reports showing that such syringes can cause deposition of SiO droplets in the vitreous body and patient discomfort. Thus, there is a need for SiO-free substitutes specifically tailored for IVI. Here, we report on the development and testing of such a syringe. This syringe has no dead volume, and its design allows for high-accuracy dosing. Also, it permits pharmaceutical compounding and storage of bevacizumab, ranibizumab, and aflibercept for up to 30 days without compromising their functional binding or transport properties. Finally, the new syringe demonstrated a favorable safety profile regarding release of SiO compared to SiO lubricated alternatives, including commercially prefilled syringes. Accordingly, the newly developed syringe is an appealing alternative for IVI.
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Affiliation(s)
- Torleif T Gjølberg
- Department of Immunology, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Department of Pharmacology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Department of Ophthalmology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Heidrun E Lode
- Department of Immunology, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Department of Pharmacology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Department of Ophthalmology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Gustavo B Melo
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
- Department of Ophthalmology, Hospital de Olhos de Sergipe, Aracaju, Brazil
| | - Simone Mester
- Department of Immunology, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Department of Pharmacology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Christine Probst
- Department of Research and Development Sciences, Luminex Corporation, Seattle, WA, United States
| | - Magne S Sivertsen
- Department of Ophthalmology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Øystein K Jørstad
- Department of Ophthalmology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jan Terje Andersen
- Department of Immunology, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Department of Pharmacology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Morten C Moe
- Department of Ophthalmology, Oslo University Hospital and University of Oslo, Oslo, Norway
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12
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Impact of the COVID-19 pandemic on patients receiving intravitreal injections. ARCH BIOL SCI 2022. [DOI: 10.2298/abs220116003z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
We analyzed the economic benefits versus safety risks of sharing
anti-vascular endothelial growth factor (VEGF) vials during the coronavirus
disease (COVID-19) pandemic. This single-center retrospective study analyzed
the data of patients with neovascular age-related macular degeneration
(nAMD), proliferative diabetic retinopathy (PDR) and retinal vein occlusion
(RVO) who received anti- VEGF between January 2016 and July 2021 at Renmin
Hospital, Wuhan University, China. Costs were compared of the two protocols
of intravitreal injections (IVIs) of ranibizumab, aflibercept and conbercept
after (i) splitting the vial content for use in two patients and after (ii)
disposal of the remaining vial content after use in a single patient, with
the COVID-19 outbreak considered as the demarcation point. The incidence
rates of post-injection endophthalmitis (PIE) pre- and post-outbreak were
analyzed. The mean cost of a single IVI increased by 33.3%, from
3917.67?71.69 to 5222.67?84.98 Chinese Yuan during the pandemic. The
incidences of IVI-related culture-positive PIE were 0.0134% (3 in 22448) and
0.0223% (1 in 4479), respectively, before and after the pandemic (P=0.6532).
We conclude that vial sharing of IVIs in a large clinical institution is not
associated with increased PIE risk and can significantly reduce the cost of
therapy.
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13
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Levin AM, Chaya CJ, Kahook MY, Wirostko BM. Intraocular Pressure Elevation Following Intravitreal Anti-VEGF Injections: Short- and Long-term Considerations. J Glaucoma 2021; 30:1019-1026. [PMID: 34086610 PMCID: PMC8635259 DOI: 10.1097/ijg.0000000000001894] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/21/2021] [Indexed: 11/26/2022]
Abstract
Published studies agree that transient intraocular pressure (IOP) spikes are common after intravitreal injections of anti-vascular endothelial growth factor agents. Currently, there is no standard of care guiding if and when to prevent these IOP spikes. Furthermore, there are challenges in determining the impact of postinjection IOP elevation on the health of the retinal ganglion cells, particularly given the often-existing comorbidities of retinal and glaucoma pathology. This review highlights the current literature regarding both acute and chronic postinjection IOP elevations and discusses management of postinjection IOP elevation, especially in patients at high risk for glaucomatous damage.
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Affiliation(s)
- Ariana M. Levin
- John Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT
| | - Craig J. Chaya
- John Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT
| | - Malik Y. Kahook
- Sue Anschutz-Rodgers Eye Center, University of Colorado School of Medicine, Aurora, CO
| | - Barbara M. Wirostko
- John Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT
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14
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Silicone oil droplets in the vitreous after intravitreal injections: review of literature with clinical examples. OPHTHALMOLOGY JOURNAL 2021. [DOI: 10.17816/ov59959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Currently, intravitreal injections are firmly in the lead as a drug delivery method for treatment of a wide range of eye diseases. With the accumulation of clinical material, knowledge about the complications and side effects of this technique is expanding. One of the undesirable phenomena that has been actively studied recently is the ingress of silicone oil droplets from single-use syringes and needles used to perform the procedure into the vitreous cavity of patients eyes. The analysis of the results of original studies on this issue is carried out, and the currently available practical recommendations aimed at reducing the risk of this complication are presented. The article is illustrated with original clinical examples. It can be concluded that the penetration of silicone oil into the eye cavity during intravitreal injections is an urgent problem of modern ophthalmology that requires further investigation and solution.
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15
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Sivertsen MS, Lode HE, Gjølberg TT, Petrovski G, Andersen JT, Jørstad ØK, Moe MC. Cluster of symptomatic silicone oil droplets following intravitreal injections: a 1-year observational study. BMJ Open Ophthalmol 2021; 6:e000764. [PMID: 34485702 PMCID: PMC8378358 DOI: 10.1136/bmjophth-2021-000764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/09/2021] [Indexed: 11/03/2022] Open
Abstract
Objective To describe a cluster of symptomatic intravitreal silicone oil (SiO) droplets following intravitreal injections (IVIs) and assess the effect of switching to a SiO-free syringe. Methods and analysis Observational quality registry study of patients receiving IVI at a large Norwegian ophthalmology centre between April 2018 (start of cluster) and November 2019 (1 year after switching to SiO-free syringes). At onset, anti-vascular endothelial growth factor drugs were administered using SiO-containing insulin syringes. From November 2018, SiO-free syringes were implemented. Spontaneously reported symptomatic SiO cases were confirmed by slit-lamp examination. A follow-up interview was performed after 1 year, assessing visual complaints. The prevalence of non-symptomatic cases was assessed in a sample of 50 eyes from 50 consecutive IVI patients. Results Among 13 429 IVIs, 50 eyes of 46 patients (29 women) with symptomatic intravitreal SiO droplets were identified. Forty-one patients reported floaters at regular appointments, whereas five patients contacted the department regarding symptoms between scheduled appointments. After 1 year, 34 patients (79%) still experienced floaters, 21 (49%) reported reduced symptoms and 3 (7%) reported worsened symptoms. Eighteen patients (42%) reported being bothered, and eight (18.6%) reported that their lives were negatively affected by the floaters. Among 50 non-symptomatic eyes that had received IVI during the same period, intravitreal SiO was found in 34 (68%). No cases of symptomatic intravitreal SiO droplets were identified after switching to SiO-free syringes. Conclusion Symptomatic intravitreal SiO following IVI can cause significant and prolonged distress for affected patients. It can be avoided by using SiO-free syringes.
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Affiliation(s)
| | - Heidrun Elisabeth Lode
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway.,Department of Immunology, Oslo University Hospital, Oslo, Norway.,Department of Pharmacology, University of Oslo, Oslo, Norway
| | - Torleif Tollefsrud Gjølberg
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway.,Department of Immunology, Oslo University Hospital, Oslo, Norway.,Department of Pharmacology, University of Oslo, Oslo, Norway
| | - Goran Petrovski
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway
| | - Jan Terje Andersen
- Department of Immunology, Oslo University Hospital, Oslo, Norway.,Department of Pharmacology, University of Oslo, Oslo, Norway
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16
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Stability study over time of clinical solutions of ziv-aflibercept prepared in infusion bags using a proper combination of physicochemical and functional strategies. J Pharm Biomed Anal 2021; 203:114209. [PMID: 34153938 DOI: 10.1016/j.jpba.2021.114209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/20/2021] [Accepted: 06/11/2021] [Indexed: 11/21/2022]
Abstract
A range of biopharmaceutical products are used to target Vascular Endothelial Growth Factor (VEGF), including Eylea® (aflibercept, AFL) and Zaltrap® (ziv-aflibercept, ziv-AFL). The first is indicated for ophthalmological diseases such as neovascular (wet) age-related macular degeneration, while the second is used in the treatment of metastatic colorectal cancer. The stability of AFL in prefilled syringes has been widely studied; however, no research has yet been done on the stability of ziv-AFL in polyolefin infusion bags. Therefore, the purpose of the present research is to evaluate the stability of ziv-AFL (Zaltrap®) clinical solutions prepared under aseptic conditions in polyolefin infusion bags at two different concentrations, i.e. 4.0 and 0.6 mg/mL, and stored refrigerated in darkness at 2-8 °C for 14 days. With that aim, the ziv-AFL clinical solutions were assessed by analysing changes in its physicochemical and functional properties. The distribution of the particulates was studied over a range of 0.001-10 μm by Dynamic Light Scattering (DLS); oligomers were analysed by Size-Exclusion High-Performance Chromatography with Diode Array Detection (SE/HLPC-DAD); the secondary structure of the protein was studied by far UV Circular Dichroism (CD) and the tertiary structure by Intrinsic Tryptophan Fluorescence (IT-F) and Intrinsic Protein Fluorescence (IP-F); charge variants were assessed by Strong Cation Exchange Ultra-High-Performance Chromatography with UV detection (SCX/UHPLC-UV); functionality was evaluated by ELISA by measuring the biological activity as manifested in the extension of the immunological reaction of the ziv-AFL with its antigen (VEGF). Neither aggregation nor oligomerization were detected by the techniques mentioned above. Secondary and tertiary structures remained unchanged over the 14-day period, as did charge variants. The functionality observed initially was maintained along time. Therefore, it could be proposed that the ziv-AFL clinical solutions studied showed great physicochemical and functional stability over a period of two weeks, regardless of the concentration, i.e. 4 or 0.6 mg/mL.
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17
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Anderson WJ, da Cruz NFS, Lima LH, Emerson GG, Rodrigues EB, Melo GB. Mechanisms of sterile inflammation after intravitreal injection of antiangiogenic drugs: a narrative review. Int J Retina Vitreous 2021; 7:37. [PMID: 33962696 PMCID: PMC8103589 DOI: 10.1186/s40942-021-00307-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/28/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Intraocular inflammation is an uncommon but potentially vision-threatening adverse event related to anti-VEGF therapy. This is of increasing importance given both the volume of injections performed, as well as the increased prevalence of inflammation seen with newer anti-VEGF agents. Brolucizumab, the newest anti-VEGF agent, has been associated with an inflammatory retinal vasculitis and the underlying mechanism is unclear. Reviewing potential mechanisms and clinical differences of intraocular inflammation may assist clinicians and scientists in reducing the risk of these events in the future. OBSERVATIONS Two types of inflammation are seen with intravitreal injections, acute onset sterile inflammation and delayed onset inflammatory vasculitis. Acute onset inflammation can be subcategorized into subclinical anterior chamber inflammation and sterile uveitis/endophthalmitis. Subclinical anterior chamber inflammation can occur at rates as high as 19% after intravitreal anti-VEGF injection. Rates of sterile uveitis/endophthalmitis range from 0.05% to 4.4% depending on the anti-VEGF agent. Inflammatory vasculitis is only associated with brolucizumab and occurred in 3.3% of injections according to the post hoc review of the HAWK/HARRIER data. In addition, silicone oil from syringes can induce immunogenic protein aggregates. Agitation of the syringe, freeze thawing, shipping and improper storage prior to injection may increase the amount of silicone oil released from the syringe. CONCLUSION The main factors which play a role in intraocular inflammation after anti-VEGF injection can be divided into three causes: patient-specific, medication-specific and delivery-specific. The majority of clinically significant inflammation seen after intravitreal injection is an acute onset inflammatory response with most patients recovering baseline VA in 3-5 weeks. The presence of pain, hypopyon, severe anterior chamber reaction, hyperemia and significant vision loss may help distinguish infectious from non-infectious etiologies of post injection inflammation. Avoiding temperature fluctuation, mechanical shock, agitation during transport and handling of syringes/drugs, and the use of SO-free syringes may help minimize intraocular inflammation. While a definitive mechanism has not yet been established, current knowledge of the clinical presentation and vitreous histopathology of brolucizumab-retinal vasculitis favors an auto-immune type IV hypersensitivity reaction.
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Affiliation(s)
- William J Anderson
- Department of Ophthalmology, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | | | - Luiz Henrique Lima
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
| | | | - Eduardo Büchele Rodrigues
- Department of Ophthalmology, Saint Louis University School of Medicine, Saint Louis, MO, USA.,Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
| | - Gustavo Barreto Melo
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil. .,Hospital de Olhos de Sergipe, Rua Campo Do Brito, 995, Aracaju, SE, 49020-380, Brazil.
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18
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Bisorca-Gassendorf L, Januschowski K, Pérez Guerra N, Szurman P, Rickmann A. [Silicone oil droplets in the vitreous body after intravitreal injection]. Ophthalmologe 2021; 119:392-394. [PMID: 33687491 DOI: 10.1007/s00347-021-01358-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/02/2021] [Accepted: 02/16/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Lukas Bisorca-Gassendorf
- Augenklinik Sulzbach, Knappschaftsklinikum Saar GmbH, An der Klinik 10, 66280, Sulzbach, Deutschland.
| | - Kai Januschowski
- Augenklinik Sulzbach, Knappschaftsklinikum Saar GmbH, An der Klinik 10, 66280, Sulzbach, Deutschland
| | - Núria Pérez Guerra
- Augenklinik Sulzbach, Knappschaftsklinikum Saar GmbH, An der Klinik 10, 66280, Sulzbach, Deutschland
| | - Peter Szurman
- Augenklinik Sulzbach, Knappschaftsklinikum Saar GmbH, An der Klinik 10, 66280, Sulzbach, Deutschland
| | - Annekatrin Rickmann
- Augenklinik Sulzbach, Knappschaftsklinikum Saar GmbH, An der Klinik 10, 66280, Sulzbach, Deutschland
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19
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Ingle RG, Fang WJ. Prefilled dual chamber devices (DCDs) - Promising high-quality and convenient drug delivery system. Int J Pharm 2021; 597:120314. [PMID: 33540011 DOI: 10.1016/j.ijpharm.2021.120314] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/14/2021] [Accepted: 01/23/2021] [Indexed: 12/22/2022]
Abstract
Prefilled dual chamber devices (DCDs) are combination products containing freeze-dried drug and diluent in two separate chambers of the device. DCDs provide high stability and convenience to patients and doctors, thus significantly improving product quality, patient compliance and market competitiveness. DCDs should also provide seal integrity, sterility and compatibility with biopharmaceuticals and avoid leachability and needle stick injuries. DCDs are promising alternatives to traditional containers or devices for biopharmaceuticals. The regulatory and medical practice to choose plastic DCDs as better alternatives over well-established glass syringes will be addressed here. The impact and major issues during processing, manufacturing, and storage of DCDs are also highlighted. Further discussion clears its business potential, composition, stability testing, and quality standard requirements to deal with market competition. It also covers major role of extractables and leachables in storage stability of the product.
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Affiliation(s)
- Rahul G Ingle
- Institute of Drug Metabolism and Pharmaceutical Analysis, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China; Hangzhou Institute of Innovative Medicine, Zhejiang University, Hangzhou 310016, China
| | - Wei-Jie Fang
- Institute of Drug Metabolism and Pharmaceutical Analysis, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China; Hangzhou Institute of Innovative Medicine, Zhejiang University, Hangzhou 310016, China.
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20
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Nicholas MP, Mysore N. Corneal neovascularization. Exp Eye Res 2020; 202:108363. [PMID: 33221371 DOI: 10.1016/j.exer.2020.108363] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 12/12/2022]
Abstract
The optical clarity of the cornea is essential for maintaining good visual acuity. Corneal neovascularization, which is a major cause of vision loss worldwide, leads to corneal opacification and often contributes to a cycle of chronic inflammation. While numerous factors prevent angiogenesis within the cornea, infection, inflammation, hypoxia, trauma, corneal degeneration, and corneal transplantation can all disrupt these homeostatic safeguards to promote neovascularization. Here, we summarize its etiopathogenesis and discuss the molecular biology of angiogenesis within the cornea. We then review the clinical assessment and diagnostic evaluation of corneal neovascularization. Finally, we describe current and emerging therapies.
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Affiliation(s)
- Matthew P Nicholas
- Flaum Eye Institute, University of Rochester Medical Center, 210 Crittenden Blvd., Rochester, NY, USA
| | - Naveen Mysore
- Flaum Eye Institute, University of Rochester Medical Center, 210 Crittenden Blvd., Rochester, NY, USA.
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21
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Melo GB, Cruz NFSD, Emerson GG, Rezende FA, Meyer CH, Uchiyama S, Carpenter J, Shiroma HF, Farah ME, Maia M, Rodrigues EB. Critical analysis of techniques and materials used in devices, syringes, and needles used for intravitreal injections. Prog Retin Eye Res 2020; 80:100862. [PMID: 32311476 DOI: 10.1016/j.preteyeres.2020.100862] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/23/2020] [Accepted: 04/02/2020] [Indexed: 12/26/2022]
Abstract
Intravitreal injections have become the most commonly performed intraocular treatments worldwide. Because intravitreal injections may induce severe adverse events, such as infectious and noninfectious endophthalmitis, cataract, ocular hypertension, vitreous hemorrhage, or retinal detachment, appropriate awareness of the materials and techniques used are essential to reduce these sight-threatening complications. This review provides insights into the needles, syringes, silicone oil coating, sterilization methods, devices to assist intravitreal injections, scleral piercing techniques using needles, syringe handling, anesthesia, and safety issues related to materials and techniques. It is paramount that physicians be aware of every step involved in intravitreal injections and consider the roles and implications of all materials and techniques used. The ability to understand the theoretical and practical circumstances may definitely lead to state-of-the-art treatments delivered to patients. The most important practical recommendations are: choosing syringes with as little silicone oil as possible, or, preferably, none; avoiding agitation of syringes; awareness that most biologics (e.g., antiangiogenic proteins) are susceptible to changes in molecular properties under some conditions, such as agitation and temperature variation; understanding that improper materials and techniques may lead to complications after intravitreal injections, e.g., inflammation; and recognizing that some devices may contribute to an enhanced, safer, and faster intravitreal injection technique.
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Affiliation(s)
- Gustavo Barreto Melo
- Hospital de Olhos de Sergipe, Rua Campo do Brito, 995, Aracaju, SE, Brazil; Department of Ophthalmology, Federal University of São Paulo, Rua Botucatu, 806, São Paulo, SP, Brazil.
| | | | | | | | - Carsten H Meyer
- Department of Ophthalmology, Federal University of São Paulo, Rua Botucatu, 806, São Paulo, SP, Brazil; Department of Ophthalmology, Philipps University of Marburg, Robert-Koch-Strasse 4, Marburg, Germany
| | - Susumu Uchiyama
- Department of Biotechnology, Graduate School of Engineering, Osaka University, 2-1 Yamadaoka, Osaka, Japan
| | - John Carpenter
- Department of Pharmaceutical Sciences, University of Colorado, Denver/Aurora, CO, USA
| | - Hélio Francisco Shiroma
- Department of Ophthalmology, Federal University of São Paulo, Rua Botucatu, 806, São Paulo, SP, Brazil
| | - Michel Eid Farah
- Department of Ophthalmology, Federal University of São Paulo, Rua Botucatu, 806, São Paulo, SP, Brazil
| | - Maurício Maia
- Department of Ophthalmology, Federal University of São Paulo, Rua Botucatu, 806, São Paulo, SP, Brazil
| | - Eduardo Büchele Rodrigues
- Department of Ophthalmology, Federal University of São Paulo, Rua Botucatu, 806, São Paulo, SP, Brazil; Department of Ophthalmology, SSM Health Saint Louis University Hospital, Saint Louis University, 1755, S. Grand Boulevard, Saint Louis, MO, USA
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22
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Schargus M, Frings A. Issues with Intravitreal Administration of Anti-VEGF Drugs. Clin Ophthalmol 2020; 14:897-904. [PMID: 32256047 PMCID: PMC7101474 DOI: 10.2147/opth.s207978] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 03/10/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To provide an update of summary of risk factors and side effects of long-term use and contamination of intravitreal anti-VEGF injections. Methods We reviewed relevant publications of the topic of contamination of anti-VEGF injections and long-term side effects due to this reason. Results Due to the long-term use of anti-VEGF drugs and the higher number of injections worldwide, various studies have shown side effects in recent years, ranging from increased intraocular pressure to visual disturbing silicone oil vesicles in the vitreous cavity. Several studies have demonstrated that both the drug and the processing, storage, environmental factors and the material and design of the syringes have a decisive influence on these side effects. Conclusion The risks of deposits from syringes in the eye can be significantly reduced by various optimizations in transport, storage and syringe and cannula selection.
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Affiliation(s)
- Marc Schargus
- Department of Ophthalmology, Heinrich Heine University, Duesseldorf, Germany.,Department of Ophthalmology, Asklepios Hospital Nord-Heidberg, Hamburg, Germany
| | - Andreas Frings
- Department of Ophthalmology, Heinrich Heine University, Duesseldorf, Germany.,Augenarztpraxis Dr. Frings, Nuremberg, Germany
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