Effect of Intravitreal Injection of Methotrexate on Human Corneal Endothelial Cells

Intraocular methotrexate for epithelial downgrowth: long-term outcomes in a multicentre case series

BACKGROUND/AIMS

Sheet-like type of epithelial downgrowth (EDG) is not easily amenable to surgical excision. We describe long-term outcomes in patients with EDG treated with intraocular methotrexate (MTX).

METHODS

This is a retrospective, multicentric case series including 10 eyes (nine patients) treated with intraocular MTX for sheet-like EDG. Relevant ocular history, previous EDG treatments, MTX injection regimen, long-term outcomes and complications are reported.

RESULTS

All cases were associated with intraocular surgery. Most patients were treated with 400 µm/0.1 mL MTX injections with a starting frequency of two times per week or weekly injections. Mean and SD number of injections per eye was 16±13 injections and duration of follow-up was 54±36 months (range: 7-120 months). Eradication of EDG was achieved in seven eyes of which one required a second MTX treatment course to achieve eradication, while clinical resolution with recurrence was observed in two. One treatment failure occurred despite eight weekly injections which slowed but did not halt EDG progression; the patient later requested that treatments be stopped given difficulty to come to follow-ups. Surface epitheliopathy developed in eight patients and was used to titrate MTX treatment. Six patients also developed endothelial failure.

CONCLUSION

We report the largest case series of diffuse, sheet-like EDG treated with intraocular MTX with follow-ups up to 10 years. Intraocular MTX may be used effectively to achieve eradication of EDG in cases where surgery is not amenable. However, further recommendations to guide treatment remain warranted.

A comprehensive review of intravitreal immunosuppressants and biologicals used in ophthalmology

Systemic immunosuppressants and biologicals have been a valuable tool in the treatment of inflammatory diseases and malignancies. The safety profile of these drugs has been debatable, especially in localized systems, such as the eye. This has led to the search for fairly local approaches, such as intravitreal, subconjunctival, and topical route of administration. Immunosuppressants have been used as a second-line drug in patients intolerable to corticosteroids or those who develop multiple recurrences on weaning corticosteroids. Similarly, biologicals have also been used as the next line of therapy, when adequate control of inflammation could not be attained or immunosuppressants were contraindicated to patients. Intravitreal immunosuppressants, such as methotrexate and sirolimus, have been extensively studied in noninfectious posterior uveitis, whereas limited studies have established the efficacy of intravitreal biologicals, such as infliximab and adalimumab. Most of these drugs have shown good safety profile and tolerability in animal studies alone and have not been studied further in human subjects. However, most of the studies in literature are single-case reports or case series which limits the level of evidence. In this comprehensive review, we discuss the mechanism of action, pharmacodynamics, pharmacokinetics, indications, efficacy, and side effects of different intravitreal immunosuppressants and biologicals that have been studied in literature.

Intravitreal Methotrexate

Intravitreal methotrexate (MTX) has been proven to be an effective treatment for various intraocular diseases. In this article, a comprehensive review was performed on intravitreal applications of methotrexate. Different aspects of the administration of intravitreal MTX for various clinical conditions such as intraocular tumors, proliferative vitreoretinopathy, diabetic retinopathy, age-related macular degeneration, and uveitis were reviewed and the adverse effects of intravitreal injection of MTX were discussed. The most common indications are intraocular lymphoma and uveitis. Other applications remain challenging and more studies are needed to establish the role of intravitreal MTX in the management of ocular diseases.

Corneal endothelial cell density in patients receiving chemotherapy

PURPOSE

This study aimed to determine if the corneal endothelium was affected by chemotherapy.

METHODS

Chemotherapy patients were recruited to undergo specular microscopy before treatment and again at 1- and 2-year follow-up visits. One eye per patient, per follow-up, was selected for comparison to baseline.

RESULTS

Forty-six volunteers completed baseline and at least one follow-up assessment. From 51 eyes, there was no significant change in endothelial cell density for 41 eyes assessed at one year (M_D = 0.73%, 95% CI -1.33 to 2.78%) and 18 eyes at two years (M_D = 0.31%, 95% CI -3.53 to 4.15%).

CONCLUSION

Although other studies have shown that chemotherapy can adversely affect the corneal epithelium, this study showed no measurable change in endothelial cell density.

Corneal Toxicity of Intravitreal Methotrexate Used for the Treatment of Proliferative Vitreoretinopathy in Silicone Oil-Filled Eyes: A Case Series

PURPOSE

The purpose of this study was to evaluate the corneal toxicity of intravitreal methotrexate used for the prevention of proliferative vitreoretinopathy (PVR).

METHODS

In this retrospective case series, eyes with recurrent retinal detachment secondary to PVR were treated with intravitreal injections of 400 μg methotrexate at an average frequency of every 7 days after vitrectomy with silicone oil tamponade. Corneas were examined for corneal epitheliopathy by slit-lamp biomicroscopy before each injection.

RESULTS

Thirteen eyes of 12 patients were reviewed. All had a history of recurrent retinal detachment secondary to PVR treated with vitrectomy and silicone oil. The median age was 35 years (range: 9-83). Four patients (33%) were female. The median follow-up duration was 8 weeks (range: 5-10). The median BCVA (logMAR notation) was 2.00 preoperatively, 2.00 at 1 month postoperatively, and 2.00 at the most recent follow-up (P = 0.969). Ten eyes (77%) were pseudophakic. Nine eyes (69%) had a preexisting ocular comorbidity. The median number of injections was 8 (range: 5-10). The median interval time between each injection was 7.0 days (range: 5.8-10.5), and the median follow-up period beyond last injection was 16 weeks (range: 8-28). Two eyes (15.4%) developed mild corneal epitheliopathy during the course of the treatment.

CONCLUSIONS

Most eyes in this small series tolerated methotrexate injections without corneal toxicity. In eyes that developed epitheliopathy, the findings were mild and not treatment-limiting.

Ocular surface complications of local anticancer drugs for treatment of ocular tumors

Local chemotherapy is increasingly used, either in combination with surgery or as monotherapy, for management of ocular tumors. Yet many of the local chemotherapeutic agents used for ocular tumors are cytotoxic drugs that are frequently associated with toxicities in normal ocular tissues. Understanding and managing these side effects are important because they affect treatment tolerability, outcome and quality of vision. Herein, we review local anticancer drugs administered for the treatment of ocular tumors, with an emphasis on their toxicities to the ocular surface, adnexa and lacrimal drainage system. We provide the underlying mechanisms and management strategies for the ocular side effects. Recent innovations in anticancer immunotherapy and ocular drug delivery systems also are discussed as new potential therapeutic modalities for alleviation of side effects.

Supercritical fluid technology for the development of innovative ophthalmic medical devices: Drug loaded intraocular lenses to mitigate posterior capsule opacification

Supercritical impregnation technology was applied to load acrylic intraocular lenses (IOLs) with methotrexate to produce a sustained drug delivery device to mitigate posterior capsule opacification. Drug release kinetics were studied in vitro and used to determine the drug loading. Loaded IOLs and control IOLs treated under the same operating conditions, but without drug, were implanted ex vivo in human donor capsular bags. The typical cell growth was observed and immunofluorescence staining of three common fibrosis markers, fibronectin, F-actin and α-smooth muscle actin was carried out. Transparent IOLs presenting a sustained release of methotrexate for more than 80 days were produced. Drug loading varying between 0.43 and 0.75 ± 0.03 µg_drug·mg^-1_IOL were obtained when varying the supercritical impregnation pressure (8 and 25 MPa) and duration (30 and 240 min) at 308 K. The use of ethanol (5 mol%) as a co-solvent did not influence the impregnation efficiency and was even unfavorable at certain conditions. Even if the implantation of methotrexate loaded IOLs did not lead to a statistically significant variation in the duration required for a full cell coverage of the posterior capsule in the human capsular bag model, it was shown to reduce fibrosis by inhibiting epithelial-mesenchymal transformation. The innovative application presented has the potential to gain clinical relevance.

Poly(lactic-co-glycolic) Acid as a Slow-Release Drug-Carrying Matrix for Methotrexate Coated onto Intraocular Lenses to Conquer Posterior Capsule Opacification

PURPOSE

Posterior capsule opacification (PCO) still represents the main long-term complication of cataract surgery. Research into pharmacologic PCO prophylaxis is extensive. One promising candidate drug is methotrexate (MTX). Our aim is to determine the in vitro feasibility of MTX-loaded poly(lactic-co-glycolic) (PLGA) biomatrices sprayed on intraocular lenses (IOLs) as a drug-delivery implant.

METHODS

Hydrophilic and hydrophobic acrylic IOLs were spray-coated with MTX-loaded PLGA. Unsprayed, solvent only, and solvent-PLGA-sprayed IOLs served as controls. All IOLs were evaluated for their growth-inhibiting properties in an in vitro anterior segment model and the ex vivo human capsular bag. The release kinetics of MTX from the IOLs was determined. The toxicity of MTX on corneal endothelial cells was evaluated by using a dye reduction colorimetric assay. MTX was also used in a scratch assay.

RESULTS

MTX-PLGA-IOL showed a significant difference in cell proliferation and migration compared with all controls in the anterior segment model (p < 0.001) and in the human capsular bag model (p = 0.04). No difference in viability was observed on corneal endothelial cells (p = 0.43; p = 0.61). MTX significantly inhibited cells in the scratch assay (p = 0.02). At all measured points, the released MTX dose remained above EC50 and below the toxic dose for the endothelium.

CONCLUSIONS

In view of the strong inhibition of PCO in vitro with the lack of toxic effects on a corneal cell line, MTX encapsulating microspheres seem to be a promising method for modifying IOL.

Case 01-2017 - Primary vitreoretinal lymphoma (PVRL): report of a case and update of literature from 1942 to 2016

Primary vitreoretinal lymphoma (PVRL), as a subset of primary central nervous system lymphoma (PCNSL), is a rare and fatal ocular malignancy. Most PVRL masquerades as chronic posterior uveitis, which makes the clinical diagnosis challenging. Vitreous cells, subretinal lesions and imaging techniques are essential for clinical diagnosis. Importantly, cytopathology/histopathology identification of malignant cells is the gold standard for the diagnosis of PVRL. In addition, molecular detection of immunoglobulin heavy chain (IgH) or T cell receptor (TCR) gene rearrangements, immunophenotyping for cell markers, and cytokine analysis of interleukine-10 elevation are often used as adjunct procedures. Current management of PVRL involves local radiation, intravitreal chemotherapy (methotrexate and rituximab), with or without systemic chemotherapy depending on the involvement of non-ocular tissues. In cases with concomitant PCNSL, systemic high-dose methotrexate/rituximab based therapy in conjunction with local therapy, whole brain radiotherapy and/or autologous stem cell transplantation is considered. Although PVRL normally responds well to initial treatment, high rates of relapse and CNS involvement usually lead to poor prognosis and limited survival. A professional team of medical experts in ophthalmologists, ocular pathologists, neuro-oncologists and hemato-oncologists is essential for optimizing patient management.

Intravitreal injection of methotrexate in persistent diabetic macular edema: a 6-month follow-up study

PURPOSE

To evaluate the efficacy of intravitreal injection of methotrexate (MTX) in patients with persistent diabetic macular edema (DME) nonresponsive to intravitreal bevacizumab.

METHODS

In this prospective, interventional study, intravitreal injection of 400 μg MTX was performed in eyes with persistent center-involving DME unresponsive to at least three consecutive bevacizumab injections or two consecutive bevacizumab injections plus macular photocoagulation. Best-corrected visual acuity (BCVA), central subfield thickness (CST), and maximum retinal thickness (MRT) were recorded before and 1, 3, and 6 months after injections.

RESULTS

Eighteen eyes of 16 patients with a mean age of 61.1 ± 6.7 years were included. Mean number of intravitreal bevacizumab injections was 3.9 ± 1.8 (range 2-8). The mean change in BCVA was -0.09 ± 0.19, -0.1 ± 0.19, and -0.1 ± 0.19 LogMAR at 1, 3, and 6 months after intravitreal MTX injections, respectively (all P = 0.04). Three eyes (16.6 %) had improvement of at least two lines of BCVA and no eye lost visual acuity. Mean change in CST was -23.7 ± 66.7, -28.7 ± 82.2 and 26.5 ± 83.4 μm at 1, 3, and 6 months after MTX injections, respectively (all P = 0.1). A decrease in CST was found in 13 eyes (72.2 %) at 1 and 3 months, and seven eyes (38.8 %) at 6 months of follow-up. Other eyes showed an increase in CST measurements. Mean change in MRT was -35.1 ± 76.4, -40.6 ± 86.3, and 29.8 ± 68.6 μm at 1, 3, and 6 months after MTX injections, respectively (P = 0.06, P = 0.06, and P = 0.08, respectively). No complication attributable to intravitreal MTX occurred.

CONCLUSION

In this study, intravitreal injection of MTX resulted in anatomical improvement in a significant proportion of eyes with persistent DME. Significant visual improvement was found in 16.6 % of eyes.