Treatments for corneal neovascularization: a review

Healing the cornea: Exploring the therapeutic solutions offered by MSCs and MSC-derived EVs

Affecting a large proportion of the population worldwide, corneal disorders constitute a concerning health hazard associated to compromised eyesight or blindness for most severe cases. In the last decades, mesenchymal stem/stromal cells (MSCs) demonstrated promising abilities in improving symptoms associated to corneal diseases or alleviating these affections, especially through their anti-inflammatory, immunomodulatory and pro-regenerative properties. More recently, MSC therapeutic potential was shown to be mediated by the molecules they release, and particularly by their extracellular vesicles (EVs; MSC-EVs). Consequently, using MSC-EVs emerged as a pioneering strategy to mitigate the risks related to cell therapy while providing MSC therapeutic benefits. Despite the promises given by MSC- and MSC-EV-based approaches, many improvements are considered to optimize the therapeutic significance of these therapies. This review aspires to provide a comprehensive and detailed overview of current knowledge on corneal therapies involving MSCs and MSC-EVs, the strategies currently under evaluation, and the gaps remaining to be addressed for clinical implementation. From encapsulating MSCs or their EVs into biomaterials to enhance the ocular retention time to loading MSC-EVs with therapeutic drugs, a wide range of ground-breaking strategies are currently contemplated to lead to the safest and most effective treatments. Promising research initiatives also include diverse gene therapies and the targeting of specific cell types through the modification of the EV surface, paving the way for future therapeutic innovations. As one of the most important challenges, MSC-EV large-scale production strategies are extensively investigated and offer a wide array of possibilities to meet the needs of clinical applications.

ALKBH5 Regulates Corneal Neovascularization by Mediating FOXM1 M6A Demethylation

Purpose

This study aims to explore the regulatory role and potential mechanisms of ALKBH5-mediated N6-methyladenosine (m6A) demethylation modification in corneal neovascularization (CNV).

Methods

A mouse CNV model was established through corneal alkali burns. Total m6A levels were measured using an m6A RNA methylation quantification kit. The mRNA expression of candidate m6A-related enzymes was quantified by quantitative RT-PCR. Small interfering RNA targeting ALKBH5 was injected subconjunctivally into alkali-burned mice. The CNV area, corneal epithelial thickness, and pathological changes were evaluated. Protein expression was detected by western blot and immunofluorescence. Human umbilical vein endothelial cells (HUVECs) were treated with IL-6. Plasmid transfection knocked down ALKBH5 or overexpressed FOXM1 in IL-6-induced HUVECs. The assays of CCK8, wound healing, and tube formation evaluated the cell proliferation, migration, and tube formation abilities, respectively. The dual-luciferase assay examined the binding between ALKBH5 and FOXM1. Methylated RNA immunoprecipitation-qPCR detected the m6A levels of FOXM1.

Results

Significant CNV was observed on the seventh day. Total m6A levels were reduced, and ALKBH5 expression was increased in CNV corneas and IL-6-induced HUVECs. ALKBH5 knockdown alleviated corneal neovascularization and inflammation and countered IL-6-induced promotion of cell proliferation, migration, and tube formation in HUVECs. ALKBH5 depletion increased m6A levels and decreased VEGFA and CD31 expression both in vivo and in vitro. This knockdown in HUVECs elevated m6A levels on FOXM1 mRNA while reducing its mRNA and protein expression. Notably, FOXM1 overexpression can reverse ALKBH5 depletion effects.

Conclusions

ALKBH5 modulates FOXM1 m6A demethylation, influencing CNV progression and highlighting its potential as a therapeutic target.

Dexamethasone acetate loaded poly(ε-caprolactone) nanofibers for rat corneal chemical burn treatment

Topical eye drop approaches to treat ocular inflammation in dry eyes often face limitations such as low efficiency and short duration of drug delivery. Nanofibers serve to overcome the limitation of the short duration of action of topical eye drops used against ocular inflammation in dry eyes. Several attempts to develop suitable nanofibers have been made; however, there is no ideal solution. Here, we developed polycaprolactone (PCL) nanofibers loaded with dexamethasone acetate (DEX), prepared by electrospinning, as a potential ocular drug delivery platform for corneal injury treatment. Thirty-nine Sprague Dawley rats (7 weeks old males) were divided into four treatment groups after alkaline burns of the cornea; negative control (no treatment group); dexamethasone eyedrops (DEX group); PCL fiber (PCL group); dexamethasone loaded PCL (PCL + DEX group). We evaluated therapeutic efficacy of PCL + DEX by examining the epithelial wound healing effect, the extent of corneal opacity and neovascularization. Additionally, various inflammatory factors, including IL-1β, were investigated through immunochemistry, western blot analysis, and quantitative real-time RT-PCR (qRT-PCR). PCL + DEX group showed histologically alleviated signs of corneal inflammation compared with DEX group, which showed a decrease in IL-1β and MMP9 in the corneal stroma. The quantitative expression on day 1 after alkaline burn of pro-inflammatory markers, including IL-1β and IL-6, in the PCL + DEX group was significantly lower than that in the DEX group. Notably, PCL + DEX treatment significantly suppressed neovascularization, and enhanced the anti-inflammatory function of DEX during the acute phase of ocular inflammation. Collectively, these findings suggest that PCL + DEX may be a promising approach to effective drug delivery in corneal burn injuries.

Biomimetic nanocomplex based corneal neovascularization theranostics

Corneal neovascularization (CNV) is a major cause of blindness worldwide. However, the recent drug treatment is limited by repeated administration and low drug bioavailability. In this work, SU6668 (an inhibitor of receptor tyrosine kinases) and indocyanine green (ICG) are loaded onto poly(lactic-co-glycolic acid) (PLGA) nanoparticles, and then coated with anti-VEGFR2 single chain antibody (AbVr2 scFv) genetically engineered cell membrane vesicles. The nanomedicine is delivered via eye drops, and the hyperthermia induced by laser irradiation could block the blood vessels. Meanwhile, the photothermal effect can also cause the degradation of nanomaterials and release chemotherapeutic drugs in the blocked area, thereby continuously inhibit the neovascularization. Furthermore, SU6668 could inhibit the expression of heat shock protein 70 (HSP70), promoting the cell death induced by photothermal effect. In conclusion, the combination of photothermal and chemotherapy drugs provides a novel, effective and safe approach for the treatment of CNV.

Recent advancements and applications of ophthalmic gene therapy strategies: A breakthrough in ocular therapeutics

Over the past twenty years, ocular gene therapy has primarily focused on addressing diseases linked to various genetic factors. The eye is an ideal candidate for gene therapy due to its unique characteristics, such as easy accessibility and the ability to target both corneal and retinal conditions, including retinitis pigmentosa (RP), Leber congenital amaurosis (LCA), age-related macular degeneration (AMD), and Stargardt disease. Currently, literature documents 33 clinical trials in this field, with the most promising results emerging from trials focused on LCA. These successes have catalyzed further research into other ocular conditions such as glaucoma, AMD, RP, and choroideremia. The effectiveness of gene therapy relies on the efficient delivery of genetic material to specific cells, ensuring sustained and optimal gene expression over time. Viral vectors have been widely used for this purpose, although concerns about potential risks such as immune reactions and genetic mutations have led to the development of non-viral vector systems. Preliminary laboratory research and clinical investigations have shown a connection between vector dosage and the intensity of immune response and inflammation in the eye. The method of administration significantly influences these reactions, with subretinal delivery resulting in a milder humoral response compared to the intravitreal route. This review discusses various ophthalmic diseases, including both corneal and retinal conditions, and their underlying mechanisms, highlighting recent advances and applications in ocular gene therapies.

Current trends in the management of corneal neovascularization

PURPOSE OF REVIEW

The aim of this study was to highlight recent developments in the medical and surgical management of corneal neovascularization (NV).

RECENT FINDINGS

Improved understanding and diagnostic criteria among clinicians have led to advancements in the characterization of corneal NV and objective assessment of treatment response through ancillary imaging devices. Developments in corneal NV treatments, such as antivascular endothelial growth factor, fine needle diathermy, and photodynamic therapy, have improved treatment success rates and visual outcomes. More recent surgical treatment advancements include corneal cross-linking, endothelial keratoplasty, and mitomycin intravascular chemoembolization. Finally, a greater appreciation of the molecular pathogenesis and angiogenic factors involved in corneal NV has identified numerous potential targeted therapies in the future.

SUMMARY

The management of corneal NV has evolved to include several standalone and combination medical and surgical options. Additionally, improvements in quantifying corneal NV and understanding its molecular basis have contributed to new management strategies with improved outcomes.

Available Therapeutic Options for Corneal Neovascularization: A Review

Corneal neovascularization can impair vision and result in a poor quality of life. The pathogenesis involves a complex interplay of angiogenic factors, notably vascular endothelial growth factor (VEGF). This review provides a comprehensive overview of potential therapies for corneal neovascularization, covering tissue inhibitors of metalloproteinases (TIMPs), transforming growth factor beta (TGF-β) inhibitors, interleukin-1L receptor antagonist (IL-1 Ra), nitric oxide synthase (NOS) isoforms, galectin-3 inhibitors, retinal pigment epithelium-derived factor (PEDF), platelet-derived growth factor (PDGF) receptor inhibitors, and surgical treatments. Conventional treatments include anti-VEGF therapy and laser interventions, while emerging therapies such as immunosuppressive drugs (cyclosporine and rapamycin) have been explored. Losartan and decorin are potential antifibrotic agents that mitigate TGF-β-induced fibrosis. Ocular nanosystems are innovative drug-delivery platforms that facilitate the targeted release of therapeutic agents. Gene therapies, such as small interfering RNA and antisense oligonucleotides, are promising approaches for selectively inhibiting angiogenesis-related gene expression. Aganirsen is efficacious in reducing the corneal neovascularization area without significant adverse effects. These multifaceted approaches underscore the corneal neovascularization management complexity and highlight ideas for enhancing therapeutic outcomes. Furthermore, the importance of combination therapies and the need for further research to develop specific inhibitors while considering their therapeutic efficacy and potential adverse effects are discussed.

Minocycline-loaded nHAP/PLGA microspheres for prevention of injury-related corneal angiogenesis

BACKGROUND

Corneal neovascularization (CoNV) threatens vision by disrupting corneal avascularity, however, current treatments, including pharmacotherapy and surgery, are hindered by limitations in efficacy and adverse effects. Minocycline, known for its anti-inflammatory properties, could suppress CoNV but faces challenges in effective delivery due to the cornea's unique structure. Therefore, in this study a novel drug delivery system using minocycline-loaded nano-hydroxyapatite/poly (lactic-co-glycolic acid) (nHAP/PLGA) nanoparticles was developed to improve treatment outcomes for CoNV.

RESULTS

Ultra-small nHAP was synthesized using high gravity technology, then encapsulated in PLGA by a double emulsion method to form nHAP/PLGA microspheres, attenuating the acidic by-products of PLGA degradation. The MINO@PLGA nanocomplex, featuring sustained release and permeation properties, demonstrated an efficient delivery system for minocycline that significantly inhibited the CoNV area in an alkali-burn model without exhibiting apparent cytotoxicity. On day 14, the in vivo microscope examination and ex vivo CD31 staining corroborated the inhibition of neovascularization, with the significantly smaller CoNV area (29.40% ± 6.55%) in the MINO@PLGA Tid group (three times daily) than that of the control group (86.81% ± 15.71%), the MINO group (72.42% ± 30.15%), and the PLGA group (86.87% ± 14.94%) (p < 0.05). Fluorescein sodium staining show MINO@PLGA treatments, administered once daily (Qd) and three times daily (Tid) demonstrated rapid corneal epithelial healing while the Alkali injury group and the DEX group showed longer healing times (p < 0.05). Additionally, compared to the control group, treatments with dexamethasone, MINO, and MINO@PLGA were associated with an increased expression of TGF-β as evidenced by immunofluorescence, while the levels of pro-inflammatory cytokines IL-1β and TNF-α demonstrated a significant decrease following alkali burn. Safety evaluations, including assessments of renal and hepatic biomarkers, along with H&E staining of major organs, revealed no significant cytotoxicity of the MINO@PLGA nanocomplex in vivo.

CONCLUSIONS

The novel MINO@PLGA nanocomplex, comprising minocycline-loaded nHAP/PLGA microspheres, has shown a substantial capacity for preventing CoNV. This study confirms the complex's ability to downregulate inflammatory pathways, significantly reducing CoNV with minimal cytotoxicity and high biosafety in vivo. Given these findings, MINO@PLGA stands as a highly promising candidate for ocular conditions characterized by CoNV.

Mitomycin intravascular chemoembolization (MICE) to treat corneal vascularization prior to penetrating keratoplasty

Purpose

To present the clinical outcome of mitomycin intravascular chemoembolization (MICE) as a prophylactic treatment in a patient with HSV-induced corneal neovascularization (NV) before penetrating keratoplasty (PKP).

Observations

A 53-year-old male patient presented with a medical history of recurrent herpes simplex virus (HSV) corneal infection. The patient reported worsening visual acuity despite maintenance treatment with systemic antivirals and topical corticosteroids. After the appearance of corneal NV, subconjunctival triamcinolone and bevacizumab injections were given with limited and temporary improvement. Due to worsening corneal NV, MICE was subsequently performed, resulting in the elimination of corneal NV from the visual axis, which allowed for successful PKP 4 months later. Cataract surgery was performed 6 months after PKP.

Conclusions and importance

This report describes the potential efficacy of MICE as a prophylactic treatment for corneal NV prior to PKP.

ICG-based laser treatments for ophthalmic diseases: Toward their safe and rapid strategy

The eye is a very important organ, and keratitis, corneal neovascularization, floaters, age-related macular degeneration, and other vision problems have seriously affected people's quality of life. Among the ophthalmic treatments, laser photocoagulations have been proposed and have shown therapeutic effects in clinical settings. However, corneal thinning and bleeding lesions induced by laser damage have led to limit its applications. To treat the issues of traditional hyperthermia treatments, photosensitizers [e.g., indocyanine green (ICG)] have been investigated to increase the therapeutic effects of corneal neovascularization and choroidal neovascularization. In the recent study, with the help of ICG, laser-induced nanobubble was proposed to treat vitreous opacities. The developed strategies could enlarge the effect of laser irradiation and reduce the side effects, so as to expand the scope of laser treatments in clinical ophthalmic diseases.

Efficient ocular delivery of siRNA via pH-sensitive vehicles for corneal neovascularization inhibition

Corneal neovascularization (CoNV)-induced blindness is an enduring and challenging condition with limited management options. Small interfering RNA (siRNA) is a promising strategy for preventing CoNV. This study reported a new strategy using siVEGFA to silence vascular endothelial growth factor A (VEGFA) for CoNV treatment. To improve the efficacy of siVEGFA delivery, a pH-sensitive polycationic mPEG_2k-PAMA₃₀-P(DEA₂₉-D5A₂₉) (TPPA) was fabricated. TPPA/siVEGFA polyplexes enter cells via clathrin-mediated endocytosis, resulting in higher cellular uptake efficiency and comparable silencing efficiency than that of Lipofectamine 2000 in vitro. Hemolytic assays verified that TPPA safe in normal physiological environments (pH 7.4) but can easily destroy membranes in acidic mature endosomes (pH 4.0). Studies on the distribution of TPPA in vivo showed that it could prolong the retention time of siVEGFA and promote its penetration in the cornea. In a mouse model induced by alkali burn, TPPA efficiently delivered siVEGFA to the lesion site and achieved VEGFA silencing efficiency. Importantly, the inhibitory effect of TPPA/siVEGFA on CoNV was comparable to that of the anti-VEGF drug ranibizumab. Delivering siRNA using pH-sensitive polycations to the ocular environment provides a new strategy to efficiently inhibit CoNV.

Management and prevention of corneal graft rejection

The management of an episode of corneal graft rejection (CGR) is primarily by corticosteroids. Immunomodulators are useful for long-term immunosuppression and in dealing with cases of high-risk (HR) corneal grafts. The classical signs of CGR following penetrating keratoplasty (PKP) include rejection line, anterior chamber (AC) reaction, and graft edema. However, these signs may be absent or subtle in cases of endothelial keratoplasty (EK). Prevention of an episode of graft rejection is of utmost importance as it can reduce the need for donor cornea significantly. In our previous article (IJO_2866_22), we had discussed about the immunopathogenesis of CGR. In this review article, we aim to discuss the various clinical aspects and management of CGR.

Recent development of polymer nanomicelles in the treatment of eye diseases

The eye, being one of the most intricate organs in the human body, hosts numerous anatomical barriers and clearance mechanisms. This highlights the importance of devising a secure and efficacious ocular medication delivery system. Over the past several decades, advancements have been made in the development of a nano-delivery platform based on polymeric micelles. These advancements encompass diverse innovations such as poloxamer, chitosan, hydrogel-encapsulated micelles, and contact lenses embedded with micelles. Such technological evolutions allow for sustained medication retention and facilitate enhanced permeation within the eye, thereby standing as the avant-garde in ocular medication technology. This review provides a comprehensive consolidation of ocular medications predicated on polymer nanomicelles from 2014 to 2023. Additionally, it explores the challenges they pose in clinical applications, a discussion intended to aid the design of future clinical research concerning ocular medication delivery formulations.

AA, Kulkarni V, Oh Y, Xia S, Ding Z, Han H, Anders N, Rudek MA, Chow W, Stark W, Ensign LM, Hanes J, Xu Q. Six-month effective treatment of corneal graft rejection

Topical corticosteroid eye drop is the mainstay for preventing and treating corneal graft rejection. While the frequent topical corticosteroid use is associated with risk of intraocular pressure (IOP) elevation and poor patient compliance that leads to graft failure and the requirement for a repeated, high-risk corneal transplantation. Here, we developed dexamethasone sodium phosphate (DSP)-loaded dicarboxyl-terminated poly(lactic acid) nanoparticle (PLA DSP-NP) formulations with relatively high drug loading (8 to 10 weight %) and 6 months of sustained intraocular DSP delivery in rats with a single dosing. PLA DSP-NP successfully reversed early signs of corneal rejection, leading to rat corneal graft survival for at least 6 months. Efficacious PLA DSP-NP doses did not affect IOP and showed no signs of ocular toxicity in rats for up to 6 months. Subconjunctival injection of DSP-NP is a promising approach for safely preventing and treating corneal graft rejection with the potential for improved patient adherence.

Overactivation of Norepinephrine-β2-Adrenergic Receptor Axis Promotes Corneal Neovascularization

Purpose

To investigate the role of the sympathetic nervous system in corneal neovascularization (CNV) and to identify the downstream pathway involved in this regulation.

Methods

Three types of CNV models were constructed with C57BL/6J mice, including the alkali burn model, suture model, and basic fibroblast growth factor (bFGF) corneal micropocket model. Subconjunctival injection of the sympathetic neurotransmitter norepinephrine (NE) was administered in these three models. Control mice received injections of water of the same volume. The corneal CNV was detected using slit-lamp microscopy and immunostaining with CD31, and the results were quantified by ImageJ. The expression of β2-adrenergic receptor (β2-AR) was stained with mouse corneas and human umbilical vein endothelial cells (HUVECs). Furthermore, the anti-CNV effects of β2-AR antagonist ICI-118,551 (ICI) were examined with HUVEC tube formation assay and with a bFGF micropocket model. Additionally, partial β2-AR knockdown mice (Adrb2+/-) were used to establish the bFGF micropocket model, and the corneal CNV size was quantified based on the slit-lamp images and vessel staining.

Results

Sympathetic nerves invaded the cornea in the suture CNV model. The NE receptor β2-AR was highly expressed in corneal epithelium and blood vessels. The addition of NE significantly promoted corneal angiogenesis, whereas ICI effectively inhibited CNV invasion and HUVEC tube formation. Adrb2 knockdown significantly reduced the cornea area occupied by CNV.

Conclusions

Our study found that sympathetic nerves grow into the cornea in conjunction with newly formed vessels. The addition of the sympathetic neurotransmitter NE and activation of its downstream receptor β2-AR promoted CNV. Targeting β2-AR could potentially be used as an anti-CNV strategy.

An Update on Novel Ocular Nanosystems with Possible Benefits in the Treatment of Corneal Neovascularization

Corneal neovascularization (CNV) is an ocular pathological change that results from an imbalance between angiogenic factors and antiangiogenic factors as a result of various ocular insults, including infection, inflammation, hypoxia, trauma, corneal degeneration, and corneal transplantation. Current clinical strategies for the treatment of CNV include pharmacological treatment and surgical intervention. Despite some degree of success, the current treatment strategies are restricted by limited efficacy, adverse effects, and a short duration of action. Recently, gene-based antiangiogenic therapy has become an emerging strategy that has attracted considerable interest. However, potential complications with the use of viral vectors, such as potential genotoxicity resulting from long-term expression and nonspecific targeting, cannot be ignored. The use of ocular nanosystems (ONS) based on nanotechnology has emerged as a great advantage in ocular disease treatment during the last two decades. The potential functions of ONS range from nanocarriers, which deliver drugs and genes to target sites in the eye, to therapeutic agents themselves. Various preclinical studies conducted to date have demonstrated promising results of the use of ONS in the treatment of CNV. In this review, we provide an overview of CNV and its current therapeutic strategies and summarize the properties and applications of various ONS related to the treatment of CNV reported to date. Our goal is to provide a comprehensive review of these considerable advances in ONS in the field of CNV therapy over the past two decades to fill the gaps in previous related reports. Finally, we discuss existing challenges and future perspectives of the use of ONS in CNV therapy, with the goal of providing a theoretical contribution to facilitate future practical growth in the area.

Magic Bullets: The Coming Age of Meaningful Pharmacological Control of the Corneal Responses to Injury and Disease

Corneal injuries from chemical burns, mechanical trauma, infections, immunological rejections, surgical complications, and some diseases are commonly associated with persistent epithelial defects (PED), neurotrophic epitheliopathy, scarring fibrosis, corneal neovascularization (CNV), and/or corneal endothelial damage that lead to vision loss. Several Food and Drug Administration (FDA) approved medications have recently become available, are currently in clinical trials, or are likely to enter clinical trials in the near future. For example, a 2-week course of topical human recombinant nerve growth factor is frequently an effective treatment for corneal neurotrophic epitheliopathy associated with PEDs. Topical losartan, an angiotensin converting enzyme II receptor antagonist that also inhibits TGF beta signaling, has been shown to effectively decrease myofibroblast generation and scarring fibrosis in alkali burn injury and Descemetorhexis rabbit models. Small molecule topical tyrosine kinase inhibitors, such as sunitinib and axitinib, FDA approved as chemotherapeutic agents to treat specific cancers, have also been found to be effective topical inhibitors of CNV in animal and human trials. Rho-kinase inhibitors, such as ripasudil and netarsudil, that are currently approved agents for the treatment of glaucoma in some countries, have been shown to stimulate corneal endothelial proliferation in animal studies and human trials, and may accelerate the regeneration of Descemet's membrane. These agents, as well as other drugs in development, will be used in targeted combinations to treat corneal pathophysiology associated with epithelial healing disorders, stromal scarring fibrosis, CNV, and corneal endothelial injury during the next decade.

Topical Nanoemulsion of an Runt-related Transcription Factor 1 Inhibitor for the Treatment of Pathologic Ocular Angiogenesis

Purpose

To test the efficacy of runt-related transcription factor 1 (RUNX1) inhibition with topical nanoemulsion containing Ro5-3335 (eNano-Ro5) in experimental ocular neovascularization.

Design

Preclinical experimental study.

Participants

In vitro primary culture human retinal endothelial cell (HREC) culture. C57BL/6J 6- to 10-week-old male and female mice.

Methods

We evaluated the effect of eNano-Ro5 in cell proliferation, cell toxicity, and migration of HRECs. We used an alkali burn model of corneal neovascularization and a laser-induced model of choroidal neovascularization to test in vivo efficacy of eNano-Ro5 in pathologic angiogenesis in mice. We used mass spectrometry to measure penetration of Ro5-3335 released from the nanoemulsion in ocular tissues.

Main Outcome Measures

Neovascular area.

Results

RUNX1 inhibition reduced cell proliferation and migration in vitro. Mass spectrometry analysis revealed detectable levels of the active RUNX1 small-molecule inhibitor Ro5-3335 in the anterior and posterior segment of the mice eyes. Topical treatment with eNano-Ro5 significantly reduced corneal neovascularization and improved corneal wound healing after alkali burn. Choroidal neovascularization lesion size and leakage were significantly reduced after treatment with topical eNano-Ro5.

Conclusions

Topical treatment with eNano-Ro5 is an effective and viable platform to deliver a small-molecule RUNX1 inhibitor. This route of administration offers advantages that could improve the management and outcomes of these sight-threatening conditions. Topical noninvasive delivery of RUNX1 inhibitor could be beneficial for many patients with pathologic ocular neovascularization.

Radiofrequency diathermy as a treatment of lipid keratopathy in a radial keratotomy incision

Purpose

We report a case of lipid keratopathy in a radial keratotomy incision that was successfully managed with radiofrequency diathermy of the neovascular pedicle responsible for the lipid deposition.

Observations

No perioperative or postoperative complications were noted. Following the procedure, the lesion showed significant decrease in lipid deposits and opacification along with disappearance of the neovascular pedicle.

Conclusions and importance

Radiofrequency diathermy of neovascular pedicle may represent an effective and safe alternative treatment option for treating lipid keratopathy. This is a first ever report of lipid keratopathy inside a radial keratotomy incision that was successfully managed by radiofrequency diathermy.

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We report a case of lipid keratopathy in a radial keratotomy incision.

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We successfully managed the case with radiofrequency diathermy of the neovascular pedicle.

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After treatment, the lesion showed regression of the opacification along with disappearance of the neovascular pedicle.

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Radiofrequency diathermy may represent an effective and safe alternative treatment option for treating lipid keratopathy.

An injectable thermosensitive hydrogel for dual delivery of diclofenac and Avastin® to effectively suppress inflammatory corneal neovascularization

Corneal neovascularization (CNV) is a sequela of anterior segment inflammation, which could lead to vision impairment and even blindness. In the present study, the dual delivery of anti-inflammatory agent (i.e., diclofenac; DIC) and anti-VEGF antibody (i.e., Avastin®; Ava) by the thermosensitive hydrogel (Poly(dl-lactide)-poly(ethylene glycol)-poly(dl-lactide); PDLLA-PEG-PDLLA) is expected to effectively inhibit CNV via their synergistic effects. The optimal DIC micelles were formulated and then mixed with Ava and PDLLA-PEG-PDLLA aqueous solution to generate various DIC@Ava-loaded hydrogels. The co-encapsulation of DIC micelles and Ava did not influence the gelling behavior of the system, and the resulting DIC@Ava-loaded hydrogel provided sustained drug release of both DIC and Ava without compromising their pharmacological activity over 19 days. As indicated by in vitro cytotoxicity and in vivo ocular biocompatibility test, the proposed PDLLA-PEG-PDLLA hydrogel caused minimal cytotoxicity against all tested cell lines at a polymeric concentration ranging from 0.05 mg/mL to 0.8 mg/mL and demonstrated good ocular biocompatibility after a single subconjunctival injection. Using the rabbit CNV model, we documented the superior anti-angiogenic effects of the DIC@Ava-loaded hydrogel over Ava alone medication (treatment with Ava solution and Ava-loaded hydrogel) due to synergistic effects of anti-VEGF and anti-inflammatory action. Overall, the proposed DIC@Ava-loaded hydrogel might be a powerful strategy to reduce CNV.

LncRNA Meg3 knockdown reduces corneal neovascularization and VEGF-induced vascular endothelial angiogenesis via SDF-1/CXCR4 and Smad2/3 pathway

The crucial effect of vascular endothelial growth factor (VEGF)-induced vascular angiogenesis has been well known in corneal neovascularization (CNV). This research aimed to determine the underlying value and mechanism of Meg3 on CNV in vivo and in vitro. In an alkali-burned mouse model, length and area of new vessels were increased along with thinning of corneal epithelium, accompanied by the overexpression of Meg3. Notably, subconjunctival injection of shMeg3 suppressed the degree of injury in cornea, causing expression of the angiogenesis markers--VEGF-A and CD31 decreased. In VEGF-induced human umbilical vein endothelial cells (HUVECs), knockdown of Meg3 antagonized the enhancement of viability, proliferation, wound healing ability and angiogenesis by VEGF. The proteins expression of VEGF-A, CD31, SDF-1/CXCR4 as well as phosphoraylation-Smad2/3 pathways, which were related to angiogenesis, were reduced with Meg3 deficiency. Overall, knockdown of Meg3 alleviated formation of neovascularization in alkali-burned corneas and reduced VEGF-induced angiogenesis by inhibiting SDF-1/CXCR4 and Smad2/3 signaling in vitro.

Customized cationic nanoemulsions loading triamcinolone acetonide for corneal neovascularization secondary to inflammatory processes

Customized cationic oil-in-water nanoemulsions (NEs) have been produced to improve the bioavailability of poorly water-soluble drugs, such as triamcinolone acetonide (TA). TA is a synthetic glucocorticoid with anti-inflammatory and antiangiogenic therapeutic properties and it is widely used as an effective treatment in ocular disorders. In this work, TA-NEs were characterized using two different custom-made cationic surfactants, showing a high positive surface charge favouring corneal penetration and a particle size below 300 nm. Both TA-NE formulations demonstrated to be stable at 4 °C during the first months of storage. Furthermore, TA-NEs were able to produce antiangiogenic effects in chicken membranes. The TA-NEs safety profile was evaluated using in vitro and in vivo ocular tolerance tests. Out of the two formulations, the one showing no irritant effects was screened in vivo demonstrating capacity to ameliorate ocular inflammation in New Zealand rabbits significantly, specially to reduce the risk of ocular inflammation processes, with antiangiogenic activity, and can therefore be exploited as a suitable formulation to avoid inflammatory reactions upon ocular surgical procedures, such as cataracts.

Improving the solubility of vorinostat using cyclodextrin inclusion complexes: The physicochemical characteristics, corneal permeability and ocular pharmacokinetics of the drug after topical application

Vorinostat (suberoylanilide hydroxamic acid, SAHA), an FDA-approved drug for cutaneous T cell lymphoma, has antiangiogenic and anti-inflammatory activity and thus has therapeutic potential for inflammatory corneal neovascularization (CNV). However, its practical administration is limited due to its poor aqueous solubility and permeability. This study aimed to enhance the corneal permeability of SAHA by promoting its inclusion into a complex with hydroxypropyl-β-CD (HPβCD) for topical application. In phase-solubility studies, the solubility of SAHA with HPβCD and sulfobutyl ether-β-CD (SEβCD) was assessed at different temperatures, and complexation efficiencies (K) were calculated. The inclusion complexes (ICs) were prepared and characterized by differential scanning calorimetry (DSC), infrared spectrometry (IR), scanning electron microscopy (SEM), and X-ray diffraction (XRD) after freeze-drying. The phase-solubility study showed that the complexation efficiencies of SAHA were higher in HPβCD solutions (297.35 M^-1, 115.28 M^-1 and 122.75 M^-1) than in SEβCD solutions (169.75 M^-1, 91.33 M^-1 and 96.49 M^-1) at 4 °C, 25 °C and 37 °C. HPβCD was selected for SAHA-IC preparation, and characterization revealed IC formation. SAHA existed in an amorphous state in the ICs. The ex vivo corneal permeability of SAHA was also evaluated and found to be greater when formulated as an HPβCD solution than as a suspension. Irritation assays in rabbit eyes showed that the SAHA-IC solution was not irritating after topical application. The ocular pharmacokinetics of SAHA in New Zealand White rabbits were assessed following topical administration (0.2%), and a 0.2% SAHA suspension was used as the control. Compared to its formulation as a suspension, the formulation of SAHA as an HPβCD solution increased its corneal bioavailability by more than 3-fold and its conjunctival bioavailability by more than 2-fold. Thus, IC formation was effective at improving the ocular bioavailability of SAHA. This study provides an important alternative approach for developing liquid pharmaceutical formulations of SAHA for topical ocular applications.

Corticosteroids in the Management of Infectious Keratitis: A Concise Review

Microbial keratitis is devastating corneal morbidity with a variable spectrum of clinical manifestations depending on the infective etiology. Irrespective of the varied presentation delayed treatment can lead to severe visual impairment resulting from corneal ulceration, possible perforation, and subsequent scarring. Corticosteroids with a potent anti-inflammatory activity reduce host inflammation, thus minimizing resultant scarring while improving ocular symptoms. These potential effects of corticosteroids have been applied widely to treat various corneal diseases ranging from vernal keratoconjunctivitis to dry eye disease. However, antimicrobial therapy remains the mainstay of treatment in microbial keratitis, whereas the use of adjunctive topical corticosteroid therapy remains a matter of debate. Understandably, the use of topical corticosteroids is a double-edged sword with pros and cons in the treatment of microbial keratitis. Herein we review the rationale for and against the use and safety of topical corticosteroids in the treatment of infective keratitis. Important considerations, including type, dose, efficacy, the timing of initiation of corticosteroids, use of concomitant antimicrobial agents, and duration of corticosteroid therapy while prescribing corticosteroids for microbial keratitis, have been discussed. This review intends to provide new insights into the therapeutic utility of steroids as adjunctive treatment of corneal ulcer.

Two Cases of Corneal Neovascularization Treatment Using High-frequency Radio Wave Electrosurgery

Purpose: To report two cases of treatment using high-frequency radio wave electrosurgery for corneal neovascularization that recurred after medication and laser photocoagulation attempts.Case summary: (Case 1) A 53-year-old man visited our hospital complaining of corneal opacity. The best-corrected visual acuity in the left eye was 0.6. Lipid keratopathy indicated new inferior vessels. There was no significant change in corneal opacity after medication and laser photocoagulation; however, the recurrence of feeder vessels was observed. Therefore, electrocautery was performed via high-frequency radio wave electrosurgery. Visual acuity, measured 1 month later, improved to 0.9. Over the subsequent 4-year observation period, new vessels did not recur and the corneal opacity decreased gradually. (Case 2) A 23-year-old woman visited complaining of left eye pain. She had undergone laser photocoagulation three times for corneal new vessels. Visual acuity in her left eye was 0.4. Recurrence of new vessels at the upper cornea was observed, and electrocautery was performed. After 2 months, corneal opacity decreased without revascularization, and visual acuity improved to 0.5.Conclusions: In patients with corneal neovascularization, electrocautery using high-frequency radio wave electrosurgery is simple and effective and can reduce corneal opacity and improve vision without complications.

Hydrogels as Emerging Materials for Cornea Wound Healing

Hydrogel biomaterials have many favorable characteristics including tuneable mechanical behavior, cytocompatibility, optical properties suitable for regeneration and restoration of the damaged cornea tissue. The cornea is a tissue susceptible to various injuries and traumas with a complicated healing cascade, in which conserving its transparency and integrity is critical. Accordingly, the hydrogels' known properties along with the stimulation of nerve and cell regeneration make them ideal scaffold for corneal tissue engineering. Hydrogels have been used extensively in clinical applications for the repair and replacement of diseased organs. The development and optimizing of novel hydrogels to repair/replace corneal injuries have been the main focus of researches within the last decade. This research aims to critically review in vitro, preclinical, as well as clinical trial studies related to corneal wound healing using hydrogels in the past 10 years, as this is considered as an emerging technology for corneal treatment. Several unique modifications of hydrogels with smart behaviors have undergone early phase clinical trials and showed promising outcomes. Financially, this considers a multibillion dollars industry and with huge interest from medical devices as well as pharmaceutical industries with several products may emerge within the next five years.

In vivo photoacoustic imaging for monitoring treatment outcome of corneal neovascularization with metformin eye drops

Corneal neovascularization (CNV) compromises corneal avascularity and visual acuity. Current clinical visualization approaches are subjective and unable to provide molecular information. Photoacoustic (PA) imaging offers an objective and non-invasive way for angiogenesis investigation through hemodynamic and oxygen saturation level (sO₂) quantification. Here, we demonstrate the utility of PA and slit lamp microscope for in vivo rat CNV model. PA images revealed untreated corneas exhibited higher sO₂ level than treatment groups. The PA results complement with the color image obtained with slit lamp. These data suggest PA could offer an objective and non-invasive method for monitoring CNV progression and treatment outcome through the sO₂ quantification.

The Role of Eph Receptors and Ephrins in Corneal Physiology and Diseases

The cornea, while appearing to be simple tissue, is actually an extremely complex structure. In order for it to retain its biomechanical and optical properties, perfect organization of its cells is essential. Proper regeneration is especially important after injuries and in the course of various diseases. Eph receptors and ephrin are mainly responsible for the proper organization of tissues as well as cell migration and communication. In this review, we present the current state of knowledge on the role of Eph and ephrins in corneal physiology and diseases, in particular, we focused on the functions of the epithelium and endothelium. Since the role of Eph and ephrins in the angiogenesis process has been well established, we also analyzed their influence on conditions with corneal neovascularization.

Corneal neovascularization

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.

Paxillin promotes the migration and angiogenesis of HUVECs and affects angiogenesis in the mouse cornea

Neonatal vascular ophthalmopathy is a refractory ophthalmologic disease, and is a major cause of blindness. Occurrence of neonatal vascular ophthalmopathy may be associated with Paxillin, a cellular adhesion molecule which promotes the migration of endothelial cells and angiogenesis. To explore the role of PXN in corneal angiogenesis, human umbilical vein endothelial cells were divided into five groups: i) Control group; ii) Empty vector-transfected control group; iii) PXN knockdown group (shPXN group); iv) PXN-negative control (NC) group; and v) PXN over-expressed group (overExp group). PXN protein levels, migration and tube formation were assessed in the different experimental groups. Mice were divided into four groups: i) Control; ii) Model; iii) shPXN; and iv) overExp groups. Tube formation was significantly increased in the overExp group compared with the empty vector-transfected control group (P<0.01). Tube formation was significantly decreased in the shPXN group compared with the PXN-NC group (P<0.01). In mice, blood corpuscles were significantly decreased in the shPXN group. PXN promoted the migration of endothelial cells and corneal angiogenesis. The results of the present study suggest a role for PXN in corneal angiogenesis and provide a theoretical basis and potential target for the treatment of corneal angiogenesis.

Pharmacological Potential of Small Molecules for Treating Corneal Neovascularization

Under healthy conditions, the cornea is an avascular structure which allows for transparency and optimal visual acuity. Its avascular nature is maintained by a balance of proangiogenic and antiangiogenic factors. An imbalance of these factors can result in abnormal blood vessel proliferation into the cornea. This corneal neovascularization (CoNV) can stem from a variety of insults including hypoxia and ocular surface inflammation caused by trauma, infection, chemical burns, and immunological diseases. CoNV threatens corneal transparency, resulting in permanent vision loss. Mainstay treatments of CoNV have partial efficacy and associated side effects, revealing the need for novel treatments. Numerous natural products and synthetic small molecules have shown potential in preclinical studies in vivo as antiangiogenic therapies for CoNV. Such small molecules include synthetic inhibitors of the vascular endothelial growth factor (VEGF) receptor and other tyrosine kinases, plus repurposed antimicrobials, as well as natural source-derived flavonoid and non-flavonoid phytochemicals, immunosuppressants, vitamins, and histone deacetylase inhibitors. They induce antiangiogenic and anti-inflammatory effects through inhibition of VEGF, NF-κB, and other growth factor receptor pathways. Here, we review the potential of small molecules, both synthetics and natural products, targeting these and other molecular mechanisms, as antiangiogenic agents in the treatment of CoNV.

Evaluation of His6-Metal Assemblies as a Drug Delivery Vehicle in the Treatment of Anterior Segment Disease Using a Corneal Inflammation Model

Keratitis is a common ophthalmological disease and also a common cause of blindness (second only to cataracts). This disease is routinely treated by topical administration of dexamethasone sodium phosphate (Dexp). However, due to the presence of anatomical and physiological barriers, frequent administration is needed, often resulting in poor patient compliance and diverse side effects. In this work, Dexp was in situ encapsulated into a His₆-metal assembly (HmA) to generate Dexp@HmA, which was utilized in the ocular delivery of Dexp. The physicochemical properties of HmA and Dexp@HmA particles were characterized in detail using various techniques such as dynamic light scattering (DLS), scanning electron microscopy (SEM), and UV-vis spectroscopy. Compared to commercial Eudragi and reported PLGA nanoparticles, HmA showed higher encapsulation efficiency (EE%) and higher loading capacity (LC wt %) of Dexp. Dexp@HmA displayed pH-dependent release; after 33 days at pH 5.8, 6.5, and 7.2, 100%, 65%, and 42% of Dexp, respectively, had been released. In addition, HmA and Dexp@HmA showed low cytotoxicity to macrophages and to all common ocular cell types tested. The effect of Dexp@HmA on corneal inflammation was evaluated using in vitro and in vivo models. Our results demonstrate that Dexp@HmA is much superior to free Dexp in both in vitro and in vivo models. These positive results suggest that HmA may represent a promising candidate nanocarrier for the treatment of various diseases of the anterior segment of the eye.

Updates on the Management of Ocular Vasculopathies with VEGF Inhibitor Conbercept

Purpose: To provide a detailed review on the therapeutic efficacy of conbercept for the management of ocular vasculopathies. Methods: A comprehensive literature search of various electronic databases was performed. Results: Ocular vasculopathy is one of the major causes of visual impairment and blindness which includes a range of disorders. Vascular endothelial growth factor (VEGF) regulates angiogenesis, enhances vascular permeability, and drives the formation of neovascularization. Anti-VEGF therapy has been shown to prevent vision loss or potentially improve vision in patients with exudative or neovascular retinal disease. The most recent anti-VEGF drug in China is conbercept. In the USA and Europe, bevacizumab is the most recently approved anti-VEGF agent. Conclusions: Conbercept serves as another anti-VEGF option for patients with neovascular AMD and other retinal vascular disorders. There have not been many clinical trials that study conbercept as compared with other currently available anti-VEGF drugs. There is a need for large-scale, well-designed, randomized clinical trials to ensure its long-term safety and efficacy and to determine if it has any advantages over other anti-VEGF agents.

Lipid Signaling in Ocular Neovascularization

Vasculogenesis and angiogenesis play a crucial role in embryonic development. Pathological neovascularization in ocular tissues can lead to vision-threatening vascular diseases, including proliferative diabetic retinopathy, retinal vein occlusion, retinopathy of prematurity, choroidal neovascularization, and corneal neovascularization. Neovascularization involves various cellular processes and signaling pathways and is regulated by angiogenic factors such as vascular endothelial growth factor (VEGF) and hypoxia-inducible factor (HIF). Modulating these circuits may represent a promising strategy to treat ocular neovascular diseases. Lipid mediators derived from membrane lipids are abundantly present in most tissues and exert a wide range of biological functions by regulating various signaling pathways. In particular, glycerophospholipids, sphingolipids, and polyunsaturated fatty acids exert potent pro-angiogenic or anti-angiogenic effects, according to the findings of numerous preclinical and clinical studies. In this review, we summarize the current knowledge regarding the regulation of ocular neovascularization by lipid mediators and their metabolites. A better understanding of the effects of lipid signaling in neovascularization may provide novel therapeutic strategies to treat ocular neovascular diseases and other human disorders.

Multimodal Photoacoustic Imaging-Guided Regression of Corneal Neovascularization: A Non-Invasive and Safe Strategy

Corneal neovascularization (CNV) is one of the main factors that induce blindness worldwide. However, current medical treatments cannot achieve non-invasive and safe inhibition of CNV. A noninvasive photoacoustic imaging (PAI)-guided method is purposed for the regression of CNV. PAI can monitor the oxygen saturation of cornea blood vessels through the endogenous contrast of hemoglobin and trace administrated drugs by themselves as exogenous contrast agents. An indocyanine green (ICG)-based nanocomposite (R-s-ICG) is prepared for CNV treatment via eye drops and subconjunctival injections. It is demonstrated that R-s-ICG can enrich corneal tissues and pathological blood vessels rapidly with minor residua in normal eyeball tissues. Anti-CNV treatment-driven changes in the blood vessels are assessed by real-time multimodal PAI in vivo, and then a safe laser irradiation strategy through the canthus is developed for phototherapy and gene therapy synergistic treatment. The treatment leads to the efficient inhibition of CNV with faint damages to normal tissues.

Development of mucoadhesive cationic polypeptide micelles for sustained cabozantinib release and inhibition of corneal neovascularization

Corneal neovascularization (CNV) is one of the leading risk factors for vision loss. Anti-angiogenic drugs can theoretically be extended to the treatment of CNV. However, the application of these drugs is often hindered by traditional administration methods, e.g., eye drops, which is ascribed to the unique structure of the cornea and tear film. In this study, cationic polypeptide nanoparticles with mucoadhesive ability that carry lipophilic cabozantinib (a tyrosine kinase inhibitor), called Cabo-NPs, were developed for sustained cabozantinib release and inhibition of CNV. The polypeptides were synthesized via N-carboxyanhydride ring-opening polymerization and could self-assemble into micelles with cabozantinib in aqueous solution. The Cabo-NPs possessed good biocompatibility both in corneal epithelial cells and mouse corneas. More importantly, in vitro angiogenesis assays demonstrated the strong inhibitory effect of Cabo-NPs on cell migration and tube formation. Furthermore, the Cabo-NPs exerted superior anti-angiogenic effects with remarkable reductions in the neovascular area, which were as effective as the clinical dexamethasone but without apparent side effects. The therapeutic mechanism of the Cabo-NPs is closely related to the significant decrease in proangiogenic and proinflammatory factors, suppressing neovascularization and inflammation. Overall, cationic Cabo-NPs offer a new prospect for safe and effective CNV treatment via enhancing the bioavailability of lipophilic cabozantinib.

Local delivery of corticosteroids in clinical ophthalmology: A review

Locally administered steroids have a long history in ophthalmology for the treatment of inflammatory conditions. Anterior segment conditions tend to be treated with topical steroids whilst posterior segment conditions generally require periocular, intravitreal or systemic administration for penetration. Over recent decades, the clinical applications of periocular steroid delivery have expanded to a wide range of conditions including macular oedema from retino-vascular conditions. Formulations have been developed with the aim to provide practical, targeted, longer-term and more efficacious therapy whilst minimizing side effects. Herein, we provide a comprehensive overview of the types of periocular steroid delivery, their clinical applications in ophthalmology and their side effects.

Microarray Analysis of circRNA Expression Pattern in Corneal Neovascularization

PURPOSE

To identify differentially expressed circular RNAs (circRNAs) in corneal neovascularization.

METHODS

We established an alkali burn-induced corneal neovascularization model and performed circRNA expression profiling to identify differentially expressed circRNAs between avascular corneas and vascularized corneas. Gene ontology enrichment and Kyoto Encyclopedia of Genes and Genomes analyses of the host genes of dysregulated circRNAs were performed to determine the related biological modules and pathological pathways. Real-time polymerase chain reactions were performed to detect the expression pattern of circRNAs in the clinical samples. In vitro experiments were performed to determine the role of circRNAs in vascular endothelial angiogenic effects.

RESULTS

Two hundred twenty-nine circRNAs were differentially expressed between avascular corneas and vascularized corneas. The host genes of dysregulated circRNAs were targeted to cell cycle (biologic process), cytoplasm (cellular component), and protein binding (molecular function). Rap1 signaling was identified as the most enriched signaling pathway. Clinical studies showed that the human ortholog of cZFP609 and cKifap3 was dysregulated in the vascularized human corneas. cKifap3 silencing facilitated vascular endothelial angiogenic effects by regulating endothelial cell proliferation, migration, and tube formation.

CONCLUSIONS

This study suggests that circRNAs are involved in the pathogenesis of corneal neovascularization. cZFP609 and cKifap3 may serve as promising targets for the treatment of corneal neovascularization.

Circular RNA-ZNF609 regulates corneal neovascularization by acting as a sponge of miR-184

Corneal neovascularization can cause abnormal blood vessels to grow in the normally transparent and translucent cornea leading to various sight-threatening eye diseases. microRNAs and circular RNAs are known to play essential roles in the regulation of numerous biological functions. It is urgently needed to understand the molecular mechanism of miRNAs and circular RNAs in the corneal neovascularization. We aimed to elucidate the role of a specific a circular RNA, cZNF609, in the corneal neovascularization. cZNF609 and miR-184 levels were determined by RT-qPCR. Luciferase reporter assay and RNA immunoprecipitation assay were conducted to verify the target of cZNF609. The biological function of cZNF609 and miR-184 were assessed via cell proliferation, migration, and tube formation assays in vitro as well as the corneal suture model in vivo. The up-regulation of cZNF609 and down-regulation of miR-184 were observed during corneal neovascularization. cZNF609 acted as a miR-184 sponge to block miR-184 activity. Overexpression of miR-184 suppressed HCEKs cell proliferation, migration in vitro, and angiogenesis in vivo. The miR-184-mediated inhibition effect can be rescued through the re-introduction of cZNF609. Mechanically, cZNF609/miR-184 interaction regulated the downstream Akt and VEGF signaling pathway. Intervention of cZNF609 and miR-184 may serve as a potential strategy for pathological corneal neovascularization treatment.

Use of Radiofrequency Diathermy for the Treatment of Chronic Corneal Neovascularization with Lipid Keratopathy

Purpose:

To present the use of radiofrequency diathermy for the management of chronic resistant corneal neovascularization with lipid keratopathy.

Methods:

Two post keratitis patients with chronic corneal neovascularization and lipid keratopathy refractory to conventional treatment underwent radiofrequency diathermy. (Klöti, Oertli ®, Switzerland) on an outpatient basis under topical anesthesia at the slit lamp biomicroscope.

Results:

No intra- or postoperative complications were encountered. After the procedure, significant regression of neovascularization with decrease in lipid deposition and improvement in corneal opacification was observed in both patients during the 12-month follow-up. Corrected distance visual acuity improved from 20/200 preoperatively to 20/80 postoperatively in the first case while remained stable at 20/20 in the second case. Significant symptomatic improvement regarding photophobia and discomfort was noted in both patients.

Conclusions:

Radiofrequency diathermy seems to represent an effective and safe minimally invasive treatment for chronic resistant corneal neovascularization with lipid keratopathy.

Intrastromal bevacizumab in the management of corneal neovascularization: a retrospective review

PURPOSE

To evaluate the long-term safety and efficacy of intrastromal bevacizumab for treatment of deep corneal neovascularization in candidates for high-risk cornea grafting.

METHODS

A single-center retrospective study involving 14 eyes of 14 patients with chronic deep corneal neovascularization, treated with intrastromal bevacizumab by a single provider from 2011 to present. Intrastromal bevacizumab (0.05-0.1 mL of 2.5 mg/0.1 mL) was administered every 4-8 weeks. On average 1-3 intrastromal injections were performed prior to corneal grafting (penetrating keratoplasty or deep anterior lamellar keratoplasty).

RESULTS

64.2% patients had neurotrophic keratitis secondary to herpes zoster or simplex. Neovascularization was encroaching the visual axis in 50% and was paracentral in 42.8%. After intrastromal bevacizumab injection, 14.2% had complete regression of neovascularization, avoiding the need of future corneal transplant. Persistent neovascularization was noticed in 21.4%. Successful penetrating keratoplasty was performed in 57% of patients. Minimal adverse effects were noted; temporary epithelial defect was seen in two eyes and self-limited intrastromal hemorrhage in one. There was no evidence of recurrence of neovascularization or graft rejection in the transplant group (mean follow-up 3 years).

CONCLUSION

Intrastromal bevacizumab appears to be a safe and effective modality in the treatment of chronic corneal neovascularization, producing durable regression of corneal neovascularization and allowing for durable success of subsequent corneal transplants in high-risk patients.

Efficacy of a new automated method for quantification of corneal neovascularisation

BACKGROUND/AIMS

To evaluate the efficacy of a new automated method for quantification of corneal neovascularisation (NV).

METHODS

An in-house software for automated measurement of corneal NV was developed. Anterior segment photographs (ASPs) of 81 consecutive patients with corneal NV were analysed using our newly developed software. Manual measurements were performed by three independent examiners using ImageJ software V.1.48 (National Institute of Health, Bethesda, Maryland, USA). Interobserver reliability of the automated and manual methods, and correlations between the results of both methods were evaluated.

RESULTS

The automated method showed a strong interexaminer reliability (intraclass correlation coefficient (ICC)=0.994), which was slightly better than the manual method (ICC=0.958). A significant correlation was found between the results of both methods (p<0.001 for all three examiners). The time spent for analysis of each ASP was significantly reduced in the automated method compared with the manual method (p<0.001 for all three examiners).

CONCLUSIONS

Our newly developed automated method for quantification of corneal NV was more reproducible and time-saving compared with the manual method. Our method can be useful for diagnosis and monitoring diseases causing corneal NV.

MMP12 Inhibits Corneal Neovascularization and Inflammation through Regulation of CCL2

Following corneal injury, coordinated cellular and protein interactions occur at the wound site to restore tissue homeostasis. Regulation of this response is required to prevent the development of chronic inflammation, abnormal neovascularization, and fibrosis. The chemokine CCL2 and its primary receptor CCR2 are key regulators of the inflammatory and neovascular responses to injury. In this study, we investigated the role of macrophage-associated matrix metalloproteinase 12 (MMP12) in the regulation of CCL2 and CCR2 after corneal wounding. Using two corneal injury models, we examined the temporal and spatial expression of CCL2 and CCR2 in Mmp12^−/− and wild-type (WT) mice. Our data showed that MMP12 downregulated CCL2 and CCR2 expression in a manner dependent on the timing and mechanism of injury. We also examined the effect of CCL2 on the injury response in Mmp12^−/− and WT corneas. We found that macrophage infiltration and neovascularization following CCL2 blockade was significantly reduced in Mmp12^−/− corneas as compared with WT corneas. These findings indicate that MMP12 inhibits corneal inflammation and neovascularization after injury through its regulation of CCL2.

Immune reactions after modern lamellar (DALK, DSAEK, DMEK) versus conventional penetrating corneal transplantation

In the past decade, novel lamellar keratoplasty techniques such as Deep Anterior Lamellar Keratoplasty (DALK) for anterior keratoplasty and Descemet stripping automated endothelial keratoplasty (DSAEK)/Descemet membrane endothelial keratoplasty (DMEK) for posterior keratoplasty have been developed. DALK eliminates the possibility of endothelial allograft rejection, which is the main reason for graft failure after penetrating keratoplasty (PK). Compared to PK, the risk of endothelial graft rejection is significantly reduced after DSAEK/DMEK. Thus, with modern lamellar techniques, the clinical problem of endothelial graft rejection seems to be nearly solved in the low-risk situation. However, even with lamellar grafts there are epithelial, subepithelial and stromal immune reactions in DALK and endothelial immune reactions in DSAEK/DMEK, and not all keratoplasties can be performed in a lamellar fashion. Therefore, endothelial graft rejection in PK is still highly relevant, especially in the "high-risk" setting, where the cornea's (lymph)angiogenic and immune privilege is lost due to severe inflammation and pathological neovascularization. For these eyes, currently available treatment options are still unsatisfactory. In this review, we will describe currently used keratoplasty techniques, namely PK, DALK, DSAEK, and DMEK. We will summarize their indications, provide surgical descriptions, and comment on their complications and outcomes. Furthermore, we will give an overview on corneal transplant immunology. A specific focus will be placed on endothelial graft rejection and we will report on its incidence, clinical presentation, and current/future treatment and prevention options. Finally, we will speculate how the field of keratoplasty and prevention of corneal allograft rejection will develop in the future.