Theoretical Assessment of the Risk of Ocular Hypotony in Patients With Intravitreal Gas Bubbles Who Travel Through Subsea Tunnels

Cationic-motif-modified exosomes for mRNA delivery to retinal photoreceptors

Topical treatment of vitreoretinal diseases remains a challenge due to slow corneal uptake and systemic clearance. Exosomes are emerging nanocarriers for drug delivery due to biocompatibility and cellular targeting properties. To apply them for retinal targeting via the topical route, exosomes must traverse various ocular barriers including the cornea, lens, vitreous humor (VH), and the retina itself. Here we engineered high-purity milk-derived exosomes by anchoring arginine-rich cationic motifs via PEG2000 lipid insertion on their surface. Modification enabled exosomes to use weak-reversible electrostatic interactions with anionic glycosaminoglycan (GAG) and water content of the tissue to enhance their transport rate and retention. Addition of cationic motifs neutralized the anionic surface charge of exosomes (-24 to -2 mV) without impacting size or morphology. Cationic-motif-modified exosomes exhibited two-fold faster steady state diffusivity through bovine corneas compared to unmodified exosomes. Fluorescence recovery after photobleaching confirmed that cationic-motif-modified exosomes can diffuse through VH without steric hindrance. In healthy VH, cationic-motif-modified exosomes demonstrated stronger binding resulting in three-fold lower average diffusivity that enhanced by six-fold in 50% GAG-depleted VH recapitulating advanced liquefaction. Cationic-motif-modified exosomes penetrated through the full-thickness of porcine retinal explants resulting in ten-fold higher uptake in photoreceptors and three-fold greater transfection with encapsulated eGFP mRNA compared to unmodified exosomes. Cationic-motif-modified exosomes are safe to use as they did not adversely affect the mechanical swelling properties of the cornea or lens nor impact retinal cell viability. Cationic-motif-modified exosomes, therefore, offer themselves as a cell-free nanocarrier platform for gene delivery to retinal photoreceptors potentially via the topical route.

Development and Testing of a Mobile Phone App for Risk Estimation of Gas Volume Expansion and Intraocular Pressure Elevation in Patients With Intravitreous Gas or Air Tamponade: Interobserver Assessment Study

Background

Pars plana vitrectomy (PPV) with intravitreous tamponade of gas or air has been widely used for a series of vitreoretinal diseases. It is estimated that 100,000 patients per year undergo PPV globally, and half of them were subsequently tamponaded with gas or air. According to Boyle’s law (P₁V₁=P₂V₂), patients with an intravitreous remnant of gas or air will be under high risk of intraocular pressure (IOP) elevation and subsequent vision loss owing to the expanded intravitreous gas or air when traveling post operation to a place with a significantly higher altitude. We always explain to patients why postoperative travel is potentially risky. Emergency cases of elevated IOP caused by postoperative traveling would sometimes come to surgeons. However, there have been few disease education or reference tools for both the surgeons and patients to have better communication.

Objective

The aim of this study was to introduce and evaluate a mobile phone app developed by surgeons (the authors) for preliminary risk estimation of volume expansion and IOP elevation in patients with intravitreous gas or air when traveling to a place of higher altitude.

Methods

The app was developed on the iOS and Android operating systems. Boyle’s law (P₁V₁=P₂V₂) was the theoretical basis of the app. Intravitreous gas or air volume and altitude values were independent factors to deduce the risk report. Consecutive patients underwent vitrectomy, and those with an intravitreous remnant of gas or air were recruited. The surgeons judged the vertical height of the fluid/gas interface through the dilated pupil; the patients were instructed to judge it according to their visual field when looking straight ahead and line it out on a chart included in the app. Finally, all the patients were required to fill a Likert scale–based questionnaire with 2 main items to evaluate the participants’ user experience and attitudes toward the app.

Results

A total of 50 patients were included (30 males and 20 females). All patients could independently operate the app to complete the test. The median heights of the fluid/gas interface independently judged by the surgeon and patients were 40% (range: 10%-75%) and 41% (range: 9%-78%), respectively (P=.63). The median altitude of the participants’ destinations was 150.0 m (range: 0-3490 m). The Bland-Altman analysis revealed a good agreement between the surgeons’ and patients’ judgments (bias of −0.3%), with 95% limits of agreement of −5.8% to 5.3%. Overall, the Likert scale revealed a positive attitude from the patients toward the app.

Conclusions

The app is reliable for patients to have preliminary risk estimation of intravitreous gas or air volume expansion and IOP elevation if travel to a place of higher altitude is planned. The surgeons could also use it as a platform for better disease communication.