The intraocular lens: challenges in the prevention and therapy of infectious endophthalmitis and posterior capsular opacification

Drug-loaded and Blue-ray Filtered Hydrogel as a Potential Intraocular Lens for Cataract Treatment

Background:

Indomethacin (IND) is a class of non-steroidal, anti-inflammatory drugs, which is used to treat various kinds of ocular inflammation, and has been reported to prevent posterior capsule opacification (PCO) by inhibiting the mitosis and collagen synthesis of human lens epithelial cells (LECs). In addition, the specific absorption spectrum of indomethacin shows the effect of absorbing short-wavelength blue-violet light.

Objective:

We prepared an indomethacin-loaded hydrogel as a potential intraocular lens (IOLs) material to prevent endophthalmitis, PCO and filter harmful blue light.

Methods:

Indomethacin prodrugs (HEMA-IND) (HI) were prepared by esterification of indomethacin and 2-hydroxyethyl methacrylate (HEMA), and poly (HEMA-co-MAA-co-MMA-co- HI) (HAMI) hydrogels were prepared by free-radical polymerization of 2-hydroxyethyl methacrylate (HEMA), methyl methacrylate (MMA), methacrylic acid (MAA) and HI. The physical and chemical properties of obtained hydrogel were detected, including optical, morphology, thermomechanical and surface properties, equilibrium water content, drug release behaviors and cytotoxicity.

Results:

HAMI hydrogels can filter harmful short-wavelength blue light and show other necessary properties like visible light transparency, glass transition temperatures, mechanical strength, and biocompatibility for making intraocular lenses. Meanwhile, MAA increases the hydrophilicity of the hydrogels, resulting in a lower water contact angle and controllable drug release from the hydrogels.

Conclusion:

In summary, HAMI hydrogels show a great potential as IOL biomaterials that can maintain the sustained release of indomethacin and filter harmful blue light after cataract surgery.

Lay Summary:

People with cataract surgery can be at high risk of postoperative complications, such as PCO and postoperative endophthalmitis. Moreover, early IOLs allowed all ultraviolet (UV) and visible light to pass through retina without restriction, thus to damage the retina and the retinal pigment epithelium, which may lead to retinopathy and age-related macular degeneration (AMD). Herein, we sought to design and prepare a kind of IOLs loaded with indomethacin to mitigate those postoperative complications and filter harmful blue light to improve the treatment prognosis.

Antibacterial Nanopillar Array for an Implantable Intraocular Lens

Postsurgical intraocular lens (IOL) infection caused by pathogenic bacteria can result in blindness and often requires a secondary operation to replace the contaminated lens. The incorporation of an antibacterial property onto the IOL surface can prevent bacterial infection and postoperative endophthalmitis. This study describes a polymeric nanopillar array (NPA) integrated onto an IOL, which captures and eradicates the bacteria by rupturing the bacterial membrane. This is accomplished by changing the behavior of the elastic nanopillars using bending, restoration, and antibacterial surface modification. The combination of the polymer coating and NPA dimensions can decrease the adhesivity of corneal endothelial cells and posterior capsule opacification without causing cytotoxicity. An ionic antibacterial polymer layer is introduced onto an NPA using an initiated chemical vapor deposition process. This improves bacterial membrane rupture efficiency by increasing the interactions between the bacteria and nanopillars and damages the bacterial membrane using quaternary ammonium compounds. The newly developed ionic polymer-coated NPA exceeds 99% antibacterial efficiency against Staphylococcus aureus, which is achieved through topological and physicochemical surface modification. Thus, this paper provides a novel, efficient strategy to prevent postoperative complications related to bacteria contamination of IOL after cataract surgery.

Development of Poly(2-Methacryloyloxyethyl Phosphorylcholine)-Functionalized Hydrogels for Reducing Protein and Bacterial Adsorption

A series of hydrogels with intrinsic antifouling properties was prepared via surface-functionalization of poly(2-hydroxyethyl methacrylate) [p(HEMA)]-based hydrogels with the biomembrane-mimicking zwitterionic polymer, poly(2-methacryloyloxyethyl phosphorylcholine) [p(MPC)]. The p(MPC)-modified hydrogels have enhanced surface wettability, high water content retention (61.0%-68.3%), and good transmittance (>90%). Notably, the presence of zwitterionic MPC moieties at the hydrogel surfaces lowered the adsorption of proteins such as lysozyme and bovine serum albumin (BSA) by 73%-74% and 59%-66%, respectively, and reduced bacterial adsorption by approximately 10%-73% relative to the unmodified control. The anti-biofouling properties of the p(MPC)-functionalized hydrogels are largely attributed to the dense hydration layer formed at the hydrogel surfaces by the zwitterionic moieties. Overall, the results demonstrate that biocompatible and antifouling hydrogels based on p(HEMA)-p(MPC) structures have promising potential for application in biomedical materials.

Fabrication of nonfouling, bactericidal, and bacteria corpse release multifunctional surface through surface-initiated RAFT polymerization

Infections after surgery or endophthalmitis are potentially blinding complications caused by bacterial adhesion and subsequent biofilm formation on the intraocular lens. Neither single-function anti-adhesion surface nor contacting killing surface can exhibit ideal antibacterial function. In this work, a novel (2-(dimethylamino)-ethyl methacrylate-co-2-methacryloyloxyethyl phosphorylcholine) (p (DMAEMA-co-MPC)) brush was synthesized by "grafting from" method through reversible-addition fragmentation chain transfer polymerization. 1-Bromoheptane was used to quaternize the p (DMAEMA-co-MPC) brush coating and to endow the surface with bactericidal function. The success of the surface functionalization was confirmed by atomic force microscopy, water contact angle, and spectroscopic ellipsometry. The quaternary ammonium salt units were employed as efficient disinfection that can eliminate bacteria through contact killing, whereas the 2-methacryloyloxyethyl phosphorylcholine units were introduced to suppress unwanted nonspecific adsorption. The functionalized poly(dimethyl siloxane) surfaces showed efficiency in reducing bovine serum albumin adsorption and in inhibiting bacteria adhesion and biofilm formation. The copolymer brushes also demonstrated excellent bactericidal function against gram-positive (Staphylococcus aureus) bacteria measured by bacteria live/dead staining and shake-flask culture methods. The surface biocompatibility was evaluated by morphology and activity measurement with human lens epithelial cells in vitro. The achievement of the p (DMAEMA+-co-MPC) copolymer brush coating with nonfouling, bactericidal, and bacteria corpse release properties can be used to modify intraocular lenses.

The Relationship between Anterior Chamber Depth, Axial Length and Intraocular Lens Power among Candidates for Cataract Surgery

Introduction

Basic anatomical parameters in ophthalmology are variable in different countries according to ethnic groups, genetics and some environmental factors. The aim of this study was to determine the relationship between axial length (AL), anterior chamber depth (ACD) and intraocular lens power (IOL) in a referral center from eastern Iran among patients who had cataract surgery, in comparison to studies from other regions of the world.

Methods

In a cross-sectional retrospective study from 2011 to 2013, the records of 698 cataract patients referring to Khatam Al Anbia general hospital in Mashhad, Iran were evaluated. We divided patients, based on their AL and ACD, into three separate groups and compared their results. The SPSS software was used for data analysis. The Chi-Square test and the Independent-samples t-test were used to compare qualitative and quantitative data between two groups, respectively. The Kendall and the Pearson product-moment correlation tests were used to assess the relationship between AL and ACD. The linear Regression model was used to obtain a mathematical model to estimate ACD, using AL, age and sex.

Results

Among individuals who had normal AL (between 22–24.5mm), there was a positive correlation between AL and ACD (p<0.001, r=0.17), however, among individuals with short (AL<22mm) or long sightedness (AL>24.5mm), no significant correlation was detected. We also found that older people have shorter AL (p=0.001 and r=−0.287). Men have an average longer AL (23.7±2.4mm vs. 22.9±2.1mm; p<0.001) and deeper ACD compared to women (2.93±0.45mm vs. 2.82±0.42mm, p=0.002).

Conclusion

Our findings were mostly similar to previous literature from other regions of the world and although some anatomical variations may exist regarding ophthalmic anatomy, factors like race and geographical area have little effect on the relationship between ACD, AL and IOL power calculation, furthermore our results support the use of third and fourth generation formulas for IOL power calculation.

Surface modification of intraocular lenses with hyaluronic acid and lysozyme for the prevention of endophthalmitis and posterior capsule opacification

Posterior capsule opacification is one of the complications of cataract surgery caused by the adhesion and reproduction of residual human lens epithelial cells (HLECs) on the posterior capsule.

Management of mydriasis and pain in cataract and intraocular lens surgery: review of current medications and future directions

The maintenance of mydriasis and the control of postoperative pain and inflammation are critical to the safety and success of cataract and intraocular lens replacement surgery. Appropriate mydriasis is usually achieved by topical and/or intracameral administration of anticholinergic agents, sympathomimetic agents, or both, with the most commonly used being cyclopentolate, tropicamide, and phenylephrine. Ocular inflammation is common after cataract surgery. Topical steroids and nonsteroidal anti-inflammatory drugs are widely used because they have been proved effective to control postsurgical inflammation and decrease pain. Topical nonsteroidal anti-inflammatory drugs have also been shown to help maintain dilation. However, use of multiple preoperative drops for pupil dilation, inflammation, and pain control have been shown to be time consuming, resulting in delays to the operating room, and they cause dissatisfaction among perioperative personnel; their use can also be associated with systemic side effects. Therefore, ophthalmologists have been in search of new options to streamline this process. This article will review the current medications commonly used for intraoperative mydriasis, as well as pain and inflammation control. In addition, a new combination of ketorolac, an anti-inflammatory agent, and phenylephrine, a mydriatic agent has recently been designed to maintain intraoperative mydriasis and to reduce postoperative pain and irritation from intraocular lens replacement surgery. Two Phase III clinical trials evaluating this combination have demonstrated statistically significant differences when compared to placebo in maintaining intraoperative mydriasis (P<0.00001) and in reducing pain in the early postoperative period (P=0.0002). This medication may be of benefit for use in cataract and lens replacement surgery in the near future.

Risk factors for acute endophthalmitis following cataract surgery: a systematic review and meta-analysis

Background

Acute endophthalmitis is one of the most serious complications of cataract surgery and often results in severe visual impairment. Several risk factors for acute postoperative endophthalmitis (POE) following cataract surgery have been reported but the level of evidence and strength of association is varied. The purpose of this study was to critically appraise published reports on and to summarize clinical risk factors associated with acute POE which could be easily assessed by ophthalmologists for the introduction and implementation of preventive measure.

Methods

A systematic review and meta-analysis of observational studies was performed. Six databases were searched with no limits on the year or language of publication. Study-specific odds ratios (Ors) or relative risk (RR) of each risk factor were pooled using a random effect model.

Results

A total of 6 686 169 participants with 8 963 endophthalmitis in 42 studies were analyzed. Of the nine risk factors identified in our systematic review and meta-analysis, extra- or intracapsular cataract extraction, a clear corneal incision, without intracameral cefazolin (1 mg in 0.1 ml solution), without intracameral cefuroxime (1 mg in 0.1 ml solution), post capsular rupture, silicone intraocular lenses and intraoperative complications were found strongly associated with acute endophthalmitis. Other significant factors with a lower strength of association (risk estimates generally 1.5 or less) were male gender and old age (85 years and older).

Conclusions

Our study provides summary data on the risk factors for acute POE. Identifying patients at high risk of this sight-threatening eye disease is important from both the public health and clinical perspectives as this would facilitate detection of disease before the onset of irreversible visual loss enabling earlier intervention.

Sustained release of antibiotic from poly(2-hydroxyethyl methacrylate) to prevent blinding infections after cataract surgery

Intraocular lens implantation after opacified natural lens removal is the primary treatment for cataracts in developed countries. Cataract surgery is generally considered safe, but entails significant risks in countries where sophisticated sterile operating theaters are not widely available. Post-operative infection (endophthalmitis) is a potential blinding complication. Infection often results from bacterial colonization of the new lens implant and subsequent antibiotic-tolerant biofilm formation. To combat this risk, we developed a polymeric hydrogel system that can deliver effective levels of antibiotic over an extended period of time within the globe of the eye. Norfloxacin antibiotic was loaded into cross-linked poly(2-hydroxyethyl methacrylate) (pHEMA) gels, which were subsequently surface-modified with octadecyl isocyanate to produce a hydrophobic rate-limiting barrier controlling norfloxacin release. Octadecyl surface modification was characterized using scanning electron microscopy (SEM) and X-ray photoelectron spectroscopy (XPS). A 15-min modification leads to a uniform surface coating and near zero order release of norfloxacin from the matrix. Norfloxacin released from coated pHEMA kills Staphylococcus epidermidis in suspension and on a simulated medical implant surface. With these data, we demonstrate a new and effective system for sustained drug release from a hydrogel matrix with specific application for intraocular lens surgery.

Imparting antifouling properties of poly(2-hydroxyethyl methacrylate) hydrogels by grafting poly(oligoethylene glycol methyl ether acrylate)

The antifouling properties of poly(2-hydroxyethyl methacrylate- co-methyl methacrylate) hydrogels were improved by the surface grafting of a brush of poly(oligoethylene glycol methyl ether acrylate) [poly(OEGA)]. The atom-transfer radical polymerization (ATRP) of OEGA (degree of polymerization = 8) was initiated from the preactivated surface of the hydrogel under mild conditions, thus in water at 25 degrees C. The catalytic system was optimized on the basis of two ligands [1,1,4,7,10,10-hexamethyl-triethylenetetramine (HMTETA) or tris[2-(dimethylamino)ethyl]amine (Me6TREN)] and two copper salts (CuIBr or CuICl). Faster polymerization was observed for the Me 6TREN/CuIBr combination. The chemical composition and morphology of the coated surface were analyzed by X-ray photoelectron spectroscopy, attenuated total reflectance Fourier transform infrared spectroscopy, contact angle measurements by the water droplet and captive bubble methods, scanning electron microscopy, and environmental scanning electron microscopy. The hydrophilicity of the surface increased with the molar mass of the grafted poly(OEGA) chains, and the surface modifications were reported in parallel. The antifouling properties of the coatings were tested by in vitro protein adsorption and cell adhesion tests, with green fluorescent protein, beta-lactamase, and lens epithelial cells, as model proteins and model cells, respectively. The grafted poly(OEGA) brush decreased the nonspecific protein adsorption and imparted high cell repellency to the hydrogel surface.

Improved Performances of Intraocular Lenses by Poly(ethylene glycol) Chemical Coatings

Cataract surgery is a routine ophthalmologic intervention resulting in replacement of the opacified natural lens by a polymeric intraocular lens (IOL). A main postoperative complication, as a result of protein adsorption and lens epithelial cell (LEC) adhesion, growth, and proliferation, is the secondary cataract, referred to as posterior capsular opacification (PCO). To avoid PCO formation, a poly(ethylene glycol) (PEG) chemical coating was created on the surface of hydrogel IOLs. Attenuated total reflectance Fourier transform infrared spectroscopy, "captive bubble" and "water droplet" contact angle measurements, and atomic force microscopy analyses proved the covalent grafting of the PEG chains on the IOL surface while keeping unchanged the optical properties of the initial material. A strong decrease of protein adsorption and cell adhesion depending on the molar mass of the grafted PEG (1100, 2000, and 5000 g/mol) was observed by performing the relevant in vitro tests with green fluorescent protein and LECs, respectively. Thus, the study provides a facile method for developing materials with nonfouling properties, particularly IOLs.

Regional mechanical properties and stress analysis of the human anterior lens capsule

The lens capsule of the eye functions, in part, as a deformable support through which the ciliary body applies tractions that can alter lens curvature and corresponding refractive power during the process of accommodation. Although it has long been recognized that characterization of the mechanical properties of the lens capsule is fundamental to understanding this physiologic process as well as clinical interventions, prior data have been limited by one-dimensional testing of excised specimens despite the existence of multiaxial loading in vivo. In this paper, we employ a novel experimental approach to study in situ the regional, multiaxial mechanical behavior of both normal and diabetic human anterior lens capsules. Furthermore, we use these data to calculate material parameters in a nonlinear stress-strain relation via a custom sub-domain inverse finite element method (FEM). These parameters are then used to predict capsular stresses in response to imposed loads using a forward FEM model. Our results for both normal and diabetic human eyes show that the anterior lens capsule exhibits a nonlinear pseudoelastic behavior over finite strains that is typical of soft tissues, and that strains are principal relative to meridional and circumferential directions. Experimental data and parameter estimation suggest further that the capsule is regionally anisotropic, with the circumferential direction becoming increasingly stiffer than the meridional direction towards the equator. Although both normal and diabetic lens capsules exhibited these general characteristic behaviors, diabetic capsules were significantly stiffer at each distension. Finally, the forward FEM model predicted a nearly uniform, equibiaxial stress field during normalcy that will be perturbed by cataract surgery. Such mechanical perturbations may be an underlying modulator of the sustained errant epithelial cell behavior that is observed well after cataract surgery and may ultimately contribute to opacification of the posterior lens capsule.