Progress in the development of a corneal replacement: keratoprostheses and tissue-engineered corneas

Polysaccharide-based hydrogels for medical devices, implants and tissue engineering: A review

Hydrogels are highly biocompatible biomaterials composed of crosslinked three-dimensional networks of hydrophilic polymers. Owing to their natural origin, polysaccharide-based hydrogels (PBHs) possess low toxicity, high biocompatibility and demonstrate in vivo biodegradability, making them great candidates for use in various biomedical devices, implants, and tissue engineering. In addition, many polysaccharides also show additional biological activities such as antimicrobial, anticoagulant, antioxidant, immunomodulatory, hemostatic, and anti-inflammatory, which can provide additional therapeutic benefits. The porous nature of PBHs allows for the immobilization of antibodies, aptamers, enzymes and other molecules on their surface, or within their matrix, potentiating their use in biosensor devices. Specific polysaccharides can be used to produce transparent hydrogels, which have been used widely to fabricate ocular implants. The ability of PBHs to encapsulate drugs and other actives has been utilized for making neural implants and coatings for cardiovascular devices (stents, pacemakers and venous catheters) and urinary catheters. Their high water-absorption capacity has been exploited to make superabsorbent diapers and sanitary napkins. The barrier property and mechanical strength of PBHs has been used to develop gels and films as anti-adhesive formulations for the prevention of post-operative adhesion. Finally, by virtue of their ability to mimic various body tissues, they have been explored as scaffolds and bio-inks for tissue engineering of a wide variety of organs. These applications have been described in detail, in this review.

Collagen membranes crosslinked by β-cyclodextrin polyrotaxane monoaldehyde with good biocompatibilities and repair capabilities for cornea repair

Better mechanical properties; suturability; corneal regeneration.

Progress in Corneal Stromal Repair: From Tissue Grafts and Biomaterials to Modular Supramolecular Tissue-Like Assemblies

Corneal injuries and degenerative conditions have major socioeconomic consequences, given that in most cases, they result in blindness. In the quest of the ideal therapy, tissue grafts, biomaterials, and modular engineering approaches are under intense investigation. Herein, advancements and shortfalls are reviewed and future perspectives for these therapeutic strategies discussed.

A double network strategy to improve epithelization of a poly(2-hydroxyethyl methacrylate) hydrogel for corneal repair application

This paper presents a novel double network scaffold and its preparation methods, in which a cell-affinitive hydrogel was made by poly(2-hydroxyethyl methacrylate) and modified gelatin.

In situ growth induction of the corneal stroma cells using uniaxially aligned composite fibrous scaffolds

An electrospun fibrous scaffold was fabricated and used in the in situ remediation of rabbits’ corneal stromata.

Corneal endothelium: developmental strategies for regeneration

The main treatment available for restoration of the corneal endothelium is keratoplasty. This procedure is faced with several difficulties, including the shortage of donor tissue, post-surgical complications associated with the use of drugs to prevent immune rejection, and a significant increase in the occurrence of glaucoma. Recently, surgical procedures such as Descemet's stripping endothelial keratoplasty have focused on the transplant of corneal endothelium, yielding better visual results but still facing the need for donor tissue. The emergent strategies in the field of cell biology and tissue cultivation of corneal endothelial cells aim at the production of transplantable endothelial cell sheets. Cell therapy focuses on the culture of corneal endothelial cells retrieved from the donor, in the donor's cornea, followed by transplantation into the recipient. Recently, research has focused on overcoming the challenge of harvesting human corneal endothelial cells and the generation of new biomembranes to be used as cell scaffolds in surgical procedures. The use of corneal endothelial precursors from the peripheral cornea has also demonstrated to be effective and represents a valuable tool for reducing the risk of rejection in allogeneic transplants. Several animal model reports also support the use of adult stem cells as therapy for corneal diseases. Current results represent important progresses in the development of new strategies based on alternative sources of tissue for the treatment of corneal endotheliopathies. Different databases were used to search literature: PubMed, Google Books, MD Consult, Google Scholar, Gene Cards, and NCBI Books. The main search terms used were: 'cornea AND embryology AND transcription factors', 'human endothelial keratoplasty AND risk factors', '(cornea OR corneal) AND (endothelium OR endothelial) AND cell culture', 'mesenchymal stem cells AND cell therapy', 'mesenchymal stem cells AND cornea', and 'stem cells AND (cornea OR corneal) AND (endothelial OR endothelium)'.

A safe Nd:YAG retroprosthetic membrane removal technique for keratoprosthesis

PURPOSE

To describe a technique for Nd:YAG laser photodiscission of retroprosthetic membrane (RPM) in keratoprosthesis patients that minimizes damage to the optic.

METHODS

Prospective review of Boston type I keratoprosthesis patients at 1 site who received Nd:YAG treatment for RPM from 2005 to 2009. Outcomes were based on slit-lamp examination of the optic immediately after YAG treatment, tactile intraocular pressure at follow-up, and complications from the outpatient procedure.

RESULTS

The incidence of RPM was 24.1% (39 of 162 eyes). Of 26 RPM eyes receiving YAG treatment, 18 had 1 YAG treatment, 6 had multiple YAG treatments, and 2 had surgical excision despite multiple YAG treatments because of membrane thickness. All 26 eyes had no intraoperative complications, no damage to the optic from slit-lamp examination, and soft tactile intraocular pressures.

CONCLUSION

Based on the office procedures from our patient base, YAG retroprosthetic membranectomy using a peripheral "can-opener" approach is effective and safe with no evident damage to the optic.

Degradable Hydrogels for Tissue Engineering – Part I: Synthesis by RAFT Polymerization and Characterization of PHEMA Containing Enzymatically Degradable Crosslinks

A nonapeptide, which is sensitive to enzymatic digestion by collagenase, was modified by the covalent attachment of an acrylamido group at the terminal positions. The functionalized peptide was used as a crosslinking agent during polymerization of 2-hydroxyethyl methacrylate (HEMA). Reversible addition-fragmentation chain transfer (RAFT) method was used to obtain a polymer (PHEMA) with an average theoretical molecular weight of 4000 Da, containing enzymatically labile peptide crosslinks. The functionalized peptide was analyzed in detail by 1H and 13C nuclear magnetic resonance (NMR) spectrometry. The polymerization reaction was monitored by near infrared spectrometry, while the resulting polymer was analyzed by size exclusion chromatography and solid NMR spectrometry. The peptide-crosslinked PHEMA was subjected to an in-vitro degradation assay in the presence of collagenase. At the highest concentration of enzyme used in the study, a weight loss of 35% was recorded after 60 days of incubation in the collagenolytic medium. This suggests that crosslinking with enzymatically degradable peptides is a valid method for inducing biodegradability in polymers that otherwise are not degradable.

Use of magnetically oriented orthogonal collagen scaffolds for hemi-corneal reconstruction and regeneration

We recently showed that the highly organized architecture of the corneal stroma could be reproduced using scaffolds consisting of orthogonally aligned multilayers of collagen fibrils prepared using a high magnetic field. Here we show that such scaffolds permit the reconstruction in vitro of human hemi-corneas (stroma + epithelium), using primary human keratocytes and limbal stem cell derived human keratinocytes. On the surface of these hemi-corneas, a well-differentiated epithelium was formed, as determined both histologically and ultrastructurally and by the expression of characteristic markers. Within the stroma, the keratocytes aligned with the directions of the fibrils in the scaffold and synthesized a new extracellular matrix with typical collagen markers and small, uniform diameter fibrils. Finally, in vivo experiments using a rabbit model showed that these orthogonally oriented multi-layer scaffolds could be used to repair the anterior region of the stroma, leading to re-epithelialization and recovery of both transparency and ultrastructural organization.

Processing porcine cornea for biomedical applications

To investigate the propriety of decellularized porcine corneas as a source of lamellar corneal xenografts, we treated porcine corneas with (1) freezing, (2) three freezing-thawing, (3) hypertonic saline, (4) hyperosmolar glycerol, (5) trypsin/sodium dodecyl sulfate/Dispase, and (6) DNase/RNase. After processing, we examined the cells and collagen structures of the decellularized corneas using hematoxylin-eosin staining, terminal deoxynucleotidyl transferase-mediated nick end labeling (TUNEL) assay, and transmission electron microscopy. Cell viability was also assessed via organ culture. In addition, the outcomes of porcine anterior lamellar corneal xenografting were evaluated in rabbits. Graft integration and corneal thickness were assessed using anterior optical coherence tomography, and the corneas were histologically examined sequentially after transplantation. We found that porcine corneas treated with hypertonic saline-based decellularization had little immunogenicity with intact collagen structures. The porcine corneal xenografts decellularized with the hypertonic saline-based method were well integrated into the adjacent host tissues and remained clear in rabbit eyes for more than 6 months.

Bioactive interpenetrating polymer network hydrogels that support corneal epithelial wound healing

The development and characterization of collagen-coupled poly(ethylene glycol)/poly(acrylic acid) (PEG/PAA) interpenetrating polymer network hydrogels is described. Quantitative amino acid analysis and FITC-labeling of collagen were used to determine the amount and distribution of collagen on the surface of the hydrogels. The bioactivity of the coupled collagen was detected by a conformation-specific antibody and was found to vary with the concentration of collagen reacted to the photochemically functionalized hydrogel surfaces. A wound healing assay based on an organ culture model demonstrated that this bioactive surface supports epithelial wound closure over the hydrogel but at a decreased rate relative to sham wounds. Implantation of the hydrogel into the corneas of live rabbits demonstrated that epithelial cell migration is supported by the material, although the rate of migration and morphology of the epithelium were not normal. The results from the study will be used as a guide toward the optimization of bioactive hydrogels with promise in corneal implant applications such as a corneal onlay and an artificial cornea.

Regeneration of corneal cells and nerves in an implanted collagen corneal substitute

PURPOSE

Our objective was to evaluate promotion of tissue regeneration by extracellular matrix (ECM) mimics, by using corneal implantation as a model system.

METHODS

Carbodiimide cross-linked porcine type I collagen was molded into appropriate corneal dimensions to serve as substitutes for natural corneal ECM. These were implanted into corneas of mini-pigs after removal of the host tissue, and tracked over 12 months, by clinical examination, slit-lamp biomicroscopy, in vivo confocal microscopy, topography, and esthesiometry. Histopathology and tensile strength testing were performed at the end of 12 months. Other samples were biotin labeled and implanted into mice to evaluate matrix remodeling.

RESULTS

The implants promoted regeneration of corneal cells, nerves, and the tear film while retaining optical clarity. Mechanical testing data were consistent with stable, seamless host-graft integration in regenerated corneas, which were as robust as the untreated fellow corneas. Biotin conjugation is an effective method for tracking the implant within the host tissue.

CONCLUSIONS

We show that a simple ECM mimetic can promote regeneration of corneal cells and nerves. Gradual turnover of matrix material as part of the natural remodeling process allowed for stable integration with host tissue and restoration of mechanical properties of the organ. The simplicity in fabrication and shown functionality shows potential for ECM substitutes in future clinical applications.

Influence of matrix processing on the optical and biomechanical properties of a corneal stroma equivalent

Interest in developing tissue-engineered cornea has increased with the decrease in the supply of donor tissue; however, the high strength and transparency of the cornea present a challenge. Both the collagen processing and crosslinking methods were hypothesized to influence the optical and biomechanical properties of collagen matrices, while regular surface topography was hypothesized to align stromal fibroblasts. Improved transparency and strength were observed when soluble tropocollagen was added to the insoluble collagen and when glucose-mediated ultraviolet (UV) crosslinking as opposed to dehydrothermal crosslinking was used. The fraction of transmittance of the collagen films fabricated from insoluble collagen and soluble tropocollagen and glucose-mediated UV crosslinking was initially 0.91 +/- 0.02 and 0.98 +/- 0.01 for the smooth films and 0.90 +/- 0.02 and 0.97 +/- 0.02 for the microgrooved films at 400 and 700 nm and was comparable to that of the native cornea, while the relaxed modulus and ultimate tensile strength ranged from 0.9 to 9.4 MPa and from 0.7 to 4.1 MPa, respectively, over the 3 weeks of culture and were initially at or below the range of values for the native cornea. These collagen scaffolds were significantly stronger and more transparent than previous scaffolds, and aligned stromal fibroblasts were observed on microgrooved surfaces.

Glucose-permeable interpenetrating polymer network hydrogels for corneal implant applications: a pilot study

Epithelialization of a keratoprosthesis requires that the implant material be sufficiently permeable to glucose. We have developed a poly(ethylene glycol)/poly(acrylic acid) (PEG/PAA) interpenetrating polymer network (IPN) hydrogel that can provide adequate passage of glucose from the aqueous humor to the epithelium in vivo. A series of PEG/PAA IPNs with varying PEG macromonomer molecular weights were synthesized and evaluated through swelling studies to determine their water content and diffusion experiments to assess their permeability to glucose. One of the PEG/PAA hydrogels prepared in this study had a glucose diffusion coefficient nearly identical to that of the human cornea (approximately 2.5 x 10(-6) cm(2)/sec). When implanted intrastromally in rabbit corneas, this hydrogel was retained and well-tolerated in 9 out of 10 cases for a period of 14 days. The retained hydrogels stayed optically clear and the epithelium remained intact and multilayered, indicating that the material facilitated glucose transport from the aqueous humor to the anterior part of the eye. The results from these experiments indicate that PEG/PAA hydrogels are promising candidates for corneal implant applications such as keratoprostheses and intracorneal lenses, and that the PEG/PAA IPN system in general is useful for creating permeable substrates for ophthalmic and other biomedical applications.

Corneal gene therapy

Gene therapy to the cornea can potentially correct inherited and acquired diseases of the cornea. Factors that facilitate corneal gene delivery are the accessibility and transparency of the cornea, its stability ex vivo and the immune privilege of the eye. Initial corneal gene delivery studies characterized the relationship between intraocular modes of administration and location of reporter gene expression. The challenge of achieving effective topical gene transfer, presumably due to tear flow, blinking and low penetration of the vector through epithlelial tight junctions left no alternative but invasive administration to the anterior chamber and corneal stroma. DNA vaccination, RNA interference and gene transfer of cytokines, growth factors and enzymes modulated the corneal microenvironment. Positive results were obtained in preclinical studies for prevention and treatment of corneal graft rejection, neovascularization, haze and herpetic stromal keratitis. These studies, corneal gene delivery systems and modes of administration, and considerations regarding the choice of animal species used are the focus of this review. Opportunities in the field of corneal gene therapy lie in expanding the array of corneal diseases investigated and in the implementation of recent designs of safer vectors with reduced immunogenicity and longer duration of gene expression.

New era in health care: tissue engineering

Tissue engineering is a rapidly expanding field, which applies the principles and methods of physical sciences, life sciences and engineering to understand physiological and pathological systems and to modify and create cells and tissues for therapeutic applications. It has emerged as a rapidly expanding ‘interdisciplinary field’ that is a significant potential alternative wherein tissue and organ failure is addressed by implanting natural, synthetic, or semi synthetic tissue or organ mimics that grow into the required functionality or that are fully functional from the start. This review presents in a comprehensive manner the various considerations for the reconstruction of various tissues and organs as well as the various applications of this young emerging field in different disciplines.