Comparative Evaluation of Antimicrobial, Antiamoebic, and Antiviral Efficacy of Ophthalmic Formulations

The potential role and limitations of antiseptic eyedrops in ophthalmic surgery

PURPOSE

the aim of the present study is to analyse the composition of the currently available topical antiseptic products and the related scientific evidence, and to discuss the implications of their use in the prevention of endophthtalmitis.

METHODS

products available on the market until February 2024 were considered. Information provided on the illustration leaflet of each product were analysed. Literature search was made on the effectiveness of these new products, focusing on those available in Italy. Articles indexed in Pubmed until June 2024 were included in the present study.

RESULTS

labelling of these products represents an issue, since most of them are presented as eye lubricants and a clear labeling of their indication as perioperative prophylaxis is needed. While promising in vitro studies have been performed, in vivo evidence is still lacking.

CONCLUSIONS

products with antiseptic activity may be promising to address the issue of endophthalmitis prevention. However, more evidence on the subject is needed.

Efficacy of 0.2% povidone-iodine and 0.1% polyhexamethylene biguanide as preoperative antiseptics in equine ophthalmic procedures

OBJECTIVE

This retrospective study evaluates the efficacy of povidone-iodine (PI) and polyhexamethylene biguanide (PHMB) as preoperative antiseptics in equine ophthalmic procedures.

ANIMALS STUDIED

Horses that underwent routine ophthalmic surgery and procedures.

PROCEDURES

Data were collected retrospectively from the medical records of equine patients undergoing ophthalmic procedures. Inclusion criteria were sampling for aerobic microbial culture at three different time points (T0: pre-irrigation, T1: post-irrigation, and T2: postoperatively) and T0 showing bacterial growth. Microbiological outcomes were assessed semi-quantitatively by creating a scoring system to describe the bacterial load. Furthermore, the species detected were evaluated. Poisson regression analysis was performed to evaluate the efficacy of the disinfectants.

RESULTS

Eighty eyes (75 horses) met the inclusion criteria, with 36 cases being aseptically prepared with PI and 44 with PHMB. Both antiseptics significantly reduced the bacterial load and number of bacterial species (p < .001) between time points T0 and T1, and T0 and T2. PHMB showed a reduction in the bacterial load by 64% (CI: 51%-73%) whereas PI reduced it by 48% (CI: 36%-58%) between time points T0 and T1. The reduction in the number of bacterial species between time points T0 to T1 was significantly greater in the PHMB group (85%, CI: 70%-93%), compared to PI (47%, CI: 26%-62%).

CONCLUSION

Both PHMB and PI reduced the bacterial load and number of species on the ocular surface and eyelids significantly, with 0.1% PHMB being superior to 0.2% PI. Therefore, PHMB can be considered as a good alternative in preoperative antisepsis in equine ophthalmic procedures.

Antimicrobial materials based on photothermal action and their application in wound treatment

Considering the increasing abundance of antibiotic-resistant bacteria, novel antimicrobial approaches need to be investigated. Photothermal therapy (PTT), an innovative noninvasive therapeutic technique, has demonstrated significant potential in addressing drug-resistant bacteria and bacterial biofilms. However, when used in isolation, PTT requires higher-temperature conditions to effectively eradicate bacteria, thereby potentially harming healthy tissues and inducing new inflammation. This study aims to present a comprehensive review of nanomaterials with intrinsic antimicrobial properties, antimicrobial materials relying on photothermal action, and nanomaterials using drug delivery antimicrobial action, along with their applications in antimicrobials. Additionally, the synergistic mechanisms of these antimicrobial approaches are elucidated. The review provides a reference for developing multifunctional photothermal nanoplatforms for treating bacterially infected wounds.

Efficacy and Safety of Keratosept Eye Drops in Patients with Punctate Keratitis: Clinical and Microbiological Evaluation on 50 Eyes

We evaluated the efficacy and safety of eye drops with antiseptic and re-epithelizing properties (Keratosept®, Bruschettini, Genova, Italy) on 50 eyes affected by punctate keratitis of suspected microbial origin. A biomicroscopic examination, fluorescein dye staining test (Fluotest), tear break-up time test (TBUT), and the ocular surface disease Index (OSDI) questionnaire were used to assess treatment efficacy. Treatment success was defined as a negative Fluotest and an OSDI score <12 on the 15th day of treatment. According to this definition, Keratosept®, either alone or in combination with antibiotics, was effective in over 80% of microbial and nonmicrobial forms. Conjunctival swabs were taken from all patients for culture examination with an antibiogram and sensitivity test for Keratosept®; 32/43 (74.4%) forms with positive culture for the bacteria were sensitive to Keratosept®. A total of 35/38 (92%) eyes treated with this product alone achieved full treatment success without any apparent adverse effects. These results suggest the use of Keratosept® eye drops in punctate keratitis as an alternative or in combination with established antibiotic therapies. Further studies are needed to evaluate its efficacy in different infectious forms and identify other indications for using this product.

Topical Antiseptics in Minimizing Ocular Surface Bacterial Load Before Ophthalmic Surgery: A Randomized Controlled Trial

PURPOSE

To investigate the reduction of the ocular surface bacterial load induced by 2 commercially available ophthalmic antiseptic formulations, povidone-iodine (PVI) 0.6% and chlorhexidine (CLX) 0.02%, before ocular surgery.

DESIGN

Randomized controlled trial.

METHODS

Seventy adult patients undergoing intraocular surgery (phacoemulsification) were randomized to receive in the index eye PVI (group A) 4 times a day for 3 days or CLX (group B) 4 times a day for 3 days before surgery. The untreated eye was used as control. A conjunctival swab was taken in both eyes before (T0) and after (T1) therapy. Microbial DNA was quantified with real-time polymerase chain reaction (PCR) analysis. The Mick algorithm was used to compare the abundance of each genus/genera against the distribution of abundances from the reference. At T1, patients filled a questionnaire to evaluate therapy-induced symptoms. Primary outcome was the reduction of bacterial DNA at T1 (microbial load), vs control arm, expressed as mean number of real-time PCR cycle times (CTs). Secondary outcomes were taxonomic composition, differential abundance, and therapy-induced ocular symptoms.

RESULTS

The T0-T1 difference in CT was significant in group B, but not in group A (mean [95% CI], 0.99 [0.33] vs 0.26 [0.15], P < .001, and 0.65 [0.3] vs 0.45 [0.41], P = .09, respectively). The taxonomic composition, alpha, and beta diversity remained consistent at all time points in both groups. The rate of patients reporting therapy-induced ocular symptoms and the mean discomfort grade were greater in group A than in group B (97% vs 26% and 4.97±2.48 vs 0.66±1.53, respectively).

CONCLUSIONS

Compared with PVI 0.6%, CLX 0.02% induced a greater reduction of ocular surface bacterial load, with no significant alterations of the taxonomic composition. Moreover, CLX was better tolerated than PVI.

Natural Terpenes Inhibit the Cytopathogenicity of Naegleria fowleri Causing Primary Amoebic Meningoencephalitis in the Human Cell Line Model

Naegleria fowleri is one of the free-living amoebae and is a causative agent of a lethal and rare central nervous system infection called primary amoebic meningoencephalitis. Despite the advancement in antimicrobial chemotherapy, the fatality rate in the reported cases is more than 95%. Most of the treatment drugs used against N. fowleri infection are repurposed drugs. Therefore, a large number of compounds have been tested against N. fowleri in vitro, but most of the compounds showed high toxicity. To overcome this, we evaluated the effectiveness of naturally occurring terpene compounds against N. fowleri. In this study, we evaluated the antiamoebic potential of natural compounds including Thymol, Borneol, Andrographolide, and Forskolin againstN. fowleri. Thymol showed the highest amoebicidal activity with IC50/24 h at 153.601 ± 19.6 μM. Two combinations of compounds Forskolin + Thymol and Forskolin + Borneol showed a higher effect on the viability of trophozoites as compared to compounds alone and hence showed a synergistic effect. The IC50 reported for Forskolin + Thymol was 81.30 ± 6.86 μM. Borneol showed maximum cysticidal activity with IC50/24 h at 192.605 ± 3.01 μM. Importantly, lactate dehydrogenase release testing revealed that all compounds displayed minimal cytotoxicity to human HaCaT, HeLa, and SH-SY5Y cell lines. The cytopathogenicity assay showed that Thymol and Borneol also significantly reduced the host cell cytotoxicity of pretreated amoeba toward the human HaCaT cell line. So, these terpene compounds hold potential as therapeutic agents against infections caused by N. fowleri and are potentially a step forward in drug development against this deadly pathogen as these compounds have also been reported to cross the blood-brain barrier. Therefore, an in vivo study using animal models is necessary to assess the efficacy of these compounds and the need for further research into the intranasal route of delivery for the treatment of these life-threatening infections.

In praise of povidone-iodine application in ophthalmology

Polyvinyl pyrrolidone or povidone-iodine (PVP-I) is a water-soluble complex formed by the combination of iodine and a water-soluble polymer, polyvinyl pyrrolidone. This complex exerts bactericidal, fungicidal, and virucidal action by gradually releasing free iodine at the site of application to react with pathogens. In ophthalmology, PVP-I is used as a disinfectant and antiseptic agent for preoperative preparation of the skin and mucous membranes and for treating contaminated wounds. PVP-I has been shown to reduce effectively the risk of endophthalmitis in various ocular procedures, including cataract surgery and intravitreal injections; however, it has also been used in the treatment of conjunctivitis, keratitis, and endophthalmitis, with promising results especially in low-resource situations. PVP-I has been associated with complications such as postoperative eye pain, persistent corneal epithelial defects, ocular inflammation, and an attendant risk of keratitis. In cases of poor PVP-I tolerance, applying PVP-I at lower concentrations or using alternative antiseptics such as chlorhexidine should be considered. We provide an update on the efficacy of PVP-I in the prophylaxis and treatment of conjunctivitis, keratitis, and endophthalmitis and a comprehensive analysis of the current literature regarding the use of PVP-I in the management of these ocular conditions. Also, PVP-I-related adverse effects and toxicities and its alternatives are discussed. The goal is to present a thorough evaluation of the available evidence and to offer practical recommendations for clinicians regarding the therapeutic usage of PVP-I in ophthalmology.

Prophylaxis of Ocular Infection in the Setting of Intraocular Surgery: Implications for Clinical Practice and Risk Management

In this review we discuss the role of intraocular surgery preoperative prophylaxis. The correct choice of antimicrobial drug is variable in each surgical setting, according to the available strengths of evidence, the anatomical district involved, and the type of procedure. In the ophthalmic surgical field, there has been a progressive shift from antibiotic formulations, which are known to cause antibiotic resistance, to a new class of antiseptic compounds, which proved to be effective not only against bacteria, but also against fungi, protozoa, and viruses. Among these, povidone-iodine (PVI) is a water-soluble polymer that can form a complex with iodine, and the perioperative application of PVI 5-10% eye drop for 3 min is the gold standard for infection prophylaxis. A new formulation of 0.6% PVI eye drop is a new option for infection prophylaxis in the days before surgery. Chlorhexidine is a biguanide compound, which is a valid alternative with a good safety and efficacy profile and is the antiseptic of choice in patients with iodine allergy. New compounds that are currently being studied include polyhexamethylene biguanide (PHMB), picloxydine, ozone, hypochlorous acid (HOCl), and Biosecur. PHMB is a biguanide polymer that was found to be more effective than PVI in in vitro studies for reducing microorganisms and extending the duration of antisepsis, but to date, there are no formulations available on the market for preoperative ocular surgery in which it is present as main ingredient. Ozone is a molecule with oxidizing effect, which showed interesting preliminary results but is not effective against virus, Staphylococcus aureus and Candida albicans. HOCl has a natural bactericidal propriety but its applicability to prophylaxis of ocular infection in the setting of ocular surgery is not established. Biosecur is a non-toxic organic alcohol-free compound that exhibited bactericidal and fungicidal effect versus all common microorganisms and is currently available as an ocular spray.

Broad-Spectrum Antimicrobial Activity of Oftasecur and Visuprime Ophthalmic Solutions

Due to the wide etiology of conjunctivitis, the expensive and time-consuming diagnosis requires new therapeutic strategies with broad-spectrum antimicrobial activity and nonselective mechanisms of action. In this context, eye drops could provide an alternative to conventional antimicrobial therapies. Here, we compare the antibacterial and antiviral activity of Oftasecur and Visuprime, commercially available ophthalmic solutions. Cytotoxicity assay was performed on Vero CCL-81 cells by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-tetrazolium bromide (MTT) test. Antibacterial efficacy was evaluated on Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, Escherichia coli, and Klebsiella pneumoniae by disk diffusion, broth microdilution methods, and time-killing tests. Furthermore, the antiviral activity against HSV-1 was estimated by co-treatment, cell and viral pretreatment and post-treatment, via plaque reduction assay, fluorescence assessment (GFP-engineered HSV-1), and real-time PCR. After 24 h of exposure, Oftasecur and Visuprime showed a volume-inducing 50% of cytotoxicity of 125 and 15.8 μL, respectively Oftasecur and Visuprime induced 90% antibacterial activity in response to mean volume of 10.0 and 4.4 µL for Gram-positive and Gram-negative strains, respectively. Oftasecur exerted bactericidal action on both bacterial populations, while Visuprime was bacteriostatic on Gram-negative strains and slightly bactericidal on Gram-positive bacteria. A major impact on infectivity occurred by exposure of viral particles to the ophthalmic solutions. In detail, 50% of inhibition was verified by exposing the viral particles to 3.12 and 0.84 μL of Oftasecur and Visuprime, respectively, for 1 h. The reduction of the fluorescence and the expression of the viral genes confirmed the recorded antiviral activity. Due to their high antimicrobial efficiency, Oftasecur and Visuprime could represent a valid empirical strategy for the treatment of conjunctivitis.

Ophthalmic Solutions with a Broad Antiviral Action: Evaluation of Their Potential against Ocular Herpetic Infections

HSV-1 can be associated with severe and recurrent eye infections characterized by a strong inflammatory response that leads to blepharoconjunctivitis, epithelial and stromal keratitis, and retinal necrosis. The incidence of HSV-1 keratitis is 1.5 million every year worldwide, including more than 40,000 new cases exhibiting serious visual failures. Generally, the therapy uses antiviral drugs to promote healing; however, there are currently no compounds that are able to completely eradicate the virus. In addition, the phenomenon of resistance is rapidly spreading among HSV-1 strains, creating mutants developing resistance to the common antiviral drugs; therefore, deep research on this issue is warranted. The efficacy of different ophthalmic solutions already on the market was evaluated for reducing HSV-1 infection. Different plaque assays were set up on epithelial cells, revealing that two ophthalmic solutions were able to inhibit viral replication in the early stages of infection. The data were further confirmed by molecular tests analyzing the expression levels of the principal genes involved in HSV-1 infection, and a strong reduction was observed after only 1 min of eye-drop treatment. Collectively, these results suggested the use of ophthalmic solutions as potential antiviral options for the treatment of ocular herpetic infection.