A new poly(ortho ester)-based drug delivery system as an adjunct treatment in filtering surgery.

PURPOSE: Pharmacologic modulation of wound healing after glaucoma filtering surgery remains a major clinical challenge in ophthalmology. Poly(ortho ester) (POE) is a bioerodible and biocompatible viscous polymer potentially useful as a sustained drug delivery system that allows the frequency of intraocular injections to be reduced. The purpose of this study was to determine the efficacy of POE containing a precise amount of 5-fluorouracil (5-FU) in an experimental model of filtering surgery in the rabbit. METHODS: Trabeculectomy was performed in pigmented rabbit eyes. An ointmentlike formulation of POE containing 1% wt/wt 5-FU was injected subconjunctivally at the site of surgery, during the procedure. Intraocular pressure (IOP), bleb persistence, and ocular inflammatory reaction were monitored until postoperative day 30. Quantitative analysis of 5-FU was performed in the anterior chamber. Histologic analysis was used to assess the appearance of the filtering fistula and the polymer's biocompatibility. RESULTS: The decrease in IOP from baseline and the persistence of the filtering bleb were significantly more marked in the 5-FU-treated eyes during postoperative days 9 through 28. Corneal toxicity triggered by 5-FU was significantly lower in the group that received 5-FU in POE compared with a 5-FU tamponade. Histopathologic evaluation showed that POE was well tolerated, and no fibrosis occurred in eyes treated with POE containing 5-FU. CONCLUSIONS: In this rabbit model of trabeculectomy, the formulation based on POE and containing a precise amount of 5-FU reduced IOP and prolonged bleb persistence in a way similar to the conventional method of a 5-FU tamponade, while significantly reducing 5-FU toxicity.

A poly(ortho ester) designed for combined ocular delivery of dexamethasone sodium phosphate and 5-fluorouracil: subconjunctival tolerance and in vitro release.

A viscous hydrophobic poly(ortho ester) (POE) has been developed as a biocompatible, biodegradable sustained release system for selected cases of glaucoma filtering surgery. Dexamethasone and 5-fluorouracil (5-FU) are frequently administered together post-operatively, for their anti-fibroblastic and anti-inflammatory properties, respectively. A combined sustained release of both drugs could be advantageously used. Drug release kinetics were studied using specially designed thermostated cells. Subconjunctival tolerance was evaluated on New Zealand albino rabbits by clinical evaluation. Due to its basicity, the addition of dexamethasone sodium phosphate (DEX-P) stabilized the polymer and prolonged 5-FU in vitro release from 2 to 4 days. Both therapeutic agents were released concomitantly, according to a linear profile. The presence of 5-FU only slightly affected the overall subconjunctival tolerance of POE in rabbits, whereas the addition of DEX-P markedly improved POE tolerance by reducing the hyperemia of the conjunctiva to a minimal grade.

Improved biocompatibility of a viscous bioerodible poly(ortho ester) by controlling the environmental pH during degradation.

The poly(ortho ester), POE, used in this investigation, is a viscous bioerodible polymer (8 kDa), which rapidly degrades into a triol and an acidic by-product, acetic acid. In order to improve biocompatibility, we have evaluated the addition of various basic excipients, such as sodium acetate, hydroxyapatite, calcium carbonate and magnesium hydroxide, which buffered and neutralized the acidic degradation product and prolonged the polymer lifetime and drug release. This decrease of POE degradation rate results in a decreased rate of formation of the acidic by-product. Similarly, a POE of higher molecular weight (14 kDa) has been tested. Sodium acetate was too hydrophilic to affect the drug release and the biocompatibility of the polymer, whereas the presence of magnesium hydroxide markedly prolonged the drug release and improved the acceptability of the polymer. The increased molecular weight POE did not improve biocompatibility and a similar but delayed, inflammatory reaction was observed.

A viscous bioerodible poly(ortho ester) as a new biomaterial for intraocular application.

The biocompatibility of a viscous, hydrophobic, bioerodible poly(ortho ester) (POE) intended for intraocular application was investigated. POE was evaluated as a blank carrier and as containing modulators of degradation. Each formulation was injected intracamerally and intravitreally in rabbit eyes, and clinical and histological examinations were performed postoperatively for 2 weeks. In the case of intracameral injections, polymer biocompatibility appeared to depend on the amount injected in the anterior chamber. When 50 microL was administered, the polymer degraded within 2 weeks, and clinical observations showed good biocompatibility of POE with no toxicity to the ocular tissues or increase in intraocular pressure. The injection of a larger volume, 100 microL, of POE, appeared inappropriate because of direct contact of polymeric material with the corneal endothelium, and triggered reversible edema and inflammation in the anterior chamber of the eye that regressed after a few days. After intravitreal administration, POE was well tolerated and no inflammatory reaction developed during the observation period. The polymer degraded slowly, appearing as a round whitish bubble in the vitreous cavity. The presence of modulators of degradation both improved POE biocompatibility and prolonged polymer lifetime in the eye. POE appears to be a promising biomaterial for clinical intraocular application.

Concomitant and controlled release of dexamethasone and 5-fluorouracil from poly(ortho ester).

A viscous bioerodible and hydrophobic poly(ortho ester) has been developed as a biocompatible, sustained drug release system for an ophthalmic application in intraocular proliferative disorders. The combination of wound healing modulators such as 5-fluorouracil and dexamethasone is a major advantage since these drugs act at different stages of these diseases. Since 5-fluorouracil is an acidic, water-soluble compound and dexamethasone exists in three chemical forms, i.e. the water-insoluble base, the highly hydrophobic acetate ester or the basic phosphate salt, it was of interest to investigate whether the physicochemical properties of the drugs have an influence on their release rates, and whether a concomitant and sustained release of both 5-fluorouracil and dexamethasone could be achieved. It has been found that lipophilicity and acidobasicity play a major role in controlling drug release rates and polymer degradation. The combination of 5-fluorouracil and dexamethasone phosphate allows a sustained and concomitant release of both drugs, due to the basic characteristics of the corticosteroid which stabilize the polymer. This system appears to be promising for concomitant and controlled drug delivery aimed at the pharmacological treatment of intraocular proliferative disorders.

In vitro drug release from self-catalyzed poly(ortho ester): case study of 5-fluorouracil.

Self-catalyzed poly(ortho esters) are a new variation of linear poly(ortho esters) prepared by the addition of diols to the diketene acetal 3,9-diethylidene-2,4,8,10-tetraoxaspiro[5,5]undecane where dimer segments of lactic acid or glycolic acid are built into the polymer backbone. By varying the concentration of these segments, polymer erosion rate can be controlled. The present investigation describes the in vitro drug release characteristics from these new polymers. Because poly(ortho esters) have potential applications for the delivery of antifibroblastic agents for example after glaucoma-filtering surgery, the in vitro release studies were evaluated using 5-fluorouracil as the active compound. It was shown that a mole ratio of 90/10 or 80/20 diol/diol-lactate incorporated into the polymer lead to a release of 5-fluorouracil by an erosion process. Smaller amounts of diol-lactate lead to a concomitant drug release by diffusion and erosion. It was also shown that the release rate depends on the alkyl chain length of the diol in the polymer backbone but it does not depend on the drug loading.

Synthesis and characterization of self-catalyzed poly(ortho ester).

Poly(ortho esters) are currently under investigation as a carrier system for an antiproliferative agent in glaucoma filtering surgery. The present investigation illustrates the development of a series of self-catalyzed poly(ortho ester). These polymers contain short dimer segments of alpha-hydroxy acids in their backbone and are prepared by the addition of different polyols to the diketene acetal 3,9-diethylidene-2,4,8,10-tetra-oxaspiro-[5.5]-undecane. The structures were confirmed by NMR- and FT-IR-spectroscopy. The polymers were characterized by determination of the molecular weight, the glass transition temperature and the rheological behavior. The amount of residual solvents was also analyzed. The characteristics of the polymer can be varied by the type of polyol incorporated in its backbone. Since poly(ortho ester) is susceptible to acid-catalyzed degradation, the polymer hydrolysis can be controlled by the amount of incorporated portion of alpha-hydroxy acid. Due to the high hydrophobicity of the polymer structure, the ester bonds are more susceptible to hydrolysis than the ortho ester bonds in the polymer backbone. The hydrolysis proceeds via initial protonation of the exocyclic alkoxy group to yield pentaerythritol dipropionate and the free diol. In a next step, the pentaerythritol dipropionate hydrolysis to pentaerythritol and propionic acid. The molecular weight decrease, weight loss and the pH profile of the polymer in aqueous medium were monitored during the degradation.

Subconjunctival biocompatibility of a viscous bioerodable poly(ortho ester).

The biocompatibility of a viscous poly(ortho ester) (POE) intended for prolonged intraocular drug delivery was studied. This hydrophobic and bioerodable carrier was subconjunctivally injected in rabbits and evaluated both clinically and histologically. To assess the cause of the triggered transient acute inflammatory reaction, the two monomers, the intermediate and final degradation products, and the local toxicity of different solvents used during the polymer preparation were tested. Since the two initial monomers and the intermediate degradation products induced only moderate inflammation, the main acute inflammatory reaction is attributed to the formation of an acidic by-product which has been monitored in vitro by measuring the progressive decrease of the environmental pH. The influence of the sterilization procedure on tissue biocompatibility was established by comparing two polymers of similar molecular weight: one after gamma-sterilization, and an aseptically synthesized one. The biocompatibility was significantly improved by avoiding irradiation of the polymer.

Purity and stability assessment of a semi-solid poly(ortho ester) used in drug delivery systems.

The research work carried out for developing bioerodible drug delivery devices in which the erosion process was to be confined to the polymer-water interface is at the origin of the discovery of a class of polymers known as poly(ortho esters) (POEs). Thus far, three POE systems have been described. The latest POE was prepared by a transesterification reaction between a triol and an ortho ester, followed by a self-condensation of the reaction product. This polymer, which exhibits viscous characteristics at room temperature, was investigated for use as a drug delivery system in glaucoma filtering surgery. The assessment of POE purity and stability was carried out by a detailed analysis of the influence of the purification procedure and storage conditions. This bioerodible semi-solid POE was purified by a repeated precipitation procedure. Elimination of the small molecular weight oligomers and monomers and of the catalysts and stabilizers used in the synthesis, as well as a decrease of the polydispersity, were obtained with this method. Fourier transform infrared analysis also verified the disappearance of degradation products after the first precipitation. Drying of the precipitated polymer was performed at 40 degrees C in order to avoid thermal degradation of the POE at higher temperatures and to facilitate solvent evaporation through the polymer network by a reduction of polymer viscosity. Water vapour uptake of the polymers stored at different relative humidities has demonstrated the high moisture sensitivity of these semi-solid POEs. The average molecular weight of the polymer and hence its viscosity, as well as the solubility characteristics of the incorporated drug, were found to have a considerable influence on the rate of water vapour absorption and on polymer degradation. The use of inert gas or vacuum to maintain the polymer under anhydrous conditions has been studied. Storage of the semi-solid POE under argon in sealed glass bottles provides good protection of the polymer over time.

Gamma sterilization of a semi-solid poly(ortho ester) designed for controlled drug delivery--validation and radiation effects.

Radiation sterilization is becoming increasingly popular for the sterilization of many pharmaceutical products. Although this technique is not limited to the sterilization of polymers, it is probably the most suitable method for such materials. This method however suffers several drawbacks. The sterilization of a product must lead to a safety level of 10(-6), i.e. one chance in a million to find a contaminated sample. In many cases, this assurance of sterility can be achieved by using a uniform treatment dose of 2.5 Mrad, recommended by the pharmacopeia. We investigated the possibility of using doses of radiation inferior to 2.5 Mrad to sterilize a semi-solid poly(ortho ester) (POE) developed for use as carrier in controlled drug delivery. After determination of the initial bioburden, the polymer was intentionally contaminated with the bioindicator Bacillus pumilus E 601. Following exposure to gamma irradiation, the D10 value of the radio resistant bioindicator was determined. Using the initial contamination value, the reduction factor D10 and the safety level, it is possible to calculate an optimal sterilizing dose for POE. All polymers are affected by ionizing radiation and the amount of radiation which produces a significant change in properties may vary from one polymer to the other. A molecular weight and dynamic viscosity decrease resulting from backbone cleavage was observed for this POE at a dose lower than 2.0 Mrad. Evaluation of the structure using 1H-NMR, 13C-NMR and IR analysis shows that for doses higher than 2.0 Mrad, another degredation process takes place.(ABSTRACT TRUNCATED AT 250 WORDS)

Biocompatibility of a new semisolid bioerodible poly(ortho ester) intended for the ocular delivery of 5-fluorouracil.

The biocompatibility of a new semisolid, hydrophobic poly(ortho ester) (POE) intended for controlled drug delivery to the eye was evaluated. The polymer was injected subconjunctivally in rabbits, and clinical and histologic examinations were performed 3, 10, 15, and 21 days after injection. Polymers injected as controls were an aqueous gel of sodium hyaluronate (SH), 1% in phosphate buffer, and medical grade silicone oil. After injection, the POE emulsified into small droplets and a focal eosinophilic reaction was noted at 3 days' implantation. At 10 days' implantation, the POE was not identified in the implantation site and the inflammatory reaction had resolved, with fibroblasts being the predominant cell type. At 15 and 21 days, no POE was identified and normal appearing tissue was present in the injection site. Sodium hyaluronate was not inflammatory over the period of the implantations. Silicone oil induced a slight inflammation at 3 days, with the presence of eosinophils and limited necrosis with cellular debris. Silicone oil was present in the implantation site at 3, 10, 15, and 21 days. The inflammatory response to the respective polymers was evaluated in the subconjunctival tissue. The inflammatory reaction was quantified at the implant site, adjacent subconjunctival tissues, and scleral and corneal stroma. The inflammatory cell densities in these respective tissue zones were determined, and the ratio of eosinophils over total inflammatory cells was calculated. POE did not become encapsulated with fibrous tissue, but biodegraded in a short time, indicating its potential for use after glaucoma filtration surgery.

Biotolerance of a semisolid hydrophobic biodegradable poly(ortho ester) for controlled drug delivery.

We evaluated the biotolerance of a new semisolid poly(ortho ester) (POE) intended for controlled drug delivery. Two different investigations were carried out in rats: subcutaneous injections and the cage-implant system. Sodium hyaluronate (SH), 1%, in phosphate buffer was used as a noninflammatory control. When injected subcutaneously in rats, the POE induced a mild and local inflammation at 3 and 7 days followed by a minimal chronic inflammation at 14 and 21 days. When using the cage-implant system, we quantified the inflammatory components of the exudate surrounding the implanted material within the cage system at 3, 7, 14, and 21 days. The total leukocyte and macrophage concentrations were higher only at 7 days for both SH and POE compared to the control (empty cage). The other parameters were not significantly different from the control. These results show that POE is well-tolerated by rats when used subcutaneously.

Sodium hyaluronate 0.25% used as a vehicle increases the bioavailability of topically administered gentamicin.

Sodium hyaluronate (SH) solutions have a longer precorneal residence time than isotonic saline solution in rabbits and in humans. The present study investigates the effect of a 0.25% SH vehicle, compared with a phosphate buffer solution (PBS), on the tear concentration after topical administration of gentamicin sulfate (GS) in humans. Eight volunteers received 25 microliters 0.5% GS in PBS in the left eye and 25 microliters 0.5% GS in 0.25% SH in the right eye. Tear samples of 1 microliters were taken from the inferior sulcus using a capillary before instillation and 5, 10, 20, and 40 min after instillation. The tear concentration of GS was determined by radioimmunoassay. There was a statistically significantly higher concentration of GS in the inferior conjunctival sulcus of the SH-instilled eye at 5 min (P < 0.01) and at 10 min (P < 0.05) after instillation (paired t-test, n = 9). At 20 min the concentration of GS in the SH-instilled eye was only slightly higher, and at 40 min GS concentrations in left and right eyes were comparable. SH 0.25% used as a vehicle therefore increases the availability of GS at the ocular surface for at least 10 min. This effect could be due to the prolonged precorneal residence time of SH.

Synthesis and characterization of a new biodegradable semi-solid poly(ortho ester) for drug delivery systems.

Since the late 1970s, three families of poly(ortho esters) (POE) were synthesized to provide bioerodible carriers for drug delivery devices. The most recent POE is a semi-solid polymer with a viscous behavior at room temperature. Polymer synthesis by a transesterification reaction between a triol and a trialkyl ortho ester is described. The structure of the polymer was confirmed by conventional methods such as 1H-NMR, 13C-NMR and FT-IR. Information concerning average molecular weight and intrinsic viscosity was obtained respectively by GPC and viscosimetry. Residual solvents in the polymer were determined using gas chromatography. The chromatographic conditions were optimized to enable the quantification of the solvents in concentrations of a few percent. The mechanical behavior of the semi-solid POE was determined by rheometric measurements. Hydrolysis of the polymer leads to the formation of the original triol and the carboxylic acid derived from the trialkyl ortho ester used in the transesterification step. No toxicological problems associated with these compounds are anticipated.

Urokinase-type plasminogen activator in human aqueous humor.

In the anterior segment of the eye, fibrin clots must be rapidly resorbed to prevent further fibrosis and scarring. The aqueous humor of patients undergoing cataract surgery was analyzed for the presence of components of the fibrinolytic cascade. In 30 patients, aqueous humor and plasma were compared for their content of urokinase-type plasminogen activator (uPA), tissue-type plasminogen activator (tPA), plasminogen activators inhibitors (PAIs), plasminogen, and total proteins. With gel electrophoresis and zymographic assays of serial dilutions of plasma and aqueous humor, all these components were found to be present at lower concentrations in aqueous humor than in plasma. For total proteins, the aqueous/plasma ratio was approximately 0.003, and for plasminogen it was 0.001. Interestingly, the aqueous/plasma ratio for uPA was not as low and varied from 0.01 to 0.03. A significant proportion of the uPA in aqueous humor was present in the two-chain active form. In addition to uPA, aqueous humor contained lower levels of tPA, but no detectable levels of reactive plasminogen activators inhibitors (PAIs). The presence of a relatively high concentration of active uPA shows that the proteolytic balance of the aqueous humor in the anterior chamber of the eye is shifted toward fibrinolysis.

[Psychological impact of cataract surgery in the elderly patients]. / Impact psychologique de l'opération de la cataracte chez le patient âgé.

A standardized interview was undertaken in twenty patients, mean age of 70, suffering from cataract fifteen days following extra-capsular extraction of the cataract, and implantation of a lens in the posterior chamber. The patients were selected on the basis that they had no risk factors of socio-psychological complications either during the illness or post-operatively. The study investigated retrospectively the impact of cataract on different aspects of personality and life-style in these patients. We also studied the degree of reactive depression in the postoperative period, as measured by the Hamilton depression scale. Although the precise psychological correlation between the two time periods was not possible, half of the patients suffered from a major affective disorder, as classified by DSM-III, 15 days before the operation and a quarter of these were depressed after the operation. Our results show this condition to be associated with considerable but non specific socio-affective upheaval in these patients.

[Preliminary results of the pterygium excision technic with conjunctival autograft]. / Résultats préliminaires de la technique d'excision du ptérygion avec autogreffe conjonctivale.

14 eyes with a pterygium, including one eye from which a pterygium had previously been removed by a simple excision, underwent a conjunctival autograft. During an average follow-up of 13 months, we observed a recurrence in 5 eyes (35%). The visual acuity stayed unchanged in 10 eyes, worsened in 1 eye and improved in 3 eyes. The corneal astigmatism measured with a Javal keratometer showed a modification in 12 eyes. This method should not be used as a standard primary surgery for pterygium in view of the high recurrence rate observed.

Immunocytochemical localization of gentamicin in the rabbit retina following intravitreal injection.

The localization of gentamicin in the retina after a single intravitreal injection in the rabbit eye was examined by indirect immunofluorescent staining with goat antigentamicin antiserum. Eight hours after the injection of 400 micrograms of gentamicin, staining was observed in the ganglion cell layer, the inner plexiform layer, the inner nuclear layer, and the photoreceptors. By 12 hours, the staining was also observed in the retinal pigment epithelium. Howeever, by 24 hours the staining was predominantly found in the retinal pigment epithelium and choriocapillaris, and only occasional staining was seen scattered in the neurosensory retina. At 36 to 48 hours, the labeling was confined to the retinal pigment epithelium and choriocapillaris. Electron microscopy confirmed the cytoplasmic localization of gentamicin in the retina.

[Effect of mydriasis and cycloplegia on close-range visual acuity in pseudophakia]. / Effet de la mydriase et de la cycloplégie sur l'acuité visuelle de près chez le pseudophaque.

We have studied 21 eyes of 17 patients which underwent 3 Months before a standard extracapsular cataract extraction and implantation into the sulcus of a posterior chamber lens. All the eyes had a final uncorrected far and near vision of 0.4 (20/50) or better. We have measured the uncorrected near vision before and after pupillary dilatation with 5% phenylephrine. Then, after additional 0.5% cyclopentolate induced cyclopegia, near vision was evaluated again. Our results show a statistically significant decrease in the uncorrected near vision after pupillary dilatation (p less than 0.001). On the contrary additional cyclopegia does not significantly reduce the uncorrected near vision (p greater than 0.08). Our observations confirm the importance of unimpaired pupillary movement as regards best possible uncorrected near vision in pseudophakic patients. The activity of the ciliary muscle does not seem to mainly contribute to the phenomenon of pseudoaccommodation.

Precorneal residence time in humans of sodium hyaluronate as measured by gamma scintigraphy.

The aim of the present study was to quantify in man the distribution and clearance of two aqueous sodium hyaluronate (SH) solutions of 0.125% and 0.250% after the administration of 25 microliters onto the cornea. Isotonic phosphate buffer (PB) was used as a reference instillation. No systemic or local medication was given to the seven 18- to 30-year-old, healthy male volunteers. A detailed evaluation of the anterior segment of the eye, as well as a Schirmer test and a break-up time measurement, yielded results within the normal range. The clearance of 0.125% and 0.250% SH solutions radiolabelled with sodium pertechnetate Tc-99m was measured by gamma scintigraphy and compared with that of a PB solution tagged with the same radiolabel. There was no statistically significant difference between the quantities of 0.125% SH and PB solutions remaining in the precorneal space at 20 min (paired t-test, P = 0.78, n = 7). However, in comparing the 0.250% SH with the PB solution, we observed a statistically significant difference (P = 0.01, n = 7) in the amount remaining in the precorneal space after the same interval. Actually, 53% of the radiolabelled 0.250% SH solution remained on the cornea as compared with 30% for the 0.125% SH solution and 18.3% for the PB solution. These results suggest that an SH solution of 0.250% might have a prolonged residence time on the precorneal surface, and that SH could therefore be used as an additive in various drug-release systems for the eye.