Corneal regeneration: A review of stromal replacements

LNP-encapsulated miRNA29b for corneal repair: A novel approach to combat fibrosis

Severe corneal injuries often result in corneal scarring, leading to visual impairment and corneal blindness. Currently, there is a lack of effective anti-corneal fibrosis drugs in clinical practice. MicroRNA-based therapies hold significant potential in combating fibrosis. However, the barrier function of the cornea and the fluid environment of the ocular surface reduce drug permeability and bioavailability, presenting significant challenges for local drug application. This study employs microfluidic technology to encapsulate miRNA29b in lipid nanoparticles (LNP) to create an LNP-miRNA29b delivery system (LNP-mir29b) for treating corneal mechanical injuries. In vitro experiments show that LNP-mir29b significantly inhibits the expression of α-smooth muscle actin (α-SMA) in an induced corneal stromal cell fibrosis model. In vivo experiments using rabbit corneal mechanical injury models indicate that LNP-mir29b effectively reduces fibrosis in the corneal stroma, promotes organized rearrangement of stromal collagen fibers, and decreases the expression of fibrosis-related genes, including Col1A2, Col3A1, Fn, and α-SMA. Additionally, LNP-mir29b accelerates the migration of corneal epithelial cells, promotes wound healing of the epithelium, restores the structural integrity of the corneal epithelium. The LNP system proposed in this study offers a novel approach with anti-fibrotic functionality, providing a new strategy for reducing scarring during the corneal injury repair process.

Silk biomaterials for corneal tissue engineering: From research approaches to therapeutic potentials; A review

The corneal complications can result in opacity and eventual blindness. Furthermore, a shortage of available donors constrains the existing therapeutic options. Therefore, one of the most promising strategies involves the application of biomaterials, particularly silk. Silk has garnered significant attention among these biomaterials due to its natural origin and diverse features derived from different sources. One of the most critical factors of silk is its transparency, which is crucial for the cornea, and there are no concerns about infection. This material also possesses several advantages, including cost-effectiveness in production, biocompatibility in vivo and in vitro, biodegradation, and desirable mechanical characteristics. Modifications in the topographical structure, porosity, and crystallinity of silk enhance its properties and optimize its suitability for wound dressing, efficient drug delivery systems, and various cornea-related treatments. In each layer, silk was examined as a single biomaterial or blended with the others, so, this review aims to explore silk as a potential material for corneal regenerative medicine from a novel viewpoint. By considering a range of studies, a classification system has been developed that categorizes the utilization of silk in the various layers of the cornea and sub-categorizes the different modifications and applications of silk.

Composite synthetic protein hydrogel for inhibition of corneal fibrosis and treatment of corneal wounds

Corneal fibrosis, a severe complication linked to ocular injuries and post-surgery, lacks effective treatment. Hydrogels are regarded as one of the most promising biomaterials, particularly in the context of corneal wound treatment, where they have attracted considerable attention. Synthetic protein hydrogels are of particular interest due to their biocompatibility, biodegradability, capacity to mitigate induced tissue inflammatory responses, and their editable and modular integrative properties. Accordingly, the present study was designed to create a mechanically stable 4XT recombinant protein based on the mechanism of corneal fibrosis. A bio-synthetic protein gel scaffold incorporating cerium oxide nanoparticles (CeONs) with reactive oxygen species (ROS) scavenging capabilities and siRNA that inhibits transforming growth factor beta 1 (TGF-β1) protein expression was constructed using 4XT as a matrix. This resulted in a composite synthetic protein hydrogel treatment system. This system is capable of achieving in situ curing in the corneal defect area, effectively promoting the repair of corneal wounds in mice while also inhibiting the progression of corneal fibrosis. By combining the programmability and controllability of synthetic protein hydrogels with therapeutic approaches targeting wound mechanisms, it is possible to achieve scarless healing of corneal wounds, thereby providing valuable insights for wound management.

Lamellar keratoplasty using acellular porcine corneal stroma for the treatment of corneal ulcers

Objective

The study aimed to investigate the efficacy and safety of acellular porcine corneal stroma (APCS) for lamellar keratoplasty in the treatment of corneal ulcers.

Methods

A total of 14 patients (14 eyes) diagnosed with corneal ulcers who underwent lamellar keratoplasty using acellular porcine corneal stroma at the Second Affiliated Hospital of Nanchang University between June 2016 and May 2017 were recruited and followed up for at least 12 months. Postoperative visual acuity, epithelial recovery, graft transparency, the recurrence rate of corneal ulcers, the rate of graft rejection, corneal neovascularization, graft infection, secondary glaucoma, and graft melting were examined and analyzed.

Results

All 14 patients (100%) who underwent lamellar keratoplasty using acellular porcine corneal stroma successfully preserved the structure of their eyeballs. The visual acuity improved in 11 patients (78.5%). Graft rejection occurred in one patient (7.1%), while two patients (14.3%) developed recurrent corneal ulcers. Corneal vessel ingrowth was observed in seven patients (50%), and one patient (7.1%) developed pseudopterygium. The average time for complete epithelial recovery was 3-7 days.

Conclusion

Lamellar keratoplasty using acellular porcine corneal stroma is an effective surgical alternative for the treatment of corneal ulcers.

"Bioactive" Therapeutic Contact Lens Triggered by Biomimetic Chiral Helical Nanoarchitectonics for Rapid Corneal Repair

Consistent corneal epithelial injury would cause chronic inflammation, neovascularization, and even corneal scarring, resulting in vision loss. Rapid repair is crucial for treatment, within which the use of therapeutic contact lenses presents great promise. A great challenge is how to achieve rapid repair of severely deficient corneal epithelium and regulation of the oxidative stress environment simultaneously. Herein, a "bioactive" therapeutic contact lens, mimicking the layered helical structure of the native cornea, is designed based on the assembly of cellulose nanocrystals (CNCs) inside poly(hydroxyethyl methacrylate) (PHEMA) with CeOx formed on the CNCs' surface (CeOx/CNC@CNC-PHEMA). The obtained CeOx/CNC@CNC-PHEMA hydrogel possesses a chiral helical structure that regulates the microenvironment, and the nanoscaled CeOx on the CNCs' surface (CeOx/CNC) acts as a reactive oxygen species (ROS) scavenger and triggers a "bioactive" therapeutic contact lens for rapid corneal repair. This hydrogel meets the conditions of a therapeutic contact lens, including high degree of transparency, excellent mechanical properties, great ROS-scavenging efficacy, and a significant enhancement of biocompatibility. Importantly, the adhesion and proliferation of human corneal epithelial cells on the CeOx/CNC@CNC-PHEMA hydrogels are successful. An in vitro corneal oxidative damage model and in vivo animal model of corneal injury experiments were conducted, and results revealed that the hydrogel realized rapid corneal epithelial cells migration with antioxidant, anti-inflammatory, and antineovascular effects, achieving modulation of the ocular surface microenvironment, evidencing a "bioactive" property of the hydrogel as a therapeutic contact lens. This biotopological hydrogel with a biomimetic corneal architecture has provided a rational strategy for rapid corneal repair.

Assessment of the general clinical condition and functional properties of the eyes of rabbits after THz irradiation

THz radiation is increasingly used for diagnostics in medicine. As technology utilizing THz radiation continues to develop rapidly, it is becoming increasingly important to consider its biological effects and establish safe exposure standards and parameters. The paper presents data on the clinical status and functional properties of the anterior and posterior structures of the eyes of rabbits after THz irradiation at the frequency of 2.3 THz. Terahertz radiation was generated at Novosibirsk Free Electron Laser (NovoFEL) at "Siberian Synchrotron and Terahertz Radiation Centre" (Budker Institute of Nuclear Physics of the Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia). The exposure durations used were 15 and 30 minutes. Intensity ranges were I1=0.012 mW/cm2, I2=0.018 mW/cm2, and I3=0.024 mW/cm2. The study investigated the effects of various time and power irradiation protocols on the California rabbit's eyes and after a period of one month, but no significant clinical or functional alterations were observed in response to the established intensity protocols. However, the study identified statistically significant changes in corneal hydration and endothelial cell density over time, particularly under protocols with 15- and 30-minute exposures. A negative correlation was found between endothelial cell density and corneal thickness (r=-0.36, p=0.042), suggesting that a reduction in the endothelial cell pool may be associated with increased corneal thickness. These changes were subclinical and did not lead to clinically significant pathological changes in the cornea. There were no signs of ASOCT (anterior segment-optical coherence tomography) hyperreflectivity. THz radiation with parameters listed above of 2.3 THz and an intensities of 0.012-0.024 mW/cm2 for 30 minutes has been shown to be conditionally safe for the structures of the rabbit eye. However, the detected subclinical corneal changes require further study to determine safe exposure limits.

Gelatin nanofibers coated with hyaluronic acid as a mesenchymal stromal cell scaffold for corneal regeneration

Electrospun gelatin nanofibers coated with hyaluronic acid (GelNF-HA) were synthesized as a scaffold for delivering human corneal mesenchymal stromal cells (C-MSCs) directly to deep corneal injuries. Aligned GelNFs were produced by electrospinning, crosslinked using vapor of glutaraldehyde, coated with HA, and crosslinked with EDC/NHS. The GelNF-HA was characterized by SEM, mechanical, and optical properties. It was then investigated as a substrate for C-MSC proliferation and migration in vitro and in a rabbit cornea culture model. The expression of α-smooth muscle actin (α-SMA) was determined in the ex vivo model. SEM showed that the GelNF-HA scaffold was composed of aligned GelNFs with 75 % of the fibers oriented against the same angle. It exhibited a Young's modulus of 1.66 ± 0.59 MPa and approximately 93 % transmittance of visible light. The GelNF-HA membranes supported C-MSC proliferation in vitro. In a scratch migration assay, it facilitated complete wound closure after 48 h in culture. C-MSC-laden GelNF-HA scaffolds supported corneal wound healing in an ex vivo model as well, expressing a lower percentage of stromal α-SMA compared to both the no-treatment keratectomy-only and C-MSC groups (p < 0.05). The C-MSC-supportive GelNF-HA scaffolds hold therapeutic potential for stromal regeneration in the treatment of deep corneal defects.

Reversed Corneal Fibroblasts Therapy Restores Transparency of Mouse Cornea after Injury

Cell-based therapies using corneal stromal stem cells (CSSC), corneal keratocytes, or a combination of both suppress corneal scarring. The number of quiescent keratocytes in the cornea is small; it is difficult to expand them in vitro in quantities suitable for transplantation. This study examined the therapeutic effect of corneal fibroblasts reversed into keratocytes (rCF) in a mouse model of mechanical corneal injury. The therapeutic effect of rCF was studied in vivo (slit lamp, optical coherence tomography) and ex vivo (transmission electron microscopy and immunofluorescence staining). Injection of rCF into the injured cornea was accompanied by recovery of corneal thickness, improvement of corneal transparency, reduction of type III collagen in the stroma, absence of myofibroblasts, and the improvement in the structural organization of collagen fibers. TEM results showed that 2 months after intrastromal injection of cells, there was a decrease in the fibril density and an increase in the fibril diameter and the average distance between collagen fibrils. The fibrils were well ordered and maintained the short-range order and the number of nearest-neighbor fibrils, although the averaged distance between them increased. Our results demonstrated that the cell therapy of rCF from ReLEx SMILe lenticules promotes the recovery of transparent corneal stroma after injury.

Central versus peripheral thickness in the human cornea explained

PURPOSE

The human cornea is thicker in the periphery than the center and it has been suggested that this must be due to greater numbers of lamellae in the peripheral corneal stroma. The purpose of this study was to use high-resolution ultrastructural imaging to determine if the greater thickness of the peripheral cornea is due to the presence of more lamellae or if there is some other anatomical explanation.

METHODS

In this study, full thickness corneas from three human donors were processed for light microscopy (LM) and transmission electron microscopy (TEM). Images were taken in three distinct stromal regions (anterior, middle, and posterior) from the central and peripheral cornea. Stromal thickness was evaluated by LM while TEM was used to evaluate numbers and thicknesses of lamellae, mean collagen fibril diameter, and mean collagen fibril density.

RESULTS

Mean stromal thickness was significantly thinner in the central (415 ± 34 µm) compared to the peripheral (536 ± 29 µm) cornea (P = 0.009). Numbers of lamellae were not significantly different between central (246 ± 14) and peripheral (251 ± 14) cornea. Average lamellar thickness was not different across all regions of the cornea, except for the peripheral posterior where the lamellae were approximately 50 % thicker (P < 0.05). Collagen fibril diameters were larger in the peripheral cornea by approximately 30 % when compared to the central cornea, in all regions (P < 0.01).

CONCLUSIONS

This study shows that it is an increase peripheral posterior lamellar thickness, rather than an increase in the number of lamellae, that accounts for the increase in corneal stromal thickness in the periphery of the human cornea. While collagen fibril diameters are greater throughout the peripheral stroma, the lamellae in the mid and anterior peripheral stroma are not thicker than centrally.

Nanohydroxyapatite Coating Attenuates Fibrotic and Immune Responses to Promote Keratoprosthesis Biointegration in Advanced Ocular Surface Disorders

Keratoprosthesis (KPro) implantation is frequently the only recourse for patients with severe corneal disease. However, problems arise due to inadequate biointegration of the KPro, particularly the PMMA optical cylinder, such as tissue detachment, tissue melting, or eye-threatening infection in the interface. Here, using the AuroKPro as a model prosthesis, a surface functionalization approach─coating the optical cylinder with nanohydroxyapatite (nHAp)─was trialed in rabbit eyes with and without a proceeding chemical injury. In chemically injured eyes, which simulated total limbal epithelial stem cell deficiency, clear benefits were conferred by the coating. The total modified Hackett-McDonald score and area of tissue apposition differences 12 weeks after implantation were 5.0 and 22.5%, respectively. Mechanical push-in tests revealed that 31.8% greater work was required to detach the tissues. These differences were less marked in uninjured eyes, which showed total score and tissue apposition differences of 2.5 and 11.5%, respectively, and a work difference of 23.5%. The improved biointegration could be contributed by the attenuated expression of fibronectin (p = 0.036), collagen 3A1 (p = 0.033), and α-smooth muscle actin (p = 0.045)─proteins typically upregulated during nonadherent fibrous capsule envelopment of bioinert material─adjacent to the optical cylinders. The coating also appeared to induce a less immunogenic milieu in the ocular surface tissue, evidenced by the markedly lower expression of tear proteins associated with immune and stimulus responses. Collectively, the level of these tear proteins in eyes with coated prostheses was 1.1 ± 13.0% of naïve eyes: substantially lower than with noncoated KPros (246.5 ± 79.3% of naïve, p = 0.038). Together, our results indicated that nHAp coating may reduce the risk of prosthesis failure in severely injured eyes, which are representative of the cohort of KPro patients.

Dimensionality Matters: Exploiting UV-Photopatterned 2D and Two-Photon-Printed 2.5D Contact Guidance Cues to Control Corneal Fibroblast Behavior and Collagen Deposition

In the event of disease or injury, restoration of the native organization of cells and extracellular matrix is crucial for regaining tissue functionality. In the cornea, a highly organized collagenous tissue, keratocytes can align along the anisotropy of the physical microenvironment, providing a blueprint for guiding the organization of the collagenous matrix. Inspired by this physiological process, anisotropic contact guidance cues have been employed to steer the alignment of keratocytes as a first step to engineer in vitro cornea-like tissues. Despite promising results, two major hurdles must still be overcome to advance the field. First, there is an enormous design space to be explored in optimizing cellular contact guidance in three dimensions. Second, the role of contact guidance cues in directing the long-term deposition and organization of extracellular matrix proteins remains unknown. To address these challenges, here we combined two microengineering strategies-UV-based protein patterning (2D) and two-photon polymerization of topographies (2.5D)-to create a library of anisotropic contact guidance cues with systematically varying height (H, 0 µm ≤ H ≤ 20 µm) and width (W, 5 µm ≤ W ≤ 100 µm). With this unique approach, we found that, in the short term (24 h), the orientation and morphology of primary human fibroblastic keratocytes were critically determined not only by the pattern width, but also by the height of the contact guidance cues. Upon extended 7-day cultures, keratocytes were shown to produce a dense, fibrous collagen network along the direction of the contact guidance cues. Moreover, increasing the heights also increased the aligned fraction of deposited collagen and the contact guidance response of cells, all whilst the cells maintained the fibroblastic keratocyte phenotype. Our study thus reveals the importance of dimensionality of the physical microenvironment in steering both cellular organization and the formation of aligned, collagenous tissues.

Chemical, Physical, and Biological Corneal Decellularization Methods: A Review of Literature

The cornea is one of the most commonly transplanted tissues worldwide. It is used to restore vision when severe visual impairment or blindness occurs in patients with corneal diseases or after trauma. Due to the global shortage of healthy donor corneas, decellularized corneal tissue has significant potential as an alternative to corneal transplantation. It preserves the native and biological ultrastructure of the cornea and, therefore, represents the most promising scaffold. This article discusses different methods of corneal decellularization based on the current literature. We searched PubMed.gov for articles from January 2009 to December 2023 using the following keywords: corneal decellularization, decellularization methods, and corneal transplantation. Although several methods of decellularization of corneal tissue have been reported, a universal standardised protocol of corneal decellularization has not yet been introduced. In general, a combination of decellularization methods has been used for efficient decellularization while preserving the optimal properties of the corneal tissue.

Corneal blindness in the developing world: The role of prevention strategies

Corneal blindness is an important contributor to the burden of global blindness and has a greater prevalence in low-income countries of the developing world where resources and infrastructure are limited. The causes of corneal blindness too are different from high-income countries and include infectious keratitis, ocular trauma, and xerophthalmia. Persons with these indications tend to have unfavourable outcomes after corneal transplantation, limiting their chances of benefitting from this sight-saving procedure. However, most causes of corneal blindness in the developing world are preventable. This highlights the importance of understanding the unique challenges in these regions and the need for targeted interventions. This article discusses various prevention strategies, including primordial, primary, and secondary prevention, aimed at reducing the burden of corneal blindness in low-income countries. These include capacity building, training, and awareness campaigns to reduce the risk factors of ocular trauma, infectious keratitis, and to improve access to first aid. It is also important to promote safe eye practices and tackle nutritional deficiencies through public health interventions and policy changes. Providing the required training to general ophthalmologists in the management of basic corneal surgeries and diseases and enhancing the accessibility of eye care services in rural areas will ensure early treatment and prevent sequelae. Current treatment modalities belong to the tertiary level of prevention and are largely limited to corneal transplantation. In developing nations, there is a scarcity of donor corneal tissue necessitating an urgent expansion of eye banking services. Alternative approaches to corneal transplantation such as 3D printed corneas, cultured stem cells, and biomaterials should also be explored to meet this demand. Thus, there is a need for collaborative efforts between healthcare professionals, policymakers, and communities to implement effective prevention strategies and reduce the prevalence of corneal blindness in the developing world.

A responsive hydrogel modulates innate immune cascade fibrosis to promote ocular surface reconstruction after chemical injury

Following an ocular chemical injury, the release of neutrophil extracellular traps (NETs) triggers an innate immune cascade fibrotic effect involving macrophages (Mø), which limits corneal repair. However, the interplay and mechanisms between NETs and macrophages, as well as the coordination between the innate immunity and corneal repair, remain challenging issues. Using a co-culture system, we report that chemical stimulation exacerbates the accumulation of reactive oxygen species (ROS) within the polymorphonuclear neutrophils, leading to NET formation and the activation of M2 macrophages, ultimately inducing pathological fibrosis of the ocular surface through the IL-10/STAT3/TGF-β1/Smad2 axis. Inspired by the locally formed acidic microenvironment mediated by innate acute inflammatory stimulation, we further integrate sericin with oxidized chitosan nanoparticles loaded with black phosphorus quantum dots (BPQDs) using Schiff base chemistry to construct a functional pH-responsive hydrogel. Following corneal injury, the hydrogel selectively releases BPQDs in response to the acidic environment, inhibiting the innate immune cascade fibrosis triggered by the PMN-ROS-NETs. Thus, corneal pathological fibrosis is alleviated and reshaping of the ocular surface takes place. These results represent a refinement of the mechanism of inherent immune effector cell interactions, and provide new research ideas for the construction of nano biomaterials that regulate pathological fibrosis.

Development of a Fully Synthetic Corneal Stromal Construct via Supramolecular Hydrogel Engineering

Recent advances in the field of ophthalmology show great potential in the design of bioengineered constructs to mimic the corneal stroma. Hydrogels based on synthetic supramolecular polymers, are attractive synthetic mimics of the natural highly hydrated corneal stroma. Here, a fully synthetic corneal stromal construct is developed via engineering of an injectable supramolecular hydrogel based on ureido-pyrimidinone (UPy) moieties. The hydrogel displays a dynamic and tunable behavior, which allows for control of biochemical and mechanical cues. Two hydrogels are developed, a fully synthetic hydrogel functionalized with a bioactive cyclic arginine-glycine-aspartate UPy (UPy-cRGD) additive, and a hybrid hydrogel based on UPy-moieties mixed with collagen type I fibers. Both hydrogels supported cell encapsulation and associated cellular deposition of extracellular matrix (ECM) proteins after 21 days. Excitingly, the hydrogels support the activation of isolated primary keratocytes into stromal fibroblasts as well as the differentiation toward more quiescent corneal stromal keratocytes, demonstrated by their characteristic long dendritic protrusions and a substantially diminished cytokine secretion. Furthermore, cells survive shear stresses during an injectability test. Together, these findings highlight the development of an injectable supramolecular hydrogel as a synthetic corneal stromal microenvironment able to host primary keratocytes.

New dawn for keratoconus treatment: potential strategies for corneal stromal regeneration

Keratoconus is a progressive, ectatic and blinding disorder of the cornea, characterized by thinning of corneal stroma. As a highly prevalent among adolescents, keratoconus has been a leading indication for corneal transplantation worldwide. However, the severe shortage of donor corneas is a global issue, and the traditional corneal transplantation surgeries may superinduce multiple complications, necessitating efforts to develop more effective strategies for keratoconus treatment. In this review, we summarized several strategies to promote corneal stromal regeneration or improve corneal stromal thickness, including cell-based therapies, biosynthetic alternatives for inducing corneal regeneration, minimally invasive intrastromal implantation and bioengineered tissues for implantation. These strategies provided more accessible but safer alternatives from various perspectives for keratoconus treatment, paving the way for arresting the keratoconus progression in its earlier stage. For the treatments of corneal ectatic diseases beyond keratoconus, these approaches will provide important references and widen the therapy options in a donor tissue-independent manner.

Electron beam-irradiated donor cornea for on-demand lenticule implantation to treat corneal diseases and refractive error

The cornea is the major contributor to the refractive power of the eye, and corneal diseases are a leading cause of reversible blindness. The main treatment for advanced corneal disease is keratoplasty: allograft transplantation of the cornea. Examples include lenticule implantation to treat corneal disorders (e.g. keratoconus) or correct refractive errors. These procedures are limited by the shelf-life of the corneal tissue, which must be discarded within 2-4 weeks. Electron-beam irradiation is an emerging sterilisation technique, which extends this shelf life to 2 years. Here, we produced lenticules from fresh and electron-beam (E-beam) irradiated corneas to establish a new source of tissue for lenticule implantation. In vitro, in vivo, and ex vivo experiments were conducted to compare fresh and E-beam-irradiated lenticules. Results were similar in terms of cutting accuracy, ultrastructure, optical transparency, ease of extraction and transplantation, resilience to mechanical handling, biocompatibility, and post-transplant wound healing process. Two main differences were noted. First, ∼59% reduction of glycosaminoglycans resulted in greater compression of E-beam-irradiated lenticules post-transplant, likely due to reduced corneal hydration-this appeared to affect keratometry after implantation. Cutting a thicker lenticule would be required to ameliorate the difference in refraction. Second, E-beam-sterilised lenticules exhibited lower Young's modulus which may indicate greater care with handling, although no damage or perforation was caused in our procedures. In summary, E-beam-irradiated corneas are a viable source of tissue for stromal lenticules, and may facilitate on-demand lenticule implantation to treat a wide range of corneal diseases. Our study suggested that its applications in human patients are warranted. STATEMENT OF SIGNIFICANCE: Corneal blindness affects over six million patients worldwide. For patients requiring corneal transplantation, current cadaver-based procedures are limited by the short shelf-life of donor tissue. Electron-beam (E-beam) sterilisation extends this shelf-life from weeks to years but there are few published studies of its use. We demonstrated that E-beam-irradiated corneas are a viable source of lenticules for implantation. We conducted in vitro, in vivo, and ex vivo comparisons of E-beam and fresh corneal lenticules. The only differences exhibited by E-beam-treated lenticules were reduced expression of glycosaminoglycans, resulting in greater tissue compression and lower refraction suggesting that a thicker cut is required to achieve the same optical and refractive outcome; and lower Young's modulus indicating extra care with handling.

Up-to-date molecular medicine strategies for management of ocular surface neovascularization

Ocular surface neovascularization and its resulting pathological changes significantly alter corneal refraction and obstruct the light path to the retina, and hence is a major cause of vision loss. Various factors such as infection, irritation, trauma, dry eye, and ocular surface surgery trigger neovascularization via angiogenesis and lymphangiogenesis dependent on VEGF-related and alternative mechanisms. Recent advances in antiangiogenic drugs, nanotechnology, gene therapy, surgical equipment and techniques, animal models, and drug delivery strategies have provided a range of novel therapeutic options for the treatment of ocular surface neovascularization. In this review article, we comprehensively discuss the etiology and mechanisms of corneal neovascularization and other types of ocular surface neovascularization, as well as emerging animal models and drug delivery strategies that facilitate its management.

Advances in Microgravity Directed Tissue Engineering

Tissue engineering aims to generate functional biological substitutes to repair, sustain, improve, or replace tissue function affected by disease. With the rapid development of space science, the application of simulated microgravity has become an active topic in the field of tissue engineering. There is a growing body of evidence demonstrating that microgravity offers excellent advantages for tissue engineering by modulating cellular morphology, metabolism, secretion, proliferation, and stem cell differentiation. To date, there have been many achievements in constructing bioartificial spheroids, organoids, or tissue analogs with or without scaffolds in vitro under simulated microgravity conditions. Herein, the current status, recent advances, challenges, and prospects of microgravity related to tissue engineering are reviewed. Current simulated-microgravity devices and cutting-edge advances of microgravity for biomaterials-dependent or biomaterials-independent tissue engineering to offer a reference for guiding further exploration of simulated microgravity strategies to produce engineered tissues are summarized and discussed.

ECM-Like Adhesive Hydrogel for the Regeneration of Large Corneal Stromal Defects

The repair of large-diameter corneal stroma defects is a major clinical problem. Although some studies have attempted to use hydrogels to repair corneal damage, most of these hydrogels can only be used for focal stromal defects that are ≤3.5 mm in diameter due to poor hydrogel adhesion. Here, a photocurable adhesive hydrogel that mimics the extracellular matrix (ECM) with regard to composition for repairing 6 mm-diameter corneal stromal defects in rabbits is investigated. This ECM-like adhesive can be rapidly cured after light exposure, with high light transmittance and good mechanical properties. More importantly, this hydrogel maintains the viability and adhesion of cornea-derived cells and promotes their migration in vitro in 2D and 3D culture environments. Proteomics analysis confirms that the hydrogel promotes cell proliferation and ECM synthesis. Furthermore, in rabbit corneal stromal defect repair experiments, it is proven by histological and proteomic analysis that this hydrogel can effectively promote corneal stroma repair, reduce scar formation, and increase corneal stromal-neural regeneration at the six months follow-up. This work demonstrates the great application of ECM-like adhesive hydrogels for the regeneration of large-diameter corneal defects.

A "T.E.S.T." hydrogel bioadhesive assisted by corneal cross-linking for in situ sutureless corneal repair

Corneal transplantation is an effective clinical treatment for corneal diseases, which, however, is limited by donor corneas. It is of great clinical value to develop bioadhesive corneal patches with functions of "Transparency" and "Epithelium & Stroma generation", as well as "Suturelessness" and "Toughness". To simultaneously meet the "T.E.S.T." requirements, a light-curable hydrogel is designed based on methacryloylated gelatin (GelMA), Pluronic F127 diacrylate (F127DA) & Aldehyded Pluronic F127 (AF127) co-assembled bi-functional micelles and collagen type I (COL I), combined with clinically applied corneal cross-linking (CXL) technology for repairing damaged cornea. The patch formed after 5 min of ultraviolet irradiation possesses transparent, highly tough, and strongly bio-adhesive performance. Multiple cross-linking makes the patch withstand deformation near 600% and exhibit a burst pressure larger than 400 mmHg, significantly higher than normal intraocular pressure (10-21 mmHg). Besides, the slower degradation than GelMA-F127DA&AF127 hydrogel without COL I makes hydrogel patch stable on stromal beds in vivo, supporting the regrowth of corneal epithelium and stroma. The hydrogel patch can replace deep corneal stromal defects and well bio-integrate into the corneal tissue in rabbit models within 4 weeks, showing great potential in surgeries for keratoconus and other corneal diseases by combining with CXL.

Advances in Polysaccharide- and Synthetic Polymer-Based Vitreous Substitutes

The vitreous humour is a gel-like structure that composes the majority of each eye. It functions to provide passage of light, be a viscoelastic dampener, and hold the retina in place. Vitreous liquefaction causes retinal detachment and retinal tears requiring pars plana vitrectomy for vitreous substitution. An ideal vitreous substitute should display similar mechanical, chemical, and rheological properties to the natural vitreous. Currently used vitreous substitutes such as silicone oil, perfluorocarbon liquids, and gases cannot be used long-term due to adverse effects such as poor retention time, cytotoxicity, and cataract formation. Long-term, experimental vitreous substitutes composed of natural, modified and synthetic polymers are currently being studied. This review discusses current long- and short-term vitreous substitutes and the disadvantages of these that have highlighted the need for an ideal vitreous substitute. The review subsequently focuses specifically on currently used polysaccharide- and synthetic polymer-based vitreous substitutes, which may be modified or functionalised, or employed as the derivative, and discusses experimental vitreous substitutes in these classes. The advantages and challenges associated with the use of polymeric substitutes are discussed. Innovative approaches to vitreous substitution, namely a novel foldable capsular vitreous body, are presented, as well as future perspectives related to the advancement of this field.

From bench to clinic: Emerging therapies for corneal scarring

Corneal diseases are one of the leading causes of moderate-to-severe visual impairment and blindness worldwide, after glaucoma, cataract, and retinal disease in overall importance. Given its tendency to affect people at a younger age than other blinding conditions such as cataract and glaucoma, corneal scarring poses a huge burden both on the individuals and society. Furthermore, corneal scarring and fibrosis disproportionately affects people in poorer and remote areas, making it a significant ophthalmic public health problem. Traditional medical strategies, such as topical corticosteroids, are not effective in preventing fibrosis or scars. Corneal transplantation, the only effective sight-restoring treatment for corneal scars, is curbed by challenges including a severe shortage of tissue, graft rejection, secondary conditions, cultural barriers, the lack of well-trained surgeons, operating rooms, and well-equipped infrastructures. Thanks to tremendous research efforts, emerging therapeutic options including gene therapy, protein therapy, cell therapy and novel molecules are in development to prevent the progression of corneal scarring and compliment the surgical options currently available for treating established corneal scars in clinics. In this article, we summarise the most relevant preclinical and clinical studies on emerging therapies for corneal scarring in recent years, showing how these approaches may prevent scarring in its early development.

Dual-crosslinked regenerative hydrogel for sutureless long-term repair of corneal defect

Corneal transplantation is the most effective clinical treatment for corneal defects, but it requires precise size of donor corneas, surgical sutures, and overcoming other technical challenges. Postoperative patients may suffer graft rejection and complications caused by sutures. Ophthalmic glues that can long-term integrate with the corneal tissue and effectively repair the focal corneal damage are highly desirable. Herein, a hybrid hydrogel consisting of porcine decellularized corneal stroma matrix (pDCSM) and methacrylated hyaluronic acid (HAMA) was developed through a non-competitive dual-crosslinking process. It can be directly filled into corneal defects with various shapes. More importantly, through formation of interpenetrating network and stable amide bonds between the hydrogel and adjacent tissue, the hydrogel manifested excellent adhesion properties to achieve suture-free repair. Meanwhile, the hybrid hydrogel not only preserved bioactive components from pDCSM, but also exhibited cornea-matching transparency, low swelling ratio, slow degradation, and enhanced mechanical properties, which was capable of withstanding superhigh intraocular pressure. The combinatorial hydrogel greatly improved the poor cell adhesion performance of HAMA, supported the viability, proliferation of corneal cells, and preservation of keratocyte phenotype. In a rabbit corneal stromal defect model, the experimental eyes treated with the hybrid hydrogel remained transparent and adhered intimately to the stroma bed with long-term retention, accelerated corneal re-epithelialization and wound healing. Giving the advantages of high bioactivity, low-cost, and good practicality, the dual-crosslinked hybrid hydrogel served effectively for long-term suture-free treatment and tissue regeneration after corneal defect.

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Double-network hydrogel contains regenerative decellularized corneal stroma matrix.

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Suture-free easy operation, high transparency, strong attachment to stroma bed.

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Long-term retention on corneal defect with excellent force and pressure resistance.

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Rapid re-epithelialization, minimal scar formation, sustained cornea regeneration.

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A functional biomaterial-based strategy for in situ corneal wound healing.

Bioengineered corneal tissue for minimally invasive vision restoration in advanced keratoconus in two clinical cohorts

Visual impairment from corneal stromal disease affects millions worldwide. We describe a cell-free engineered corneal tissue, bioengineered porcine construct, double crosslinked (BPCDX) and a minimally invasive surgical method for its implantation. In a pilot feasibility study in India and Iran (clinicaltrials.gov no. NCT04653922 ), we implanted BPCDX in 20 advanced keratoconus subjects to reshape the native corneal stroma without removing existing tissue or using sutures. During 24 months of follow-up, no adverse event was observed. We document improvements in corneal thickness (mean increase of 209 ± 18 µm in India, 285 ± 99 µm in Iran), maximum keratometry (mean decrease of 13.9 ± 7.9 D in India and 11.2 ± 8.9 D in Iran) and visual acuity (to a mean contact-lens-corrected acuity of 20/26 in India and spectacle-corrected acuity of 20/58 in Iran). Fourteen of 14 initially blind subjects had a final mean best-corrected vision (spectacle or contact lens) of 20/36 and restored tolerance to contact lens wear. This work demonstrates restoration of vision using an approach that is potentially equally effective, safer, simpler and more broadly available than donor cornea transplantation.

Bioprinted Membranes for Corneal Tissue Engineering: A Review

Corneal transplantation is considered a convenient strategy for various types of corneal disease needs. Even though it has been applied as a suitable solution for most corneal disorders, patients still face several issues due to a lack of healthy donor corneas, and rejection is another unknown risk of corneal transplant tissue. Corneal tissue engineering (CTE) has gained significant consideration as an efficient approach to developing tissue-engineered scaffolds for corneal healing and regeneration. Several approaches are tested to develop a substrate with equal transmittance and mechanical properties to improve the regeneration of cornea tissue. In this regard, bioprinted scaffolds have recently received sufficient attention in simulating corneal structure, owing to their spectacular spatial control which produces a three-cell-loaded-dimensional corneal structure. In this review, the anatomy and function of different layers of corneal tissue are highlighted, and then the potential of the 3D bioprinting technique for promoting corneal regeneration is also discussed.

Collagen as a Biomaterial for Skin and Corneal Wound Healing

The cornea and the skin are two organs that form the outer barrier of the human body. When either is injured (e.g., from surgery, physical trauma, or chemical burns), wound healing is initiated to restore integrity. Many cells are activated during wound healing. In particular, fibroblasts that are stimulated often transition into repair fibroblasts or myofibroblasts that synthesize extracellular matrix (ECM) components into the wound area. Control of wound ECM deposition is critical, as a disorganized ECM can block restoration of function. One of the most abundant structural proteins in the mammalian ECM is collagen. Collagen type I is the main component in connective tissues. It can be readily obtained and purified, and short analogs have also been developed for tissue engineering applications, including modulating the wound healing response. This review discusses the effect of several current collagen implants on the stimulation of corneal and skin wound healing. These range from collagen sponges and hydrogels to films and membranes.

Corneal stromal repair and regeneration

The cornea is a specialized, transparent, avascular, immune-privileged, and heavily innervated tissue that affords 2/3rd of refraction to the eye. Ocular injuries, infections, and genetic factors affect corneal function and cause vision impairment. Presently, a variety of laser/non-laser surgeries, immunosuppressants, and/or corneal transplants are predominantly used to revive sight in human patients. The development of novel, precision-guided, and tissue-targeted non-surgical therapies promoting corneal repair and regeneration based on mechanistic understanding is of paramount importance to reduce the impact of global blindness. Research over the past decade revealed that modulation of pathological signaling pathways and factors by a variety of therapeutic delivery methods effectively treats corneal disorders including corneal scar/haze, inflammation, and angiogenesis in various pre-clinical animal models and are primed for human translation. This review discusses recent advances in the areas of corneal repair, restoration, and regeneration. Herein, we provide an overview of evolving approaches and therapeutic modalities that have shown great promise in reviving corneal transparency and function through the use of small drug molecules, gene therapy, nanomedicine, stem cells, trophic factors, exosomes, stromal equivalents, bioengineered stromal scaffolds, tissue adhesives, and 3D bioprinting.

Application Prospect and Preliminary Exploration of GelMA in Corneal Stroma Regeneration

Corneal regeneration has become a prominent study area in recent decades. Because the corneal stroma contributes about 90% of the corneal thickness in the corneal structure, corneal stromal regeneration is critical for the treatment of cornea disease. Numerous materials, including deacetylated chitosan, hydrophilic gel, collagen, gelatin methacrylate (GelMA), serine protein, glycerol sebacate, and decellularized extracellular matrix, have been explored for keratocytes regeneration. GelMA is one of the most prominent materials, which is becoming more and more popular because of its outstanding three-dimensional scaffold structure, strong mechanics, good optical transmittance, and biocompatibility. This review discussed recent research on corneal stroma regeneration materials and related GelMA.

Corneal Stroma Regeneration with Collagen-Based Hydrogel as an Artificial Stroma Equivalent: A Comprehensive In Vivo Study

Restoring the anatomical and functional characteristics of the cornea using various biomaterials is especially relevant in the context of a global shortage of donor tissue. Such biomaterials must be biocompatible, strong, and transparent. Here, we report a Viscoll collagen membrane with mechanical and optical properties suitable for replacing damaged stromal tissue. After removing a portion of the stroma, a Viscoll collagen membrane was implanted into the corneas of rabbits. After 6 months, the active migration of host cells into Viscoll collagen membranes was noted, with the preservation of corneal transparency in all experimental animals. Effective integration of the Viscoll collagen membrane with corneal tissue promoted nerve regeneration in vivo, as confirmed by in vivo confocal microscopy. We also demonstrated the safety and efficacy of the Viscoll collagen membrane for corneal stroma regeneration. Thus, in combination with the proposed packaging format that provides long-term storage of up to 10 months, this material has great potential for replacing and regenerating damaged stromal tissues.

Electrical Signal Initiates Kinetic Assembly of Collagen to Construct Optically Transparent and Geometry Customized Artificial Cornea Substitutes

Corneal transplantation is an effective treatment for reconstructing injured corneas but is very limited due to insufficient donors, which has led to a growing demand for development of artificial corneal substitutes (ACSs). Collagen is a potential building block for ACS fabrication, whereas technically there are limited capabilities to control the collagen assembly for creating highly transparent collagen ACSs. Here, we report an electro-assembly technique to kinetically control collagen assembly on the nanoscale that allows the yielding collagen ACSs with structure determined superior optics. Structurally, the kinetically electro-assembled collagen (KEA-Col) is composed of partially aligned microfibrils (∼10 nm in diameter) with compacted lamellar organization. Optical analysis reveals that such microstructure is directly responsible for its optimal light transmittance by reducing light scattering. Moreover, this method allows the creation of complex three-dimensional geometries and thus is convenient to customize collagen ACSs with specific curvatures to meet refractive power requirements. Available properties (e.g., optics and mechanics) of cross-linked KEA-Cols were studied to meet the clinical requirement as ACSs, and in vitro tests further proved their beneficial characteristics of cell growth and migration. An in vivo study established a rabbit lamellar keratectomy corneal wound model and demonstrated the customized collagen ACSs can adapt to the defective cornea and support epithelial healing as well as stroma integration and reconstruction with lower immunoreaction compared with commercial xenografts, which suggests its promising application prospects. More broadly, this work illustrates the potential for enlisting electrical signals to mediate collagen's assembly and microstructure organization for specific structural functionalization for regenerative medicine.

Myofibroblast transdifferentiation of keratocytes results in slower migration and lower sensitivity to mesoscale curvatures

Functional tissue repair after injury or disease is governed by the regenerative or fibrotic response by cells within the tissue. In the case of corneal damage, keratocytes are a key cell type that determine the outcome of the remodeling response by either adapting to a fibroblast or myofibroblast phenotype. Although a growing body of literature indicates that geometrical cues in the environment can influence Myo(fibroblast) phenotype, there is a lack of knowledge on whether and how differentiated keratocyte phenotype is affected by the curved tissue geometry in the cornea. To address this gap, in this study we characterized the phenotype of fibroblastic and transforming growth factor β (TGFβ)-induced myofibroblastic keratocytes and studied their migration behavior on curved culture substrates with varying curvatures. Immunofluorescence staining and quantification of cell morphological parameters showed that, generally, fibroblastic keratocytes were more likely to elongate, whereas myofibroblastic keratocytes expressed more pronounced α smooth muscle actin (α-SMA) and actin stress fibers as well as more mature focal adhesions. Interestingly, keratocyte adhesion on convex structures was weak and unstable, whereas they adhered normally on flat and concave structures. On concave cylinders, fibroblastic keratocytes migrated faster and with higher persistence along the longitudinal direction compared to myofibroblastic keratocytes. Moreover, this behavior became more pronounced on smaller cylinders (i.e., higher curvatures). Taken together, both keratocyte phenotypes can sense and respond to the sign and magnitude of substrate curvatures, however, myofibroblastic keratocytes exhibit weaker curvature sensing and slower migration on curved substrates compared to fibroblastic keratocytes. These findings provide fundamental insights into keratocyte phenotype after injury, but also exemplify the potential of tuning the physical cell environments in tissue engineering settings to steer towards a favorable regeneration response.

Modification of Collagen Film via Surface Grafting of Taurine Molecular to Promote Corneal Nerve Repair and Epithelization Process

Corneal defects can seriously affect human vision, and keratoplasty is the most widely accepted therapy method for visual rehabilitation. Currently, effective treatment for clinical patients has been restricted due to a serious shortage of donated cornea tissue and high-quality artificial repair materials. As the predominant component of cornea tissue, collagen-based materials have promising applications for corneal repair. However, the corneal nerve repair and epithelization process after corneal transplantation must be improved. This research proposes a new collagen-based scaffold with good biocompatibility and biological functionality enhanced by surface chemical grafting of natural taurine molecular. The chemical composition of collagen-taurine (Col-Tau) material is evaluated by Fourier transform infrared spectroscopy and X-ray photoelectron spectroscopy, and its hydrophilic properties, light transmittance, swelling performance and mechanical tensile properties have been measured. The research results indicate that the Col-Tau sample has high transmittance and good mechanical properties, and exhibits excellent capacity to promote corneal nerve cell growth and the epithelization process of corneal epithelial cells. This novel Col-Tau material, which can be easily prepared at a low cost, should have significant application potential for the treating corneal disease in the future.

Single-cell atlas of keratoconus corneas revealed aberrant transcriptional signatures and implicated mechanical stretch as a trigger for keratoconus pathogenesis

Keratoconus is a common ectatic corneal disorder in adolescents and young adults that can lead to progressive visual impairment or even legal blindness. Despite the high prevalence, its etiology is not fully understood. In this study, we performed single-cell RNA sequencing (scRNA-Seq) analysis on 39,214 cells from central corneas of patients with keratoconus and healthy individuals, to define the involvement of each cell type during disease progression. We confirmed the central role of corneal stromal cells in this disease, where dysregulation of collagen and extracellular matrix (ECM) occurred. Differential gene expression and histological analyses revealed two potential novel markers for keratoconus stromal cells, namely CTSD and CTSK. Intriguingly, we detected elevated levels of YAP1 and TEAD1, the master regulators of biomechanical homeostasis, in keratoconus stromal cells. Cyclical mechanical experiments implicated the mechanical stretch in prompting protease production in corneal stromal cells during keratoconus progression. In the epithelial cells of keratoconus corneas, we observed reduced basal cells and abnormally differentiated superficial cells, unraveling the corneal epithelial lesions that were usually neglected in clinical diagnosis. In addition, several elevated cytokines in immune cells of keratoconus samples supported the involvement of inflammatory response in the progression of keratoconus. Finally, we revealed the dysregulated cell-cell communications in keratoconus, and found that only few ligand-receptor interactions were gained but a large fraction of interactional pairs was erased in keratoconus, especially for those related to protease inhibition and anti-inflammatory process. Taken together, this study facilitates the understanding of molecular mechanisms underlying keratoconus pathogenesis, providing insights into keratoconus diagnosis and potential interventions.

Collagen Film with Bionic Layered Structure and High Light Transmittance for Personalized Corneal Repair Fabricated by Controlled Solvent Evaporation Technique

Corneal blindness is a common phenomenon, and corneal transplantation is an effective treatment for corneal defects. However, there is usually a mismatch between the corneal repair material and the degree of the patient’s corneal defect. Therefore, patients with different corneal defects need suitable corneal repair materials with a specific microstructure for personalized treatment. In this research, collagen films with bionic structures were fabricated through ethanol evaporation technique by regulating the volume ratios of collagen solution: ethanol = 10:0(Col)/9:1(CC91)/8:2(CC82)/CC73(CC73). Under various preparation conditions, the obtained collagen films contain layered structures of different density. SEM photos show that the CC73 film with a dense layer arrangement has a microstructure similar to that of the corneal epithelial layer, whereas the Col film has a loose layered structure similar to that of the corneal stroma layer. Four kinds of collagen films showed different optical properties and water absorption ability. A more ordered arrangement of internal layer structure leads to better mechanical properties of the collagen film. In view of this, we think that these collagen films with different microstructures and different interlayer spacing may have huge potential applications for personalized corneal repair.

Lamellar Keratoplasty Using Acellular Bioengineering Cornea (BioCorneaVetTM) for the Treatment of Feline Corneal Sequestrum: A Retrospective Study of 62 Eyes (2018–2021)

Simple Summary

Corneal sequestrum is a specific and common corneal disease in cats. Surgery treatment is the recommended option. Acellular bioengineering cornea (ABC) is a popular and effective corneal transplantation material. However, no study has been published to evaluate the effectiveness and outcome of ABC lamellar transplantation for the treatment of feline corneal sequestrum (FCS). The purpose of this retrospective study was to evaluate the surgical effect of ABC lamellar transplantation in the treatment of FCS. All cats were diagnosed with FCS. All eyes received ABC lamellar transplantation for the first time, including 61 cats (62 eyes), aged 6–120 months. The average sequestrum size was 7.98 mm, with a medium of 7.75 mm (range, 4.75–11.75 mm), and the sequestrum thickness included 200 microns for 1 eye (1.61%), 300 microns for 28 eyes (45.16%), 400 microns for 29 eyes (46.77%), and 450 microns for 4 eyes (6.45%). All eyes retained vision after surgical treatment, and there was no recurrence during the follow-up period. This study has several limitations, including incomplete unification and standardization of data collection, some vacancies of follow-up time, inconsistency between then optical coherence tomography(OCT) examination and postoperative photo collection. Despite several limitations, our results show that ABC is easy to obtain and store, and has the choice of different sizes and thicknesses to achieve rapid corneal healing, and satisfactory visual and cosmetic effects in FCS treatment. Acellular bioengineering cornea can be a good alternative for the treatment of FCS.

Abstract

To retrospectively evaluate the effectiveness and outcome of lamellar keratoplasty using acellular bioengineering cornea (BioCorneaVet^TM) for the treatment of feline corneal sequestrum (FCS). The medical records of cats diagnosed with FCS that underwent lamellar keratoplasty with BioCorneaVet^TM between 2018 and 2021 with a minimum of 3 months of follow-up were reviewed. Follow-up examinations were performed weekly for 3 months, and then optical coherence tomography (OCT) examination was performed on select patients at 0, 3, 6, and 12 months post-operatively. A total of 61 cats (30 left eyes and 32 right eyes) were included. The Persian breed was overrepresented, 48/61 (78.69%). Four different thicknesses of acellular bioengineering cornea were used (200, 300, 400, or 450 microns), and the mean graft size was 8.23 mm (range, 5.00–12.00 mm). Minor complications were composed of partial dehiscence, and protrusion of the graft occurred in 7/62 eyes (11.29%). The median postoperative follow-up was 12.00 months (range, 3–41 months). A good visual outcome was achieved in 60/62 eyes (96.77%), and a mild to moderate corneal opacification occurred in 2/62 (3.23%). No recurrence of corneal sequestrum was observed. From the results, lamellar keratoplasty using acellular bioengineering cornea (BioCorneaVet^TM) is an effective treatment for FCS, providing a good tectonic support and natural collagen framework, and resulting in satisfactory visual and cosmetic effects.

Dexamethasone-loaded keratin films for ocular surface reconstruction

Amniotic membrane (AM) is often applied as a substitute material during ocular surface reconstruction. However, since AM has several disadvantages, alternative materials must be considered for this application. Keratin films made from human hair (KFs) have previously been presented as a promising option; they exhibited suitable characteristics and satisfactory biocompatibility in an in vivo rabbit model. Nevertheless, dexamethasone (DEX) eye drops are necessary after surgery to suppress inflammation. Since eye drops must be administered frequently, this might result in poor patient compliance, and the release of DEX at the transplant site would be clinically beneficial. Therefore, we aimed to incorporate DEX into KFs without hindering the positive film characteristics. Drug-loaded KFs were generated either by suspension technique or by the addition of solubilizing agents. The resulting specimens were analyzed regarding appearance, loading capacity, transparency, mechanical characteristics, swelling behavior and in vitro release. Furthermore, biocompatibility was assessed in vitro by determining the cell viability, seeding efficiency and growth behavior of corneal epithelial cells. The amount of incorporated DEX influenced the transparency and biomechanical properties of the films, but even highly loaded films showed properties similar to those of AM. The suspension technique was identified as the best incorporation approach regarding chemical stability and prolonged DEX release. Moreover, suspended DEX in the films did not negatively impact cell seeding efficiencies, and the cell-growth behaviors on the specimens with moderate DEX loads were satisfactory. This suggest that these films could comprise a suitable alternative material with additional anti-inflammatory activity for ocular surface reconstruction. Graphical abstract.

Supramolecular Adhesive Hydrogels for Tissue Engineering Applications

Tissue engineering is a promising and revolutionary strategy to treat patients who suffer the loss or failure of an organ or tissue, with the aim to restore the dysfunctional tissues and enhance life expectancy. Supramolecular adhesive hydrogels are emerging as appealing materials for tissue engineering applications owing to their favorable attributes such as tailorable structure, inherent flexibility, excellent biocompatibility, near-physiological environment, dynamic mechanical strength, and particularly attractive self-adhesiveness. In this review, the key design principles and various supramolecular strategies to construct adhesive hydrogels are comprehensively summarized. Thereafter, the recent research progress regarding their tissue engineering applications, including primarily dermal tissue repair, muscle tissue repair, bone tissue repair, neural tissue repair, vascular tissue repair, oral tissue repair, corneal tissue repair, cardiac tissue repair, fetal membrane repair, hepatic tissue repair, and gastric tissue repair, is systematically highlighted. Finally, the scientific challenges and the remaining opportunities are underlined to show a full picture of the supramolecular adhesive hydrogels. This review is expected to offer comparative views and critical insights to inspire more advanced studies on supramolecular adhesive hydrogels and pave the way for different fields even beyond tissue engineering applications.

[Modern prerequisites for creating a collagen-based artificial analogue of the corneal stroma]

Despite the fact that various collagen biomaterials have been actively used in ophthalmology for more than 30 years, the problem of creating a material that could replace the donor cornea have not been solved. Recent advances in the field of tissue engineering and regenerative medicine have shifted the focus of approaches to solving the problem of creating an artificial cornea towards laying conditions for the restoration of its specific layers through mechanisms of its own cellular regeneration. In this regard, extracellular matrices based on collagen are gaining popularity. This review discusses general limitations and advantages of collagen for creating an artificial cornea.

Melt electro-written scaffolds with box-architecture support orthogonally oriented collagen

Melt electro-writing (MEW) is a state-of-the-art technique that supports fabrication of 3D, precisely controlled and reproducible fiber structures. A standard MEW scaffold design is a box-structure, where a repeat layer of 90° boxes is produced from a single fiber. In 3D form (i.e. multiple layers), this structure has the potential to mimic orthogonal arrangements of collagen, as observed in the corneal stroma. In this study, we determined the response of human primary corneal stromal cells and their deposited fibrillar collagen (detected using a CNA35 probe) following six weeksin vitroculture on these box-structures made from poly(ϵ-caprolactone) (PCL). Comparison was also made to glass substrates (topography-free) and electrospun PCL fibers (aligned topography). Cell orientation and collagen deposition were non-uniform on glass substrates. Electrospun scaffolds supported an excellent parallel arrangement of cells and deposited collagen to the underlying architecture of aligned fibers, but there was no evidence of bidirectional collagen. In contrast, MEW scaffolds encouraged the formation of a dense, interconnected cellular network and deposited fibrillar collagen layers with a distinct orthogonal-arrangement. Collagen fibrils were particularly dominant through the middle layers of the MEW scaffolds' total thickness and closer examination revealed these fibrils to be concentrated within the pores' central regions. With the demand for donor corneas far exceeding the supply-leaving many with visual impairment-the application of MEW as a potential technique to recreate the corneal stroma with spontaneous, bidirectional collagen organization warrants further study.

In vivo biocompatibility evaluation of in situ-forming polyethylene glycol-collagen hydrogels in corneal defects

The available treatment options include corneal transplantation for significant corneal defects and opacity. However, shortage of donor corneas and safety issues in performing corneal transplantation are the main limitations. Accordingly, we adopted the injectable in situ-forming hydrogels of collagen type I crosslinked via multifunctional polyethylene glycol (PEG)-N-hydroxysuccinimide (NHS) for treatment and evaluated in vivo biocompatibility. The New Zealand White rabbits (N = 20) were randomly grouped into the keratectomy-only and keratectomy with PEG-collagen hydrogel-treated groups. Samples were processed for immunohistochemical evaluation. In both clinical and histologic observations, epithelial cells were able to migrate and form multilayers over the PEG-collagen hydrogels at the site of the corneal stromal defect. There was no evidence of inflammatory or immunological reactions or increased IOP for PEG-collagen hydrogel-treated corneas during the four weeks of observation. Immunohistochemistry revealed the presence of α-smooth muscle actin (α-SMA) in the superior corneal stroma of the keratectomy-only group (indicative of fibrotic healing), whereas low stromal α-SMA expression was detected in the keratectomy with PEG-collagen hydrogel-treated group. Taken together, we suggest that PEG-collagen may be used as a safe and effective alternative in treating corneal defect in clinical setting.

3D reactive inkjet printing of poly-ɛ-lysine/gellan gum hydrogels for potential corneal constructs

Corneal opacities are the 4th leading cause of blindness, and the only current treatment method is the replacement of damaged tissue with a donor cornea. The worldwide shortage of donor eye bank tissue has influenced research into biomaterial substrates for both partial and full thickness corneal implantation. Here, polymer hydrogels based on natural peptides, poly-ɛ-lysine and gellan gum, can be manufactured using reactive inkjet printing (RIJ). The inks used for printing were optimised based on their rheological properties. Printing alternating layers of ink forms a unique surface pattern, based on the immediate formation of ionic bonds between polymers of opposing charges. This surface pattern resembles a repeating honeycomb-like structure, visible by both optical and scanning electron microscopy. The structure of the printed hydrogels can be modified to include pores, a feature of interest for the tissue engineering of full thickness corneal constructs. Printed poly-ɛ-lysine/gellan gum hydrogels demonstrated a transparency of 80% and cyto-compatibility with both corneal epithelial and endothelial cells. Both corneal cell types demonstrated cell attachment across the surface of the printed hydrogel arrays, displaying their typical cell morphology. This gives confidence of the cyto-compatibility of these hydrogels in vitro. Reactive inkjet printing can produce 3D structures with a high resolution, producing printed tracks in the micron range. Additionally, RIJ demonstrates versatility, as constructs can be tailored to meet various dimension and thickness requirements. Furthermore, this work demonstrates for the first time that reactive inkjet printing can been used to produce hydrogel constructs based on these two inks, with the aim of producing constructs for corneal tissue engineering.

Tissue Engineering Meets Nanotechnology: Molecular Mechanism Modulations in Cornea Regeneration

Nowadays, tissue engineering is one of the most promising approaches for the regeneration of various tissues and organs, including the cornea. However, the inability of biomaterial scaffolds to successfully integrate into the environment of surrounding tissues is one of the main challenges that sufficiently limits the restoration of damaged corneal tissues. Thus, the modulation of molecular and cellular mechanisms is important and necessary for successful graft integration and long-term survival. The dynamics of molecular interactions affecting the site of injury will determine the corneal transplantation efficacy and the post-surgery clinical outcome. The interactions between biomaterial surfaces, cells and their microenvironment can regulate cell behavior and alter their physiology and signaling pathways. Nanotechnology is an advantageous tool for the current understanding, coordination, and directed regulation of molecular cell-transplant interactions on behalf of the healing of corneal wounds. Therefore, the use of various nanotechnological strategies will provide new solutions to the problem of corneal allograft rejection, by modulating and regulating host-graft interaction dynamics towards proper integration and long-term functionality of the transplant.

Supramolecular Host-Guest Hydrogels for Corneal Regeneration

Over 6.2 million people worldwide suffer from moderate to severe vision loss due to corneal disease. While transplantation with allogenic donor tissue is sight-restoring for many patients with corneal blindness, this treatment modality is limited by long waiting lists and high rejection rates, particularly in patients with severe tissue damage and ocular surface pathologies. Hydrogel biomaterials represent a promising alternative to donor tissue for scalable, nonimmunogenic corneal reconstruction. However, implanted hydrogel materials require invasive surgeries and do not precisely conform to tissue defects, increasing the risk of patient discomfort, infection, and visual distortions. Moreover, most hydrogel crosslinking chemistries for the in situ formation of hydrogels exhibit off-target effects such as cross-reactivity with biological structures and/or result in extractable solutes that can have an impact on wound-healing and inflammation. To address the need for cytocompatible, minimally invasive, injectable tissue substitutes, host-guest interactions have emerged as an important crosslinking strategy. This review provides an overview of host-guest hydrogels as injectable therapeutics and highlights the potential application of host-guest interactions in the design of corneal stromal tissue substitutes.

Mechanical Properties of Bioengineered Corneal Stroma

For the majority of patients with severe corneal injury or disease, corneal transplantation is the only suitable treatment option. Unfortunately, the demand for donor corneas greatly exceeds the availability. To overcome shortage issues, a myriad of bioengineered constructs have been developed as mimetics of the corneal stroma over the last few decades. Despite the sheer number of bioengineered stromas developed , these implants fail clinical trials exhibiting poor tissue integration and adverse effects in vivo. Such shortcomings can partially be ascribed to poor biomechanical performance. In this review, existing approaches for bioengineering corneal stromal constructs and their mechanical properties are described. The information collected in this review can be used to critically analyze the biomechanical properties of future stromal constructs, which are often overlooked, but can determine the failure or success of corresponding implants.

Biofabrication of Artificial Stem Cell Niches in the Anterior Ocular Segment

The anterior segment of the eye is a complex set of structures that collectively act to maintain the integrity of the globe and direct light towards the posteriorly located retina. The eye is exposed to numerous physical and environmental insults such as infection, UV radiation, physical or chemical injuries. Loss of transparency to the cornea or lens (cataract) and dysfunctional regulation of intra ocular pressure (glaucoma) are leading causes of worldwide blindness. Whilst traditional therapeutic approaches can improve vision, their effect often fails to control the multiple pathological events that lead to long-term vision loss. Regenerative medicine approaches in the eye have already had success with ocular stem cell therapy and ex vivo production of cornea and conjunctival tissue for transplant recovering patients' vision. However, advancements are required to increase the efficacy of these as well as develop other ocular cell therapies. One of the most important challenges that determines the success of regenerative approaches is the preservation of the stem cell properties during expansion culture in vitro. To achieve this, the environment must provide the physical, chemical and biological factors that ensure the maintenance of their undifferentiated state, as well as their proliferative capacity. This is likely to be accomplished by replicating the natural stem cell niche in vitro. Due to the complex nature of the cell microenvironment, the creation of such artificial niches requires the use of bioengineering techniques which can replicate the physico-chemical properties and the dynamic cell-extracellular matrix interactions that maintain the stem cell phenotype. This review discusses the progress made in the replication of stem cell niches from the anterior ocular segment by using bioengineering approaches and their therapeutic implications.

Preliminary Study on Fish Scale Collagen Lamellar Matrix as Artificial Cornea

To construct a novel artificial cornea biomaterial, a method to prepare collagen lamellar matrix was developed in this study using grass carp scales as raw materials. The relationship between the structure of fish scale collagen lamellar matrix and the optical and mechanical properties was analyzed, and co-culture of it and rat bone marrow mesenchymal stem cells (BMSCs) was performed to preliminarily analyze the cellular compatibility of fish scale collagen lamellar matrix. The results show that the grass carp scales could be divided into base region, lateral region and parietal region according to the surface morphology. The inorganic calcium in the surface layer could be effectively removed by decalcification, and the decalcification rate could reach 99%. After etching treatment, homogeneous collagen lamellar matrix could be obtained. With the decalcification and etching treatment, the water content of the sample increased gradually, but the cross-linking treatment had no obvious effect on the water content of fish scale collagen lamellar matrix. Fish scale collagen lamellar matrix has good transparency, refractive index, mechanical properties and cellular compatibility, which may represent a prospect for the construction of cornea tissue engineering products.

High-Resolution Bioprinting of Recombinant Human Collagen Type III

The development of commercial collagen inks for extrusion-based bioprinting has increased the amount of research on pure collagen bioprinting, i.e., collagen inks not mixed with gelatin, alginate, or other more common biomaterial inks. New printing techniques have also improved the resolution achievable with pure collagen bioprinting. However, the resultant collagen constructs still appear too weak to replicate dense collagenous tissues, such as the cornea. This work aims to demonstrate the first reported case of bioprinted recombinant collagen films with suitable optical and mechanical properties for corneal tissue engineering. The printing technology used, aerosol jet® printing (AJP), is a high-resolution printing method normally used to deposit conductive inks for electronic printing. In this work, AJP was employed to deposit recombinant human collagen type III (RHCIII) in overlapping continuous lines of 60 µm to form thin layers. Layers were repeated up to 764 times to result in a construct that was considered a few hundred microns thick when swollen. Samples were subsequently neutralised and crosslinked using EDC:NHS crosslinking. Nanoindentation and absorbance measurements were conducted, and the results show that the AJP-deposited RHCIII samples possess suitable mechanical and optical properties for corneal tissue engineering: an average effective elastic modulus of 506 ± 173 kPa and transparency ≥87% at all visible wavelengths. Circular dichroism showed that there was some loss of helicity of the collagen due to aerosolisation. SDS-PAGE and pepsin digestion were used to show that while some collagen is degraded due to aerosolisation, it remains an inaccessible substrate for pepsin cleavage.

Tissue engineering of corneal stroma via melt electrowriting

The cornea serves as the main refractive component of the eye with the corneal stroma constituting the thickest component in a stratified layered system of epithelia, stroma, and endothelium. Current treatment options for patients suffering from corneal diseases are limited to transplantation of a human donor cornea (keratoplasty) or to implantation of an artificial cornea (keratoprosthesis). Nevertheless, donor shortage and failure of artificial corneas to integrate with local tissue constitute important problems that have not been yet circumvented. Recent advances in biofabrication have made great progress toward the manufacture of tailored biomaterial templates with the potential of guiding partially or totally the regeneration process of the native cornea. However, the role of the corneal stroma on current tissue engineering strategies is often neglected. Here, we achieved a tissue-engineered corneal stroma substitute culturing primary keratocytes on scaffolds prepared via melt electrowriting (MEW). Scaffolds were designed to contain highly organized micrometric fibers to ensure transparency and encourage primary human keratocytes to self-orchestrate their own extracellular matrix deposition and remodeling. Results demonstrated reliable cell attachment and growth over a period of 5 weeks and confirmed the formation of a dense and highly organized de novo tissue containing collagen I, V, and VI as well as Keratocan, which resembled very closely the native corneal stoma. In summary, MEW brings us closer to the biofabrication of a viable corneal stroma substitute.