Delayed vitreous hemorrhage after placement of a ganciclovir implant for cytomegalovirus retinitis

Dipeptide monoester ganciclovir prodrugs for transscleral drug delivery: targeting the oligopeptide transporter on rabbit retina

PURPOSE

The overall aim of this research work was to evaluate a series of dipeptide monoester prodrugs of an antiviral agent, ganciclovir (GCV), for oligopeptide transporter-targeted transscleral drug delivery to rabbit retina.

METHODS

The permeability and enzymatic hydrolysis of dipeptide monoester GCV prodrugs were evaluated using freshly excized rabbit retinal pigment epithelium (RPE)-choroidsclera (RCS) and sclera tissue preparations. Affinity and transport mechanism of these prodrugs and their translocation across RCS were investigated through competitive inhibition studies of [(3)H]glycylsarcosine with the prodrugs.

RESULTS

The transport of glycylsarcosine was found to be saturable (K(m) = 1.21 +/- 0.41 mM, V(max) = 15.89 +/- 1.54 pmoles/min/cm(2)), pH, temperature, and energy dependant. Dipeptides, angiotensin converting enzyme inhibitors, and a beta-lactum antibiotic strongly inhibited the transport of glycylsarcosine indicating the functional presence of oligopeptide transport (OPT) system on the RPE. Dipeptide prodrugs (valine-valine-GCV, glycine-valine-GCV, and tyrosine-valine-GCV), and valine-GCV demonstrate a high enzymatic stability and affinity toward the retinal OPT system. The transport of the prodrugs was significantly inhibited ( approximately 50%) in the presence of glycylsarcosine. The rank order of scleral permeability was Gly-Val-GCV approximately GCV>Val-GCV>Tyr-Val-GCV approximately Val-Val-GCV. The RCS permeability values of Val-GCV (3.29 +/- 0.09 x 10(6)cm/s), Val-Val-GCV (4.14 +/- 0.33 x 10(6)cm/s), Gly-Val-GCV (3.40 +/- 0.47 x 10(6)cm/s) and Tyr-Val-GCV (3.08 +/- 0.29 x 10(6)cm/s) were two-fold higher than that of GCV (1.61 +/- 0.06 x 10(6)cm/s).

CONCLUSIONS

The dipeptide monoester GCV prodrugs, owning to higher lipophilicity and OPT-mediated translocation across RPE, appear to be promising candidates in the treatment of ocular cytomegalovirus infections following an episcleral administration.

Vitreal pharmacokinetics of dipeptide monoester prodrugs of ganciclovir

PURPOSE

The aim of this study was to determine vitreal pharmacokinetics of a series of dipeptide monoester ganciclovir (GCV) prodrugs and to study their interaction with the retinal peptide transporter.

METHODS

New Zealand albino male rabbits were selected as the animal model. Ocular microdialysis technique was employed to delineate the pharmacokinetics of GCV, L-valine-GCV and dipeptide monoester GCV prodrugs (L-valine-L-valine, L-tyrosine-L-valine, and L-glycine- L-valine) following intravitreal administration.

RESULTS

Val-GCV and Val-Val-GCV inhibited retinal uptake of [3H]Gly-Sar by 43% and 37%, respectively, suggesting that these prodrugs may be substrates of the retinal peptide transport system. Val-GCV and Gly-Val-GCV were observed to be the most stable GCV prodrugs in vitreous humor. All GCV prodrugs were rapidly converted to GCV in retinal homogenates. Vitreal pharmacokinetic studies suggest that Val-GCV and Val-Val-GCV are rapidly eliminated from the vitreous chamber, compared to GCV, whereas Gly-Val-GCV is eliminated at a much slower rate. Retinal GCV concentrations generated from all three prodrugs, at the end of 5 h, were almost equivalent and were almost twice that following intravitreal administration of GCV. Gly-Pro, however, did not demonstrate any effect on retinal uptake of Val-GCV or Gly-Val-GCV.

CONCLUSIONS

Considering retinal GCV concentrations generated and vitreal pharmacokinetic profiles, Gly-Val-GCV appears to be a lead candidate for further in vivo evaluation against human cytomegalovirus (HCMV) retinitis.

Ganciclovir implant in the treatment of cytomegalovirus retinitis

The ganciclovir implant is a sustained-release intraocular drug delivery system used to treat cytomegalovirus retinitis that provides a high and steady-state concentration of the drug in the vitreous cavity over a period of 7-8 months. Randomized, controlled clinical trials have demonstrated a superior efficacy of the implant compared with intravenous ganciclovir. Severe adverse events associated with the implant are uncommon, though potentially blinding. In addition, the implant provides no protection against second-eye or visceral cytomegalovirus retinitis infections. This review summarizes the clinical indications for and complications associated with the ganciclovir implant.

Complications of ganciclovir implant surgery in patients with cytomegalovirus retinitis: the Ganciclovir Cidofovir Cytomegalovirus Retinitis Trial

PURPOSE

To describe the complications of ganciclovir implant surgery in patients with cytomegalovirus retinitis.

METHODS

Prospective data collection within the context of a randomized, controlled clinical trial, comparing a regimen of the ganciclovir implant plus oral ganciclovir to one of intravenous cidofovir for the treatment of cytomegalovirus retinitis in patients with AIDS. Adverse events were compared for patients undergoing implant surgery in the following groups: primary versus replacement implant surgery, inpatient versus outpatient surgery, and general versus local anesthesia.

RESULTS

Fifty-six eyes of 42 patients underwent a total of 74 ganciclovir implant surgeries. Vitreous hemorrhage was the most common adverse event, occurring in 10% of eyes undergoing surgery with local anesthesia but in no eyes undergoing surgery with general anesthesia. All vitreous hemorrhages resolved within 60 days. Patients in the general anesthesia and inpatient surgery groups tended to have a lower risk of complications in the first 30 days than did patients in the local anesthesia and outpatient surgery groups, but no differences in the complication rate were found after 60 days. Visual acuity was similar among these different groups. There were no cases of endophthalmitis.

CONCLUSION

Ganciclovir implant surgery in patients with AIDS and cytomegalovirus retinitis was associated with a low risk of serious complications in the first 60 days after surgery. Vitreous hemorrhage was the most commonly observed complication and resolved in all cases.