Effects of topical nonsteroidal antiinflammatory drugs on the expression of matrix metalloproteinases in the cornea

[Use of dexpanthenol in corneal damage]

Issues of regeneration of the cornea, which is the most vulnerable structure of the eyeball, suffering from various diseases and injuries, burns, when wearing contact lenses and glaucoma, are highly relevant for ophthalmologists. It is also necessary to minimize damage and stimulate corneal epithelization during and after the use of steroidal and non-steroidal anti-inflammatory drugs, antibacterial drugs and antiseptics, which have a cytotoxic effect and often inhibit regeneration processes, potentially even leading to the development of corneal epithelial defects. This review analyzes the effectiveness of a promising drug 5% dexpanthenol in terms of improving the reparative processes and the function of epithelial cells.

The use of topical nalbuphine in different concentrations to control pain after photorefractive keratectomy

PURPOSE

This is a randomized controlled study aiming to evaluate the safety and efficacy of two different concentrations of topical nalbuphine hydrochloride, when used to relieve pain in the first days following photorefractive keratectomy (PRK).

METHODS

This is a prospective double blinded randomized clinical trial that included 189 patients who had PRK for correction of low and moderate refractive errors. Patients were randomly assigned to three groups according to the eye drops given to relieve pain in the first three postoperative days; the first group received topical nalbuphine with a concentration of 2 mg/ml (Group A = 64 patients), the second group received topical nalbuphine in a concentration of 1 mg/ml (Group B = 69 patients) and the third group received topical artificial tears only (Group C = 56 patients).The patients were asked to rate their pain daily using a numeric rating scale and to record the number of drops instillation times/day. The time needed for complete epithelial healing, best-corrected visual acuity (BCVA) and spherical equivalent after three months were recorded in each group.

RESULTS

In the first three days, there was a statistically significant difference in pain score among the three groups with lower values in the two topical nalbuphine groups when compared with the control group receiving artificial tears. Moreover, the higher concentration group showed significantly lower pain score and less number of drops used /day in comparison with the lower concentration group.There were no statistically significant differences in epithelial healing time, BCVA and spherical equivalent after three months among the three groups.

CONCLUSION

The use of topical nalbuphine is effective in relieving pain in the first few days following PRK and this pain relief is not associated with any compromise regarding epithelial healing nor refractive outcome. The pain control with 2 mg/ml concentration is significantly higher than that with 1 mg/ml concentration of nalbuphine. Trial registration numberISRCTN21394752 https://doi.org/10.1186/ISRCTN21394752 The trial is retrospectively registered in ISRCTN registry at March 08, 2021.

Effect of topical non-steroidal anti-inflammatory drugs on healing times and complications in dogs with spontaneous chronic corneal epithelial defects

BACKGROUND

Little is published regarding topical NSAID effect on corneal healing in dogs. This retrospective cohort study aimed to compare healing times and complications in dogs with spontaneous chronic corneal epithelial defects (SCCED) treated with and without topical non-steroidal anti-inflammatory drugs (NSAID).

METHODS

Medical records of 66 dogs (71 eyes) diagnosed with SCCED between 2008 and 2019 were included. Eyes were divided into: (1) those receiving topical NSAIDs (n = 33) versus (2) those not receiving topical NSAID (n = 38). Follow-up until healed, such as comfortable eye, negative fluorescein stain was required. Use of topical or systemic anti-inflammatories outside of NSAID or presence of ocular disorders or systemic endocrinopathies that may contribute to delayed healing resulted in study exclusion.

RESULTS

Healing times were significantly longer in eyes that received topical NSAID (p = 0.008), however, the use of more topical medications for treatment was also associated with longer healing times (p = 0.001). The majority of eyes in the NSAID group received multiple medications, compared to the non-NSAID group, so it was not possible to separate the effects of NSAID from a number of medications. Complications occurred in three eyes of three dogs within the NSAID group.

CONCLUSIONS

In these canine SCCED eyes, the use of more topical medications, including NSAID, was associated with significantly delayed healing time.

Deterioration of wound healing and intense suppression of MMP-9 mRNA expression after short-term administration of different topical glucocorticoids or NSAIDs in an avian model of corneal lesions

Background

Corneal lesions are considered among important ophthalmic conditions in avian patients. Short-term outcome of using anti-inflammatory agents in corneal lesions of birds are not well-described.

Aims

The study evaluates effects of different anti-inflammatory agents on healing of alkali burn-induced corneal lesions in layer hens as an avian model.

Methods

Adult layers were randomly allocated into 7 groups (n=15) as follows: 1. Negative (normal) control (NC), and 2. Positive control (PC) with an experimentally induced-corneal lesion, 3-7. Birds with corneal lesions that were treated with dexamethasone, fluorometholone, prednisolone, ketorolac, or diclofenac eye-drops every 6 hours (QID) for 5 consecutive days.

Results

At the end of the experiment, proper healing was observed in PC group based on lesion area, while treated groups showed statistically larger lesion sizes as compared to PC birds (P<0.05). Although no significant difference was observed among groups, birds treated with ketorolac, diclofenac or fluorometholone had higher histopathological scores for most of the assayed parameters than other groups. Levels of tumor necrosis factor-α (TNF-α) and vascular endothelial growth factor (VEGF) in corneal tissue of different groups were statistically the same. The mRNA expression of matrix metalloproteinase-9 (MMP-9) was increased 2.5 folds in PC group as compared to NC birds. However, birds treated with anti-inflammatory agents showed no detectable expression of MMP-9 mRNA.

Conclusion

Five days of topical administration of non-steroidal anti-inflammatory agents (NSAIDs) or glucocorticoids (GCs) is associated with suppression of MMP-9 mRNA expression in corneal tissue and detrimental effects on wound healing in layers with alkali burn-induced corneal ulcers.

Role of Cold Balanced Salt Solution (BSS) in the Prophylaxis of Cystoid Macular Edema After Cataract Surgery: A Prospective Randomized Study

Purpose

To evaluate the postoperative effect on central retinal macular thickness of a cooled irrigating eye solution used during cataract surgery.

Patients and Methods

In this prospective, single-center study, 100 eyes of 50 patients (26 males and 24 females) were evaluated with spectral domain optical coherence tomography (SD-OCT) before and after phacoemulsification for senile cataract. Eyes were randomly divided into two groups based on the irrigating solution used during surgery: Group 1, 50 eyes received intraoperative irrigating solution at room temperature (~20.0±0.1°C); and Group 2, 50 fellow eyes received cold intraoperative irrigating solution (2.7±0.1°C). Changes in central macular thickness (CMT) were evaluated in both groups by SD-OCT macular raster scan for the nine Early Treatment of Diabetic Retinopathy Study (ETDRS) subfields and total macular volume, performed pre-surgery, and 1 and 4 weeks post-surgery.

Results

Despite there being no significant differences in variables between the two groups preoperatively, significant increases in CMT were observed at 1 week after surgery in both groups (p=0.02 and p=0.03, respectively), as well as in total macular volume (p<0.0001 and p=0.02, respectively). Inter-subgroup analysis showed a significant reduction in CMT (p=0.03) and total macular volume (p=0.001) at 1 week post-surgery in Group 2 compared to Group 1, whereas no significant differences were observed at 4 weeks.

Conclusion

The use of a cooled irrigating eye solution during phacoemulsification may be beneficial in preventing the possible development of postoperative macular thickening. Further clinical studies may support this finding.

Controversy of indomethacin eye drops in the treatment of rheumatoid arthritis-induced corneal ulceration: a case report

Background

Perforation of the cornea is a rare finding in patients with rheumatoid arthritis (RA). Addressing a perforated cornea associated with RA is challenging, since its pathogenesis is not fully elucidated. Topical nonsteroidal anti-inflammatory drugs (NSAIDs) were developed to prevent cystoid macular edema following cataract surgery in patients at risk. Their prescription in inflammation of the anterior segment of the eye may induce negative effects on the ocular surface. We bring into focus a corneal perforation in a patient with RA who used indomethacin eye drops to treat corneal ulceration, but responded promptly to drug discontinuation and initiation of topical cyclosporine 0.1%. Our aim is to emphasize two issues: the contraindication of topical indomethacin in corneal defects, and the immediate positive impact of topical cyclosporine 0.1% on corneal healing.

Case presentation

A 73-year-old Caucasian woman with a 13-year history of RA was treated for corneal ulceration in her oculus sinister (OS) with topical indomethacin and gentamicin. The patient was being treated with systemic immunosuppression and NSAIDs for the underlying RA and artificial tears in both eyes. No bandage contact lens was used. After 3 weeks of treatment, perforation of the left cornea occurred and the patient was referred to our hospital. Upon admission, visual acuity (VA) in the OS was 20/630. Slit lamp examination of the OS revealed paracentral corneal perforation, iris plugging the perforation site, shallow anterior chamber, clear aqueous humor, and clear lens. Anterior segment optical coherence tomography showed the inclavated iris in the perforation site and minimum corneal thickness of 101 µm. Topical NSAIDs were discontinued and topical treatment was initiated with tobramycin, tropicamide 1%, phenylephrine 10%, and artificial tears five times a day, and occlusive patch. For 5 days, there was no improvement, so topical cyclosporine 0.1% was started, one drop every evening. Within 7 days, the cornea had healed, the iris was liberated from the perforation site, the minimum corneal thickness increased to 250 µm, VA improved to 20/25, and the patient was free of symptoms.

Conclusions

The main “takeaway” lessons from this case are that topical indomethacin should not be prescribed in cases of inflammation of the anterior segment of the eye, and that topical cyclosporine was efficacious in healing corneal perforation in our patient.

Effect of nepafenac 0.1% on retinal thickness after cataract surgery in patients without risk factors for cystoid macular edema

AIM

To evaluate the effect of topical preoperative nepafenac 0.1% treatment on postoperative macular edema using optical coherence tomography (OCT) after uncomplicated cataract surgery.

METHODS

Ninety eyes of 90 patients without any risk factors were included in the study. The patients were assigned to three groups: group 1, treated with topical prednisolone acetate 1%; group 2, treated with topical nepafenac 0.1% in addition to prednisolone acetate (1%); and group 3, those who started receiving nepafenac 0.1% treatment 3d prior to surgery and continued the treatment postoperatively in addition to prednisolone acetate (1%). Central retinal thickness (CRT) and macular volume values were recorded using OCT at weeks 3 and 6.

RESULTS

The increases in macular volume in the central 1 mm area after 3 and 6wk were significantly lower in patients who used prophylactic topical nepafenac preoperatively (group 3) compared with those in group 1 (P=0.028 and 0.008, respectively). No significant differences in the increase in macular volume and CRT were noted between groups 2 and 3 (P>0.05). In group 1, the increases in macular volume in the central 3 mm area at weeks 3 and 6 were significantly higher than that in group 2 and 3 (3^rd week, P=0.004; 6^th week, P=0.005).

CONCLUSION

Nepafenac 0.1% treatment in addition to topical steroids after uncomplicated cataract surgery reduce the increase in macular volume in the early postoperative period.

Corneal graft melting: a systematic review

Corneal graft melting is a severe complication of keratoplasty. This review is to summarize the incidence, the pathogenesis, the risk factors, the prognosis and the prevention of corneal graft melting after keratoplasty. We systematically searched PubMed, Web of Science and WanFang database to retrieve potentially eligible articles about relevant clinical reports and animal experiments. We read the full texts to identify eligible articles. The selection of studies and data extraction were performed independently by two reviewers. In conclusion, the pathogenesis of corneal graft melting is complicated, and many risk factors are closely related to corneal graft melting. Analysis of pathogenesis and risk factors of corneal graft melting can facilitate the development of targeted therapies to better guide clinical practice.

TFOS DEWS II iatrogenic report

Dry eye can be caused by a variety of iatrogenic interventions. The increasing number of patients looking for eye care or cosmetic procedures involving the eyes, together with a better understanding of the pathophysiological mechanisms of dry eye disease (DED), have led to the need for a specific report about iatrogenic dry eye within the TFOS DEWS II. Topical medications can cause DED due to their allergic, toxic and immuno-inflammatory effects on the ocular surface. Preservatives, such as benzalkonium chloride, may further aggravate DED. A variety of systemic drugs can also induce DED secondary to multiple mechanisms. Moreover, the use of contact lens induces or is associated with DED. However, one of the most emblematic situations is DED caused by surgical procedures such as corneal refractive surgery as in laser-assisted in situ keratomileusis (LASIK) and keratoplasty due to mechanisms intrinsic to the procedure (i.e. corneal nerve cutting) or even by the use of postoperative topical drugs. Cataract surgery, lid surgeries, botulinum toxin application and cosmetic procedures are also considered risk factors to iatrogenic DED, which can cause patient dissatisfaction, visual disturbance and poor surgical outcomes. This report also presents future directions to address iatrogenic DED, including the need for more in-depth epidemiological studies about the risk factors, development of less toxic medications and preservatives, as well as new techniques for less invasive eye surgeries. Novel research into detection of early dry eye prior to surgeries, efforts to establish appropriate therapeutics and a greater attempt to regulate and oversee medications, preservatives and procedures should be considered.

Effect of Systemically Used Anti-Tumor Necrosis Factor-α Medication on the Corneal Epithelium and Stroma of Patients with Ankylosing Spondylitis

PURPOSE

To evaluate the effect of systemically used anti-tumor necrosis factor alpha (TNF-α) medication on the thickness of corneal epithelium and stroma in patients with ankylosing spondylitis (AS).

METHODS

A total of 125 eyes of 69 participants were included in this retrospective study of three groups: healthy participants (Group 1), AS patients receiving anti-TNF-α medication (Group 2), and AS patients receiving a nonsteroidal anti-inflammatory medication (Group 3).

RESULTS

According to anterior segment optical coherence tomography, the mean thickness of the corneal epithelium was significantly thicker in Group 2 than in Group 3 (51.6 ± 3.2 µm versus 50.4 ± 3 µm, p = 0.01), as was that of the stroma (475 ± 33 µm versus 443 ± 29 µm, p = 0.002).

CONCLUSIONS

Anti-TNF-α medication and/or avoidance of nonsteroidal anti-inflammatory drugs could improve the thickness of both the corneal epithelium and stroma in AS patients.

Differential Effects of Dexamethasone and Doxycycline on Inflammation and MMP Production in Murine Alkali-Burned Corneas Associated with Dry Eye

Alkali burns to the cornea are among the most devastating injuries to the eye. The purpose of this study was to evaluate the effects of dexamethasone (Dex) or doxycycline (Doxy) on protease activity and corneal complications in a combined model (CM) of alkali burn and dry eye. C57BL/6 mice were subjected to the CM for 2 or 5 days (D). Mice were topically treated either with Dex (0.1%), Dox (0.025%) or vehicle QID and observed daily for appearance of corneal perforation. Quantitative real time PCR was performed to measure expression of inflammation cytokines and matrix metalloproteinases (MMPs) in whole cornea lysates. No perforations were observed in the Dex-treated corneas. All wounds in Doxy-treated corneas were closed 2D post-injury, and they had significantly lower corneal opacity scores at days 4 and 5 post-injury compared to BSS treatment. Dex-treated corneas had the lowest corneal opacity scores. Dex treatment significantly decreased expression of IL-1β, IL-6, MMPs -1, -9, -13, and TIMP-1 after 2 days but increased levels of MMP-8, while Doxy treatment significantly decreased IL-1β, IL-6, MMP-8, and -9, compared to vehicle. Decreased MMP-1, -9 and -13 immunoreactivity and gelatinolytic activity were seen in corneas treated with Doxy and Dex compared to vehicle. Increased neutrophil infiltration and myeloperoxidase activity was noted in the vehicle group compared to Dex 2 days post-injury. These findings demonstrate that early initiation of anti-inflammatory therapy is very efficacious in preserving corneal clarity and facilitating wound healing, while modulating MMP production and suppressing neutrophil infiltration.

Analgesic effect of preoperative topical nonsteroidal antiinflammatory drugs on postoperative pain after laser-assisted subepithelial keratectomy

PURPOSE

To assess the effect of preoperative topical nonsteroidal antiinflammatory drugs (NSAIDs) on postoperative pain after laser-assisted subepithelial keratectomy (LASEK) and to investigate their mechanism.

SETTING

Severance Eye Hospital and Saeyan Eye Clinic, Seoul, South Korea.

DESIGN

Prospective randomized clinical trial.

METHODS

Participants in 2 related studies were assessed. Study 1 comprised patients scheduled for bilateral LASEK (Group 1) who were randomized to receive an NSAID in 1 eye and a placebo in the fellow eye 30, 20, and 10 minutes before LASEK. Postoperative pain, glare, tearing, and irritation were assessed using a visual analog scale. Study 2 comprised healthy subjects (Group 2) who were randomly divided into subgroups. The participants in these subgroups were randomized to receive ketorolac tromethamine 0.5% in 1 eye and placebo (ofloxacin 0.3%) in the fellow eye (Group 2A), proparacaine hydrochloride 0.5% in 1 eye and placebo in the fellow eye (Group 2B), or ketorolac tromethamine 0.5% in 1 eye and placebo in the fellow eye, followed 10 minutes later by 1 drop of proparacaine hydrochloride 0.5% in both eyes (Group 2C). In all 3 groups, corneal sensitivity was measured after 1, 2, and 6 hours.

RESULTS

The mean postoperative pain score in the NSAID-pretreated eye was statistically significantly lower than in the placebo-pretreated eye 6, 12, and 24 hours postoperatively (P < .05). The mean corneal sensitivity was statistically significantly lower in the NSAID-treated eye than in the placebo-treated eye at 1 and 2 hours in Groups 2A and 2C (P < .05).

CONCLUSION

Preoperative administration of topical NSAIDs before LASEK effectively reduces postoperative pain.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Ocular safety comparison of non-steroidal anti-inflammatory eye drops used in pseudophakic cystoid macular edema prevention

Non-steroidal anti-inflammatory drug (NSAID) eye drops are widely used to treat ocular inflammatory conditions related to ophthalmic surgical procedures, such as pseudophakic cystoid macular edema, and they have been used for off-label treatments. The most commonly used NSAIDs are diclofenac and ketorolac and the new molecules bromfenac and nepafenac have also been used. We used primary human keratocytes in cell culture in combination with a novel technology that evaluates dynamic real-time cytotoxicity through impedance analysis. This study also included classic cell viability tests (WST-1(®) and AlamarBlue(®)), wound healing assay, Hen's Egg Test and an ex vivo histopathological assay. NSAIDs were shown to have important cytotoxicities and to retard the healing response. Furthermore, the new eye drops containing bromfenac and nepafenac were more cytotoxic than the more classical eye drops. Nevertheless, no immuno-histochemical changes or acute irritation processes were observed after the administration of any eye drops tested. Due to cytotoxicity and the total absence of discomfort and observable injuries after the administration of these drugs, significant corneal alterations, such as corneal melts, can develop without any previous warning signs of toxicity.

Desiccating Stress-Induced MMP Production and Activity Worsens Wound Healing in Alkali-Burned Corneas

PURPOSE

To evaluate the effects of dry eye on ocular surface protease activity and sight threatening corneal complications following ocular surface chemical injury.

METHODS

C57BL/6 mice were subjected to unilateral alkali burn (AB) with or without concomitant dry eye for 2 or 5 days. Mice were observed daily for appearance of corneal perforation. Whole corneas were harvested and lysed for RNA extraction. Quantitative real-time PCR was performed to measure expression of inflammation cytokines, matrix metalloproteinases (MMP). Matrix metalloproteinase-9 activity, gelatinase activity, and myeloperoxidase (MPO) activity were evaluated in corneal lysates. Presence of infiltrating neutrophils was evaluated by immunohistochemistry and flow cytometry.

RESULTS

Eyes subjected to the combined model of AB and dry eye (CM) had 20% sterile corneal perforation rate as soon as 1 day after the initial injury, which increased to 35% by 5 days, delayed wound closure and increased corneal opacity. Increased levels of IL-1β, -6, and MMPs-1, -3, -8, -9, and -13, and chemokine (C-X-C motif) ligand 1 (CSCL1) transcripts were found after 2 days in CM compared with AB corneas. Increased MMP-1, -3, -9, and -13 immunoreactivity and gelatinolytic activity were seen in CM corneas compared with AB. Increased neutrophil infiltration and MPO activity was noted in the CM group compared with AB 2 days post injury.

CONCLUSIONS

Desiccating stress worsens outcome of ocular AB, creating a cytokine and protease storm with greater neutrophil infiltration, increasing the risk of corneal perforation.

Interface haze associated with topical nonsteroidal anti-inflammatory drug use after descemet stripping automated endothelial keratoplasty

PURPOSE

To determine if topical nonsteroidal anti-inflammatory drug (NSAID) use after Descemet stripping automated endothelial keratoplasty (DSAEK) is associated with the development of interface haze.

METHODS

A retrospective case-control study of patients undergoing DSAEK surgery.

RESULTS

Of the 61 patients receiving topical NSAIDs, 51% were noted to develop interface haze, and 9% of the control group (N=100, no NSAID) developed haze. There was no significant difference in best corrected visual acuity between the 2 groups.

CONCLUSIONS

Topical NSAID use is associated with the development of interface haze, although it may not be visually significant and could be related to confounding factors.

Update on twice-daily bromfenac sodium sesquihydrate to treat postoperative ocular inflammation following cataract extraction

Ophthalmic bromfenac sodium sesquihydrate is a topically applied selective cyclooxygenase (COX)-2 inhibitor. It is similar to amfenac, except for a bromine atom at the C(4) of the benzoyl ring position, which markedly affects its in vitro and in vivo potency, extends the duration of anti-inflammatory activity, and enhances its inhibitory effect on COX-2 absorption across the cornea and penetration into ocular tissues. The United States Food and Drug Administration approved bromfenac in 2005 for the treatment of postoperative inflammation and the reduction of ocular pain in patients who have undergone cataract surgery. Nonsteroidal anti-inflammatory drugs (NSAIDs), and among them bromfenac, could be even more effective than steroids at reestablishing the blood-aqueous barrier, as revealed by flare on slit-lamp examination and as quantitatively measured using ocular fluorophotometry. Similar to other NSAIDs, it has a role in inhibiting intraoperative miosis during cataract surgery. However, bromfenac also seems to be useful in other situations, such as refractive surgery, allergic conjunctivitis (not useful in dry eye), choroidal neovascularization, and even ocular oncology. No reports of systemic toxicity have been published and bromfenac has good topical tolerance with a low incidence of adverse effects.

Ex vivo corneal epithelial wound healing following exposure to ophthalmic nonsteroidal anti-inflammatory drugs

Purpose:

Ketorolac 0.45% is a new formulation of topical ketorolac in which preservative (benzalkonium chloride, BAK) was removed and carboxymethylcellulose (CMC) was added to improve tolerability and reduce dosing frequency. This study compared the effects of ketorolac 0.45% on corneal wound healing to prior ketorolac formulations (0.4% and 0.5%), bromfenac 0.09%, and nepafenac 0.1%.

Methods:

Two parallel-group comparisons were performed in series. A 5-mm central epithelial wound was made in fresh porcine corneas. After 24 hours in minimum essential medium (MEM), corneas were incubated for 10 minutes with study drugs, Triton X-100 1% (positive control), or MEM (negative control), followed by 24 hours in MEM. The remaining wound area was stained, photographed, and quantified (pixels). Study 1 compared ketorolac 0.45% to ketorolac 0.4% and ketorolac 0.5%. Study 2 compared ketorolac 0.45% to bromfenac 0.09% and nepafenac 0.1%.

Results:

The mean (±SD) original wound area was 200,506 ± 4,363 pixels, which was reduced to 59,509 ± 4850 at 48 hours after exposure to Triton X-100 1%. In study 1, the mean remaining wound areas at 48 hours in pixels were 2969 ± 1633 with MEM, 586 ± 299 with ketorolac 0.45% (significantly reduced, P < 0.05 vs all other treatments), 10,228 ± 7541 with ketorolac 0.4%, and 50,674 ± 33,409 with ketorolac 0.5% (significantly enlarged, P < 0.05 vs MEM). In study 2, the mean remaining wound areas at 48 hours were 565 ± 1263 with MEM, 322 ± 229 with ketorolac 0.45% (significantly reduced, P < 0.01 vs bromfenac 0.09% and nepafenac 0.1%), 29,093 ± 14,295 with bromfenac 0.09% (significantly enlarged, P <0.01 vs MEM) and 47,322 ± 13,736 with nepafenac 0.1% (significantly enlarged, P < 0.01 vs MEM and vs bromfenac 0.09%).

Conclusion:

Corneas treated with ketorolac 0.45% healed as rapidly as those treated with MEM, likely secondary to addition of CMC and removal of BAK. In the ex vivo corneal organ culture model, ketorolac 0.45% had statistically less impact on corneal re-epithelialization than prior ketorolac formulations (0.4% and 0.5%), bromfenac 0.09%, and nepafenac 0.01%.

Ibuprofen upregulates expressions of matrix metalloproteinase-1, -8, -9, and -13 without affecting expressions of types I and III collagen in tendon cells

Nonsteroidal antiinflammatory drugs are widely used to treat sports-related tendon injuries or tendinopathy. This study was designed to investigate the effect of ibuprofen on expressions of types I and III collagen, as well as collagen-degrading enzymes including matrix metalloproteinase (MMP)-1, -2, -8, -9, and -13. Rat Achilles tendon cells were treated with ibuprofen and then underwent MTT [3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] assay. Reverse transcription-polymerase chain reaction was used to evaluate mRNA expressions of types I and III collagen, MMP-1, -2, -8, -9, and -13. Protein expressions of types I and III collagen, MMP-1, -8, and -13 were determined by Western blot analysis. Gelatin zymography was used to evaluate the enzymatic activities of MMP-2 and MMP-9. The results revealed that ibuprofen upregulated expressions of MMP-1, -8, -9, and -13, both at mRNA and protein levels. There was no effect of ibuprofen on mRNA and protein expressions of types I and III collagen. Gelatin zymography revealed that the enzymatic activity of MMP-9 was upregulated after ibuprofen treatment. In conclusion, ibuprofen upregulates the expressions of collagenases including MMP-1, -8, -9, and -13 without affecting the expressions of types I and III collagen. These findings suggest a molecular mechanism potentially accounting for the inhibition of tendon healing by ibuprofen.

Cleavage of functional IL-2 receptor alpha chain (CD25) from murine corneal and conjunctival epithelia by MMP-9

BACKGROUND

IL-2 has classically been considered a cytokine that regulates T cell proliferation and differentiation, signaling through its heterotrimeric receptor (IL-2R) consisting of alpha (CD25), beta (CD122), gamma chains (CD132). Expression of IL-2R has also been detected in mucosal epithelial cells. Soluble IL-2Ralpha (CD25) has been reported as an inflammatory marker. We evaluated the expression of CD25 and CD122 in the ocular surface epithelium and investigated the mechanism of proteolytic cleavage of CD25 from these cells.

METHODS

Desiccating stress (DS) was used as an inducer of matrix metalloproteinase 9 (MMP-9). DS was created by subjecting C57BL/6 and MMP-9 knockout (BKO) mice and their wild-type littermates (WT) mice to a low humidity and drafty environment for 5 days (DS5). A separate group of C57BL/6 mice was subjected to DS5 and treatment with topical 0.025% doxycycline, a MMP inhibitor, administered QID. The expression of CD25 and CD122 was evaluated in cryosections by dual-label laser scanning confocal microscopy. Western blot was used to measure relative levels of CD25 in epithelial lysates. Gelatinase activity was evaluated by in situ zymography. Soluble CD25 in tear fluid was measured by an immunobead assay.

RESULTS

CD25 and CD122 were abundantly expressed in cornea (all layers) and conjunctiva epithelia (apical and subapical layers) in nonstressed control mice. After desiccating stress, we found that immunoreactivity to CD25, but not CD122, decreased by the ocular surface epithelia and concentration of soluble CD25 in tears increased as MMP-9 staining increased. CD25 was preserved in C57BL/6 mice topically treated with an MMP-9 inhibitor and in MMP-9 knock-out mice. MMP-9 treatment of human cultured corneal epithelial cells decreased levels of CD25 protein in a concentration dependent fashion.

CONCLUSION

Our results indicate that functional IL-2R is produced by the ocular surface epithelia and that CD25 is proteolytic cleaved to its soluble form by MMP-9, which increases in desiccating stress. These findings provide new insight into IL-2 signaling in mucosal epithelia.

Secretory Leukoprotease Inhibitor: A Native Antimicrobial Protein in the Innate Immune Response in a Rat Model of S. aureus Keratitis

Purpose. To describe the presence of secretory leukocyte protease inhibitor (SLPI), a cationic peptide with antimicrobial and antiprotease activity in the innate immune reaction in a rat model of Staphylococcus aureus keratitis. Methods. Forty female Lewis rats were divided into 2 groups: the infectious keratitis and the epithelial defect groups. Eyes were processed for immunohistochemical studies for SLPI, interleukin-1, interleukin-6, tumor necrosis factor-alpha, and matrix metalloproteinase-8. Results. Immunohistochemical studies confirmed high levels of SLPI, IL-1, IL-6, TNF-α, and MMP-8 expression in eyes with S. aureus keratitis and with epithelial defects, in contrast to undetectable SLPI expression in the normal control corneas. Conclusions. To our knowledge, this paper is the first to demonstrate the presence of SLPI with increased amounts of proinflammatory cytokines in inflamed and infected corneas.

Effect of nepafenac sodium 0.1% on delayed corneal epithelial healing and haze after photorefractive keratectomy: retrospective comparative study

PURPOSE

To assess delayed epithelialization and corneal haze related to nepafenac ophthalmic suspension 0.1% (Nevanac) use after photorefractive keratectomy (PRK).

SETTING

Private practice, Beverly Hills, California, USA.

METHODS

This retrospective comparative chart review comprised 69 eyes (44 patients) that were divided into 2 treatment groups that were not statistically significantly different in age or preoperative spherical equivalent. The nepafenac group consisted of 34 eyes (22 patients) that received nepafenac 0.1%, moxifloxacin, and fluorometholone postoperatively. The non-nepafenac group included 35 eyes (22 patients) that received moxifloxacin and fluorometholone only. Patients were seen between 1 day and 5 days postoperatively for evaluation of epithelial healing and haze formation. Delayed epithelialization was defined as healing after day 5. All patients were followed for haze formation for a minimum of 3 months.

RESULTS

Statistical analysis showed no difference between the nepafenac and non-nepafenac groups in delayed epithelialization (P = .61, chi-square test). Neither group had significant corneal haze.

CONCLUSION

Nepafenac did not appear to delay corneal epithelial healing or contribute to haze formation after PRK.

Corneal melting and perforation in Stevens Johnson syndrome following topical bromfenac use

We report a case of a 20-year-old woman with tear deficiency secondary to Stevens Johnson syndrome who developed bilateral corneal melting following use of bromfenac (Xibrom), a nonsteroidal antiinflammatory drug (NSAID), for 2 weeks. The patient presented with complaints of light sensitivity and pain in the right eye. The slitlamp examination revealed a corneal perforation with iris plug in the right eye and an 85% thinned cornea in the left eye. She was admitted to the hospital, where Xibrom was discontinued, therapeutic contact lenses were placed, and a regimen of topical antibiotic agents was instituted. One day after admission, penetrating keratoplasty was performed in the right eye, an amniotic membrane was placed in the left eye, and tarsorrhaphy was performed bilaterally. The clinical features of this case highlight the importance of being selective when administering NSAIDs in patients with a compromised ocular surface.

Case of Corneal Melting Associated With the Use of Topical Nepafenac

PURPOSE

To report a case of corneal melting associated with the use of the topical nonsteroidal anti-inflammatory agent Nepafenac.

METHODS

Case report and literature review.

RESULTS

A 62-year-old woman with a complicated ocular history developed corneal melting associated with the use of Nepafenac. On discontinuation of Nepafenac, the melt rapidly resolved.

CONCLUSIONS

Topical nonsteroidal anti-inflammatory agents have been associated with corneal ulceration and stromal melts. This is, to our knowledge, the first reported case involving the new agent, Nepafenac.

New insights into the diagnosis and treatment of neurotrophic keratopathy

Abnormalities of the ocular surface can be acquired or inherited disorders of the central nervous system. Loss of neural stimulation from the sensory division of the trigeminal nerve or from the autonomic nervous system can have devastating consequences on corneal epithelial wound healing and the precorneal tear film, leading to decreased vision. The pathogenesis of neurotrophic keratopathy is reviewed, and treatment modalities are recommended.

The role of NSAIDs in the management of postoperative ophthalmic inflammation

Recent advances in cataract surgery, such as phacoemulsification, small-incision surgery and advances in foldable intraocular lenses, have resulted in the decrease of physical trauma associated with cataract surgery. The decrease in the physical surgical trauma decreases the release of prostaglandins, which are the main players in postoperative ocular inflammation. However, postoperative inflammation continues to be a cause of patient discomfort, delayed recovery and, in some cases, suboptimal visual results. Left untreated, this inflammation might interfere with patients' rehabilitation and/or contribute to the development of other complications, such as cystoid macular oedema.NSAIDs are commercially available, in topical or systemic formulations, for the prophylaxis and treatment of ocular conditions. Topically applied NSAIDs are commonly used in the management and prevention of non-infectious ocular inflammation and cystoid macular oedema following cataract surgery. They are also used in the management of pain following refractive surgery and in the treatment of allergic conjunctivitis. Despite their chemical heterogeneity, all NSAIDs share the similar therapeutic property of inhibiting the cyclo-oxygenase enzyme. The appeal of using NSAIDs in the treatment of ocular inflammation hinges on the complications associated with corticosteroids, the other commonly used therapy for ophthalmic inflammation.

Proteinases of the cornea and preocular tear film

Maintenance and repair of corneal stromal extracellular matrix (ECM) requires a tightly coordinated balance of ECM synthesis, degradation and remodeling in which proteolytic enzymes (proteinases) perform important functions. There are natural proteinase inhibitors present in preocular tear film (PTF) and cornea simultaneously with proteinases that prevent excessive degradation of normal healthy tissue. Disorders occur when there is an imbalance between proteinases and proteinase inhibitors in favor of the proteinases, causing pathologic degradation of stromal collagen and proteoglycans in the cornea. Two matrix metalloproteinases (MMPs), MMP-2 and MMP-9, are of major importance in terms of remodeling and degradation of the corneal stromal collagen. Immunohistochemical studies have shown different origins of MMP-2 and -9. MMP-2 is synthesized by corneal keratocytes and performs a surveillance function in the normal cornea, becoming locally activated to degrade collagen molecules that occasionally become damaged. Alternatively, MMP-9 may be produced by epithelial cells and polymorphonuclear neutrophils following corneal wounding. Because the cornea is in close contact with the preocular tear film (PTF), proteinases have been evaluated in the PTF. In damaged corneas, total proteolytic activity in the tear fluid was found to be significantly increased compared to normal eyes and contralateral eyes. Studies analyzing the proteolytic activity in serial PTF samples during corneal healing led to the following conclusions: ulcerative keratitis in animals is associated with initially high levels of tear film proteolytic activity, which decrease as ulcers heal; proteinase levels in melting ulcers remain elevated leading to rapid progression of the ulcers. The success of medical and surgical treatment of the corneal ulcers is reflected by the proteolytic activity in tears. In animals, successful treatment leads to a rapid reduction in tear film proteolytic activity that corresponds with the improvement in the clinical signs of corneal ulceration. The in vitro effects of various compounds on proteolytic activity in the tear fluid of animals with ulcerative keratitis have been evaluated and their important inhibitory effects have been confirmed. Because these various compounds utilize different mechanisms to inhibit various families of proteinases, a combination of these proteinase inhibitors may be beneficial.

Double-Masked Comparison of Ketorolac Tromethamine 0.4% Versus Nepafenac Sodium 0.1% for Postoperative Healing Rates and Pain Control in Eyes Undergoing Surface Ablation

PURPOSE

Determine the degree of postoperative pain and rate of healing in eyes treated with either ketorolac tromethamine 0.4% (Acular LS) or nepafenac sodium 0.1% (Nevanac) after flapless surface ablation [epi-laser in situ keratomileusis (LASIK)].

METHODS

Prospective, randomized, double-masked, paired-eye comparison. Patients undergoing flapless surface ablation were randomized to receive ketorolac in 1 eye and nepafenac in the other. Drops were instilled immediately after the surgical procedure, and patients continued to instill the masked drops 3 times daily for 5 days. Study follow-up visits were at days 1 and 5 postoperatively. Patients were queried by phone regarding their level of pain at 5 hours postoperatively and on days 2, 3, and 4. Outcome measures included postoperative pain levels including need for additional rescue medications, rate of healing, and adverse events.

RESULTS

Although the original target population was 60 eyes of 30 patients, this study was halted after only 14 eyes of 7 patients because of concern for patient safety, because most patients in 1 arm developed haze. Eyes treated with nepafenac healed at a slower rate than eyes treated with ketorolac in 57% of patients. Mean time to healing was 5.7 +/- 1.1 days with ketorolac and 7.9 +/- 2.1 days with nepafenac (P = 0.066). Moreover, eyes treated with nepafenac exhibited statistically significant greater mean hazing scores at week 2 (P = 0.024) and month 1 (P = 0.039). Throughout the study, a greater percentage of nepafenac-treated eyes exhibited haze than did ketorolac-treated eyes. This difference was statistically significant at week 2 (P = 0.005) and month 1 (P = 0.039). Patients reported significantly more pain in nepafenac-treated eyes at day 3 when pain was at its peak (P = 0.046).

CONCLUSIONS

In patients undergoing epi-LASIK, a statistically significant trend postoperative toward increased corneal haze was seen with nepafenac compared with ketorolac. Nepafenac therapy resulted in a non-statistically significant trend toward delayed healing. The study was halted because of safety concerns.

Expression of Matrix Metalloproteinases 2 and 9 in Experimental Corneal Injury and Fungal Keratitis

PURPOSE

Levels of matrix metalloproteinases (MMPs) can be modulated during corneal infection, but little is known about MMP profiles during fungal keratitis. The purpose of this study was to determine the effect of corneal trauma and immunosuppressive treatment on the expression kinetics of MMP-2 and MMP-9 during experimental keratomycosis.

METHODS

Corneas of immunocompetent and cyclophosphamide-treated adult BALB/c mice were topically inoculated with 1 x 10 culturable units of Fusarium solani or mock-inoculated with or without superficial corneal scarification. Eyes were scored daily for disease severity and processed for zymography after 1.5 hours, 6 hours, 1 day, 4 days, or 8 days. Gelatinase activity was densitometrically quantitated and normalized to MMP-2 and MMP-9 controls.

RESULTS

MMP-9 levels in nontraumatized eyes transiently increased at 6 hours after fungal exposure, but this increase was inhibited by cyclophosphamide treatment. Corneal injury significantly induced early MMP-9 expression that returned to baseline levels within 4 days. Cyclophosphamide pretreatment reduced and delayed MMP-9 after scarification. Fusarium exposure dampened the MMP-9 response to corneal trauma in immunocompetent and cyclophosphamide-treated animals. Ocular levels of MMP-2 were not affected by scarification, fungal exposure, or immunosuppressive treatment.

CONCLUSIONS

Ocular MMP-9 levels, but not MMP-2 levels, increased soon after corneal injury. A similar, although muted, MMP-9 response occurs during early filamentous fungal keratitis, with a kinetic profile similar to corneal disease progression. The early stage of ulcerative keratitis may involve selective regulation of corneal matrix metalloproteinases, suggesting an initial opportunity for therapeutic intervention.

Corneal melting associated with topical diclofenac use after laser-assisted subepithelial keratectomy

We report a case of corneal melting associated with topically applied preservative-free diclofenac (Voltaren Ofta) after laser-assisted subepithelial keratectomy. Keratolysis was detected on day 5; further progression toward perforation was arrested by immediate suspension of diclofenac and prescription of topical dexamethasone with 24-hour patching. At the last follow-up, the visual acuity had improved from counting fingers to 20/20. Preservative-free diclofenac instillation had never been associated with keratolysis. Topical steroids may be useful in treating corneal melting associated with nonsteroidal antiinflammatory drugs.

Corneal ulceration and perforation with ketorolac tromethamine (Acular) use after PRK

PURPOSE

To report a case of corneal ulceration and perforation after PRK connected with high doses of ketorolac tromethamine (Acula).

METHODS

A 31-year-old man presented 5 days after PRK in the left eye with corneal ulceration and perforation requiring penetrating keratoplasty. The patient admitted to using Acular every hour, ciprofloxocin every hour, and prednisolone acetate 1% QID postoperatively.

RESULTS

Laboratory tests, including corneal cultures, were normal. A diagnosis of corneal ulceration secondary to incorrect use of high-dose ketorolac tromethamine was made.

CONCLUSION

Judicious patient counseling is recommended when using topical NSAIDs in the setting of PRK.

Emerging guidelines for use of NSAID therapy to optimize cataract surgery patient care

This analysis provides guidelines for the proper use of topical ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs), discusses their effect on inflammation, and their role in the prevention of cystoid macular edema (CME). A novel treatment strategy is presented for recommended topical ophthalmic NSAID dosing in patient populations based on risk factors for CME. The article reviews current topical ophthalmic NSAIDs, as well as a newest generation of pro-drug NSAIDs. In addition, combination therapy of NSAIDs and corticosteroids are discussed, along with a general review of therapeutic guidelines for dosing regimens, and benefits and risks of therapy. The goal of this analysis is to provide a suggested therapeutic regimen with topical NSAIDs to assist in achieving optimal clinical and functional outcomes.

Contact lens assisted pharmacologically induced keratoshaping

PURPOSE

To retrospectively evaluate the effectiveness and describe the process of reducing hyperopia with a nonsteroidal antiinflammatory agent and a soft disposable contact lens in postoperative excimer laser patients with consecutive hyperopia.

SETTING

Private practice.

METHODS

This study includes a retrospective analysis of 14 eyes of 12 patients who underwent laser in situ keratomileusis or photorefractive keratectomy and experienced consecutive hyperopia. Patients were treated with a tightly fit, extended-wear contact lens in combination with the use of ketorolac tromethamine 0.5% (Acular) in an attempt to steepen the cornea. Uncorrected visual acuity, manifest refraction, and slitlamp examination were performed on a weekly basis until the desired outcome was achieved or until treatment was discontinued.

RESULTS

A total of 78.57% of eyes experienced a decrease in consecutive hyperopia (>or=0.50 diopters [D]) (P = 0.002). The mean dioptric change was 1.05D. A total of 88.89% of eyes experienced an increase in uncorrected visual acuity (>or=1 line) (P < 0.001). The mean increase was three lines of Snellen or Jaeger acuity. The mean number of weeks to see an effect was 1.71 weeks, and the mean number of weeks to achieve endpoint was 8.29 weeks (median, 6 weeks). CONCLUSIONS.: Contact lens-assisted pharmacologically induced keratoshaping is an effective treatment option for patients who experience consecutive hyperopia after laser in situ keratomileusis or photorefractive keratectomy.