Synthetic polymers for ophthalmic applications

The contact lens represents a well-established important class of biomaterials. This thesis brings together the literature, mostly Japanese and American patents, concerned with an important group of polymers, `rigid gas permeable contact lens materials'. A comparison is made of similarities in the underlying chemical themes, centring on the use of variants of highly branched siloxy compounds with polymerizable methacrylate groups. There is a need for standard techniques to assess laboratory behaviour in relation to in vitro performance. A major part of the present work is dedicated to the establishment of such standardised techniques. It is apparent that property design requirements in this field (i.e. oxygen permeability, surface and mechanical properties) are to some extent conflicting. In principle, the structural approaches used to obtain high oxygen permeability lead to surface properties that are less than ideal in terms of compatibility with tears. PMMA is known to have uniquely good (but not perfect) surface properties in this respect; it has been used as a starting point in attempting to design new materials that possess a more acceptable compromise of transport and surface properties for ocular use. Initial examination of the oxygen permeabilities of relatively simple alkyl methacrylates, show that butyl methacrylate which has a permeability some fifty times greater than PMMA, represents an interesting and hitherto unexplored group of materials for ophthalmic applications. Consideration was similarly given to surface modification techniques that would produce materials having the ability to sustain coherent tear film in the eye without markedly impairing oxygen transport properties. Particular attention is paid to the use of oxygen plasma techniques in this respect. In conclusion, similar design considerations were applied to an extended wear hydrogel lens material in an attempt to overcome mechanical stability deficiencies which manifest themselves lq`in vivo' but not `in vitro'. A relatively simple structure modification, involving steric shielding of the amide substituent group, proved to be an effective solution to the problem.

Lipoidal species in ocular spoilation processes

Tear component deposition onto contact lenses is termed `spoilation' and occurs due to the interaction of synthetic polymers with their biological fluid environment. Spoilation phenomena alter the physico-chemical properties of hydrophilic contact lenses, diminishing the optical properties of the lens; causing discomfort and complications for the wearer. Eventually these alterations render the lens unwearable. The primary aim of this interdisciplinary study was to develop analytical techniques capable of analysing the minute quantities of biological deposition involved, in particular the lipid fraction. Prior to this work such techniques were unavailable for single contact lenses. It is envisaged that these investigations will further the understanding of this biological interfacial conversion. Two main analytical techniques were developed: a high performance liquid chromatography (HPLC) technique and fluorescence spectrofluorimetry. The HPLC method allows analysis of a single contact lens and provided previously unavailable valuable information about variations in the lipid profiles of deposited contact lenses and patient tear films. Fluorescence spectrophotofluorimetry is a sensitive non-destructive technique for observing changes in the fluorescence intensity of biological components on contact lenses. The progression and deposition of tear materials can be monitored and assessed for both in vivo and in vitro spoiled lenses using this technique. An improved in vitro model which is comparable to tears and chemically mimics ocular spoilation was also developed. This model allows the controlled study of extrinsic factors and hydrogel compositions. These studies show that unsaturated tear lipids, probably unsaturated fatty acids, are involved in the interfacial conversion of hydrogel lenses, rendering them incompatible with the ocular microenvironment. Lipid interaction with the lens surface then facilitates secondary deposition of other tear components. Interaction, exchange and immobilisation (by polymerisation) of the lipid layer appears to occur before the final and rapid growth of more complex, insoluble discrete deposits, sometimes called `white spots'.

Tear protein interaction with hydrogel contact lenses

The design and synthesis of biomaterials covers a growing number of biomedical applications. The use of biomaterials in biological environment is associated with a number of problems, the most important of which is biocompatabUity. If the implanted biomaterial is not compatible with the environment, it will be rejected by the biological site. This may be manifested in many ways depending on the environment in which it is used. Adsorption of proteins takes place almost instantaneously when a biomaterial comes into contact with most biological fluids. The eye is a unique body site for the study of protein interactions with biomaterials, because of its ease of access and deceptive complexity of the tears. The use of contact lenses for either vision correction and cosmetic reasons or as a route for the controlled drug delivery, has significantly increased in recent years. It is relatively easy to introduce a contact lens Into the tear fluid and remove after a few minutes without surgery or trauma to the patient. A range of analytical techniques were used and developed to measure the proteins absorbed to some existing commercial contact lens materials and also to novel hydrogels synthesised within the research group. Analysis of the identity and quantity of proteins absorbed to biomaterials revealed the importance of many factors on the absorption process. The effect of biomaterial structure, protein nature in terms of size. shape and charge and pH of the environment on the absorption process were examined in order to determine the relative up-take of tear proteins. This study showed that both lysozyme and lactoferrin penetrate the lens matrix of ionic materials. Measurement of the mobility and activity of the protein deposited into the surface and within the matrix of ionic lens materials demonstrated that the mobility is pH dependent and, within the experimental errors, the biological activity of lysozyme remained unchanged after adsorption and desorption. The study on the effect of different monomers copolymerised with hydroxyethyl methacrylate (HEMA) on the protein up-take showed that monomers producing a positive charge on the copolymer can reduce the spoilation with lysozyme. The studies were extended to real cases in order to compare the patient dependent factors. The in-vivo studies showed that the spoilation is patient dependent as well as other factors. Studies on the extrinsic factors such as dye used in colour lenses showed that the addition of colourant affects protein absorption and, in one case, its effect is beneficial to the wearer as it reduces the quantity of the protein absorbed.

Towards an improved ocular drug delivery system

The ultimate aim of this project was to design new biomaterials which will improve the efficiency of ocular drug delivery systems. Initially, it was necessary to review the information available on the nature of the tear fluid and its relationship with the eye. An extensive survey of the relevant literature was made. There is a common belief in the literature that the ocular glycoprotein, mucin, plays an important role in tear film stability, and furthermore, that it exists as an adherent layer covering the corneal surface. If this belief is true, the muco-corneal interaction provides the ideal basis for the development of sustained release drug delivery. Preliminary investigations were made to assess the ability of mucin to adhere to polymer surfaces. The intention was to develop a synthetic model which would mimic the supposed corneal/mucin interaction. Analytical procedures included the use of microscopy (phase contrast and fluorescence), fluorophotometry, and mucin-staining dyes. Additionally, the physical properties of tears and tear models were assessed under conditions mimicking those of the preocular environment, using rheological and tensiometric techniques. The wetting abilities of these tear models and opthalmic formulations were also investigated. Tissue culture techniques were employed to enable the surface properties of the corneal surface to be studied by means of cultured corneal cells. The results of these investigations enabled the calculation of interfacial and surface characteristics of tears, tear models, and the corneal surface. Over all, this work cast doubt on the accepted relationship of mucin with the cornea. A corneal surface model was designed, on the basis of the information obtained during this project, which would possess similar surface chemical properties (i.e. would be biomimetic) to the more complex original. This model, together with the information gained on the properties of tears and solutions intended for ocular instillation, could be valuable in the design of drug formulations with enhanced ocular retention times. Furthermore, the model itself may form the basis for the design of an effective drug-carrier.

Reproducibility and repeatability of the OcuSense TearLab™ osmometer

BACKGROUND: Some studies report that increased tear osmolarity is a reliable indicator of dry eye syndrome (DES). The OcuSense TearLab™ osmometer requires less than a 100-nl sample of tears and provides an instant quantitative result. Our aim was to clinically evaluate this instrument in terms of its reproducibility and repeatability. METHODS: Twenty-nine participants who ranged in age from 19 to 49 years (mean?±?SD: 23.3?±?5.5 years) were recruited. Osmolarity readings were collected by two operators, in two sessions separated by 1 or 2 weeks in order to assess test reproducibility and repeatability. RESULTS: The coefficient of reproducibility was 39 mOsms/l; the coefficient of repeatability was 33 mOsms/l. CONCLUSIONS: Our mean coefficient of variation over four readings for 29 subjects is 2.9%, which compares well with that reported by the manufacturer. Our results inform practitioners about the level of change over time that can be considered clinically relevant for healthy subjects. This value is 33mOsms/l; any change smaller than this could be attributed to measurement noise.

Fibre optics sensors in tear electrolyte analysis:towards a novel point of care potassium sensor

The diagnosis of ocular disease is increasingly important in optometric practice and there is a need for cost effective point of care assays to assist in that. Although tears are a potentially valuable source of diagnostic information difficulties associated with sample collection and limited sample size together with sample storage and transport have proved major limitations. Progressive developments in electronics and fibre optics together with innovation in sensing technology mean that the construction of inexpensive point of care fibre optic sensing devices is now possible. Tear electrolytes are an obvious family of target analytes, not least to complement the availability of devices that make the routine measurement of tear osmolarity possible in the clinic. In this paper we describe the design, fabrication and calibration of a fibre-optic based electrolyte sensor for the quantification of potassium in tears using the ex vivo contact lens as the sample source. The technology is generic and the same principles can be used in the development of calcium and magnesium sensors. An important objective of this sensor technology development is to provide information at the point of routine optometric examination, which would provide supportive evidence of tear abnormality.

Clinical evaluation of the Oculus Keratograph

AIM: To determine the validity and reliability of the measurement of corneal curvature and non-invasive tear break-up time (NITBUT) measures using the Oculus Keratograph. METHOD: One hundred eyes of 100 patients had their corneal curvature assessed with the Keratograph and the Nidek ARKT TonorefII. NITBUT was then measured objectively with the Keratograph with Tear Film Scan software and subjectively with the Keeler Tearscope. The Keratograph measurements of corneal curvature and NITBUT were repeated to test reliability. The ocular sensitivity disease index questionnaire was completed to quantify ocular comfort. RESULTS: The Keratograph consistently measured significantly flatter corneal curvatures than the ARKT (MSE difference: +1.83±0.44D), but was repeatable (p>0.05). Keratograph NITBUT measurements were significantly lower than observation using the Tearscope (by 12.35±7.45s; pp < 0.001) and decreased on subsequent measurement (by -1.64 ± 6.03s; p < 0.01). The Keratograph measures the first time the tears break up anywhere on the cornea with 63% of subjects having NI-TBUT's <5s and a further 22% having readings between 5 and 10s. The Tearscope results were found to correlate better with the patients symptoms (r = -0.32) compared to the Keratograph (r = -0.19). Conclusions: The Keratograph requires a calibration off-set to be comparable to other keratometry devices. Its current software detects very early tear film changes, recording significantly lower NITBUT values than conventional subjective assessment. Adjustments to instrumentation software have the potential to enhance the value of Keratograph objective measures in clinical practice.

The fall and rise of tear albumin levels:a multifactorial phenomenon

Albumin in tears is used as a diagnostic marker of ocular insult and inflammation, but whether its presence in tears is responsive or part of an adaptive reaction remains unresolved. A review of the literature on tear albumin concentration emphasizes that variables such as collection method, stimulus, assay technique, and disease state influence the quoted values to different extents. Influence of assay technique is negligible in comparison to variation in sampling conditions. Ocular disease increases albumin concentrations but not in a specific manner. The literature review also highlighted that little systematic research has been carried out on the daily cycle of tear albumin levels. In order to remedy this shortcoming, we investigated variations in tear albumin concentration during the waking day. The concentration of albumin in 400 tear samples collected from 13 subjects was assessed at 2-hourly intervals throughout the waking day. Highest daytime albumin concentrations were obtained within 10 minutes of waking, with a mean concentration of >50 ± 22 µg/ml. Albumin levels were at their lowest, but most consistent, 2-6 hours post-waking. This pattern was followed by a progressive increase in albumin concentration during the latter part of the day. Although individual subject-to-subject concentration differences were observed, this distinctive pattern of diurnal variation was found in all subjects. The results presented suggest a regulated, not random, pattern of variation within the period of study. © 2013 Elsevier Inc. All rights reserved.

A preliminary investigation into the effects of ocular lubricants on higher order aberrations in normal and dry eye subjects

Purpose: To study the effects of ocular lubricants on higher order aberrations in normal and self-diagnosed dry eyes. Methods: Unpreserved hypromellose drops, Tears Again™ liposome spray and a combination of both were administered to the right eye of 24 normal and 24 dry eye subjects following classification according to a 5 point questionnaire. Total ocular higher order aberrations, coma, spherical aberration and Strehl ratios for higher order aberrations were measured using the Nidek OPD-Scan III (Nidek Technologies, Gamagori, Japan) at baseline, immediately after application and after 60. min. The aberration data were analyzed over a 5. mm natural pupil using Zernike polynomials. Each intervention was assessed on a separate day and comfort levels were recorded before and after application. Corneal staining was assessed and product preference recorded after the final measurement for each intervention. Results: Hypromellose drops caused an increase in total higher order aberrations (p= <0.01 in normal and dry eyes) and a reduction in Strehl ratio (normal eyes: p= <0.01, dry eyes p= 0.01) immediately after instillation. There were no significant differences between normal and self-diagnosed dry eyes for response to intervention and no improvement in visual quality or reduction in higher order aberrations after 60. min. Differences in comfort levels failed to reach statistical significance. Conclusion: Combining treatments does not offer any benefit over individual treatments in self-diagnosed dry eyes and no individual intervention reached statistical significance. Symptomatic subjects with dry eye and no corneal staining reported an improvement in comfort after using lubricants. © 2013 British Contact Lens Association.

Effectiveness of nonpharmacologic treatments for acute seasonal allergic conjunctivitis

Objective - To investigate whether artificial tears and cold compress alone or in combination provide a treatment benefit and whether they were as effective as or could enhance topical antiallergic medication. Design - Randomized, masked clinical trial. Participants - Eighteen subjects (mean age, 29.5±11.0 years) allergic to grass pollen. Intervention - Controlled exposure to grass pollen using an environmental chamber to stimulate an ocular allergic reaction followed by application of artificial tears (ATs), 5 minutes of cold compress (CC), ATs combined with CC, or no treatment applied at each separate visit in random order. A subset of 11 subjects also had epinastine hydrochloride (EH) applied alone and combined with CC in random order or instillation of a volume-matched saline control. Main Outcome Measures - Bulbar conjunctival hyperemia, ocular surface temperature, and ocular symptoms repeated before and every 10 minutes after treatment for 1 hour. Results - Bulbar conjunctival hyperemia and ocular symptoms decreased and temperature recovered to baseline faster with nonpharmaceutical treatments compared with no treatment (P?tears combined with CC reduced hyperemia more than other treatments (P??0.05). At all measurement intervals, symptoms were reduced for both EH and EH combined with CC than CC or ATs alone or in combination (P?

Effectiveness of nonpharmacologic treatments for acute seasonal allergic conjunctivitis

Objective To investigate whether artificial tears and cold compress alone or in combination provide a treatment benefit and whether they were as effective as or could enhance topical antiallergic medication. Design Randomized, masked clinical trial. Participants Eighteen subjects (mean age, 29.5±11.0 years) allergic to grass pollen. Intervention Controlled exposure to grass pollen using an environmental chamber to stimulate an ocular allergic reaction followed by application of artificial tears (ATs), 5 minutes of cold compress (CC), ATs combined with CC, or no treatment applied at each separate visit in random order. A subset of 11 subjects also had epinastine hydrochloride (EH) applied alone and combined with CC in random order or instillation of a volume-matched saline control. Main Outcome Measures Bulbar conjunctival hyperemia, ocular surface temperature, and ocular symptoms repeated before and every 10 minutes after treatment for 1 hour. Results Bulbar conjunctival hyperemia and ocular symptoms decreased and temperature recovered to baseline faster with nonpharmaceutical treatments compared with no treatment (P <0.05). Artificial tears combined with CC reduced hyperemia more than other treatments (P <0.05). The treatment effect of EH was enhanced by combining it with a CC (P <0.001). Cold compress combined with ATs or EH lowered the antigen-raised ocular surface temperature to less than the pre-exposure baseline. Artificial tear instillation alone or CC combined with ATs or EH significantly reduced the temperature (P <0.05). Cold compress combined with ATs or EH had a similar cooling effect (P > 0.05). At all measurement intervals, symptoms were reduced for both EH and EH combined with CC than CC or ATs alone or in combination (P <0.014). Conclusions After controlled exposure to grass pollen, CC and AT treatment showed a therapeutic effect on the signs and symptoms of allergic conjunctivitis. A CC enhanced the use of EH alone and was the only treatment to reduce symptoms to baseline within 1 hour of antigenic challenge. Signs of allergic conjunctivitis generally were reduced most by a combination of a CC in combination with ATs or EH. © 2014 by the American Academy of Ophthalmology.

Management of allergic conjunctivitis and dry eye

Ocular allergy is a common eye condition encountered in clinical practice. However, little is known how seasonal allergic conjunctivitis (SAC), the most common subtype, is managed in clinical practice. Further, dry eye, another common eye condition, may be misdiagnosed as SAC and vice-versa as they share similar signs and symptoms. In addition, despite the frequent recommendation of non-pharmacological treatments for SAC, evidenceto support their use has not been identified in the scientific literature. The aim of this thesis was therefore to determine the actual diagnosis and management of SAC and dry eye in clinical practice and investigate the efficacy of non-pharmacological treatments for these conditions. The diagnostic and management strategies for SAC and dry eye employed by pharmacy staff are found to be inconsistent with current guidelines and scientific evidence based upon a mystery shopper design. Cluster analysis of tear film metrics in normal and dry eye patients identified several clinically relevant groups of patients that may allow for targeted treatment recommendations. Using a novel environmental chamber model of SAC, the use of artificial tears and cold compresses, either alone or combined is an effective treatment modality for acute and symptomatic SAC, on a par with topical anti-allergic medication, and has been demonstrated for the first time. In addition, eyelid warming therapy with a simple, readily available, seed filled device is an effective method of treating meibomian gland dysfunction (MGD) related evaporative dry eye, perhaps the most common dry eye subtype. A greater focus on ophthalmology must be implemented as part of the formal education and training of pharmacy staff, while greater professional communication between community pharmacists, optometrists and the population they serve is required. Artificial tears and cold compresses may be considered as front line agents for acute SAC by pharmacy staff and optometrists, to whom pharmacological treatment options are limited.

Contact lens interactions with the tear film

Biochemical changes brought about by the influence of the contact lens on the tear film are conveniently split into two categories. Firstly, the lens can remove or reduce the levels of specific components in the tear film, and secondly, the lens can augment the tear film, by stimulating the influx of new components or increasing the level of existing components. The most obvious tear film components for study in this context are lipids, proteins, mucins and electrolytes. The interactions are affected by the properties of the lens, the characteristics of the individual wearer and the wear schedule. An additional complicating factor is the fact that the lens is many times thicker than the tear film and any immobilised tear components will be more extensively exposed to oxygen and UV radiation than is the case in the absence of a lens. It is arguably the lipoidal components that are most markedly affected by lens wear, since their immobilisation on the lens surface markedly increases their susceptibility to autoxidative degradation. The limited information that is available highlights the importance of subject specificity and suggests that lipid oxidation phenomena are potentially important in contributing to the 'end of day' discomfort of symptomatic contact lens patients. It is clear that tear lipids, although regarded as relatively inert for many years, are now seen as a reactive and potentially important family of compounds in the search for understanding of contact lens-induced discomfort. The influence of the lens on tear proteins shows the greatest range of complexity. Deposition and denaturation can stimulate immune response, lower molecular weight proteins can be extensively absorbed into the lens matrix and the lens can stimulate cascade or upregulation processes leading either to the generation of additional proteins and peptides or an increase in concentration of existing components. Added to this is the stimulating influence of the lens on vascular leakage leading to the influx of plasma proteins such as albumin. The evidence from studies of mucin expression in tears is not consistent and conclusive. This is in part because sample sources, lens materials and methods of analysis vary considerably, and in some cases the study population numbers are low. Expression levels show mucin and material specificity but clear patterns of behaviour are elusive. The electrolyte composition of tears is significantly different from that of other body fluids. Sodium and potassium dominate but potassium ion concentrations in tears are much higher than in serum levels. Calcium and magnesium concentrations in tears are lower than in serum but closer to interstitial fluids. The contact lens provides the potential for increased osmolarity through enhanced evaporation and differential electrolyte concentrations between the anterior and posterior tear films. Since the changes in ocular biochemistry consequent upon contact lens wear are known to be subject-dependent - as indeed is wearer response to the lens - pre-characterisation of individual participant tear chemistry in clinical studies would enhance understanding of these complex effects. © 2013 Elsevier Ltd.

Tear analysis and lens-tear interactions:Part I. Protein fingerprinting with microfluidic technology

The purpose of this work is to establish the application of a fully automated microfluidic chip based protein separation assay in tear analysis. It is rapid, requires small sample volumes and is vastly superior to, and more convenient than, comparable conventional gel electrophoresis assays. The protein sizing chip technology was applied to three specific fields of analysis. Firstly tear samples were collected regularly from subjects establishing the baseline effects of tear stimulation, tear state and patient health. Secondly tear samples were taken from lens wearing eyes and thirdly the use of microfluidic technology was assessed as a means to investigate a novel area of tear analysis, which we have termed the 'tear envelope'. Utilising the Agilent 2100 Bioanalyzer in combination with the Protein 200 Plus LabChip kit, these studies investigated tear proteins in the range of 14-200 kDa. Particular attention was paid to the relative concentrations of lysozyme, tear lipocalin, secretory IgA (sIgA), IgG and lactoferrin, together with the overall tear electropherogram 'fingerprint'. Furthermore, whilst lens-tear interaction studies are generally thought of as an investigation into the effects of tears components on the contact lens material, i.e. deposition studies, this report addresses the reverse phenomenon-the effect of the lens, and particularly the newly inserted lens, on the tear fluid composition and dynamics. The use of microfluidic technology provides a significant advance in tear studies and should prove invaluable in tear diagnostics and contact lens performance analysis.

The detection of kinin activity in contact lens wear

Many factors can be, and have been, attributed to the appearance of complications in lens wear, but the greatest is associated with deposition. Reduced acuity, irritation and inflammatory responses are often referred to as adverse reactions arising as a result of deposition. In this study, particular attention was paid to the potential role of adsorbed proteins in activating, mediating and/or stimulating a host immune response, i.e., the hypothesis that the adsorption of certain proteins from the tears and ocular surfaces may actively affect successful lens wear. In particular, the purpose of this study was to investigate the presence of a group of proteins previously undiscovered in the ocular environment. The intention was to target a family of proteins/glycoproteins that have become prominent recently in a variety of inflammatory responses and disorders at many other mucosal associated sites around the body, e.g. in nasal rhinitis and in joint inflammation. The protein cascade in question is the kinin family of inflammatory mediators. The aim was to investigate their presence in the ocular environment, specifically in relation to contact lens wear, and consequently assess the implications of their discovery. High molecular weight kininogen (HMWK), with its central role in kinin responses, was investigated initially as the marker of kinin activity, with subsequent members examined thereafter.