Corneal alteration potentially leading to ulceration remains a major health concern in ocular surface diseases. A treatment that would improve both the quality and speed of healing and control the inflammation would be of great interest. Regenerating agents (RGTAs) have been shown to stimulate wound healing and modulate undesired fibrosis in various in vivo systems. We investigated the effects of RGTA-OTR4120(®) in a rabbit corneal model in order to assess its potential use in ocular surface diseases. First, we assessed its safety for 7 and 28 days using the Draize test criteria in healthy rabbit eyes; then, we investigated the effect of a single dose (50μl, 5μg) in an alkali-burned cornea model. Daily follow-up of clinical signs of healing was scored, and histology was performed at D7. RGTA was well tolerated; no signs of ocular irritation were observed. In the corneal alkali-burn model, non-RGTA-treated eyes showed inflammatory clinical signs, and histology confirmed a loss of superficial corneal layers with epithelial disorganization, neovascularization and infiltration of inflammatory cells. When compared to NaCl control, RGTA treatment appeared effective in reducing clinical signs of inflammation, enhancing re-epithelialization, and improving histological patterns: edema, fibrosis, neovascularization and inflammation. Three to four layers of epithelial cells were already organized, stroma was virtually unvascularized and keratocytes well implanted in parallel collagen fibers with an overall reorganization similar to normal cornea. RGTA appears to be a promising agent for controlling ocular surface inflammation and promoting corneal healing and was well tolerated. This study offers preclinical information and supports the findings of other (compassionate or pilot) studies conducted in patients with various ocular surface diseases.

PURPOSE:Prospective evaluation of aqueous flare following intravitreal bevacizumab (Avastin, Genentech Inc., San Francisco, CA, USA) injections in eyes with choroidal neovascularization due to age-related macular degeneration. PATIENTS AND METHODS:Sixteen eyes of eight patients were recruited. Aqueous humor flare was determined by laser flare meter every month after one intravitreal injection of 1.25mg of bevacizumab at baseline followed by a second injection at month3 (day 100±21days). Four patients received an injection at month6 (±10days), and one patient received an injection at month7. RESULTS:Two months after the first intravitreal bevacizumab injection, flare values decreased from 10±5.57 (mean±standard deviation) to 5.2±1.69photon count/ms (P=0.0207) and from 8.3±3.59 to 5.4±0photon counts/ms, 2months after the second injection (P=0.02). CONCLUSION:Significantly decreased aqueous humor flare levels were noted after repeated injections of bevacizumab.

Introduction. - The various forms of ophthalmic pharmaceutical presentation of steroids is proliferating on the market: solutions, gels, and suspensions. Suspensions are characterized by particles in solution and require agitation before instillation. This trial studied the impact of agitation on the corticoid concentration of eye drop solutions, gels, and suspensions.Methods. - Corticosteroid levels in a drop of a dexamethasone solution or suspension or betamethasone suspension or gel were compared using liquid chromatography. These levels were measured after shaking for 5, 10, 30s, and 1 min using a vortex or without shaking.Results. - The results of this study show that, whatever shaking time was used, the suspension form seems less suited to instillation of corticosteroids. The suspension did not deliver consistent levels of corticosteroids (mean between 23 and 99%) compared to solutions and gels, which released about 100% of the corticosteroid content in each drop.Conclusion. - Physicians, ophthalmologists, and pharmacists should remind the patient of the proper use of these suspensions before instillation. In cases of treatment failure, it is necessary to check the instillation method before questioning patient compliance. (C) 2011 Published by Elsevier Masson SAS.

Preservatives are present in numerous multidose eyedrops and provide the sterility of the solution against bacteria and fungi However, numerous studies have shown their toxicity for the ocular surface, particularly in long term treatments The most widely used preservative in eyedrops is benzalkonium chloride This quaternary ammonium acts as a deter gent, antiseptic, disinfectant, fungicide, bactericide, and spermicide Its use on the ocular surface therefore has significant consequences Indeed, the preservatives are pro apoptotic, pro inflammatory and they cause the dissolution of the lachrymal film The prolonged administration of one or several eye drops containing preservatives induces changes in the superficial structures (conjunctiva, cornea) as well as in deeper structures (trabecula, lens) The least severe symptoms are irritation and discomfort, including sensation of a foreign body, itching, or burning sensations However, more severe side effects have been described, such as chronic inflammation of variable intensity or the progressive development of fibrosis with higher risk of failure after glaucoma filtering surgery Ideally, preservative-free eyedrops should be recommended, or at least a reduction of the number of Instilled preserved eyedrops should be considered All these strategies could increase patient comfort, quality of life, and compliance, with better outcome at the time of filtering surgery (C) 2010 Elsevier Masson SAS All rights reserved

Les conservateurs sont présents dans de nombreux collyres multidoses. Ils assurent la stérilité de la solution vis-à-vis des bactéries et champignons. Cependant, des études ont montré que les conservateurs sont toxiques pour la surface oculaire notamment chez les patients prenant des collyres au long cours. Le conservateur le plus employé dans les collyres est le chlorure de benzalkonium, ammonium quaternaire utilisé comme détergent, antiseptique, désinfectant, fongicide, bactéricide et spermicide. Son utilisation sur la surface oculaire pourrait avoir des conséquences importantes en particulier sur le long terme. En effet, les conservateurs provoquent la dissolution du film lacrymal et sont pro-apoptotiques et pro-inflammatoires. L’administration prolongée de collyres contenant un ou plusieurs conservateurs conduit à une altération des structures superficielles (conjonctive, cornée) et plus profondes (trabéculum, cristallin). Les signes et symptômes oculaires les moins sévères se manifestent par une gêne ou des irritations : sensation de corps étranger de picotement ou brûlure, d’œil sec. Pour les effets secondaires les plus graves, on observe une inflammation d’intensité variable allant d’une simple réaction infraclinique au développement progressif d’une fibrose avec entre autres un risque accru d’échec en cas de chirurgie du glaucome. Le meilleur moyen de limiter ces complications passe par la réduction du nombre d’instillations de collyres conservés, et idéalement par l’utilisation de collyres sans conservateur, chaque fois que cela est possible. Une meilleure prise en charge de la surface oculaire devrait permettre d’augmenter le confort du patient, l’observance du traitement et d’assurer l’efficacité d’une future chirurgie filtrante chez les patients atteints de glaucome.

CACICOL20 (R) is a new ophthalmic device, derived from RGTA (R) based matrix therapy. RGTA (R) are biodegradable nanobiopolymers engineered to mimic heparan sulfates and used after injury to restore extracellular matrix microenvironment back to its original architecture. A pilot study was performed on eleven eyes from ten patients with severe keratitis or painful corneal ulcers rating over 50 on the visual analog pain scale (VAS). All had undergone unsuccessful treatments with a mean lasting over 8 years. CACICOL20 (R) was instilled once a week over 1 month. General and local tolerance were excellent. Mean VAS dropped from 72.73 +/- 7.86. to 32+/-15.49, and increased after the end of the treatment, Mean severity of keratitis measured by initial Oxford Score was 3.37 +/- 1.06, decreased significantly to 1.57 +/- 0.97 and rose again after the end of the treatment. Four from the five included ulcers healed during the protocol, two reversed after. CACICOL20 (R) is available in Europe and provides an innovative solution for unresolved pain and corneal surface healing problems.

Nous présentons l'observation d'un patient pseudophaque porteur d'une bulle intracamérulaire supérieure de deux millimètres de diamètre. Nous étayons notre observation par un OCT Visante et une analyse en spectre infrarouge de la composition de la bulle. Il s'agit d'un patient âgé de 75 ans adressé pour une inflammation de chambre antérieure de l'œil gauche. Ce patient est pseudophaque en chamber postérieure depuis 4 ans. Il présente depuis quelques mois une gêne visuelle à type de flou positionnel intermittent. L'acuité visuelle était à 7/10. Il existait une bulle mobile dans chambre antérieure à midi de deux millimètres de diamètre associée à un tyndall protéique minime. À l'OCT Visante, la bulle est bien visible, hyperéchogène, homogène arrondie. Cette bulle a été extraite chirurgicalement et étudiée par spectrographie infrarouge. Cette analyse a mis en évidence des alcanes non ramifiés dont le spectre est celui d'une huile minérale compatible avec la composition de la pommade à la dexaméthasone et oxytétracycline (Sterdex). Un aspect comparable a été rapporté dans la littérature. Différentes substances ont été incriminées. Le Sterdex peut constituer une étiologie rare de bulle intra-camérulaire après chirurgie de la cataracte.

C. Khammari Chebbi, K. Kichenin, N. Amar, H. Nourry, J.M. Warnet, D. Barritault, C. Baudouin

AIMS:This study's objective was to evaluate the tolerance and safety of a new ophthalmic solution based on ReGeneraTing agent (RGTA) technology in a pilot noncontrolled exploration on compassion use for corneal ulcers and severe chronic dystrophies resistant to the usual treatments.RATIONALE:RGTAs are large biopolymers engineered to replace heparan sulfates specifically bound to matrix proteins and growth factors destroyed after a lesion has occurred. The RGTA-bound proteins are protected from proteolysis and this allows the extracellular matrix microenvironment to restore its original proper organization. The initial endogenous signals needed for tissues to regenerate are back on the restored matrix. They are expected to trigger the natural onset of events, signaling cells to migrate and multiply with the cascades and equilibrium found in tissue homeostasis. RGTA-induced matrix therapy is a possible alternative to cell or gene therapy in regenerative medicine. In a rabbit preclinical model of alkali-induced severe corneal ulcers, a single instillation of RGTA ophthalmic solution was found sufficient to enhance speed and quality of healing, restoring an almost normal corneal histology after only 1 week. These data prompted us to initiate this study.PATIENTS AND METHODS:Eleven eyes from ten patients were included in this study. All patients had severe dystrophic cornea or painful corneal ulcers rated over 50 on the VAS pain scale ranging from 0 to 100 and had undergone unsuccessful treatments. The RGTA ophthalmic solution was administered by the investigator during each weekly consultation as a single drop over 1 month. Tolerance and efficacy were judged on subjective criteria based on pain evaluation and functional inconvenience as well as on objective clinical criteria through a complete ophthalmic examination at days 3, 7, 14, 21, 28 and after 2 and 3 months from the beginning of the treatment.RESULTS:The study was conducted to completion for all patients included at the beginning. Tolerance was excellent both locally and generally: no uneasiness during instillation, no worsening of the initial pathology, no occurrence of ocular inflammation or increase in ocular pressure, and no general side effects were observed. In addition, we observed a noticeable analgesic effect, increasing with time and instillations, but pain reappeared in the majority of cases as treatment ended. The mean visual analog scale pain score was 72.73 +/- 7.86, it decreased significantly with the first drops of treatment. After 1 month, the mean visual analog scale pain score was 32+/-15.49, then it increased after the end of the treatment, confirming the link between the effects observed and the treatment. Efficacy on keratitis was moderate but with an overall tendency toward improvement. The initial Oxford Score was 3.37 +/- 1.06. After 1 month, it decreased significantly to 1.57 +/- 0.97 and then it rose again after the end of the treatment. As for corneal ulcers, of the five cases included, four healed during the protocol. Two reversed when the treatment stopped, two healed without reversion at the last follow-up visit. The last case was characterized by stem cell deficiency and no improvement was noted. It is important to keep in mind that these ulcers were all resistant to usual therapies.CONCLUSION:This RGTA ophthalmic solution is the first matrix therapy product in ophthalmology. The RGTA OTR4120 was used in treating chronic and severe corneal dystrophies as well as corneal ulcers resistant to usual treatments. It was very well tolerated with no side effects. It significantly reduced pain and favored corneal healing in almost all corneal ulcers. Weekly instillation of a single drop seems insufficient and these very promising data need to be confirmed on a larger population in a controlled trial with more adapted dosages. Based on these preliminary data, a RGTA-based matrix therapy product may be a very innovative solution to unresolved pain and corneal surface healing problems.

La gestion du risque prion (circulaire n° 138), nécessite l’utilisation de désinfectants du groupe II (dérivés chlorés et d’acide peracétique). Des problèmes de stabilité, de compatibilité, de toxicité ont été évoqués en endoscopie. Durant 3 ans, nous avons analysé ces critères sur des dispositifs médicaux thermosensibles d’ophtalmologie. L’évaluation de désinfectants chlorés et de solutions à base d’acide peracétique (avec activateur type anioxyde 1 000 ou prêt-à-l’emploi) a été effectuée sur plus de 3 ans sur différents dispositifs médicaux neufs (verres 3 miroirs-V3 M et quadrasphériques, sondes de diopexy, pachymétrie) avec des concentrations variables en acide peracétique (600 à 1 500 ppm et 3 à 5 % d’H2O2 ). La toxicité (libération d’H2O2 gazeux inodore et irritant pulmonaire) a été évaluée avec des badges portatifs sur les personnels. Les dérivés chlorés (0,5 % c.a), induisent des altérations précoces (3-6 cycles) de la surface des lentilles. Les désinfectants à base d’acide peracétique avec activateurs (> 1 500 ppm d’acide peracétique) altèrent précocement les V3 M (80 cycles). Ils peuvent induire une libération de vapeurs toxiques d’H2O2(VLE > 1 ppm−15 min). Les désinfectants, à base d’acide peracétique prêt-à-l’emploi, faiblement dosés (< 1 000 ppm d’acide peracétique), permettent 230 à 250 cycles de désinfection. Les vapeurs d’H2O2 sont limitées (< 1 ppm) durant tout le cycle surtout avec les dernières formulations d’acide peracétique. Les dérivés chlorés et les dérivés d’acide peracétique fortement dosés (> 1 500 ppm d’acide peracétique) ont une toxicité et ne sont pas compatibles avec la majorité des polymères d’ophtalmologie. Des procédures de désinfection efficaces avec des dérivés prêts – à-l’emploi d’acide peracétique (< 1 000 ppm) sont possibles et ont été validées avec les principales marques de lentilles thermosensibles.

Devant la multiplicité des présentations de corticoïdes à usage ophtalmique, associés ou non à un antibiotique, et le développement des génériques, le service Pharmacie du CHNO des XV-XX a souhaité analyser l’impact de la formulation galénique sur la teneur en principe actif d’une goutte instillée. Dans cette étude, deux corticoïdes ont été choisis sous différentes formes galéniques : la dexaméthasone en suspension et en solution et la bétaméthasone en suspension et en gel. L’analyse de la teneur d’une goutte de chaque formulation a été réalisée par chromatographie, soit sans agitation préalable, soit après une agitation de 5 secondes à 1 minute. Les résultats montrent un taux de recouvrement de 100 % de la teneur en corticoïde pour la solution de dexaméthasone et pour le gel de betaméthasone. En revanche, pour les suspensions de dexaméthasone et de betaméthasone, le taux de recouvrement est de l’ordre de 60 % quelle que soit la durée d’agitation. Si les solutions et gels oculaires de corticoïdes sont plus homogènes que les suspensions, le choix d’un corticoïde ne doit pas reposer uniquement sur cet argument car les suspensions permettent d’instiller des molécules lipophiles qui ont une meilleure pénétration cornéenne. Aussi, face à un échec thérapeutique avec un collyre à base de corticoïde, le médecin doit vérifier impérativement la forme galénique dispensée et revoir avec le patient le bon usage des collyres, notamment en suspension, cette dernière forme ne délivrant pas forcément 100 % de la teneur attendue.

PURPOSE:To determine whether multipurpose solutions, widely used for contact lens disinfections, could be at the origin of ocular pathologies (contact lens intolerance and ocular infections).METHODS:An observational cohort study (questionnaire analysis) was carried out to estimate the number of contact lens wearers, type of infection, and type of lens care regimen used by patients. Besides, multipurpose solutions cytotoxicity (necrosis and apoptosis) was evaluated on a conjunctival cell line using cytofluorometry.RESULTS:In the general population, 59% of contact lens wearers use multipurpose solutions whereas 35% use oxidative products. Of the questioned contact lens wearers with ocular infections, 80% used multipurpose solutions. Multipurpose solutions are therefore not efficient enough against microorganisms, and cannot be considered as disinfectant solutions but only as preservatives. However, preservatives are known to be toxic to ocular surface, so apoptosis induced by multipurpose solutions could lead to ocular surface diseases. Our cytofluorometry study allowed us to demonstrate that contact lens multipurpose solutions containing preservatives are cytotoxic through caspase 3 induction, chromatin condensation and P2X7 cell-death receptor activation, in contrast with unpreserved sterile saline solutions that were found inert.CONCLUSIONS:Multipurpose solutions seem to be preservative but not disinfecting solutions. They are not adapted to the final rinse of contact lenses because of apoptosis induction. It could explain part of lens intolerance.