Preclinical Safety and Efficacy Assessments for Novel Femtosecond Lasers in Corneal Refractive Surgery.

Preclinical safety requirements and test methods have been standardized over time to guide medical device developers in the path needed to manufacture safe devices and achieve regulatory approval. Today, femtosecond lasers are commonly used in cataract and refractive surgeries. Currently, an industry standard to guide developers in preclinical testing of ophthalmic lasers does not exist. Consequently, the data presented in regulatory submissions may vary between manufacturers, making the regulatory review process more ambiguous. Here, the authors present a comprehensive discussion of preclinical test methods applied to the evaluation of an ophthalmic laser. We include in vitro and ex vivo models, as well as an in vivo rabbit model subject to corneal refractive treatments, for consideration in a preclinical safety evaluation plan. Scientific rationale to support the ocular endpoints of evaluation in the rabbit model to demonstrate safety is also presented and discussed.

Preclinical Safety Evaluation of Ophthalmic Viscosurgical Devices in Rabbits and a Novel Mini-Pig Model.

INTRODUCTION: To establish the preclinical safety and equivalency of ophthalmic viscosurgical devices (OVDs) comprised of bacterially sourced sodium hyaluronate (HA) to animal sourced HA using pyrogenicity and aqueous exchange models in rabbits and a novel mini-pig model to evaluate corneal endothelial cell protection in vivo. METHODS: HEALON OVD and HEALON5 OVD containing animal-derived HA and HEALON PRO OVD and HEALON5 PRO OVD containing bacterial-derived HA were used. Two rabbit aqueous exchange studies were conducted where aqueous humor was exchanged with OVDs in six animals each to observe potential ocular inflammation, intraocular pressure (IOP) response, corneal health and pachymetry until 7 days post procedure, as well as overall assessment of the OVDs. Endothelial cell protection was evaluated in a Yucatan mini-pig cataract surgery model where HEALON PRO and HEALON5 PRO OVDs were compared to HEALON and HEALON5 OVDs, respectively. Following cataract surgery with use of OVDs in six animals per study, animals were evaluated for ocular and general health, IOP, corneal thickness, ocular inflammation, and endothelial cell protection on days 1, 3, 7 and 14 post-surgery. RESULTS: All rabbit studies demonstrated equivalence between bacterial-derived and animal-derived OVDs. Mild, post-surgical irritation, IOP increase, and corneal thickness measurements were not significantly different in HEALON PRO OVD and HEALON5 PRO OVD compared to HEALON and HEALON5 OVDs, respectively. The mini-pig model developed to investigate endothelial cell protection was successful in demonstrating equivalence between the OVDs studied. Changes in IOP mirrored actual surgical procedures, while corneal pachymetry and endothelial cell density remained constant for all OVDs used. Slit lamp observations showed expected inflammation following surgical procedures, likely due to challenges encountered during surgical procedures. CONCLUSION: Rabbit pyrogenicity and aqueous exchanged paired with a novel simulated cataract surgery mini-pig model demonstrate equivalence of OVDs regardless of HA source. Albeit with challenges, the mini-pig model was shown to be a promising tool for endothelial cell evaluation during the development of new OVDs for ophthalmic use. FUNDING: Johnson & Johnson Surgical Vision, Inc.

Penetrating and Intrastromal Corneal Arcuate Incisions in Rabbit and Human Cadaver Eyes: Manual Diamond Blade and Femtosecond Laser-Created Incisions.

OBJECTIVES: To compare morphologic differences between freehand diamond or femtosecond laser-assisted penetrating and intrastromal arcuate incisions. METHODS: Freehand diamond blade, corneal arcuate incisions (180° apart, 60° arc lengths) and 150 kHz femtosecond laser (80% scheimpflug pachymetry depth corneal thickness) arcuate incisions were performed in rabbits. Intrastromal arcuate incisions (100 µm above Descemet's membrane, 100 µm below epithelium) were performed in rabbit corneas (energy 1.2 µJ, spot line separation 3 × 3 µm, 90° side cut angle). Eyes were examined by slit lamp and light microscopy up to 47 days post-procedure. Freehand diamond blade penetrating incisions, and femtosecond laser penetrating and intrastromal arcuate incisions (energy 1.8 µJ, spot line separation 2 × 2 µm) were performed in cadaver eyes. Optical coherence tomography was performed immediately after surgery and the corneas were fixed for light scanning and transmission electron microscopy. RESULTS: The rabbit model showed anterior stromal inflammation with epithelial hyperplasia in penetrating blade and laser penetrating wounds. The laser intrastromal and penetrating incisions showed localized constriction of the stromal layers of the cornea near the wound. In cadaver eyes, penetrating wound morphology was similar between blade and laser whereas intrastromal wounds did not affect the cornea above or below incisions. CONCLUSION: Penetrating femtosecond laser arcuate incisions have more predictable and controlled outcomes shown by less post-operative scarring than incisions performed with a diamond blade. Intrastromal incisions do not affect uncut corneal layers as demonstrated by histopathology. The femtosecond laser has significant advantages in its ability to make intrastromal incisions which are not achievable by traditional freehand or mechanical diamond blades.

Engineering the crystalline lens with a biodegradable or non-degradable scaffold.

Both a biodegradable hyaluronic acid (HA) and a nondegradable polymeric gel were evaluated as scaffolds for tissue engineering the lens in Dutch Belt pigmented and New Zealand white rabbits. Following removal of the crystalline lens through a 2 mm capsulorhexis, a collagen patch or a silicone plug was placed in the capsule bag to seal the capsulotomy. In Part I, a cross-linked HA or cohesive solution of HA was injected into the capsule bag. In Part II, a synthetic polymer (SP) was injected into the capsular bag of one eye and HA followed by SP (HA/SP) was injected into the capsule bag of the opposite eye. At 3 months focal Nd:YAG laser photocoagulation was performed in an attempt to remove some retained HA gel in one eye. Overall the regenerated lenses of the HA gel groups were spherical with excellent cortical structure and clarity and a spherical nucleus of condensed HA gel. In the one eye treated with focal photocoagulation, partial clearing of the retained HA gel was noted. In the SP and HA/SP eyes, lens regrowth around the polymer was generally clear in the anterior and peripheral capsule bag and more opacified posterior to the polymeric scaffold. In summary, naturally regenerating lens tissue was directed to grow in a more normal, regular pattern by providing a biodegradable hyaluronic acid scaffold or a nondegradable polymeric optical scaffold.

Preparation and evaluation of a lubricious treated cartridge used for implantation of intraocular lenses.

In the last decades, many surface modification technologies have been developed in an attempt to improve the function of medical device surfaces by adding or enhancing surface characteristics. These value-added processes included treatment to affect lubricity, hemocompatibility and drug delivery. A unique hydrophilic, lubricious coating was developed to treat hydrophobic polymer surfaces. The coating platforms described are composed of a polyelectrolyte molecular film containing hydrophilic, lubricant molecules. The molecular film is then further cross-linked with di-functional aldehyde molecules to form an interpenetrating network (IPN). The IPN entraps lubricant molecules in the matrix and provides for prolonged stability of the lubricity. This coating was applied to cartridges which were used to deliver intraocular lenses (IOLs) that replaced the cataractous crystalline lenses in patients In order to determine the safety and effectiveness of the coating, a rabbit in vivo study was designed to evaluate the ease of implantation and postoperative response to implantation of the foldable acrylic IOLs. The performance evaluation of the lubricious treated cartridges focused on the ease of insertion and post-IOL implantation response. It was found that the UNFOLDER Emerald Insertion System (Advanced Medical Optics) with lubricious treated cartridges generally required lower insertion forces than the standard UNFOLDER Emerald cartridges. The postoperative inflammatory response following lens extraction and posterior chamber implantation of low (6D), medium (20D) and high (30D) diopter foldable acrylic IOLs with both treated and standard cartridges was mild. Inflammation generally resolved by 3 weeks. Thus, in this animal study, the coating was shown to be effective in assisting the delivery of IOLs through cartridges, without causing any adverse effects.

Lens regeneration in mammals: a review.

Lens regeneration occurs in New Zealand albino rabbits after endocapsular lens extraction, if the anterior and posterior capsules remain relatively intact. Research beginning in the 19th century showed that regeneration of the lens begins as early as 2 weeks postoperatively, depends on the size of the capsulotomy and how it has scarred, and is faster in younger animals. More recently, implantation of embryonic ectoderm at the time of lens removal has been shown to improve the growth and quality of the regenerated lenses. Lens fiber differentiation follows a process similar to embryological development with proliferation of epithelial cells along the anterior and posterior capsule, elongation of the posterior epithelial cells, and differentiation into lens fibers. Signals required for lens fiber differentiation include FGF, IGF-1, and TGF-beta. Identifying other signals, and providing these factors to the regenerating lens, could speed up lens regeneration and improve normality of the resulting structure. The regenerated lenses contain the same proteins as normal lenses, including all the major crystallins (alpha, beta, and gamma). However, regenerated lenses have typically been irregular in shape due to lack of lens growth at the site of the anterior capsulotomy and its adhesion to the posterior capsule. Sealing the capsulotomy and refilling the bag to maintain its shape seem to allow for more normal lens regeneration. Lens regeneration is a potential approach to restoring normal vision after cataract surgery. Importantly, lenses have been shown to regenerate after removal of cataracts in several mammals, and primate lenses do have regenerative capability.