Cytotoxicity of topical medications after cataract surgery for human corneal endothelial/epithelial cells, and conjunctival epithelial cells

1
Cytotoxicity of topical medications after
cataract surgery for human corneal
endothelial/epithelial cells, and conjunctival
epithelial cells

• 1)Masahiko Ayaki, MD, 1)Shigeo Yaguchi, MD, PhD,
  2)Atsuo Iwasawa, PhD, 3)Ryohei Koide, MD PhD.
• 1)Department of Ophthalmology and 2) Department
  of Clinical Pathology, Fujigaoka Hospital, Showa
  University School of Medicine, 3) Department of
  Ophthalmology, Showa University School of Medicine

Authors have no financial interest.
2
Purpose and Methods

• Purpose
• Cataract surgeons sometimes encounter unexplained
  persistent corneal edema after surgery and drug
  toxicity may be one of the potential etiologies.
  The purpose of this study is to evaluate
  cytotoxicity of topical medications to corneal
  and conjunctival cells.
• Cells
• Human corneal endothelial cells (primary culture
  from eye bank eyes)
• SIRC (human corneal epithelial cells, ATCC
  CCL-60,ATCC American tissue and Cells
  Corporation)
• Chang conjunctiva (human conjunctival epithelial
  cells, ATCC CCL-20.2, ATCC)
• Cell survival was measured using the WST-1 assay
  for endothelial cells and the MTT assay for
  epithelial cells after 48 hours exposure at 10,
  100, and 1000-fold dilution.
• Culture method (reference)
• Masahiko Ayaki, Shigeo Yaguchi, Ryohei Koide,
  Atsuo Iwasawa Cytotoxicity of ophthalmic
  solutions with and without preservatives for
  human corneal endothelial cells, epithelial
  cells, and conjunctival epithelial cells. Exp
  Clin Ophthalmol, 200836(6)553-559

3
Tested ophthalmic solutions

• Antibiotics
• gatifloxacin (GatifloR , Senjyu, Japan)
• moxifloxacin (VegamoxR , Alcon)
• levofloxacin (CravitR , Santen)
• norfloxacin (NofloR, Banyu, Japan)
• tosufloxacin (TosufloR, Nidek)
• dibekacin (PanimycinR, Meiji, Japan)
• cefmenoxime( BestronR, Kaken, Japan)
• Anti-inflammatory Non steroid
• diclofenac (DiclodR, DiclostarR, Nitten, Japan,
  DiclostarRPF)
• bromfenac (BronuckR , Senjyu)
• pranoprofen (NiflanR, Senjyu)
• Anti-inflammatory Steroid
• betamethasone (RinderonR, Shinogi, Japan,
  RinbetaR, Nitten, Japan, RinbetaRPF)
• betamethasonfradiomycin (RinderonR A, Shionogi)
• fluolomethorone (FlumethoronR, Santen)

4
Preservatives in Tested Ophthalmic Solutions
Trade Name ActiveComponent Preservative
Rinderon Betamethason Methyl Para, Propyl Para
Rinderon A Betamethason, Fradiomycin Methyl Para, Propyl Para
Rinbeta Betamethason (Generic) Boric acid, EDTA
RinbetaPF Betamethason (Generic with filter in the tip) Removed by filtration
Flumethoron 0.1 Fluolomethoron 0.1 BAK, Polysorbate 80, EDTA
Flumethoron 0.02 Fluolomethoron 0.02 BAK, Polysorbate 80, EDTA
Diclod (Voltaren) Diclofenac Chlorobutanol, Polysorbate 80 Boric Acid
Diclostar Diclofenac (Generic) Boric Acid, EDTA
Diclostar PF Diclofenac (Generic with filter in the tip) Removed by filtration
Bronuck (Zybrom) Bromfenac BAK, Polysorbate 80
Niflan Pranoprofen BAK, Polysorbate 80, Boric Acid, EDTA
Benoxil Oxybuprocain BAK, EDTA
Trade Name ActiveComponent Preservative
Levoquin, Cravit Levofloxacine No
Vegamox Moxifloxacin No
Zymer, Gatiflo Gatifloxacin No
Noflo Norfloxacin No
Tosflo Tosufloxacin No
Panimycin Dibekacin BAK
Bestron Cefmenoxime Methyl Para, Propyl Para, EDTA, Boric acid
BAKBenzalkonium Chloride Para
Parahydroxybenzoate EDTAethylene-diaminetetraacet
ic acid (edetic acid)
5
Results Corneal Endothelia
Antibiotics (10-fold dilution, 48 hours exposure)
140 120 100 80 60 40 20 0
Cell survival ()
Levofloxacin
Moxifloxacin
Gatifloxacin
Norfloxacin
Tosufloxacin
Panimycin
Bestron
Anti-inflammatory (10-fold dilution, 48 hours
exposure)
140 120 100 80 60 40 20 0
Cell survival ()
Oxybuprocain
Pranoprofen
Bromfenac
Diclofenac
BetamethasonFradiomycin
Betamethason
Fluolomethorone 0.1
Fluolomethorone 0.02
Diclofenac(G)
Diclofenac(G)-F
Betamethason(G)-F
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Results Epithelia-Antibiotics
Antibiotics (Corneal epithelia, 10-fold dilution,
48 hours exposure)
Antibiotics (Conjunctival Epithelia, 10-fold
dilution, 48 hours exposure)
140 120 100 80 60 40 20 0
Cell survival ()
Levofloxacin
Moxifloxacin
Gatifloxacin
Norfloxacin
Tosufloxacin
Panimycin
Bestron
7
Results Epithelia-Antiinflammatory
Antiinflamatory (Corneal epithelia, 10-fold
dilution, 48 hours exposure)
140 120 100 80 60 40 20 0
Cell survival ()
Pranoprofen
Bromfenac
Diclofenac
BetamethasonFladiomycin
Betamethason
Diclofenac(G)
Oxybuprocain
Fluolomethorone 0.1
Fluolomethorone 0.02
Diclofenac(G)-F
Betamethason(G)-F
Antiinflammatory (Conjunctival Epithelia ,
10-fold dilution, 48 hours exposure)
140 120 100 80 60 40 20 0
Cell survival ()
Oxybuprocain
Pranoprofen
Bromfenac
Diclofenac
BetamethasonFladiomycin
Betamethason
Fluolomethorone 0.1
Fluolomethorone 0.02
Diclofenac(G)
Diclofenac(G)-F
Betamethason(G)-F
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Summary of Results

• Most of tested solutions had corneal and
  conjunctival toxicity in 10-fold dilution
  (steroids lt antibiotics lt non steroidal
  anti-inflammatory medications).
• It decreased (cell survival gt 80) after
  1000-fold or more dilution and seemed to depend
  mostly on the components of ophthalmic solution
  such as benzalkonium chloride.

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Cause of postoperative corneal edema (Liu, JCRS,
2001)

• 1.Preexisting endothelial damage
• (a) Fuchs corneal endothelial dystrophy or
  advanced cornea guttata
• (b) Posterior polymorphous corneal dystrophy
• (c) Low endothelial cell count
• 2.Surgical trauma
• (a) Cavitational energy
• (b) Direct touch by instruments or intraocular
  lens
• (c) Turbulent flow of irrigation solution
• (d) Lens or lens particle contact with the cornea
  
• (e) Repeated anterior chamber collapse
• (f) Descemets detachment
• (g) Corneal burn
• 3.Use of unphysiologic or toxic intraocular
  fluids and drugs
• (a) Hypoosmotic (under 200 mOsm) or
  hyperosmotic(over 400 mOsm) fluids
• (b) Low or high pH value (under 6.8 or over 8.2)
• (c) Lack of calcium in irrigating fluid
• (d) Toxic concentrations of drugs ( antibiotics,
  local anesthetics, miotics)

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Conclusions

• The postoperative topical medications had
  cytotoxicity and those preserved with
  benzalkonium showed higher toxicity than those
  without them. Considering actual concentration at
  corneal endothelium, they do not seem to cause
  endothelial damage.
• Correspondence
• Masahiko Ayaki MD, Showa University School of
  Medicine, Yokohama, Japan
• ayaki_at_showaf.jp