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1.
Introduction
2.
3.
4.
6.
Conclusions
7.
Expert opinion
Introduction: Most ophthalmic drugs are delivered through eye drops even
though only about 1 -- 5% of the drug reaches the target tissue and the
patient compliance is not good. Drug-eluting contact lenses could significantly increase bioavailability, reduce side effects and improve patient
compliance.
Areas covered: Recent research on drug-eluting contact lenses has focused on
increasing the release duration through molecular imprinting, dispersion of
barriers or nanoparticles, increasing drug binding to the polymer, sandwiching a PLGA (poly[lactic-co-glycolic acid]) layer in a lens and developing novel
materials. This review covers all these studies with a specific focus on the
transport mechanisms and advantages and disadvantages of each approach.
Expert opinion: The main reason for prior failures was the short duration of
release from the lenses. The new technologies can provide extended drug
release for hours to days. The in vivo animal and clinical studies have proven
the safety and efficacy of drug-eluting contact lenses, while showing considerable improvements compared to eye drops. The future appears to be promising but several challenges remain such as processing and storage issues,
regulatory hurdles, high costs of clinical studies, potential lack of acceptance
by the elderly, etc.
Keywords: bioavailability, contact lenses, drug delivery, imprinting, nanoparticles, vitamin E
Expert Opin. Drug Deliv. (2013) 10(11):1483-1496
1.
Introduction
Ocular drug delivery (ODD) to the anterior region of the eye is most commonly
achieved through eye drops in form of solutions and suspensions [1], even though
it is well understood that only a very small fraction of drug delivered through eye
drops reaches the target tissue [2]. There are several factors that contribute to the
inefficiencies of eye drops. A human tear film contains about 7 l of fluid [3] and
even though it can hold a larger amount after an eye drop instillation, a fraction
of the instilled 30 l eye drop is quickly squeezed out of the eye [2]. The remaining
drug mixes within the entire tear volume and then exits through canalicular drainage into the nose or transports across the corneal and the conjunctival epithelia. The
area of the conjunctiva is about 16 -- 18 times the area of the cornea, and the conjunctiva permeability is also higher than the corneal permeability, and thus the net
drug flux into cornea is much lower than that into the conjunctiva [4,5]. A very large
fraction of the drug absorbed into the conjunctiva and that drained into the
nose enter systemic circulation, leading to the very low corneal bioavailability
of < 5% [2]. The fraction of the delivered drug that enters the systemic circulation
escapes the first-pass metabolism and enters all major organs, with a potential for
side effects [6,7]. The problem of low bioavailability is exacerbated by the short
tear film residence time of only about 2 -- 3 min, leading to a necessity of a frequent
dosing regimen [2]. In certain cases, hourly instillations of eye drops are required for
delivery of dexamethasone phosphate disodium (DXP) for anti-inflammatory
10.1517/17425247.2013.821462 2013 Informa UK, Ltd. ISSN 1742-5247, e-ISSN 1744-7593
All rights reserved: reproduction in whole or in part not permitted
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Article highlights.
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the regulatory approval process. For an ODD device to significantly improve the corneal bioavailability, it must be
preferentially located closer to the cornea, compared to the
conjunctiva, making a contact lens the obvious choice. It
was, thus, natural to explore contact lenses for delivering ocular drugs and several studies focusing on this goal were
attempted as early as several decades ago. While several studies
proved the feasibility of the concept, drug-eluting contact
lenses never reached the market mainly because the earliest
attempts were conducted with lenses that were not ideally
suited for drug delivery. The increasing research and latest
advances in biomaterials and nanotechnology has now led to
the design of drug-eluting contact lenses which have overcome
most of the technological challenges and so commercialization
is likely in near future. In this review, we focus on summarizing prior research, while specifically emphasizing on mechanisms and noting the advantages and disadvantages of
various approaches and finally present our opinion on the
challenges and future of this field.
2.
The mechanisms relevant to ophthalmic drug delivery by contact lenses are illustrated in Figure 1. A normal human tear
film is about 7 -- 10 m in thickness, while a typical contact
lens has a central thickness of about 80 -- 150 m [19]. On
insertion of a contact lens, the tear film partitions into a
pre-lens tear film (PLTF) and post-LTF (POLTF), which
are a few microns in thickness [19]. A drug-loaded contact
lens releases drug both into the PLTF and POLTF. The
drug that is released into the POLTF can either diffuse into
the cornea or diffuse radially out into the outer tear lake.
Owing to the very large disparity in the thickness (~ 5 m)
and the radius (5 mm) of the POLTF, almost the entire
drug amount released into the POLTF by the contact lens
diffuses into the cornea, even after accounting for the
enhancement of radial transport due to lens motion. The
drug released by the contact lens into the PLTF will likely
absorb into the conjunctiva or drain through the canaliculi
and eventually enter the systemic circulation. It is difficult
to predict the ratio of the masses of drug released into the
PLTF and POLTF but the ratio can be expected to be about
unity if both of the tear volumes are considered to be sinks.
A ratio of one between the releases into the PLTF and POLTF
will likely yield about 50% corneal bioavailability, compared
to about 1 -- 5% with eye drops. Detailed mathematical
modeling based on the basic mechanisms described above
shows that the bioavailability from drug-eluting contact lenses
could be 50% or possibly higher [20]. The model also suggests
that the POLTF is likely a perfect sink in spite of the very
small tear volume because the drug released from the lenses
diffuses into the cornea ensuring that the POLTF drug concentration remains low. The sink assumption for the POLTF
becomes more accurate for contact lenses with extended drug
Post-lens tear
film (POLTF)
Drug eluting
contact lens
Pre-lens
tear film (PLTF)
Eyelid
Cornea
3.
As discussed above, a contact lens is ideally suited for increasing corneal bioavailability. Contact lenses also meet several of
the other requirements such as biocompatibility, ease of insertion, transparency, with minimal effect of ocular functions; at
least for the population that wear contact lenses for vision
4.
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Figure 2. Image of pure NIGHT & DAY lens (right) and NIGHT
& DAY with 30% vitamin E loading (left).
Polymer matrix
VE diffusion barrier
Drug molecule
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Functional monomers
Drug template
Crosslinker
Self-assembling due to favorable interactions
Extraction
Polymer
Polymerization
Figure 4. Schematic illustration of the formation of high-affinity cavities for molecular imprinting.
EGDMA
EGDMA
MAA
DEAA, HEMA,
SiMA/DMAA
(50:50 v/v)
MMA/DMAA
(50:50 v/v)z
DMAA/TRIS
(50:50 v/v)z
Hyaluronic acid
(1,200000, Da)
Timolol
AA (6:1 -- 32:1)
HEMA
HEMA
Nelfilcon A formulation
with modified PVAz
macromer
HEMA
Ketotifen fumarate
Norfloxacin
[55]
[54]
[53,58]
[52]
[98]
[62]
[97]
[61]
[51]
Refs.
*The mole percentage of crosslinker or functional monomer are added into the mixtures of backbone monomer, functional monomer, crosslinker and template molecules.
z
1-(tristrimethyl-siloxysilylpropyl)-metharylate (SiMA), N, N-dimethylacrylamide (DMAA), tris(trimethylsiloxy)silylpropyl methacrylate (TRIS), 4-vinyl-pyridine (VP), N-(3-aminopropyl) methacrylamide (APMA), polyvinyl alcohol
(PVA), 2-(diethylamino) ethyl methacrylate (DEAEM), 1-vinylimidazole(1VI), 4-vinylimidazole (4VI), N-hydroxyethyl acrylamide (HEAA).
EGDMA
PEG200DMA
EGDMA
Ibuprofen,
diclofenac
VP, APMAz
HEMA
EGDMA
MAA
Timolol
Timolol
Timolol
Timolol
Drugs (template
molecules)
DEAA
EGDMA
EGDMA
(0.32-8.34 mol%)*
DEAA
Crosslinker
Functional monomers
Backbone monomers
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HEMA
HEMA
HEMA
EGDMA
PEG200DMA
PEG200DMA
EGDMA
PEG200DMA,
EGDMA
EGDMA
Crosslinker
Ciprofloxacin
Diclofenac sodium
Prednisolone
acetate
Ketotifen fumarate
HPMC(120 kDA)z
Acetazolamide,
Ethoxzolamide
Drugs (template
molecules)
[102]
[101]
[67]
[57]
[56]
[99,100]
Refs.
*The mole percentage of crosslinker or functional monomer are added into the mixtures of backbone monomer, functional monomer, crosslinker and template molecules.
z
1-(tristrimethyl-siloxysilylpropyl)-metharylate (SiMA), N, N-dimethylacrylamide (DMAA), tris(trimethylsiloxy)silylpropyl methacrylate (TRIS), 4-vinyl-pyridine (VP), N-(3-aminopropyl) methacrylamide (APMA), polyvinyl alcohol
(PVA), 2-(diethylamino) ethyl methacrylate (DEAEM), 1-vinylimidazole(1VI), 4-vinylimidazole (4VI), N-hydroxyethyl acrylamide (HEAA).
AA
HEMA, NVP/DMA
(20/80 molar ratio)
Betacon
macromere/TRIS/DMA
Functional monomers
Backbone monomers
L. C. Bengani et al.
Figure 5. Image of control (left) and 10% cationic surfactantloaded 1-Day Acuvue contact lens (right) containing a drop
of water (0.1 ml).
the first few hours. Also, the gels were 1 mm thick, which is
about 10 times thicker than most contact lenses [70]. MEs of
canola oil stabilized by Tween 80 with an additional silica
shell were also explored for extended release of lidocaine
from p-HEMA hydrogels. The hydrogels were reported to
be opaque due to the aggregation and segregation during
polymerization. The transparency loss was minimized by dispersing MEs stabilized by Brij 97 with an additional silica
shell, but the drug release profiles still contained a burst followed by a slow release for a few days [71]. To minimize the
initial burst, Ferreira et al. loaded silicone-coated particles
containing flurbiprofen, Brij 35 and decane into HEMA-coMAA hydrogels. The release profiles still contained an initial
burst, followed by sustained release over 8 days [72]. Jung
and Chauhan prepared highly crosslinked spherical nanoparticles of propoxylated glyceryl triacrylate with covalently
attached timolol, and then loaded the particles in both
p-HEMA and silicone hydrogels by direct addition to the
polymerization mixture. The gels exhibited a sustained release
for about 30 days at room temperature due to the slow hydrolysis of the ester bond that connected timolol to the lens
matrix. The release duration was, however, considerably
shorter at physiological temperatures due to the higher reaction rates. The timolol-linked nanoparticles were also loaded
into commercial contact lenses by soaking the lenses in a solution of the nanoparticles in ethanol followed by evaporation
of ethanol. The efficacy of the timolol-releasing lenses was
demonstrated in a glaucoma animal model by measuring the
intraocular pressure after insertion of the lenses. The particleloaded lenses achieved intraocular pressure reduction comparable to eye drops but with about one-tenth of the drug loading,
which is in agreement with the predicted increase in bioavailability from about 5% for eye drops to about 50% for contact
lenses. The intraocular pressure (IOP) decreased for about
4 days, which correlated well with the in vitro release profiles
at physiological temperatures, suggesting that the in vitro
release under sink conditions is a reasonable model for the
in vivo release in the eyes [73]. In another study with nanoparticles, p-HEMA hydrogels loaded with pullulan and polycaprolactone copolymer core-shell nanospheres exhibited
antibacterial activity for about 3 days due to extended release
of ciprofloxacin [74]. Recently, a 30-day release of dexamethasone acetate was reported from lenses loaded with rod-like
silica shell crosslinked methoxy micelles [75].
In most of the studies described above, nanoparticles were
first fabricated, and then incorporated into the lenses either
by soaking or through its addition to the polymerization mixture. To avoid the two-step process, non-ionic Brij surfactant
aggregates were self-assembled into p-HEMA hydrogels by
addition of the surfactant to the polymerization mixture.
The 50 -- 100 nm size surfactant aggregates exhibited high
partitioning for hydrophobic drug cyclosporine and significantly reduced the diffusion rates [76,77].
The approach of incorporating nanoparticles into contact
lenses for extended drug release is certainly effective and can
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5.4
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Chauhan recently proposed to adsorb ionic surfactants to a preformed lens to impart the charge. Cationic surfactants were
adsorbed on the p-HEMA and a commercial contact lens to
design a lens for extended release of an anionic drug dexamethasone phosphate. The surfactant incorporation increased the
release duration by about 100-fold in the p-HEMA lens and
about 10-fold in the commercial lenses. Commercial 1-Day
Acuvue lenses loaded with cationic surfactant remained
transparent, and the presence of surfactant had the additional
benefit of increased surface wettability (Figure 5) [83].
Other approaches
Kim et al. designed silicone-hydrogel contact lenses comprising of a hydrophilic monomer N,N-dimethylacrylamide
(DMA) and a silicone monomer methacryloxypropyltris
(trimethylsiloxy)silane (TRIS), with a new macromer bisalpha, omega-(methacryloxypropyl) polydimethylsiloxane
(MW 7152) to produce lenses that exhibited extended release
of both hydrophobic and hydrophilic drugs. The lenses
released timolol and dexamethasone for extended periods
ranging from 2 weeks to 3 months depending on the composition. Also, several key properties including transparency,
ion permeability and modulus were shown to be suitable for
contact lens applications [84]. Xu et al. incorporated
b-cyclodextrins (BCD) in HEMA hydrogels to increase
release durations of puerarin, which complexes with the
BCD. The addition of BCD into the polymer resulted in
increased equilibrium swelling ratio and tensile strength.
The BCD incorporation led to a 40% increase in drug uptake
and an increase in the release times [85]. BCD incorporation in
HEMA hydrogels also increased loading by about 1300% and
led to continuous release rate for 12 days [86]. A copolymer of
DMA and 2-(N-ethylperfluorooctanesulfonamido) ethyl acrylate (FOSA) was prepared by free-radical polymerization, and
it was shown that the inclusion of FOSA led to a decrease in
the diffusion coefficient of pheniramine maleate [87].
Ciolino et al. sandwiched drug-loaded poly(lactic-co-glycolic
acid) (PLGA) films in a p-HEMA contact lens for extended
delivery of fluorescein and ciprofloxacin. The lenses exhibited
extended release for about 1 month at zero-order rates. The
same approach was shown to be effective for extended release
of econazole at adequate rates to provide antifungal activity
against Candida albicans fungi [88,89].
5.5
6.
Conclusions
Expert opinion
The past few years have seen renewed scientific as well as commercial interest in developing contact lenses for ODD. In
addition to several research studies, a number of patents based
on MEs [90], nanoparticles [91], organic--inorganic chitosansilica nanocarrier [92], multilayer structure [93], imprinting
and vitamin E incorporation [94,95] are recently published or
issued. Moreover, a Phase III study has been recently concluded on release of ketotifen fumarate from contact lenses
using the soak and release technology to develop antiallergy contact lenses [96]. Most recent focus has been on
increasing the drug release durations, which are just a few
hours for most drugs in commercial contact lenses. Several
technologies have been successfully utilized to extend the
release durations for several drugs including glaucoma drug
timolol, dry eye drug cyclosporine, anti-inflammatory
dexamethasone, anesthetic lidocaine, antibiotics, antivirals,
antifungals, etc. Most of the technologies are based on
p-HEMA contact lenses and are thus unsuitable for continuous wear. Some of those technologies can create continuous
wear silicone hydrogel contact lenses with release duration
consistent with the wear schedule, thus affording the possibility of continuous drug delivery without lens replacement for
2 -- 4 weeks. Several of the lens designs have also been tested
in various animal models which demonstrate the superiority
of these modified contact lenses, though there are very few
human studies. In addition, detailed characterization to determine if the extended release contact lenses can meet all the
requirements for the extended wear contact lenses, including
Declaration of interest
The authors thank the National Science Foundation (CBET
CMMI Grant 1129932) for providing partial support for
this work.
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Samuel Gause & Anuj Chauhan