Synthetic nanocarriers for the delivery of polynucleotides to the eye
Sofia M. Saraiva1, Vanessa Castro-López1, Covadonga Pañeda2, María José Alonso1, 3, 4*
1
Center for Research in Molecular Medicine and Chronic Diseases (CIMUS), Av. Barcelona s/n, Campus Vida,
Universidade de Santiago de Compostela, 15706 Santiago de Compostela, Spain.
2
Sylentis, R&D department c/Santiago Grisolía 2, 28760 Tres Cantos, Madrid, Spain.
3
Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, Universidade de Santiago de
Compostela, 15782 Santiago de Compostela, Spain.
4
Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.
*
Corresponding Author: Prof. María José Alonso
CIMUS Research Institute
Av. Barcelona s/n
Campus Vida-Universidade de Santiago de Compostela
15706 Santiago de Compostela, Spain
Tel: + 00 34 881815454/ +34 981594488 ext. 15454
Fax: + 00 34 881815403
E-mail: mariaj.alonso@usc.es
1
Abstract
This review is a comprehensive analysis of the progress made so far on the delivery of polynucleotide-based
therapeutics to the eye, using synthetic nanocarriers. Attention has been addressed to the capacity of different
nanocarriers for the specific delivery of polynucleotides to both, the anterior and posterior segments of the eye,
with emphasis on their ability to (i) improve the transport of polynucleotides across the different eye barriers;
(ii) promote their intracellular penetration into the target cells; (iii) protect them against degradation and, (iv)
deliver them in a long-term fashion way. Overall, the conclusion is that despite the advantages that
nanotechnology may offer to the area of ocular polynucleotide-based therapies (especially AS-ODN and siRNA
delivery), the knowledge disclosed so far is still limited. This fact underlines the necessity of more fundamental
and product-oriented research for making the way of the said nanotherapies towards clinical translation.
Keywords: polynucleotides; nanocarriers; ocular polynucleotide delivery; anterior segment; posterior segment;
eye.
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1. Introduction
According to the World Health Organization (WHO), 285 million individuals (4.25% of the world’s population)
suffered from visual impairment in 2010, of which 246 million had low vision and 39 million were blind
(Pascolini and Mariotti, 2011). Furthermore, it is predicted that by 2020, 76 million individuals will presumably
suffer from blindness mainly due to cataract, glaucoma and age-related macular degeneration (AMD)
(Pizzarello et al., 2004). This scenario underlines the necessity of more innovative and effective ocular therapy
strategies. Nowadays approaches based on polynucleotide ocular delivery hold great promise since they may
alter gene expression without affecting the structure and sequence of the gene.
The eye is an attractive organ for the development of polynucleotide-based therapies due to the fact that the
target tissues are accessible without the need of systemic administration. However, apart from this, the eye is
protected by extraordinary barriers, which are very difficult to circumvent, especially in the case of hydrophilic
and high molecular weight molecules such as polynucleotides. These barriers are illustrated in Fig. 1, and are
briefly described as follows:
In the anterior segment, the first barrier encountered by topically applied molecules is the tear film that is
composed of three layers consisting of lipid, aqueous fluid and mucus layers. The presence of different enzymes
and mucins in the tear film as well as its constant turnover protect the eye against external pathogens. This is
followed by the glycocalyx which is formed by cell surface mucins and covers the surface of the corneal and
conjunctival epithelia (Spurr-Michaud et al., 2007). The corneal barrier consists of a transparent and avascular
multiple layer epithelium, a collagenous layer (stroma) and an internal endothelium. The corneal epithelium
continues with the conjunctiva, a transparent and vascularized epithelial membrane that contains goblet cells
which are responsible for the production of the mucin MUC5AC (Ruponen and Urtti, 2015). In addition, the
presence of tight junctions in both tissues constitutes an obstacle for permeation of drugs, especially through
the cornea (Yoshida et al., 2009). The aqueous humor is also part of the anterior segment and it is mostly
composed of water and electrolytes, low molecular weight compounds and proteins (de Berardinis et al., 1965;
Tripathi et al., 1989).
The posterior segment is protected by the sclera, which represents the continuation of the cornea, and it is formed
by the vitreous humor, retina, choroid and optical nerve. The vitreous humor is a highly dense matrix mainly
composed of collagen, hyaluronic acid (HA) and also proteoglycans that contain negatively charged
glycosaminoglycans (GAGs), that can hinder the diffusion of drugs to the retina, even when they are directly
injected into this compartment (Peeters et al., 2005). However, it can also serve as a reservoir for the sustained
release of drugs (Bourges et al., 2003). The retina encompasses different cell layers consisting mainly of nerve
cells (ganglion cell layer (GCL)), photoreceptors and retinal pigment epithelium (RPE).
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Fig. 1 Representation of the structure of human eye (in more detail the tear film, cornea, conjunctiva, vitreous humor and
retina) and some examples of diseases affecting both anterior and posterior segments.
Both the anterior and posterior segments are also protected by blood-barriers, the blood-aqueous and the bloodretinal barriers, respectively. The blood-aqueous barrier contains the uveal endothelium and ciliary epithelium.
This barrier restricts the access of compounds such as plasma albumin and hydrophilic drugs into the aqueous
humor, but it is also responsible for the passage of nutrients essential for corneal function (del Amo and Urtti,
2008). The inner and outer blood-retinal barrier is formed by the retinal vessels’ endothelial cells and the retinal
pigment epithelium cells, respectively. In both parts of the blood-retinal barrier, the constituent cells are
connected by tight junctions. This barrier plays a fundamental role in the regulation of nutrients flux and the
restriction of drug diffusion into and out of the retina (Mannermaa et al., 2006).
There are several routes intended to reach either the anterior or posterior segments of the eye. Topical
administration and subconjunctival injections are normally oriented towards treating the anterior segment
whereas intravitreal (IVT) and subretinal injections are the most common methods used for the treatment of
relevant diseases that affect the back of the eye.
In the next sections we will comparatively analyze the nanotechnology-based strategies that have been reported
so far to deliver polynucleotides to both the anterior and posterior segments of the eye. We will highlight their
potential for targeting specific tissues and thus, for the treatment of specific ocular diseases. We will conclude
with a perspective of the challenges that need to be overcome for the clinical translation and industrial
development of these nanomedicines.
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2. Polynucleotides used for the treatment of ocular diseases
The polynucleotides that have been studied until now as potential treatments for ocular disorders are described
below.
Plamid DNA (pDNA)
Plasmid DNA-therapeutics aims to express a specific therapeutic gene. Therefore, the plasmid needs to be
internalized into the nucleus of the cell (which is still a challenge) where it will be transcripted into a messenger
RNA (mRNA). Thereafter, the newly formed mRNA is transported into the cytoplasm where it is translated into
the codified protein. The first nucleotide-based therapy reaching clinical trials was a pDNA construct proposed
for the treatment of an immunodeficiency disease caused by an adenosine deaminase deficiency (Blaese et al.,
1995). Since then, according to the clinical trials database (clinicaltrials.gov), several pDNA clinical trials have
been conducted although only three of them have been oriented to the treatment of ocular diseases focusing on
intraocular melanoma and allergic rhinoconjunctivitis.
Antisense oligonucleotides (AS-ODNs)
AS-ODNs are synthetic single-stranded RNA fragments (13 to 25 nucleotides) firstly described in 1978
(Stephenson and Zamecnik, 1978), that bind to complementary intracellular mRNA strands by base pairing,
forming a short double helix and ultimately blocking its transcription into the undesirable protein. AS-ODNs
can also modulate gene expression by enzymatic degradation of targeted mRNA by ribonuclease H (Walder and
Walder, 1988). The activity of AS-ODNs is highly limited due to their poor intracellular uptake and poor
stability in biological fluids (Opalinska and Gewirtz, 2002).
The only AS-ODNs-based drug (without the association to any type of carrier) approved by the FDA for an
ocular condition was registered in 1998. This nucleic-acid based drug, fomivirsen, was marketed as Vitravene
for the treatment of cytomegalovirus (CMV)-induced retinitis in immunocompromised patients (Crooke, 1998).
However, in 2004 Novartis Ophtalmics discontinued the product due to the significant decrease of Vitravene
sales as a consequence of the low number of patients infected with CMV. Other AS-ODNs are currently under
clinical trials for the treatment of different ocular diseases (see Table 1). For instance, aganirsen (GS-101) has
completed a phase III clinical trial for the topical treatment of corneal neovascularization and it is currently in
phase II for the treatment of AMD, neovascular glaucoma, retinopathy of prematurity and diabetic macular
edema.
Small interfering RNA (siRNA)
RNAi-based technology, namely siRNA is a promising alternative for treating eye diseases affecting both, the
anterior and posterior segments of the eye. This is a double-stranded RNA (dsRNA) of 21-23 base pairs designed
to specifically knockdown target genes (Elbashir et al., 2001). Unlike pDNA, this type of polynucleotide only
needs to get into the cytoplasm of the cell where it is loaded into the RNA-induced silencing complex (RISC)
(Hammond et al., 2000).
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The first clinical trial using a siRNA (Cand5) was conducted in 2004 for the treatment of wet AMD and, since
then, other clinical trials based on siRNA have been performed for ocular therapies such as Sirna-027 for
choroidal neovascularization (CNV), PF-04523655 for diabetic retinopathy, SYL1001 for dry eye and
SYL040012 and QPI-1007 for glaucoma (see Table 1). Moreover, several siRNA therapies are under preclinical
development for corneal neovascularization (corneal NV), retinitis pigmentosa, diabetic retinopathy, and
fibrotic eye disease, among others. Nonetheless, the majority of the undergoing siRNA studies target diseases
affecting the retina.
As other polynucleotides, siRNA also suffers from poor stability in biological fluids and restricted capacity to
enter cells. Different chemical modifications have been performed in the structure of polynucleotides especially
to ameliorate their stability when in contact with biologic fluids thus, improving their bioavailability (Beigelman
et al., 1995; Beverly et al., 2006; Chiu and Rana, 2003; Epstein and Kurz, 2007; Hall et al., 2004).
Aptamers
Aptamers are small molecules synthesized from DNA or RNA sequences that have the capacity to bind to
specific proteins, as well as to nucleic acids and other compounds. Due to their unique three-dimensional
structure they may act in a similar way as antibodies do but with the advantages of being non-immunogenic and
highly stable molecules (Chandola et al., 2016). The only aptamer that has received marketing approval, in
2004, for ocular administration is Pegaptanib sodium (Macugen), which is an RNA-based aptamer directed
against vascular endothelial growth factor (VEGF) (Xu et al., 2008). There are other aptamers like E10030 also
known as pegpleranib (Fovista) and ARC1905 (Zimura) that are under clinical trial for the treatment of AMD
(Table 1).
Table 1. Products under clinical development for both the anterior and posterior segments of the eye.
Product
Indication
Target
Administra
Developer
tion route
Status
Allergic
Rhinoconjunctivitis
JRC allergens
Intramuscular Immunomic
injection
Therapeutics, Inc.
Completed Phase I
Gp 100
Intramuscular
Memorial Sloan
/
Kettering Cancer
epidermal jet
Center
injection
Completed Phase
I/II
pDNA
CryJ2-DNALAMP
Mouse gp100
Intraocular melanoma
siRNA
Completed Phase
I, Recruting Phase
II/III
NAION
QPI-1007
Caspase 2
APACG
IVT
Quark
Completed Phase
II
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Wet AMD
PF-04523655
RTP801
IVT
Quark/Pfizer
Completed Phase I
and phase II
Terminated Phase
II
DME
SYL040012
(Bamosiran)
Glaucoma
β2 ADR
Eye drop
Sylentis
Completed Phase I
and Phase II
SYL1001
Ocular pain associated to
DES
TRPV1
Eye drop
Sylentis
Completed Phase I
and Phase II
RXI-109
Subretinal fibrosis, Wet
AMD
CTGF
IVT
Rxi
Recruting Phase
I/II
GS-101
(aganirsen)
iCRVO Patients at Risk of
Developing NVG
IRS-1
Eye drop
Gene Signal
Not yet recruting
Phase II/III
ISTH0036
Glaucoma, undergoing
trabeculectomy
TGF-β2
IVT
Isarna Therapeutics
Active Phase I
iCo-007
DME and DR
c-raf kinase
IVT
iCoTherapeutics
Completed Phase I
Undisclosed
IVT
Ionis Pharmaceuticals
Active Phase I
AS-ODN
IONIS-GSK4Undisclosed
LRx
Aptamer
E10030
(Fovista)
Wet AMD
PDGF-B
IVT
Ophthotech
Corporation
Terminated Phase
II and Phase III
Active Phase III
Active Phase I
ARC1905
(Zimura)
IPCV, Dry and Wet AMD
GA and MD
C5
IVT
Ophthotech
Corporation
Completed Phase I
Active Phase II
pDNA, plasmid DNA; siRNA, small interfering RNA; AS-ODN, antisense oligonucleotides; NAION, Non-arteritic
anterior ischemic optic neuropathy; APACG, Primary angle closure glaucoma; AMD, Age-related macular degeneration;
DME, Diabetic macular edema; DES, Dry eye syndrome; iCRVO, Ischemic central retinal vein occlusion; NVG,
Neovascular glaucoma; DR, Diabetic retinopathy; IPCV, Idiopathic polypoidal choroidal vasculopathy; GA, Geographic
atrophy; MD, macular degeneration; JCR, Japanese Red Cedar pollen; Gp 100, glycoprotein 100; RTP801, hypoxiainducible factor 1-responsive gene; β2 ADR, β2-adrenergic receptor; TRPV1, transient receptor potential vanilloid 1;
CTGF, connective tissue growth factor; IRS-1, insulin receptor substrate-1; TGF-β2, transforming growth factor β2;
PDGF-B, platelet-derived growth factor; C5-complement component 5; IVT, intravitreal.
3. Synthetic nanocarriers for the delivery of polynucleotides to the eye
In general, the delivery of polynucleotides has been attempted using viral vectors (adenovirus (Ads), adenoassociated virus (AAVs), lentivirus, and retrovirus) and non-viral carriers (e.g. nanoparticles, liposomes,
dendrimers, nanoemulsions, micelles, etc.). Currently, there are already some approved gene therapy products
using viral vectors. These products include a recombinant Ads-p53 gene therapy for the treatment of head and
neck squamous cell carcinoma (Gendicine®) (Pearson et al., 2004), an oncolytic virus that promotes cytotoxicity
in cancer cells for nasopharyngeal cancer (Oncorine®), a retroviral vector loaded with a human cytocidal cyclin
G1 construct for the treatment of solid tumors (Rexin-G®) (Gordon and Hall, 2010) and an AAV1 delivering a
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human lipoprotein lipase (LPL) variant for the treatment of LPL deficiency (Glybera®) (Ylä-Herttuala, 2012).
While these therapies have been approved in China (i.e. Gendicine®, Oncorine®), the Philippines (Rexin-G®)
and Europe (Glybera®), major concerns associated to their immunogenic and mutagenic risks remain (Thomas
et al., 2003). These concerns have motivated the search of synthetic delivery systems, which are safer and easier
to produce in large scale.
Currently, there are a few ocular nanotechnology-based products on the market, that include a few over the
counter products for the treatment of dry eye syndrome (DES), such as nanoemulsions (Lipimix™, Soothe XP®,
Cationorm®), and liposomes (Lipomil®), as well as drug-containing nanomedicines, such as cyclosporin-A
nanoemulsion (Restasis®), indicated for severe DES, a difluprednate nanoemulsion (Durezol®) indicated for the
treatment of ocular inflammation, verteporfin liposomes (Visudyne®), a photodynamic therapy and pegaptanib
(Macugen®), a PEGylated anti-VEGF, both approved for the treatment of AMD. Despite of this, the
development of synthetic nanocarriers for the delivery of polynucleotides to the eye is still in an early stage.
This early development is illustrated in Fig. 2, whereby the number of research articles describing non-viral
carriers for ocular polynucleotide therapy has been scarce until the last decade.
Fig. 2 Illustration of the evolution of the number of published research articles describing the use of non-viral carriers for
ocular polynucleotides delivery from 1997 to 2016. Data obtained from Scopus. Search defined with the combination of
keywords and or groups of keywords: [ocular, eye] and/or [pDNA, RNA, siRNA, antisense oligonucleotides,
polynucleotides] and/or [nanoparticles, nanocomplexes, liposomes, lipoplexes, niosomes, micelles, nanoemulsions,
nanocapsules, dendrimers]. Language: English.
An additional observation is that polymeric nanoparticles/nanocomplexes followed by liposomes have been the
nanostructures that have received most of the attention up to now. Fig. 3 shows how most of the research so far
has been concentrated on pDNA delivery although as described in the next section, the tendency is now being
oriented towards RNA-based therapies.
Fig. 4 illustrates non-viral delivery systems currently under development for ocular polynucleotide/drug
delivery. Overall, the composition and characteristics of the nanocarriers currently under investigation are
discussed below.
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Nanocomplexes and Nanoparticles
The design of these non-viral carriers for polynucleotide delivery has evolved over time going from simple
nanocomplexes of cationic polymers, e.g. polyethyleneimine (PEI), and polynucleotides (dos Santos et al.,
2006a; dos Santos et al., 2006b; Ketola et al., 2013; Kuo et al., 2005) to more defined nanoparticles. These
nanoparticles have been developed using an array of biomaterials which include hydrophobic and amphiphilic
polyesters, such as poly(lactic-co-glycolic acid) (PLGA) and PLGA-polyethylene glycol (PLA-PEG) (Csaba et
al., 2005; Perez et al., 2001), which were investigated at first by our laboratory, as well as proteins such as
gelatin (Xu et al., 2008), albumin (Arnedo et al., 2004), and cationic polymers, mainly poly-L-lysine (PLL)
(Ketola et al., 2013; Männistö et al., 2002) and chitosan (Csaba et al., 2009; de la Fuente et al., 2008a; de la
Fuente et al., 2008b).
Our group was among the pioneers in the development of nanoparticles for topical ocular drug delivery (Calvo
et al., 1996; Calvo et al., 1994; Losa et al., 1991; Losa et al., 1993) and reported for the first time the potential
of chitosan/hyaluronic acid nanoparticles for the delivery of polynucleotides, i.e. pDNA, to the eye (de la Fuente
et al., 2008a; de la Fuente et al., 2008b). The inclusion of HA allowed a better retention and permeation through
the rabbits’ corneal epithelium, which resulted in a more efficient transfection of the epithelial cells (de la Fuente
et al., 2008a; de la Fuente et al., 2008b). The combination of different characteristics of these systems, such as
biocompatibility, mucoadhesion and targeting of CD44 receptors make them suitable carriers for polynucleotide
delivery to the cornea and conjunctiva. In a different study, Urtti’s group determined that the HA coating of
DNA/PEI complexes decreases PEI’s toxicity by shielding the positive charges and reducing non-specific
interactions with cell membrane by the CD44 receptor targeting (Hornof et al., 2008).
With regard to the properties that influence the interaction of nanoparticles with the corneal epithelium, we have
found that, in addition to the size (Calvo et al., 1996), the surface composition of the nanoparticles and their
charge play an important role in their interaction with the corneal epithelium. For example, we observed that
chitosan nanoparticles have the ability to interact with the ocular mucosa and be internalized by the corneal
epithelial cells (de Campos et al., 2004). Other authors have explored the functionalization of particles with
specific targeting ligands, such as transferrin and arginine-glycine-aspartic acid (RGD), which are expected to
improve nanoparticle uptake by ocular cells (Chen et al., 2013; Singh et al., 2009).
Liposomes and lipoplexes
As an alternative to polymers, cationic lipids such as 3-β[N-(N’,N’ imethylaminoethane)- carbamoyl]
cholesterol (DC-cholesterol) and 1,2-Dioleoyl-3- trimethylammonium propane (DOTAP) (Jääskeläinen et al.,
2000; Lajunen et al., 2014; Matsuo et al., 1996; Rajala et al., 2014), have also been used to produce complexes
with polynucleotides, named lipoplexes or liposomes. Cationic lipids, in addition to their capacity to complex
polynucleotides, are supposed to help the liposomes interacting with the corneal epithelium (Jiang et al., 2012).
Neutral lipids such as 1,2-dioleoyl-3- hosphatidylethanolamine (DOPE) have also been included in liposomal
formulations as “helper” lipids since they can change the conformation of these systems to an inverted hexagonal
organization thus facilitating their endocytosis and delivering the polynucleotide into the cytoplasm (Koltover
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et al., 1998; Smisterová et al., 2001). The surface modification of liposomes with polymers has also been studied
as a way to enhance their stability, e.g. through PEGylation (Bochot et al., 2002; Chen et al., 2013; Liu et al.,
2011) and to facilitate their internalization and transfection efficiency through the use of peptide penetration
enhancers (Mannermaa et al., 2005; Rajala et al., 2014).
Stimuli-responsive liposomes have also been developed. This is the case of the light-induced liposomal
formulation containing verteporfin (Visudyne®), which has been marketed for the treatment of AMD. Due to
the different laser applications in ophthalmology, and the time- and site-specific drug release from lightactivated liposomes, these systems are of particular interest for the ocular field (Lajunen et al., 2016b). More
specifically, indocyanine green-liposomes might be an attractive option for ocular drug delivery. Indocyanine
green is an FDA approved imaging agent and the only one approved for clinical use under near infrered (NIR)
light, which is less damaging that UV light. Moreover, a fast exposure of these light-activated liposomes to NIR
light, led to a complete release of the loaded calcein and FITC-Dextran (Lajunen et al., 2016a).
Niosomes
These nanostructures are made of amphiphilic non-ionic surfactants such as Span 60, Brij 35, Brij 78, Brij
98 (Kaur et al., 2012; Saettone et al., 1996), which are known for their penetration enhancer capacity. Several
niosome formulations have been developed for ocular drug delivery and some of them have shown promising
results for ocular polynucleotide delivery (Ojeda et al., 2016; Puras et al., 2015; Puras et al., 2014). Still, as
shown in Fig. 3, these carriers are the least common nanocarriers used for polynucleotide delivery to ocular
tissues.
Micelles
Micelles comprise self-assembling diblock or multiblock amphiphilic molecules forming highly ordered
monolayer structures. An example of a triblock copolymer micelle approved by the FDA for ophthalmic
products is the micellar system formed by the copolymer poly(ethylene oxide)–poly(propylene oxide)–
poly(ethylene oxide) (PEO–PPO–PEO) (Tong et al., 2007). This specific composition has been explored for the
delivery of pDNA to different ocular tissues (Liaw et al., 2001; Tong et al., 2007).
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Fig. 3 Illustration of the number of published research articles describing the use of non-viral carriers for ocular pDNA,
siRNA and AS-ODN delivery from 1997 to 2016. Data obtained from Scopus. Search defined with the combination of
keywords and or groups of keywords: [ocular, eye] and/or [pDNA, siRNA, antisense oligonucleotides] and/or
[nanoparticles, nanocomplexes, liposomes, lipoplexes, niosomes, micelles, nanoemulsions, nanocapsules, dendrimers].
Language: English.
Nanoemulsions and Nanocapsules
Nanoemulsions were evaluated in the early 90s by Benita’s group for topical ocular drug delivery (Muchtar et
al., 1992), and a few years later they were suggested for AS-ODN delivery (Teixeira et al., 1999). More recently,
Benita’s group evaluated cationic nanoemulsions which contain the surfactant DOTAP to enhance the carrier
residence time on the ocular surface and efficiently deliver AS-ODNs to the retina (Hagigit et al., 2010; Hagigit
et al., 2012).
Nanocapsules share common features with nanoemulsions and polymer nanoparticles, as they are formed by
oily nanodroplets surrounded by a polymer coating. Our group pioneered the development of nanocapsules for
topical ocular drug delivery (Calvo et al., 1997; Losa et al., 1993). Interestingly, working with PEGylated
polyester nanocapsules we also observed that the PEG coating was critical in terms of preserving the stability
of these nanocapsules in the ocular fluids and, this improved stability was translated into a greater transport of
the nanocapsules across the corneal epithelium (de Campos et al., 2003). More recently, we have found that
nanocapsules containing polyarginine and protamine arginine-rich polymer shells, have an improved ocular
retention and can be used for corneal wound healing (Reimondez-Troitiño et al., 2016).
Fig. 4 Representation of the structure of different types of nanocarriers.
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Solid lipid nanoparticles (SLN)
SLN are made of solid lipids such as Compritol®888 ATO, Precirol® ATO 5, Gelucire® 44/14 and stearylamine
(del Pozo-Rodríguez et al., 2008; Li et al., 2008). These nanoparticles have been shown to facilitate drug
penetration into the cornea (Cavalli et al., 2002; Li et al., 2008) and were used for the first time for ocular
polynucleotide delivery in 2008 by del Pozo-Rodriguez (del Pozo-Rodríguez et al., 2008).
Dendrimers
Dendrimers are tree-like branched structures that consist of an inner core, repetitive branched units (i.e. different
generations) and peripheral multivalent functional groups, which play a key role in the complexation with
polynucleotides. The use of PAMAM (Chaum et al., 1999; Hudde et al., 1999) and PLL (Marano et al., 2004)
based dendrimers for ocular polynucleotide delivery was first reported in 1999 and 2004, respectively. Since
then, only a few reports have described the use of these nanocarriers for oligonucleotide (Marano et al., 2004;
Wimmer et al., 2002) and pDNA (Hudde et al., 1999) ocular delivery and none for siRNA.
Fig. 5 Schematic representation of the main strategies used to develop nanocarriers aiming to treat different diseases
affecting both anterior (A) and posterior eye segments (B). When targeting the anterior segment structures, the topically
applied carriers usually present a positive surface charge and a mucoadhesive polymeric coating to increase the retention
time in the ocular surface. They can also be PEGylated in order to be muco-penetrating and even include specific targeting
moieties like arginine-glycine-aspartic acid sequences to target the desired tissue. When targeting the posterior eye segment,
nanocarriers administered by intravitreal injection usually present a negative surface charge in order to avoid aggregation
with the glycosaminoglycans present in the vitreous humor and a PEGylated surface to improve the diffusion through the
vitreous. They might also present targeting moieties to target a specific tissue.
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4. Site-specific nanocarriers-based polynucleotide delivery for the treatment of ocular pathologies
The main diseases affecting the anterior and posterior segments of the eye will be discussed in the next sections
as well as the nanocarriers developed for polynucleotide delivery to both segments. Tables 2 and 3 summarize
some of the nanocarriers used for the delivery of polynucleotides aiming at the treatment of the discussed
diseases.
4.1. Nanomedicine approaches for the treatment of anterior segment ocular diseases
There are two main target tissues in the anterior segment of the eye, the cornea and the conjunctiva. The cornea
represents a key challenge for many drugs due to its highly organized multilayer epithelium and the presence of
tight junctions that limit the permeation of drugs and polynucleotides (Ruponen and Urtti, 2015). Several viral
vectors and naked-polynucleotide formulations have reached the clinical development phase for the treatment
of ocular disorders, although none of them have been marketed yet.
While the ocular delivery of polynucleotides has been achieved by physical means, such as electroporation
(Blair‐Parks et al., 2002; Hao et al., 2009), iontophoresis (Berdugo et al., 2003; Hao et al., 2009), gene gun
(Tanelian et al., 1997; Zhang et al., 2002) and sonophoresis (Yamashita et al., 2007), the use of nanocarriers
offers specific advantages, such as (i) their nanometric size and components properties may allow their transport
in the conjunctival and corneal epithelium (Amrite and Kompella, 2005), (ii) they may provide a sustained
delivery of polynucleotides in vivo (Cohen et al., 2000; dos Santos et al., 2006a; Khan et al., 2004) and, (iii)
they may target the cornea, the conjunctiva or both (de la Fuente et al., 2008a; de la Fuente et al., 2008b).
The most prevalent pharmacological ocular conditions in the anterior segment are DES, ocular inflammation
(i.e. keratitis, allergic conjunctivitis, anterior uveitis), corneal wounds and, corneal NV.
Dry eye syndrome
DES is a multifactorial ocular pathology characterized by inflammation, pain and ocular discomfort due to
insufficient tear secretion, excessive evaporation and alteration in the composition of the tear film (Pañeda et
al., 2012). Current therapies for treating dry eye include drug-free artificial tears and nanosystems such as drugfree cationic nanoemulsions and cyclosporine A loaded nanoemulsions. As an alternative, polynucleotides have
been proposed for the treatment of severe dry-eye associated to a deficiency of mucus glycoproteins, such as
MUC5AC (Contreras-Ruiz et al., 2013; Konat Zorzi et al., 2011). For example, Contreras-Ruiz et al. (2013)
developed cationized gelatin-based nanoparticles to deliver a plasmid encoding a modified MUC5AC protein
(pMUC5AC). This nanoformulation was instilled to a dry eye mouse model and the result of the treatment was
a reduction in ocular inflammation accompanied by an improved tear production (Contreras-Ruiz et al., 2013).
Keratitis, conjunctivitis, anterior uveitis
These are diseases related to inflammation in the cornea, conjunctiva and the anterior uvea, respectively. The
most common treatment strategies for these types of infections are antimicrobial ophthalmic solutions in the
form of eye drops containing different drugs (e.g. anti-histamines, non-steroidal anti-inflammatory drugs,
antibiotics or corticosteroids). Polynucleotide-based therapies have also been considered as an alternative for
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the treatment of severe infectious and inflammatory processes. For example, stromal keratitis and angiogenesis
induced by herpes simplex virus-I (HSV) in mice have been reported to be significantly reduced by intravenous
injection of cationic polyplexes of PEG-PEI-RGD and anti-VEGF siRNA (Kim et al., 2004a). In a different
study, PEI-siRNA complexes targeting the HSV-1 infected-cell polypeptide 4 gene were evaluated on a mouse
model of herpes simplex keratitis. Following topical administration, the said complexes were found to inhibit
HSV-I replication in vivo for 96 h (Li et al., 2014).
Corneal neovascularization
Corneal NV is a pathological event that occurs associated with many ocular diseases that can cause blindness.
Corneal NV means the formation of blood vessels within the transparent avascular tissue due to inflammation,
infection and hypoxia, among other reasons. The available treatments include topical corticosteroids and nonsteroidal anti-inflammatory eye drops and anti-VEGF-A compounds, such as bevacizumab, which were found
to have limited clinical efficacy and negative side effects. Based on the critical role that angiogenesis plays in
ocular neovascularization diseases, attempts have been made to attack these diseases using new anti-VEGF
polynucleotide therapies (targeting VEGF or its receptors). PLGA nanoparticles loaded with a plasmid
containing a small hairpin RNA (shRNA) expression cassette against VEGF-A (pSEC.shRNA.VEGF-A) were
injected into the corneal stroma in a corneal NV mice model. The plasmid-loaded nanoparticles were found to
be effective in reducing the corneal expression of VEGF-A (Qazi et al., 2012). In another study, human serum
albumin (HSA) nanoparticles encapsulating a plasmid (pCMV.Flt23K) were also injected into the cornea of
mice and tested for their efficacy against corneal NV (Jani et al., 2007). The results showed that HSA
nanoparticles provided a 40% reduction corneal NV after 5 weeks of treatment. A faster response was observed
upon subconjunctival injection in mice of PEGylated micelles containing the VEGFR1 plasmid (sflt-1). In this
case, at seven days post-injection the corneal neovascularized area was reduced by 45% (Iriyama et al., 2011).
In summary, only a few studies, which are summarized in Table 2, have disclosed the efficacy of synthetic
nanocarriers for the treatment of eye-surface diseases either following topical instillation or intracornea/conjunctival injection. Nonetheless, and despite their ability to improve the retention time of
polynucleotides in the ocular surface and transfect tissues, i.e. cornea and conjunctiva, their efficiency is difficult
to judge. In fact, the in vivo studies reported so far do not provide a comparison of these new polynucleotides
therapies with the currently available treatments.
14
Table 2. Polynucleotide-loaded nanomedicines for the treatment of diseases affecting the anterior segment of
the eye.
Nanocarrier
Polynucleotide
Administration
route
Animal
model
Outcome
(PK/PD)
Ref.
Eye drops
Dry eye mice
model
Reduced ocular
inflammation;
improved tear
production
(ContrerasRuiz et al.,
2013)
Dry eye syndrome
Gelatin
nanoparticles
pMUC5AC
Herpes Simplex Keratitis
PEG-PEI-RGD
polyplexes
Anti- VEGF
siRNA
Intravenous
injection
HSK mice
model
Reduced stromal
keratitis and
angiogenesis
(Kim et al.,
2004b)
PEI complexes
ICP4-siRNA
Eye drops
HSK mice
model
Inhibited HSV
replication
(Li et al.,
2014)
PLGA
nanoparticles
pSEC.shRNA.VEGF-A
Corneal
intrastromal
injection
Corneal NV
mice model
Reduced VEGFA expression
(Qazi et
al., 2012)
HSA
nanoparticles
pCMV.Flt23K
Corneal
intrastromal
injection
Corneal NV
mice model
40% reduction of
Corneal NV after
5 weeks
(Jani et al.,
2007)
PEGylated
micelles
psflt-1
Subconjunctival
injection
Corneal NV
mice model
45% reduction of
Corneal NV after
7 days
(Iriyama et
al., 2011)
Corneal NV
PEG, polyethylene glycol; PEI, polyethyleneimine; RGD, arginine-glycine-aspartic acid; PLGA, poly(lactic-co-glycolic
acid); HSA; human serum albumin, pMUC5AC, plasmid encoding the mucus glycoprotein MUC5AC; ICP4-siRNA,
siRNA targeting the infected-cell polypeptide 4 gene of HSV-1; pSEC.shRNA.-VEGF-A, plasmid containing a small
hairpin RNA expression cassette against vascular endothelial growth factor A; pCMV.Flt23K, plasmid encoding domains
2 and 3 of the Flt binding domain for VEGF; psflt-1, plasmid encoding soluble VEGF receptor 1; HSK, herpes simplex
keratitis; Corneal NV, corneal neovascularization; HSV, herpes simplex virus.
4.2. Nanomedicine approaches for the treatment of back of the eye diseases
Diseases affecting the retina can potentially be treated with polynucleotides-based therapies. The retina is a
photosensitive tissue composed of three main layers or cell types. The retinal pigmented epithelium is in the
outermost layer followed by the photoreceptors (cones and rods), and the retinal ganglion cells in the innermost
layer. Defects in these cell layers can lead to AMD (retinal pigmented epithelium and photoreceptors), retinitis
pigmentosa, Leber’s congenital amaurosis (LCA) (photoreceptors), glaucoma and optic neuropathy (retinal
ganglion cells). According to the WHO, among the diseases affecting the posterior segment of the eye, glaucoma
and AMD are the main causes for blindness.
15
Subretinal injection is the most effective way to deliver drugs to the photoreceptors and RPE layer of the retina.
Additionally, drugs can be injected into the vitreous humor through IVT injection that is less invasive and allows
for a broader and more uniform transduction of the retina. Despite their efficacy, these methods are invasive
and not acceptable when there is the need for frequent intraocular administrations. Repeated injections may lead
to undesired side effects like high risk of infections, cataract development, vitreous hemorrhage and even retinal
detachment and endophthalmitis that can potentially cause vision loss. Besides the risks of repeated injections,
the poor stability of polynucleotides in biological fluids and their short vitreal half-life urges the need of
developing carriers able to protect and deliver them in a specific, efficient and sustained way.
As summarized in Table 3, several types of nanocarriers have been used to deliver polynucleotides to the back
of the eye. Such systems have aimed to target different tissues (i.e. choroid, macula, and retina) or cell types
(i.e. RGC, photoreceptors, and RPE) of this eye segment, expressing mutations responsible for diseases like
AMD, glaucoma, CNV and X-linked juvenile retinoschisis (XLRS), among others. These potential
nanomedicines have been injected into the subretinal space or the vitreous humor. In this sense, it has been
reported that positively charged particles may aggregate upon interaction with components present in these
compartments, i.e. HA and GAGs, and this aggregation would ultimately hamper their cellular uptake (Peeters
et al., 2005; Pitkänen et al., 2003). However, the vitreous humor can also act as a reservoir where the carriers
can gradually release the compound of interest to yield a sustained delivery of drugs to the retina (Bourges et
al., 2003).
Glaucoma
Glaucoma is characterized by the progressive damage of the optic nerve leading to retinal ganglion cells death
and permanent vision loss. According to the WHO, glaucoma is the second cause of vision loss worldwide after
cataracts, being responsible for 8% of all blindness cases (Pascolini and Mariotti, 2011). Factors like local
ischaemia-hypoxia, excessive stimulation of the glutamatergic system, alterations in glial cells, aberrant
immunity and mainly high intraocular pressure (IOP) seem to contribute to glaucoma (Weinreb and Khaw,
2004).
The current standard treatment for glaucoma involves medication to lower IOP levels by means of either
diminishing aqueous humor production (beta blockers) or improving its drainage (prostaglandin analogs). These
treatments are chronic and they often suffer from limited patient compliance. In addition, the side effects
associated to systemic absorption are no negligible. Therefore, there is a clear need for advanced treatments and
delivery technologies.
In vivo studies of nanocarriers loaded with different drugs (e.g. timolol, brimonidine tartrate, pilocarpine) have
shown promising results with increased bioavailability, prolonged retention time and sustained drug delivery in
addition to minimizing systemic absorption of the associated drugs (Reimondez-Troitiño et al., 2015). Along
the same line, a number of patents on ophthalmic nanoformulations such as nanoemulsions (Carli et al., 2013),
and contact lenses delivering nanoemulsions (Chauhan and Gulsen, 2012), have been recently issued.
16
Therapies based on polynucleotides could improve the commercially available anti-glaucoma treatments.
Trabecular meshwork, ciliary epithelium and muscle and ganglion cell layer are some examples of target tissues
for polynucleotide-based glaucoma therapy. However, research in this line is in a very early stage and has mainly
made use of naked polynucleotides or viral vectors administered topically or as IVT and subretinal injections.
The studies reported until now to contribute to the development of polynucleotide-based nanomedicines for the
treatment of glaucoma have used model polynucleotides associated to lipid nanocarriers. For example, Matsuo
and colleagues (Matsuo et al., 1996) studied different liposomes loaded with pDNA encoding β-Gal through
topical instillation. In vivo data in rats showed gene β-Gal expression for up to a month in conjunctival, corneal
and retinal ganglion cells after administration of N-(alpha-trimethylammonioacetyl)-didodecyl-D-glutamate
(TMAG) and DC-cholesterol liposomes. A different approach consisted of liposomes with a viral envelopecoating of inactivated hemagglutinating virus of Japan HVJ (Sendai virus) (Hangai et al., 1996; Hangai et al.,
1998a, b), which was supposed to allow the fusion of the liposomes with the cell membrane and deliver the
encapsulated nucleotide into the cytoplasm. These liposomes were loaded with LacZ pDNA and a high-mobility
group 1 (HMG1) nonhistone nuclear protein, which guides the pDNA into the nucleus. The in vivo results
following intravitreal and subretinal injections of these formulations to rat and mice presented LacZ expression
in the photoreceptors for more than 30 days (Hangai et al., 1996). Moreover, these liposomes encapsulating
FITC-labeled phosphorothioate oligonucleotides were injected into the anterior chamber of rats and monkeys.
Fluorescence was detected in the trabecular meshwork of monkeys and in the iris and ciliary body of rats lasting
as long as 7 and 14 days, respectively (Hangai et al., 1998b).
Johnson et al. (Johnson et al., 2008) synthesized what they called a “peptide for ocular delivery (POD),
containing specific aminoacids (GGG(ARKKAAKA)4), which theoretically endowed the peptide with cell
penetrating properties, and used it for the delivery of pDNA encoding a red fluorescent protein (pCAGRFP) and
siRNA to the eye. After topical instillation to mice, the pDNA-POD complexes were found to penetrate the
corneal epithelium, sclera, choroid and even the optic nerve. The same nanocomplexes were also found to enter
and deliver the associated siRNA in the GCL and RPE, following subretinal and IVT injection, respectively. A
different formulation tested in vivo was the one combining pDNA with surfactant gemini and “helper” lipids
DOPE and DOPE:1,2-dipalmitoyl-sn-glycero-3-phosphocholine (DOPE:DPPC). After topical application,
these nanoparticles were found in the limbus, iris and conjunctiva for 48 h and, following IVT injection they
were localized within the nerve fiber and GCL of the retina (Alqawlaq et al., 2014).
Among the presented approaches only model polynucleotides and healthy animal models were used, thus no
therapeutic effect or comparison with current treatments has been reported.
Age-related macular degeneration
AMD is the leading cause of irreversible blindness in people over 60 years old and it is predicted to affect about
196 million people worldwide by 2020 (Wong et al., 2014). This multifactorial disease leads to a progressive
degeneration of photoreceptors in the central retina that can result in blindness. There are two forms of AMD,
the “dry” and “wet” AMD. Wet AMD, also known as CNV, is caused by the promotion of blood vessels growth
17
mainly by the protein VEGF, which affects the central part of the retina, while dry AMD or nonexudative form
is characterized by RPE cell death and consequent photoreceptor degeneration (Pañeda et al., 2012). Currently,
AMD has no cure but there are some FDA approved treatments especially for the wet form like pegaptanib
(Macugen) an anti-VEGF aptamer, ranibizumab (Lucentis®) an antibody fragment, and aflibercept (Eylea) a
recombinant fusion protein, which is quickly becoming the gold standard treatment. Bevacizumab (Avastin)
is a monoclonal antibody which has also been used as an off-label treatment.
With the idea of exploring new treatments for AMD, different pDNAs have been associated to different
polymers originating nanoparticles and nanocomplexes of various compositions. For example, HSA has been
found to be able to condense DNA and protect it from degradation (Langer et al., 2003; Mo et al., 2007). A
plasmid encoding the Cu and Zn superoxide dismutase gene 1 (SOD1), a gene whose deficiency is associated
with CNV and RPE dysfunction, was complexed with HSA and injected intravitreally to mice. Unfortunately,
in vivo results revealed that protein expression was only detected for up to 2 days after IVT injection (Mo et al.,
2007).
In another study, PLGA nanoparticles were used to deliver a shRNA-expressing pDNA targeting hypoxiainducible factor-1α (HIF-1α), which regulates the transcription of pro-angiogenic factors like VEGF (Zhang et
al., 2010). The in vivo results obtained following IVT injection to a laser-induced CNV rat model showed a
decreased of VEGF expression and a reduction on the extent of NV.
A different strategy involving the intravenous administration of PLGA nanoparticles functionalized with an
RGD peptide, a ligand of integrin receptors, has been evaluated in mice and also primates. The results indicated
that the said nanoparticles loaded with the plasmid pFlt23k.NR were able to get into the retina lesion, promote
the plasmid expression for up to 6 weeks and lower the CNV (Luo et al., 2013). In another study, the intravenous
administration of anti-VEGF plasmid-loaded PLGA nanoparticles, functionalized with RGD and transferrin
peptides, led to a high gene expression in RPE, and the subsequent inhibition of CNV (Singh et al., 2009). These
positive results obtained following intravenous administration are surprising if we take into account the bloodretinal barrier that considerably limits access to the retina. In our understanding, a high dose will be required
when using this modality of administration with the potential undesired off-target effects. Recently, Lajunen
and co-workers (Lajunen et al., 2014) demonstrated that transferrin-decorated liposomes were able to reach the
RPE by topical instillation in Sprague Dawley rats, thus avoiding the possible undesired side-effects associated
with IVT and intravenous administrations.
PEGylated liposomes containing protamine sulfate (PS) and HA loaded with a siRNA targeting VEGF-R1 were
also tested in vivo through IVT injection in a laser-induced mice model of CNV. This system was able to protect
the loaded siRNA and decrease the CNV area (Liu et al., 2011).
Dendrimers have also been tested as polynucleotide carriers in CNV animal models and could be considered as
potential strategies for AMD treatment (Marano et al., 2004; Wimmer et al., 2002). For example, Marano et al.
(2004) developed different lipid-lysine dendrimers that led to a significant reduction in VEGF expression levels
and were able to significantly inhibit CNV in a mice model. A long-term study using the laser-induced CNV
18
mice model revealed that a single IVT injection of dendrimers loaded with ODN-1 inhibited up to 95% the
development of CNV in rats and the response lasted for up to six months. This system was able to penetrate
through all the retinal cell layers up to the RPE (Marano et al., 2005).
Finally, the cationic nanoemulsions originally developed by Benita’s group (Hagigit et al., 2010; Hagigit et al.,
2012; Hagigit et al., 2008) and containing DOTAP were used to deliver a 17-mer partially phosphorothioated
ODN directed to the VEGF KDR receptor. This cationic nanoemulsion was administered by topical instillation
and IVT injection and the results showed that, as expected, only the injected nanoparticles were able to reach
the inner nuclear layer (INL) of the retina maintaining therapeutic levels for about 72 h after injection. (Hagigit
et al., 2010).
Retinitis pigmentosa
This disease affects one in 3,500 to 5,000 people worldwide and can be inherited as autosomal recessive (5060%), autosomal dominant (30-40%) or X-linked (5-15%). RP can be the result of mutations in more than 60
genes being one of them rhodopsin, which accounts for 25% of autosomal dominant RP cases (Anasagasti et
al., 2012).
Based on the PEG stabilizing properties, the PEG-substituted lysine CK30-PEG was used for the formation of
complexes with pDNA molecules of interest for RP treatment (Liu et al., 2003; Ziady et al., 2003). The use of
this carrier allowed for the efficient delivery of a plasmid containing Rds cDNA and a rod opsin (MOP)
promoter, and its expression in photoreceptors of a RP mouse model preventing cone degeneration. Gene
expression was detected at least one month post-treatment (Cai et al., 2010). More recently, Han et al. used these
particles to compare the efficacy between a genomic DNA (gDNA), which included introns from the rhodopsin
gene, and a rhodopsin complementary DNA (cDNA). The introduction of specific genomic sequences improved
the rhodopsin expression levels, delaying photoreceptor cells death and improving functionality up to eight
months in a rhodopsin knockout (RKO) mouse model (Han et al., 2015).
X-linked juvenile retinoschisis
XLRS affects one in 5,000 to 20,000 males who are diagnosed very early within their first years of life. The
progression of this disease usually involves vitreous hemorrhage and retinal detachment that ultimately can lead
to vision loss. Significant progress has been achieved in understanding the genetic and molecular mechanisms
responsible for this disease. Currently, about 190 disease-causing mutations have been identified in the
retinoschisis RS1 gene. The RS1 protein is secreted in the retina and it is responsible for maintaining the retina’s
integrity (Molday et al., 2012).
Gascón’s group developed a hybrid nanostructure consisting of a dextran-protamine sulphate–pDNA complex
(i.e. pCMS-EGFP or pCEP4-RS1) adsorbed onto the surface of solid lipid nanoparticles (Delgado et al., 2012).
These plasmid-loaded particles were administered to rats through three different routes: IVT injection,
subretinal injection and topical instillation. The results of these studies presented plasmid expression in the
cornea after topical instillation, the nanocarriers were also able to transfect the RPE cells and photoreceptors by
19
subretinal injection while by IVT administration gene expression was mainly detected in the ganglion cell layer.
In a subsequent study, the same nanoparticles and a different kind containing HA instead of dextran (HAprotamine-pDNA-SLN) were administered by IVT and subretinal injections to C57BL/6 wild type and Rs1hdeficient mice models. Both carriers were able to transfect different layers of the retina, following both
administration methods. However, when subretinal injection was used a higher amount of RS1 expression was
detected in the photoreceptors and the expression was maintained for up to two months after injection it in GCL
and INL. In addition, both carriers were able to lead to a partial recovery of the retina that consisted of mainly
in a decreased loss of photoreceptors and an amelioration of the organization of retina layers (Apaolaza et al.,
2015).
Leber’s congenital amaurosis
The prevalence of LCA is between 1 in 81,000 newborns (Stone, 2007). Fourteen mutated genes have already
been identified and they are responsible for photoreceptor cell death at an early age causing blindness. About 6
% of LCA patients present mutations in RPE65 gene that encodes for all-trans-retinyl-ester hydrolase (den
Hollander et al., 2008).
PEG-Lysine complexed to a pEPI-eGFP and phRPE65, containing a scaffold matrix attachment region
(S/MAR) and a macular dystrophy 2 promoter (VMD2), were subretinally administered to wild-type mice and
to an RPE65-deficient LCA mice model, respectively (Koirala et al., 2013) S/MAR inclusion was used
considering its self-replication capacity residing inside cells for more than 100 generations (Piechaczek et al.,
1999) and increase gene expression (Kim et al., 2004b; Klehr et al., 1991). The treatment led to higher DNA
expression levels that lasted at least two and a half years in the wild-type mice and despite the fact that only
about 20% of the RPE cells expressed the gene, it still led to improvements in RPE65-deficient LCA disease
that were noticed up to six months (Koirala et al., 2013).
More recently, a different strategy combining DOTAP/DOPE/cholesterol liposomes with protamine-plasmid
complexes, nuclear localization signaling and cell-penetrating transactivator of transcription (TAT) peptides
was developed. These liposomes were administered by subretinal injection in a RPE65-associated blind mice
model and the results showed the capacity of these nanocarriers to maintain gene expression for at least three
months. Furthermore, in vivo results revealed that the treatment led to blindness correction (Rajala et al., 2014).
Stargardt’s disease
This autosomal recessive disease has no cure yet and it is the most common inherited juvenile macular
degeneration affecting one in 8,000-10,000 people worldwide. Stargardt’s disease causes problems to adapt to
darkness and a progressive and irreversible loss of central vision. The disease is caused by mutations in the
ABCA4 gene that encodes a protein of the ABC lipid transporter family (Allikmets et al., 1997). Hundreds of
disease-causing mutations have been identified in this gene that can lead to Stardardt’s or to cone-rod dystrophy
and several forms of autosomal recessive RP (Cremers et al., 1998). To the extent of our knowledge, only PEGLysine complexed to pDNA have been assessed for this disease and gene expression was detected for about
eight months improving mice’s recovery of dark adaptation (Han et al., 2012).
20
Diabetic retinopathy
This ocular pathology is the most frequent complication of diabetes mellitus, a disease that according to the
WHO affects more than 422 million individuals around the world. Diabetic retinopathy which affects more than
93 million people results from vascular abnormalities causing glial dysfunction and death of retinal neurons,
and ultimately, blindness (Yau et al., 2012). Monoclonal antibody-based therapies, such as Eylea® and Lucentis®
are some of the FDA approved treatments for this disease. As an alternative, different siRNA therapies, such as
those targeting the connective tissue growth factor (CTGF) (Winkler et al., 2012), VEGF (Jiang et al., 2009),
fibronectin, collagen and laminin (Oshitari et al., 2005), HIF-1α (Jiang et al., 2009), or hypoxia-inducible gene
RTP801 (Nguyen et al., 2012) have been proposed. However, these siRNAs have not been used in association
with nanocarriers so far.
Different approaches making use of anti-angiogenic microRNAs (Mitra et al., 2016) and plasminogen fragments
(Park et al., 2009) associated to PEG-Lysine have also been explored. These nanocomplexes were intravitreally
injected in a mouse model for late-onset diabetic retinopathy. A single administration reduced the expression of
VEGFR-2, suppressing angiogenesis for at least three months after treatment (Mitra et al., 2016). In another
study, PLGA nanoparticles loaded with a plasminogen fragment Kringle 5 (K5) plasmid were administered by
IVT injection in oxygen-induced retinopathy (OIR) and streptozotocin-induced diabetic mice models. Similarly,
a single injection led to a significant reduction of retinal vascular leakage and attenuated VEGF over-expression
and retinal NV for at least one month (Park et al., 2009).
Despite the ability of synthetic nanocarriers for ocular polynucleotide delivery and all the potential advantages
and the promising results observed in animal models, their delivery efficiency is still low. On the other hand,
the majority of the clinical trials using polynucleotides for ocular diseases have used naked polynucleotide
treatments and about 20% have combined them with viral vectors, especially AAVs,. These clinical trials have
been oriented to the treatment of macular degeneration, LCA and Leber´s hereditary optic atrophy. Despite of
this, it should be recognized that major advances in ocular polynucleotide-based therapies have already been
achieved and that this field is now opening opportunities for future developmental programs. The main
approaches used to improve non-viral carriers performance in the treatment of the previously discussed diseases
affecting both anterior and posterior segments are summarized in Fig. 5 A and B, respectively.
21
Table 3. Polynucleotide-loaded nanocarriers for the treatment of conditions affecting the posterior segment of
the eye.
Nanocarrier
Polynucleotide
Administration
route
Animal model
Outcome (PK/PD)
Ref.
TMAG-DCCholesterol,
liposomes
pCMV-β-Gal
Eye drops
Healthy rat
β-Gal expression in
conjunctiva, cornea and
RGC for 1 month
(Matsuo et
al., 1996)
HVJ-AVE
liposomes
pCMV-β-Gal
IVT and subretinal
injections
Healthy rat
β-Gal expression in neural
retina for 1 month
(Hangai et
al., 1996)
HVJ-AVE
liposomes
Phosphorothioated
oligonucleotides
Injection into the
anterior chamber
Healthy rat and
monkeys
Fluorescence in trabecular
meshwork for 7
(monkeys) and 14 days
(rat)
(Hangai et
al., 1998b)
Gemini
nanoparticles
pCMV-tdTomato
Eye drops and IVT
injection
Healthy mice
pDNA detected in retina’s
nerve fiber and GCL 48h
after IVT injection
(Alqawlaq
et al.,
2014)
Glaucoma
Age-related macular degeneration
HSA
nanoparticles
pSOD
IVT injection
Healthy mice
Protein expression
detected 2 days after
injection but not after 7
days
(Mo et al.,
2007)
PLGA
nanoparticles
pshHIF-1α
IVT injection
CNV rat model
Decreased VEGF
expression and reduced
CNV for 1 month
(Zhang et
al., 2010)
RGDfunctionalized
PLGA
nanoparticles
Flt23k plasmid
Intravenous
injection
Primate and
mice CNV
models
Lowered CNV; improved
40% mice’s vision
(Luo et
al., 2013)
RGD/transferrin
functionalized
PLGA
nanoparticles
Anti-VEGF intraceptor
plasmid
Intravenous
injection
CNV mice
model
47-73% reduced CNV
area, 2 weeks after
treatment
(Singh et
al., 2009)
Lipid-lysine
dendrimers
Anti-VEGF
oligonucleotide
IVT injection
CNV mice
model
Inhibited by 95% the
development of CNV for
4-6 months
(Marano
et al.,
2005)
PS/HA
PEGylated
lyposomes
siRNA targeting VEGFR1
IVT injection
CNV mice
model
Decreased CNV area
(Liu et al.,
2011)
Cationic
nanoemulsions
(oleylamine,
DOTAP, AOA)
AS-ODN against VEGF
KDR
Eye drops,
Healthy rabbits
Injected nanoemulsions
reached the retina’s INL
(Hagigit et
al., 2010)
RKO mice
model
Improved rhodopsin
levels and improved
photoreceptors
functionality for 8 months
(Han et
al., 2015)
IVT injection
Retinitis pigmentosa
CK30PEG
nanoparticles
gDNA
Subretinal injection
22
CK30PEG
nanoparticles
MOP-NMP vector
carrying Rds gene
Subretinal injection
Rod-dominant
RP mice model
Prevention of cone
degeneration
(Cai et al.,
2010)
pCMS-EGFP
Eye drops
Healthy mice
pCEP4-RS1
Subretinal and IVT
injections
Transfection of different
ocular tissues
(Delgado
et al.,
2012)
pCAG-GFP-CMV-RS1
Subretinal and IVT
injections
Healthy mice
Partial recovery of retina
for 2 months
(Apaolaza
et al.,
2015)
Subretinal injection
Healthy mice
Gene expression lasted
for 2.5 years in the
healthy mice
(Koirala et
al., 2013)
X-linked juvenile retinoschisis
Dextran/PS SLN
Dextran/PS SLN
HA/PS SLN
Rs1h-deficient
mice model
Leber’s Congenital Amaurosis
CK30PEG
nanoparticles
DOTAP/DOPE/
cholesterol/PS
liposomes
containing NLS
and TAT
pEPI-EGFP
pEPI-hRPE65 containing
S/MAR and VMD2
promoter
pcDNA3
RPE65-deficient
mice model
Improved the phenotype
of RPE65-deficient mice
Subretinal injection
pGFP
RPE65-deficient
mice model
Gene expression in RPE
for 3 months
(Rajala et
al., 2014)
Blindness correction
chicken Rpe65 cDNA
Stargardt’s disease
CK30PEG
nanoparticles
pEPI-CMV-EGFP with
ABCA4 cDNA and
MOP-ABCA4
Subretinal injection
ABCA deficient
mice model
Gene expression in the
retina for 8 months
(Han et
al., 2012)
Improved recovery of
dark adaptation
Diabetic retinopathy
CK30PEG
nanoparticles
pCAG-miR200-b-IRESeGFP
IVT injection
Ins2Akita mice
Angiogenesis marked
suppression
(Mitra et
al., 2016)
PLGA
nanoparticles
pK5
IVT injection
OIR mice model
Reduced retinal NV for 1
month
(Park et
al., 2009)
Diabetic mice
model
TMAG, N-(alpha-trimethylammonioacetyl)-didodecyl-D-glutamate; DC-cholesterol, 3-β[N-(N’,N’ imethylaminoethane)carbamoyl] colesterol; HJV-AVE, inactivated hemagglutinating virus of Japan-artificial viral envelope; HSA, human
serum albumin; PLGA, poly(lactic-co-glycolic acid); RGD, arginine-glycine-aspartic acid; PS, protamine sulfate; HA,
hyaluronic acid; SLN, solid lipid nanoparticles; DOTAP, 1,2-Dioleoyl-3- trimethylammonium propane; AOA, arginine
octadecyl amide; DOPE, 1,2-dioleoyl-3- hosphatidylethanolamine; NLS, peptide of nuclear localization signaling; TAT,
cell-penetrating transactivator of transcription; pCMV-β-Gal, plasmid containing cytomegalovirus pomoter and enconding
β-galactosidase gene; pSOD, plasmid encoding superoxide dismutase gene; pshHIF-1α, plasmid containing a small hairpin
RNA targeting the hypoxia-inducible factor 1α; AS-ODN, antisense oligonucleotides; VEGF, vascular endothelial growth
factor; gDNA, genomic DNA; pEPI-EGFP, plasmid encoding a green fluorescent protein; S/MAR, scaffold matrix
attachment region; VMD2, vitelliform macular dystrophy 2 promoter; pK5, Kringle 5 plasmid; pCAG-GFP_CMV-RS1,
plasmid encoding both GFP and retinoschisin; IVT, intravitreal; CNV, choroidal neovascularization; RKO, rhodopsin
knockout; OIR, oxygen-induced retinopathy; GCL, ganglion cell layer; RGC, retinal ganglion cells; GCL, ganglion cell
layer; INL, inner nuclear layer; RPE, retinal pigmented epithelium
23
5. Translational aspects of ocular delivery of polynucleotides
Despite the multiple reports centered on the benefits of nanotechnology for treating ophthalmic conditions it is
surprising that only a small number of these products have obtained marketing authorization. As indicated in
section 3, besides a variety of emulsions and liposomes, which are over-the-counter products for the treatment
of DES, there are nanoemulsions containing specific drugs, such as cyclosporine A (Restasis®, Lipomil®) and
difluprednate (Durezol®) for the treatment of ocular inflammation, and liposomes containing verteporfin
(Visudyne®) and the PEGylated anti-VEGF aptamer, pegaptanib (Macugen®), both for the treatment of AMD.
The majority of these products are emulsions composed of well-known oils (castor oil or medium-chain
triglycerides oil), emulsifiers (polysorbate 80, pemulen, poloxamer 188, tyloxapol or cetalkonium chloride) and
excipients to maintain tonicity and pH. However, the application of more sophisticated technologies for the
development of oligonucleotide-based nanomedicines is associated to significant challenges as highlighted
below.
The term nanomedicine includes an ample range of products with enormous variations in size, shape, materials
and other characteristics. This heterogeneity makes consensus definitions and classifications of these products
difficult to establish from the regulatory standpoint, thus complicating the generation of appropriate regulatory
guidance. Both, the FDA and the EMA, however, consider that the development of a product that falls within
the definition of nanotechnology may require special attention in terms of toxicity and safety.
Market authorization of pharmaceuticals requires a full physical and chemical characterization of the drug. The
increasing complexity of nanomedicines indicates that characterization has most likely to be tailored for the
specific product in development. The initial phases of product development may require a thorough
characterization to select the specific tests that will subsequently be used to release batches and test the quality
of the final product. Therefore, as with other medicinal products, it is important to identify the critical quality
attributes (CQAs) that maintain a direct relationship with products quality, efficacy and toxicity; these CQAs
should be the basis for the product’s quality control throughout its lifecycle. CQAs for ophthalmic
nanomedicines may include aspects related to nanotechnology such as particle size, size distribution, surface
charge, hydrophilicity; but also attributes related to pharmaceuticals, such as purity, stability, sterility, and
manufacture controls. Among the ophthalmic products approved so far, only the cationic nanoemulsion
containing cyclosporine A specifically lists CQA related to nanotechnology: particle size and zeta potential.
This is important as it is well known that size has a direct impact on the biodistribution and clearance of the
nanomedicine. For instance, subconjunctival administration of fluorescent polystyrene nanoparticles has shown
that 20 nm nanoparticles exhibit a rapid clearance from ocular and periocular tissues while 200 nm nanoparticles
made of the same material are retained in the eye for a period of two months (Amrite and Kompella, 2005). It
should also be considered that the nanomaterial administered to the eye can aggregate, thereby influencing the
in vivo behavior of the nanomedicines.
On the other hand, although small scale manufacturing of different types of nanomedicines in research
laboratories is fairly common, with the exception of nanoemulsions, the experience in large-scale manufacturing
is still limited. Large-scale manufacturing requires standardization and manufacturing under Good
24
Manufacturing Practices (GMP). Factors affected by the scale-up include changes in particle size, drug loading,
quality and quantity of impurities, structural alterations, among others. In particular, for oligonucleotides
changes in manufacturing processes may lead to decreased stability or even degradation of the product, as a
consequence, a very well controlled small-scale process may turn out to be unreliable or non-reproducible at a
larger scale if the process has not been efficiently controlled during the scale-up. For multi-step processes it is
usually useful to establish mid-process controls that can inform of the quality of the intermediate products in
order to better control the process as a whole.
An additional specific requirement of ocular pharmaceuticals is sterility. Many materials used to produce
nanomedicines are susceptible to routine sterilization techniques such as gamma irradiations or autoclaving. For
small or malleable particles double filtration may be an option for sterilizing the final product but for bigger
rigid particles aseptic manufacturing may be the only option.
Many nanocarriers are specifically designed to improve delivery of the active ingredient, thus it is expected that
biodistribution of the nanomedicine and its unformulated counterpart should be significantly different. In fact,
for ocular administration, it is crucial to determine whether the formulation changes the ability of the drug to
enter systemic circulation. Many approaches to develop nanomedicines for eye conditions seek precisely this
aim; to reduce the amount of compound that enters systemic circulation reducing the potential systemic side or
off-target effects of the drug. One of the main challenges of pharmacokinetic (PK) studies of nanomedicines is
to address the fate of the free drug following administration of a nanomedicine. For efficacy assessment the
amount of free drug reaching the intended site should be measured. On the other hand, the distribution of the
complete nanomedicine and its fate following delivery should be studied in order to address eventual toxicities
associated to the nanocarrier. For larger molecules, such as oligonucleotides specific methods used to assess the
free drug should be used to quantify the amount of drug reaching the target site. Subtle variations in the
characteristics of nanomedicines may result in altered patterns of biodistribution; therefore it is generally
expected that PK profiles of nanomedicines have greater variability than PK profiles obtained with unformulated
drugs. In addition, for ocular pharmaceuticals administered in eye drops the percentage of entrapment, which is
the amount of drug in one eye drop, is difficult to control further increasing the variability of the PK profiles.
These inherent characteristics of nanomedicines for ophthalmic use should be taken into account when
designing PK studies to avoid unnecessary duplication of experimental work. The surface characteristics of the
nanomedicine have a strong impact on the absorption and distribution of the drug and can be modified by surface
coatings in order to obtain particles with the desired characteristics.
It is generally accepted that specific types of nanomedicines may raise concerns in terms of toxicity, but the
general battery for assessing toxicity of drugs in a preclinical setting should be able to identify these toxic effects
and their potential relation to dose. Knowledge about the differences in biodistribution between the
unformulated drug and the nanomedicine are helpful to pinpoint possible target tissues for toxicity. Also,
additional tests may be needed if components of the nanomedicine are known to have dose-limiting toxicities
or if any of the components are not naturally degraded and excreted. Particular attention should be made on
potential immunotoxic effects. These toxicities are not necessarily deduced from the unformulated drug as they
25
may arise from specific interaction of the drug with other components of the nanocarrier or by interactions of
the nanomedicine with proteins present in biological fluids. The physical characteristics of the nanomedicines
may also increase their potential to interact with biological components. In the particular case of the eye,
interaction with melanin may alter the PK profile of the drug in the eye generating locally high concentration
of the drug upon release from melanin (Agrahari et al., 2016). Formulations reaching the bloodstream may also
potentially interact with components of the complement system or coagulation inducing side effects (Yousefi et
al., 2014). The assessment of these toxicities is not necessarily straightforward as animal models are not
necessarily good predictors of human immune systems. In these cases, in vitro tests with human cells can be
used to complement animal studies.
The production of nanosystems usually requires the use of surfactants. Surfactants lower the surface tension
between the nanosystem and the dispersion liquid acting as stabilizing agents. Usually there is a correlation
between the amount of surfactant used and the size of the nanoparticles, with low concentration of surfactant
generally yielding smaller particles. Unfortunately, surfactants may cause ocular irritation when administered
at high concentrations and need to be removed from the formulation or used in concentrations that are
compatible with the ocular surface. For ophthalmic products this approaches are combined with the aim of
reducing the amount of surfactants to concentrations that are tolerable by the eye without removing them
completely as they usually act as penetration enhancers facilitating the entrance of compounds (Leonardi et al.,
2014).
Clinical translation of nanomedicines for ophthalmic conditions has different requirements depending on the
indication and route of administration. Topical ocular eye drops are the preferred option for treating the anterior
segment of the eye whereas nanodrugs for the back of the eye are usually developed to release drug over an
extended period of time to reduce the frequency of administration. Nanomedicines that include oligonucleotides
should protect them against degradation by nucleases. Human biological fluids contain higher concentration of
nuclease activity than most animal models, therefore stability studies of the nanomedicine need to be
complemented to assess the stability of the drug in humans (Martínez et al., 2014). In addition, ophthalmic
nanomedicines need to comply with the general requirements for drugs administered by the ocular route. For
topical forms parameters such as sterility, osmolality, antimicrobial agents, buffering, viscosity, pH, particulate
matter and compatibility with packaging have to be considered.
Finally, it should be mentioned that development of complex delivery systems for ophthalmic drugs is highly
costly. As previously mentioned, the processes for developing nanomedicines may require additional data not
generally required for small molecules. This, added to the insufficient regulatory framework and the potential
complexity of the scale-up processes may further increase the associated costs of developing nanomedicines.
As such, it seems difficult for the industry to design developmental plans where the size of the ophthalmic
market outweighs the efforts and financial expenses associated to the development.
Currently there are several advanced preclinical programs developing nanomedicines with small drugs for
different ocular conditions. Most of these drugs are already commercialized and are being reformulated in order
to improve their efficacy as well as to find new indications for them. Overall, the more advanced technologies
26
include the production of nanoemulsions and liposomes. As these compounds reach the market it is expected
that nanoformulations are also incorporated into the pipelines of more complex molecules such as
oligonucleotides or peptides.
6. Conclusions and future perspectives
Although therapies involving polynucleotides for treating ocular diseases are in an early development stage,
preliminary human clinical trials begin to show promising results. Currently, there are two FDA approved
nucleic acid-based drugs for eye conditions: Vitravene, an AS-ODN for cytomegalovirus-induced retinitis
treatment in immunocompromised patients, and Macugen an aptamer designed to treat wet AMD. Curiously,
this aptamer is PEGylated and, as such, maybe considered as a nanomedicine. In principle polynucleotide-based
drugs do not comply with the best physicochemical properties to be used as effective drugs, however, their
chemical modification and the development of easy to produce nanocarriers offer a great window of opportunity
for the exploitation of these new therapies. Currently, several ocular diseases of the anterior and posterior
segment of the eye such as glaucoma, AMD, ocular pain associated to dry eye and CNV are under gene-based
clinical trials evaluation. Development of effective future ocular treatments will be a combination of
understanding the diseases genetic basis as well as improving and developing long-term and nontoxic ocular
drug delivery systems for both segments of the eye. It is believed that AS-ODN and RNA-based therapeutics
(specially siRNA-based as it is a potent inhibitor of protein expression) will continue further development
reaching the market in a reasonable time frame being the major task to achieve their nanosystems delivery along
with investigating alternative routes of administration.
If nanotechnology is successfully combined with polynucleotides, their delivery, the greatest hurdle holding
these drugs from the clinic, could be overcome. The following years will tell if these combined approaches can
be used in the treatment of severe ocular diseases that nowadays relay on painful, inconvenient and inefficacious
treatments. Much effort will have to be put into place for the efficient delivery of the genetic material to targeted
cells/tissues being one of the most challenging tasks to be accomplished by multidisciplinary research teams
composed of researchers, clinicians and pharmaceutical companies.
Acknowledgments
This work was supported by the European Union’s Horizon 2020 Research and Innovation Program under the
Marie Sklodowska-Curie Grant agreement No. 642028 (NABBA) and by the Spanish Ministry of Economy and
Competitiveness (MINECO) under Grant agreement No. RTC-2014-2375-1 (SURFeye).
27
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