1. 1 Cytotoxicity of topical medications after cataract surgery for human corneal endothelial/epithelial cells, and conjunctival epithelial cells 1) Masahiko Ayaki, MD, 1) Shigeo Yaguchi, MD, PhD, 2) Atsuo Iwasawa, PhD, 3) Ryohei Koide, MD PhD. 1) Department of Ophthalmology and 2) Department of Clinical Pathology, Fujigaoka Hospital, Showa University School of Medicine, 3) Department of Ophthalmology, Showa University School of Medicine Authors have no financial interest.

2. 2 Purpose and Methods Purpose –Cataract surgeons sometimes encounter unexplained persistent corneal edema after surgery and drug toxicity may be one of the potential etiologies. The purpose of this study is to evaluate cytotoxicity of topical medications to corneal and conjunctival cells. Cells –Human corneal endothelial cells (primary culture from eye bank eyes) –SIRC (human corneal epithelial cells, ATCC CCL-60,ATCC; American tissue and Cells Corporation) –Chang conjunctiva (human conjunctival epithelial cells, ATCC CCL-20.2, ATCC) Cell survival was measured using the WST-1 assay for endothelial cells and the MTT assay for epithelial cells after 48 hours exposure at 10, 100, and 1000-fold dilution. Culture method (reference) –Masahiko Ayaki, Shigeo Yaguchi, Ryohei Koide, Atsuo Iwasawa Cytotoxicity of ophthalmic solutions with and without preservatives for human corneal endothelial cells, epithelial cells, and conjunctival epithelial cells. Exp Clin Ophthalmol, 2008 ： 36 （ 6 ）； 553-559

3. 3 Tested ophthalmic solutions Antibiotics –gatifloxacin (Gatiflo R, Senjyu, Japan) –moxifloxacin (Vegamox R, Alcon) –levofloxacin (Cravit R, Santen) –norfloxacin (Noflo R, Banyu, Japan) –tosufloxacin (Tosuflo R, Nidek) –dibekacin (Panimycin R, Meiji, Japan) –cefmenoxime( Bestron R, Kaken, Japan) Anti-inflammatory; Non steroid –diclofenac (Diclod R, Diclostar R, Nitten, Japan, Diclostar R PF) –bromfenac (Bronuck R, Senjyu) –pranoprofen (Niflan R, Senjyu) Anti-inflammatory; Steroid –betamethasone (Rinderon R, Shinogi, Japan, Rinbeta R, Nitten, Japan, Rinbeta R PF) –betamethason&fradiomycin (Rinderon R A, Shionogi) –fluolomethorone (Flumethoron R, Santen) Topical anesthetics –oxybuprocain (Benoxil R, Santen)

4. 4 Preservatives in Tested Ophthalmic Solutions Trade NameActiveComponentPreser vative Levoquin, Cravit LevofloxacineNo VegamoxMoxifloxacinNo Zymer, GatifloGatifloxacinNo NofloNorfloxacinNo TosfloTosufloxacinNo PanimycinDibekacinBAK BestronCefmenoximeMethyl Para, Propyl Para, EDTA, Boric acid Trade NameActiveComponent Preservative RinderonBetamethasonMethyl Para, Propyl Para Rinderon ABetamethason, Fradiomycin Methyl Para, Propyl Para RinbetaBetamethason (Generic) Boric acid, EDTA RinbetaPFBetamethason (Generic with filter in the tip) Removed by filtration Flumethoron 0.1%Fluolomethoron 0.1%BAK, Polysorbate 80, EDTA Flumethoron 0.02%Fluolomethoron 0.02%BAK, Polysorbate 80, EDTA Diclod (Voltaren)DiclofenacChlorobutanol, Polysorbate 80 Boric Acid DiclostarDiclofenac (Generic)Boric Acid, EDTA Diclostar PFDiclofenac (Generic with filter in the tip) Removed by filtration Bronuck (Zybrom)BromfenacBAK, Polysorbate 80 NiflanPranoprofenBAK, Polysorbate 80, Boric Acid, EDTA BenoxilOxybuprocainBAK, EDTA BAK=Benzalkonium Chloride Para= Parahydroxybenzoate EDTA=ethylene-diaminetetraacetic acid (edetic acid)

5. 5 Results :Corneal Endothelia Cell survival (%) Anti-inflammatory (10-fold dilution, 48 hours exposure) 140 120 100 80 60 40 20 0 Betamethason Betamethason(G)-F Fluolomethorone 0.1% Fluolomethorone 0.02% Diclofenac(G) Diclofenac(G)-F Pranoprofen Oxybuprocain Bromfenac Diclofenac Betamethason+ Fradiomycin Antibiotics (10-fold dilution, 48 hours exposure) Cell survival (%) 140 120 100 80 60 40 20 0 LevofloxacinMoxifloxacinGatifloxacinNorfloxacinTosufloxacinPanimycinBestron

6. 6 Results : Epithelia-Antibiotics Antibiotics (Corneal epithelia, 10-fold dilution, 48 hours exposure) Cell survival (%) 140 120 100 80 60 40 20 0 LevofloxacinMoxifloxacinGatifloxacinNorfloxacinTosufloxacinDibekacinCefmenoximeSulperin Cell survival (%) Antibiotics (Conjunctival Epithelia, 10-fold dilution, 48 hours exposure) 140 120 100 80 60 40 20 0 LevofloxacinMoxifloxacinGatifloxacinNorfloxacinTosufloxacinPanimycinBestron

7. 7 Results : Epithelia-Antiinflammatory Cell survival (%) 140 120 100 80 60 40 20 0 Betamethason Betamethason(G )-F Flu olomethorone 0.1% Fluolomethorone 0.02% Diclofenac(G) Diclofenac(G )-F Pranoprofen Oxybuprocain Bromfenac Diclofenac Betamethaso n+ Fladiomycin Cell survival (%) 140 120 100 80 60 40 20 0 Betamethaso n Betamethason(G )-F Fluolomethor one 0.1% Fluolomethorone 0.02% Diclofenac(G) Diclofenac(G)-F Pranoprofen Oxybuprocain Bromfenac Diclofenac Betameth a son +Fladiomycin Antiinflamatory (Corneal epithelia, 10-fold dilution, 48 hours exposure) Antiinflammatory (Conjunctival Epithelia, 10-fold dilution, 48 hours exposure)

8. 8 Summary of Results Most of tested solutions had corneal and conjunctival toxicity in 10-fold dilution (steroids < antibiotics < non steroidal anti- inflammatory medications). It decreased (cell survival > 80%) after 1000-fold or more dilution and seemed to depend mostly on the components of ophthalmic solution such as benzalkonium chloride.

9. 9 Cause of postoperative corneal edema (Liu, JCRS, 2001) 1.Preexisting endothelial damage –(a) Fuchs‘ corneal endothelial dystrophy or advanced cornea guttata –(b) Posterior polymorphous corneal dystrophy –(c) Low endothelial cell count 2.Surgical trauma –(a) Cavitational energy –(b) Direct touch by instruments or intraocular lens –(c) Turbulent flow of irrigation solution –(d) Lens or lens particle contact with the cornea –(e) Repeated anterior chamber collapse –(f) Descemet‘s detachment –(g) Corneal burn 3.Use of unphysiologic or toxic intraocular fluids and drugs –(a) Hypoosmotic (under 200 mOsm) or hyperosmotic(over 400 mOsm) fluids –(b) Low or high pH value (under 6.8 or over 8.2) –(c) Lack of calcium in irrigating fluid –(d) Toxic concentrations of drugs ( antibiotics, local anesthetics, miotics) –(e) Detergents and sterilizing agents –(f) Preservatives 4.Postoperative conditions –(a) Excessive inflammation –(b) High intraocular pressure –(c) Adherence of vitreous, iriis, or lens capsule –(d) Epithelial downgrowth

10. 10 Conclusions The postoperative topical medications had cytotoxicity and those preserved with benzalkonium showed higher toxicity than those without them. Considering actual concentration at corneal endothelium, they do not seem to cause endothelial damage. Correspondence Masahiko Ayaki MD, Showa University School of Medicine, Yokohama, Japan ayaki@showaf.jp