Struct Chem (2009) 20:341–349
DOI 10.1007/s11224-009-9435-y
ORIGINAL RESEARCH
Therapeutic use of hyaluronan
Endre A. Balazs
Received: 28 January 2009 / Accepted: 3 February 2009 / Published online: 4 March 2009
Ó Springer Science+Business Media, LLC 2009
Abstract Hyaluronan used today as a therapeutic agent in
human and animal medicine must be in a highly purified
form, free of immunologically active protein molecules,
from endotoxin and from inflammatory molecules origi-
nating from the tissues or bacterial cultures—the source of
hyaluronan. All hyaluronans, whether in liquid or in cova-
lently crosslinked gel form, must have certain elastoviscous
properties to be usable for current therapeutic applications.
Elastoviscous properties are especially important in the
ophthalmic viscosurgical use. The metabolism of hyaluro-
nan is very fast in most tissues, except in the vitreus. The
ability of injected hyaluronan with a short half-life time in
the joint to accomplish long-lasting analgesia represents a
challenge for the design of the various products. The history
of the therapeutic use of hyaluronan and its present status is
described, with emphasis on its use in ophthalmic surgery
and for a long-lasting analgesia in arthritic joints in humans
and animals. The use of hyaluronan gels is described in
viscoaugmentation as injected into the dermal layer of the
skin. Hyaluronan gels were also used as viscosupplements
injected into sphincter muscles to improve their function in
aging or disease. The use of hyaluronan and its gel for drug
delivery was suggested several decades ago, and is also
mentioned.
Keywords Non-inflammatory fraction of hyaluronan

Drug delivery
Hyaluronan gel
Osteoarthritis

Analgesic effect
Elastoviscosity
Hyaluronan

Viscosupplementation
Viscosurgery
Viscoaugmentation
E. A. Balazs (&)
Matrix Biology Institute, 725 River Road, Edgewater,
NJ 07020, USA
e-mail: eabalazs@matrixbio.org; jdenlinger@matrixbio.org
The properties of hyaluronan that make
it suitable for therapeutic use
Chemical purity
Hyaluronan is a well-known linear unbranched polysac-
charide, the only one present in the biological matrix. It fills
the space between the cells of all tissues as one of the
structural components of the biomatrix in the vertebrate
body. As far as we know, its average molecular weight (MW)
in the biomatrix is in the range of 6 to 12 million, and it is
extremely polydisperse. In biological liquids, like the lymph
and blood, its MW is considerably less. Most of the hyalu-
ronan molecules do not contain protein covalently bound to
the polysaccharide chain. It is conceivable that a small
percentage of this molecule is attached to the proteinous
structures in the biomatrix. It is known that in some solid
biomatrices, like cartilage, there is a non-covalent associa-
tion between hyaluronan and certain proteoglycans. In
liquid biomatrices, such as liquid vitreus and synovial fluid,
such associations have not been observed. In the vitreus and
aqueous of fish eyes such associations have been found.
Biological purity
Hyaluronan molecules used for therapeutic purposes must
be purified. This purification process must remove all
proteins, nucleic acids, and other molecules that may pro-
duce irritation, inflammation, or an antigenic reaction.
Hyaluronan for therapeutic purposes has been prepared
from human umbilical cord, rooster comb, and from the
capsules of some bacteria such as streptococcus, and the
purification process is not always a simple task. In the late
1960s, the biggest challenge of this purification process
was to remove the unidentified, inflammation-causing
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342 Struct Chem (2009) 20:341–349

molecules originating from the tissue homogenate. This

impurity was not an endotoxin, but acted as one. The
purified hyaluronan that had no inflammatory impurities
was called the non-inflammatory fraction of Na-hyaluronan
(NIF-NaHA), and was the first hyaluronan used for thera-
peutic purposes, starting with clinical trials in veterinary
and human medicine in the late 1960s. Today all hyalu-
ronan used for such purposes must be proven to be NIF-
NaHA. It was also well established that the higher the Mw,
the more difficult it is to remove all protein and nucleic
acids from the hyaluronan. This is mostly due to the fact
that during purification, the mechanical process (homoge-
nizing, filtration, mixing) and heat treatment (sterilization)
degrade the larger molecules. It is very important to realize
that this difficult purification process resulted in hyaluro-
nan products with a great variety of MW and polydispersity.

Elastoviscous properties

One of the most important properties of hyaluronan solu-

Fig. 1 Dynamic viscoelastic properties of hyaluronan in human
tions is their rheology, that is, their viscous and elastic synovial fluid. Note the frequency (Hz) at which the elastic and
behavior in solution when exposed to various shear rates. viscous dynamic moduli (G0 , G00 ) have the same value. This value at
The purification processes of hyaluronan decrease the Mw, the crossover point characterizes the elastoviscous properties of a
non-Newtonian fluid. The Pa values for both moduli are also an
and increase the polydispersity. Truly monodisperse poly-
important definition of these rheological properties (Gibbs, Seppälä,
saccharides have not been found in nature, nor have they Rydell, Balazs, 1966–1970)
been synthesized. Therefore, one can characterize these
molecular systems only by MW and polydispersity (not by
Daltons which should be used only to characterize the
exact molecular weight of proteins and molecules with
similar monodisperse characteristics).
Hyaluronan solutions above a certain MW and concen-
tration are viscous and elastic and behave as non-Newtonian
fluids. The elastoviscous properties of hyaluronan are
usually demonstrated with the shear rate (frequency in Hz)
dependence of the dynamic elastic (G0 ) and viscous (G00 )
moduli. The crossover point (x) at which these two moduli
have equal value (in Hz) is also used for the rheological
characterization of hyaluronan fluids. Above this frequency,
hyaluronan solutions become dominantly elastic, whereas
below this frequency, viscosity is the dominating rheolog-
ical property (Fig. 1). In this figure, the viscous and elastic
properties of the hyaluronan in a healthy and an osteoar-
thritic human synovial (joint) fluid are compared. The
elastic behavior can also be demonstrated by the so-called
normal stress or Weissenberg effect, in a dilute hyaluronan
solution (0.5% in physiological NaCl). Note that the
viscoelastic fluid does not form a vortex, but climbs up both
inside and around the rotating tube (Fig. 2). The same Fig. 2 Normal stress effect (Weissenberg effect) demonstrated on a
0.5% hyaluronan solution with a Mw of 4 million
hyaluronan solution at pH 2.5 behaves as a semisolid elastic
‘‘putty.’’ After being exposed to rotation, it takes up its
original shape (Fig. 3) and does not stick to plastic or glass Hyaluronan in solution, both from natural sources
surfaces because hyaluronan at this pH has high surface (synovial fluid, liquid vitreus) or in purified form, has been
tension. characterized by its coil overlap parameter, also called the

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Struct Chem (2009) 20:341–349
Fig. 3 Demonstration of the elastic properties of hyaluronan of Mw
4 million dissolved in 1% 0.15 N NaCl solution at pH 2.5. Note the
black string embedded into the ‘‘putty’’ (left), when rotated (middle)
regains its original shape (right) due to its elasticity
Simha factor after its discoverer. Figure 4 shows the rela-
tionship between specific viscosity and the Simha factor,
which is defined as a product of the volume of random coil
molecules defined in limiting viscosity number ([g]) and
the concentration of the polymer in its ideal solvent. At a
certain value of the factor (c[g]) the relationship changes
because above that concentration due to the crowding of
the individual molecular coils they touch each other and
begin to overlap. Figure 5 shows the Simha factor (coil
overlap parameter) applied for the first time to hyaluronan-
containing solutions, synovial fluid. The coil overlap
parameter of human synovial fluids of healthy and arthritic
joints, as well as healthy cow synovial fluids, is plotted
against the dynamic viscous and elastic moduli of the
solutions.
Metabolism
One of the most important observations is that these large
molecules metabolize very quickly in all biomatrices
investigated. The turnover is dependent on the mechanical
forces to which the biomatrix is exposed. For example, in
the synovial fluid of joints that are exposed to constant
flexion and extension, the turnover is driven by the flow of
the fluid. In such conditions, the half-life of hyaluronan is a
few days. In other liquid biomatrices such as the liquid
and gel vitreus where there is no fluid movement, the
turnover is very slow (weeks) and is based on diffusion
driven by concentration gradients of hyaluronan. This fast
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Fig. 4 The coil overlap parameter demonstrates the relationship
between the specific viscosity of a polymer and the product of
concentration times limiting viscosity number (c[g])
metabolism of hyaluronan is very advantageous in some
therapeutic applications, such as ophthalmic viscosurgery,
when it is used only during a short surgical procedure. It is
less advantageous in viscosupplementation or in adhesion
prevention after surgery where the injected hyaluronan
must stay for a longer time to be efficacious. In order to
extend the residence time of injected hyaluronan, cross-
linked gels made from it were invented and are now used
extensively.
Therapeutic use in joints
Viscosupplementation is the name that was given to the use
of hyaluronan solutions, alone or in combination with gel
particles, used to replace and supplement the pathological
synovial fluid. The original concept behind this replace-
ment process was based on experiments carried out during
the 1960s and 1970s. These experiments gave us infor-
mation about the hyaluronan content and rheological
properties of synovial fluids in horse and human joints,
both healthy and diseased. We also discovered that in
traumatic arthritis in dogs and horses, replacing the path-
ological joint fluid with highly viscoelastic hyaluronan
solution resulted in long-lasting analgesia. The fate of this
injected hyaluronan supplement in rabbit and horse joints
and the beneficial effect of this supplement on the healing
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Fig. 5 The relationship of the coil overlap parameter with dynamic
viscous and elastic moduli in human and cow synovial fluids.
Concentration of hyaluronan measured in g/mL. Limiting viscosity
number ([g]) in mL/g measured at 37°. Human healthy fluid (open
circle), human pathological fluid (filled circle), cow healthy fluid
(filled square)
of cartilage wounds was also observed. In in vitro experi-
ments, it was also found that viscous hyaluronan solutions
dramatically affect—inhibit or stimulate, depending on the
viscosity—the activity of the cells of the lymphomyeloid
system, that is, the cells circulating in the blood and lymph,
known as lymphocytes, granulocytes, and macrophages.
For example, it was found that hyaluronan with very low
Mw (\200,000) stimulates phagocytosis of macrophages
in vitro, but the same concentration of molecules of very
high Mw inhibits this same process. The inhibition is due to
the viscosity effect, and even viscous DNA solutions
inhibit the rate of phagocytosis. Prostaglandin production
and release from macrophages during phagocytosis are
affected the same way. This effect of purified hyaluronan
on macrophages was also demonstrated using synovial
fluid from horses.
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Struct Chem (2009) 20:341–349
The first two decades of development
of viscosupplementation
The analgesic effect was established in 1970 in veterinary
clinical trials of race horses with traumatic arthritis. In 1975,
clinical trials in four different countries found the same
analgesic effect in human osteoarthritis. In the mid-1970s in
Sweden and then in the USA in 1976, viscosupplementation
with a 1% hyaluronan solution with Mw 2–3 million was
approved as a therapeutic agent in veterinary medicine. In
human osteoarthritis, more than a dozen clinical trials were
completed in Scandinavia, USA, and England with exactly
the same preparation used worldwide in veterinary arthritis,
but this preparation was never made available as a thera-
peutic for humans. The reason was not medical, but was due
to the marketing policies of the same company who had
marketed this same hyaluronan preparation worldwide for
ophthalmic viscosurgery (Pharmacia AB, Uppsala, Swe-
den). Finally in 1987, more than a decade later, a very
different hyaluronan from Japan and Italy became available
for viscosupplementation. The purity (NIF-NaHA) and the
concentration of hyaluronan were the same in the products
of both companies, but the Mw of hyaluronan was consid-
erably lower (0.5–0.7 million) than the Pharmacia product.
This significantly changed the concept of viscosupplemen-
tation, because with this product, while the concentration of
hyaluronan in the pathological synovial fluid was increased,
the increase in the elastoviscosity from a pathological low
level to the healthy level was not achieved. Nevertheless,
increasing the number of injections to five to ten weekly
injections resulted in long-lasting analgesia in some
patients. This proved that even the exchange of the patho-
logical fluid with lower elastoviscous hyaluronan solution is
beneficial when it is repeated for longer time. Consequently,
it became clear that two factors play a role in the therapeutic
concept of viscosupplementation: first, the washing out of
the painful joint with more than 20 times higher concen-
tration of hyaluronan than is present in the pathological
fluid; and second, maintaining the presence of this high
concentration of hyaluronan in the joint as long as possible.
The manufacturers of these products also recognized that
while this low elastoviscous solution was effective in some
patients, higher elastoviscosity was preferable. This point
was proved by studying the analgesic effect of hyaluronan
injections in animals to counteract pain caused by pain-
producing chemicals.
The first hyaluronan with very high Mw (6 million) was
not made available for therapeutic use until 1992 in Canada
and, before the end of that decade, worldwide. This product
had an elastoviscosity similar to that of the healthy syno-
vial fluid and the concentration of hyaluronan was still
higher than normal (0.8%). Hyaluronan was present in the
product in two forms: as a fluid, called hylan A, and as a
Struct Chem (2009) 20:341–349
soft gel, hylan B (generic names). The final product con-
sisted of 80% fluid and 20% gel.
Today, there are three types of viscosupplementation
products available worldwide. The major difference
between them is in their average molecular weight and in
the broad distribution of the molecular weight. Figure 6
shows the molecular weight distribution and the polydis-
persity of the products.
The primary and often the only reason why regulatory
agencies approved intra-articular injections of hyaluronan
for the treatment of osteoarthritis was because of its long-
lasting analgesic effect. Painful osteoarthritis occurs mostly
in the knee joint, because this is the most complicated joint
under the load of the entire body weight. This and the other
joints of the leg are subjected to various frequencies of
loading conditions, that is, from the low frequency of
standing up to the highest frequency of running and
jumping. Pain in a healthy joint can be experienced under
intense compression, produced, for example, by jumping
from a great height or stretching the joint beyond its normal
range of motion against the resistance of the synovium,
joint capsule, and ligaments. If the pain is only momentary
and disappears as the mechanical stimulus is released, the
pain is not caused by a chemical agent, but by a mechanical
stimulus. In an arthritic joint, on the other hand, pain at rest
is caused by the stimulation of the nociceptors by pressure,
caused by a volume increase in the intercellular matrix
(swelling) or by the stimulation of specific pain-producing
molecules. Pain on movement in a patient with inflam-
mation in the synovium can be caused by sensitization of
high threshold nociceptors for movement within the normal
range of motion of the joint. Intra-articular pain in trau-
matic arthritis, on the other hand, is caused by the
chemicals released from the acute intra-articular wounds in
Fig. 6 The three types of hyaluronan products available for viscosup-
plementation worldwide designated 1, 2, and 3, showing their
gel electrophoresis molecular weight distribution pattern. The peak
molecular weight, and the weight, and number average molecular
weights are as follows: 1 6.8 million, 5.2 million, 4.0 million;
2 4.5 million, 3.0 million, 1.9 million; 3 1.2 million, 1.2 million,
0.8 million. The polydispersity indices are 1.3, 1.7, and 1.5,
respectively
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the synovial tissue or ligaments. The cartilage has no
nociceptors; therefore, the pain cannot originate in the
cartilage itself. It can be caused by chemicals released from
a cartilage wound.
Hyaluronan solutions with very low Mw (\500,000)
even in 30 mg/mL concentration were not effective.
Neurophysiological studies in the 1990s confirmed these
behavioral studies. These studies concluded that several
mechanisms can explain the analgesic effect of viscous
hyaluronan solutions: one, elastoviscous mechanoprotec-
tion—that is, elastic stabilization of nociceptors against
stimuli for mechanical dislocation; two, the molecular
sieve effect, that is, ionic interaction of hyaluronan with
positively charged Ca?? channel activators; and three, a
detoxicating effect—that is, the interaction of hyaluronan
with the nociceptors or with pain-producing molecules,
resulting in protection of the receptors by inactivation of
these agents.
How viscosupplementation works
What is the hypothesis that explains how viscosupple-
mentation works? First of all, in the majority, but by no
means all the cases of osteoarthritis with inflammation, the
total amount of hyaluronan increases. This increase is
caused by an increase of the volume of the synovial fluid
due to an influx of water triggered by inflammation or by
the blockage of the outflow of the fluid from the joint
(Fig. 7). This causes a decrease in the concentration of
hyaluronan in the joint, but does not necessarily result in
pain in the joint. The concentration of hyaluronan can
decrease to 0.1 mg/mL or below, which is a substantial
decrease compared to normal levels of 2–3 mg/mL. At the
Fig. 7 The total amount of hyaluronan (in mg) in the synovial fluid
collected from a healthy and an osteoarthritic human knee joint. The
fluid volume collected from the healthy joint was 2 mL and from the
osteoarthritic joint was 20 mL. Two fractions of the fluid represent
hyaluronan molecules under MW 2 million (solid black columns) and
over Mw 2 million (dotted columns) (Balazs, Cowman, Band, and
Weiss, 1999)
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same time, the amount of low-molecular weight hyaluro-
nan, that is, molecules below MW 2 million, increases
significantly, while the amount of hyaluronan with high Mw
may increase significantly in quantity as well. This fact is
often overlooked. We have not found one human arthritic
fluid among the several hundreds studied that did not have
significant amounts of hyaluronan with the same high Mw
as that found in the healthy joint. A good example is shown
in Fig. 8. This was an elderly patient with chronic osteo-
arthritis of both knees. For years, this patient repeatedly
produced large amounts of hyaluronan in large volumes of
fluid (exudates). This figure shows the gel electrophoretic
analyses of three exudates taken from the same knee at the
first visit and at two follow-up visits 28 days and 7 months
later. The volumes of the synovial exudates were 60, 65,
and 45 mL. The patient had no osteoarthritic pain, but
came to the doctor because of the discomfort caused by the
extraordinary swelling of the joint. The healthy joint con-
tains 2 mL fluid. Note how similar the curves are, which
means that the joint regularly produced and maintained a
similar hyaluronan content during the 7 months. About
4 months earlier, the first arthrocentesis produced a similar
volume of exudate (data not shown). Notice also that the
polydispersity clearly indicates that about half of all the
hyaluronan present in this exudate is in MW range of 2 to
6 million, the latter being in the healthy range. The other
half of the molecular population is in the pathological
range, that is, between 2 million and 200,000.
In summary, the osteoarthritic synovial fluid has lower
hyaluronan concentration, mostly because of the influx of
water or because the hyaluronan production is impaired.
The polydispersity is always greater because of the pres-
ence of lower than normal molecular weight hyaluronan.
The healthy or osteoarthritic synovial fluid has no hyalu-
ronic acid degrading agents in it (enzymatic, oxidative, or
free radicals). Consequently, the lower molecular weight
hyaluronan population must be released from the cell sur-
face, and not degraded later in the synovial fluid. In other
Fig. 8 Gel electrophoresis analysis of three synovial fluid exudates of
the same knee joint of a patient, collected at three different visits (first
0 time; second 28 days later; third 7 months later). The volume of
fluid collected were 60, 65, and 45 mL, respectively (Balazs,
Cowman, Band and Weiss, 1999)
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Struct Chem (2009) 20:341–349
words, the broad polydispersity of the hyaluronan in the
synovial fluid cannot be explained with an HA-degrading
system in the fluid. It is possible that there are two different
cell types producing the two distinctly different hyaluronan
molecular populations.
We suggested some time ago that the long-lasting
analgesic effect of hyaluronan injections could be
explained only if the analgesia triggered other important
events. The injection itself causes a significant increase in
concentration of hyaluronan, and when certain viscosup-
plementation products are used, the viscoelasticity of the
hyaluronan will also be restored to healthy levels. These
factors result in analgesia, and it lasts as long these changes
are maintained. We know that in the human knee joints this
period is about 1 week. By repeated weekly injections, this
analgesia can be extended for several weeks. This extended
analgesia depends on the level of pain before injection and
the sensitivity of the patient to pain, as well as the activity
of the joint. The painless joint movement restores the
normal synovial fluid flow that depends on the full use of
the joint.
Regulatory issues
There is much of misinformation in the literature about the
drug versus medical device status of hyaluronan as an in
intra-articular injection for the treatment of arthritic pain,
and for its use as a viscoelastic fluid for ophthalmic vi-
scosurgery. When the first hyaluronan was introduced for
the above therapeutic uses in Europe and Japan, there were
no regulatory laws for medical devices in these parts of the
world. Consequently, hyaluronan was introduced as a drug
for all therapeutic purposes. In the USA, the first hyalu-
ronan preparation for viscosupplementation in veterinary
medicine was also introduced as a drug (1976) and still has
this classification in the USA. In Japan, hyaluronan for
most therapeutic purposes is still classified as a drug. Only
in the USA was a highly viscoelastic hyaluronan solution
approved as a device for ophthalmic viscosurgery and later
for all other currently used therapeutic applications. This
includes the use of gels of hyaluronan for various thera-
peutic purposes. It is obvious that the regulatory definition
of hyaluronan as a drug or device is not based on scientific
considerations.
Current and future improvements
Finally, I would like to discuss briefly the current devel-
opment work of drug companies to improve viscosup-
plementation products. There is an attempt to increase the
residence time of the injected hyaluronan in the joint in
order to decrease the number of weekly injections required
(now a minimum of three weekly injections). In order to
Struct Chem (2009) 20:341–349
accomplish this, they are experimenting with hyaluronan
gel particles that have longer residence time in the joint as
well as increasing the concentration and volume of hya-
luronan injected into the joint.
I believe it would be useful to develop a diagnostic
method that permits selection of patients who respond well
to viscosupplementation. For this purpose one would have
to identify the pain-causing agents. It would also be helpful
to prove that viscosupplementation not only produces a
long-lasting analgesia, but is also a disease-modifying
therapy. Of course, there are those of us who argue that
analgesia itself is a disease-modifying process because the
patient’s only complaint is the pain that led him or her to
the doctor. It would be also useful to prove that visco-
supplementation provides protection of the cartilage by
maintaining a healthy lamina splendens and restoring its
integrity after injury. Similar anti-inflammatory and wound
healing effects on the synovial tissue would provide new
dimensions for viscosupplementation as a therapeutic
modality.
Ophthalmic viscosurgery with hyaluronan
Ophthalmic viscosurgery is probably the most established
successful clinical application of highly elastoviscous
solutions of purified hyaluronan. The applications in vari-
ous parts of the eye can be summarized as follows:
1. Use during vitreoretinal surgery as replacement of the
vitreus or as a tool to manipulate the detached retina to
hold it in place at the back of the eye.
2. Use during trauma surgery as a surgical tool.
3. In transplantation of the cornea, its use to protect the
endothelium from damage during handling of the
tissue. The transplantation of the cornea was the first
organ transplantation in medicine. The endothelium, a
single-cell layer covering the inner surface of the
cornea, does not regenerate after injury. When these
cells are damaged, the cornea becomes opaque and
non-transparent, rendering the transplant useless.
4. In implantation of plastic lens after cataract surgery.
During implantation of a plastic lens after removal of
the cataractous lens, the surgery will fail if the corneal
endothelium is damaged. The use of elastoviscous
hyaluronan in intraocular lens implantation revolu-
tionized and assured fast progress in this field.
5. Hyaluronan in both fluid and gel form has been tested,
but not yet generally used, in glaucoma surgery.
6. On the surface of the eye hyaluronan solutions have
been used since the late 1980s to hydrate and protect
the surface of the eye in dry eye syndrome and during
extended surgical procedures.
347
7. Use of hyaluronan as a moisturizing eye drop in
healthy eyes to prevent discomfort and fatigue after
extended use of the television or computer screen was
proposed in the 1970s and is now used worldwide.
In the beginning of 1980, viscosurgery in ophthalmol-
ogy was in generally used worldwide, and the only product
available was a highly purified (NIF-NaHA) product with
Mw of 2–3 million and a concentration of 1%, resulting in a
fluid with a very high elastoviscosity. During the following
decades, similar products with lower elastoviscosity were
also used. Some were made from plastic materials with
very low viscosity and no elastic properties at all. These
products are much less expensive, but their usefulness is
limited.
The name ophthalmic viscoelastic device (OVD) became
the general description of the dozens of products that
became available. Depending on their use in ophthalmic
surgery, the various preparations were described as visco-
adhesive, viscodispersive, and viscoadaptive products. This
was based on their usefulness as surgical tools and how
easily they could be removed from the eye after surgery.
Today four major products lead the market. The first three
are the original product, marketed first in the 1980s, and its
two subsequent improvements. The improvements were an
increase of the Mw and/or concentration, both of which
increased the elastoviscous properties of the OVD. One
very different product was also introduced that contained
chondroitin sulfate as well as hyaluronan. The advantage of
this product in certain surgical situations is that it has some
stickiness due to its chondroitin sulfate content.
Therapeutic use of hyaluronan gels
Gels are made of hyaluronan by a crosslinking process,
leaving these gels insoluble in water or physiological salt
solution. The first hyaluronan gel developed for therapeutic
use in the early 1980s was made by vinyl sulfone cross-
linking and called by the generic name hylan B. All such
chemically modified hyaluronans may be called hylans,
provided the crosslinking process does not involve or in
any way affect the carboxylic acid, the N-acetyl glucosa-
mine and the end groups of the molecule. The vinyl sulfone
crosslinking did not affect the basic structure of the
molecular chain, because only the hydroxyl group was
involved with a bis (ethyl) sulfone crosslink. This highly
hydrated, soft gel has an exceptional biocompatibility. This
hylan B gel was the first used for tissue augmentation, drug
delivery, and viscoseparation, to prevent postsurgical
adhesions and excessive scar formation. One decade later
hyaluronan was also developed with epoxy crosslinking
and was used for tissue augmentation.
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Hyaluronan as filler of the biomatrix of connective
tissues
Hyaluronan gels are also being used to correct leaking
sphincters, such as the sphincter of the bladder. Hyaluronan
gel injected into the biomatrix of the connective tissues
between the muscles cells of the sphincter serves as a
bulking substance and corrects the incomplete function of
the sphincter. This application was conceived in the late
1980s, but has not been widely used.
Hyaluronan and its modified forms have been suggested
and clinically tested since the 1980s to coat surfaces of
various surgical implants to decrease excessive tissue
reaction around the implant. Such implanted materials,
because they are foreign to the body, can cause inflam-
matory reactions, called ‘‘foreign body reactions.’’ The
hyaluronan coating can prevent this tissue response.
Finally, hyaluronan gels and solutions were also tested
for targeted delivery of various drugs. Drugs mixed with
hyaluronan solutions or incorporated into gels facilitate the
targeted and localized delivery of such drugs. Such appli-
cations, for example, were designed for delivery of
anticancer dugs into the space from which cancerous tissue
was removed to kill cancer cells that may remain in the
wounded area. The concept of using hyaluronan (fluids or
gels) for drug delivery was developed when the first hya-
luronan gel for therapeutic purposes was created. The gel
can be used as a sponge that contains the drug, or the drug
can be covalently attached to a hyaluronan fluid and
delivered slowly into the tissue. The use of hyaluronan as a
drug delivery system has not yet been fully exploited.
Notes This article was written to summarize the intellectual effort
behind the concept of using hyaluronan as a therapeutic agent in
veterinary and human medicine. Its intention is to present the
development and current status of the ‘‘movement’’ to use a
ubiquitous and unique polysaccharide of the vertebrate body as a
drug or as a device. The references that follow will give readers an
opportunity to read more about this broad and ever-expanding field.
Bibliography
1. Acosta MC, Gallar J, Belmonte C (1999) Exp Eye Res 68:663–
669. doi:10.1006/exer.1998.0656
2. Algvere P (1971) Acta Ophthalmol 49:975–976
3. Arshinoff SA (1999) J Cataract Refract Surg 25:167–173.
doi:10.1016/S0886-3350(99)80121-7
4. Arshinoff SA (1995) Ophthal Prac 13:98–104
5. Avila LZ, Gianolio DA, Konowicz PA, Philbrook M, Santos MR,
Miller RJ (2008) In: Garg HG, Cowman MK, Hales CA (eds)
Carbohydrate chemistry biology and medical applications.
Elsevier, Amsterdam, pp 333–357
6. Balazs EA (1968) Univ Mich Med Cent J (Suppl):255–259
7. Balazs EA (1971) Hyaluronic acid and matrix implantation, 2nd
edn. PubMatrix, Edgewater, NJ
123
Struct Chem (2009) 20:341–349
8. Balazs EA (1983) In: Miller D, Stegmann R (eds) Healon: a
guide to its use in ophthalmic surgery. Wiley, New York,
pp 5–28
9. Balazs EA, Eliezer IK, Dennebaum RA, Larsen NE, Whetstone
JL (2002) In: Kennedy JF, Phillips GO, Williams PA, Hascall VC
(eds) Hyaluronan, volume 2. Biomedical, medical and clinical
aspects. Woodhead, Cambridge, UK, pp 33–38
10. Balazs EA, Leshchiner EA (1989) In: Inagaki H, Phillips GO
(eds) Cellulosics utilization: research and rewards in cellulosics.
Elsevier Applied Science, New York, pp 233–241
11. Balazs EA, Leshchiner E, Larsen N, Band P (1995) In: Wise DL
(ed) Handbook of biomaterials and applications. Marcel Dekker,
New York, pp 1693–1715
12. Balazs EA, Larsen NE, Leshchiner EA, Boney JD, Mitlitski V,
Parent EG, Whetstone JL (2002) In: Kennedy JF, Phillips GO,
Williams PA, Hascall VC (eds) Hyaluronan, volume 2.
Biomedical, medical and clinical aspects. Woodhead, Cambridge,
UK, pp 7–12
13. Balazs EA, Weiss C (2002) In: Hascall VC, Kuettner KE (eds)
The many faces of osteoarthritis. Birkhäuser, Basel, pp 189–206
14. Balazs EA (2003) Cells Tissues Organs 174:49–62. doi:10.1159/
000070574
15. Balazs EA (2004) Surg Technol Int 12:278–289
16. Balazs EA (2004) In: Garg HG, Hales CA (eds) Chemistry and
biology of hyaluronan. Elsevier, Amsterdam, pp 415–455
17. Balazs EA, Freeman MI, Klöti R, Meyer-Schwickerath G,
Regnault F, Sweeney DB (1972) In: Streiff EB (ed) Modern
problems in ophthalmology (secondary detachment of the retina,
Lausanne, 1970). S. Karger, Basel, pp 3–21
18. Balazs EA, Band PA (2008) In: Garg HG, Cowman MK, Hales
CA (eds) Carbohydrate chemistry, biology and medical applica-
tions. Elsevier, Amsterdam, pp 311–332
19. Band PA (2002) In: Kennedy JF, Phillips GO, Williams PA,
Hascall VC (eds) Hyaluronan, volume 2. Biomedical, medical
and clinical aspects. Woodhead, Cambridge, UK, pp 427–440
20. Band P, Balazs EA (1985) J Soc Cosmet Chem 36:104
21. Biomatrix, Inc. (2002) In: Kennedy JF, Phillips GO, Williams
PA, Hascall VC (eds) Hyaluronan, volume 2. Biomedical,
medical and clinical aspects. Woodhead, Cambridge, UK, pp
115–118
22. Biomatrix, Inc. (2002) In: Kennedy JF, Phillips GO, Williams
PA, Hascall VC (eds) Hyaluronan, volume 2. Biomedical, med-
ical and clinical aspects. Woodhead, Cambridge, UK, pp 285–288
23. Biomatrix, Inc. (2002) In: Kennedy JF, Phillips GO, Williams
PA, Hascall VC (eds) Hyaluronan, volume 2. Biomedical,
medical and clinical aspects. Woodhead, Cambridge, UK,
pp 41–44
24. Burns JW, Skinner K, Colt J, Sheidlin A, Bronson R, Yaacobi Y,
Goldberg EP (1995) J Surg Res 59:644–652. doi:10.1006/
jsre.1995.1218
25. Burns JW, Colt MJ, Burgess LS, Skinner KC (1997) Eur J Surg
163(Suppl 577):40–48
26. Edmund J (1976) In: Irvine AR, O’Malley C (eds) Advances in
vitreus surgeries. C. Thomas, Springfield, IL, pp 624–625
27. Gibbs DA, Merrill EW, Smith KA, Balazs EA (1968) Biopoly-
mers 6:777–791. doi:10.1002/bip.1968.360060603
28. Gomis A, Pawlak M, Balazs EA, Schmidt RF, Belmonte C (2004)
Arthritis Rheum 50:314–326. doi:10.1002/art.11421
29. Gomis A, De la Peña E, Balazs EA, Schmidt RF, Belmonte C
(2005) In: Balazs EA, Hascall VC (eds) Hyaluronan: structure
metabolism biological activities therapeutic applications, vol II.
Matrix Biology Institute, Edgewater, NJ, pp 503–507
30. Graue EL, Polack FM, Balazs EA (1980) Exp Eye Res 31:119–
127. doi:10.1016/0014-4835(80)90094-9
31. Gunson DE, Hilal SK, Leshchiner EA, Larsen NE, Balazs EA
(1988) In: Twenty-third annual meeting american society for
Struct Chem (2009) 20:341–349
clinical pathology, Kansas City, MO, October 31–November 4,
1988, p 43
32. Klöti R (1972) Schweiz Ophthal Ges 165:351–359
33. Larsen NE, Balazs EA (1991) Adv Drug Deliv Rev 7:279–293.
doi:10.1016/0169-409X(91)90007-Y
34. Larsen NE, Balazs EA (1994) Ophthalmic Pract 12:137–140
35. Larsen NE, Leshchiner EA, Parent EG, Hendrikson-Aho J,
Balazs EA, Hilal SK (1991) J Biomed Mater Res 25:699–710.
doi:10.1002/jbm.820250602
36. Larsen NE, Leshchiner EA, Parent EG, Balazs EA (1991) In:
Gebelein CG, Cheng F, Yang V (eds) Cosmetic and pharma-
ceutical application of polymers. Plenum Press, New York,
pp 147–157
37. Larsen NE (1998) In: Laurent TC (ed) In: Proceedings of the
Wenner-Gren foundation international symposium held in honor
of Endre A. Balazs, Stockholm, Sweden, 18–21 September 1996.
Portland Press Ltd., London, pp 267–282
38. Larsen NE, Mess DF, Denlinger JL (2002) In: Kennedy JF,
Phillips GO, Williams PA, Hascall VC (eds) Hyaluronan, volume
2. Biomedical, medical and clinical aspects. Woodhead, Cam-
bridge, UK, pp 441–444
39. Meyer-Schwickerath G (1974) Mod Probl Ophthalmol 12:384
40. Miller D, Stegmann R (eds) (1983) Healon (sodium hyaluronate).
A guide to its use in ophthalmic surgery. Wiley, New York, p 234
349
41. Pape LG, Balazs EA (1980) Ophthalmology 87:699–705
42. Pozo MA, Balazs EA, Belmonte C (1997) Exp Brain Res 116:
3–9. doi:10.1007/PL00005742
43. Prestwich GD, Shu XZ, Liu Y, Cai S, Walsh JF, Hughes CW,
Ahmad S, Kirker KR, Yu B, Orlandi RR, Park AH, Thibeault SL,
Duflo S, Smith ME (2006) Adv Exp Med Biol 585:125–133.
doi:10.1007/978-0-387-34133-0_9
44. Prestwich G (2007) In: Seventh international conference on
hyaluronan (book of abstracts), Charleston, SC, USA, 22–27
April 2007, p 8
45. Prestwich GD, Kuo J-W (2008) Curr Pharm Biotechnol 9:242–
245. doi:10.2174/138920108785161523
46. Rydell N, Balazs EA (1971) Clin Orthop Relat Res 80:25–32.
doi:10.1097/00003086-197110000-00006
47. St Onge R, Weiss C, Denlinger JL, Balazs EA (1980) Clin Orthop
Relat Res 146:269–275
48. Shu XZ, Prestwich G (2004) In: Garg HG, Hales CA (eds)
Chemistry and biology of hyaluronan. Elsevier, Amsterdam,
pp 475–504
49. Wik HB, Wik O (1998) In: Laurent TC (ed) Proceedings of the
Wenner-Gren foundation international symposium held in honor
of Endre A. Balazs, Stockholm, Sweden, 18–21 September 1996.
Portland Press Ltd, London, pp 25–32
123