Enhanced oxygen saturation in optic nerve head of non-human primate eyes following the intravitreal injection of NCX 434, an innovative nitric oxide-donating glucocorticoid

Hyperspectral retinal imaging biomarkers of ocular and systemic diseases

Hyperspectral imaging is a frontier in the field of medical imaging technology. It enables the simultaneous collection of spectroscopic and spatial data. Structural and physiological information encoded in these data can be used to identify and localise typically elusive biomarkers. Studies of retinal hyperspectral imaging have provided novel insights into disease pathophysiology and new ways of non-invasive diagnosis and monitoring of retinal and systemic diseases. This review provides a concise overview of recent advances in retinal hyperspectral imaging.

Emerging trends in long-acting sustained drug delivery for glaucoma management

Glaucoma is an optic neuropathy in which progressive degeneration of retinal ganglion cells and the optic nerve leads to irreversible visual loss. Glaucoma is one of the leading causes of blindness. The pathogenesis of glaucoma is determined by different pathogenetic mechanisms, including increased intraocular pressure, mechanical stress, excitotoxicity, resistance to aqueous drainage and oxidative stress. Topical formulations are often used in glaucoma treatment, whereas surgical measures are used in acute glaucoma cases. For most patients, long-term glaucoma treatments are given. Poor patient compliance and low bioavailability are often associated with topical therapy, which suggests that sustained-release, long-acting drug delivery systems could be beneficial in managing glaucoma. This review summarizes the eye's physiology, the pathogenesis of glaucoma, current treatments, including both pharmacological and nonpharmacological interventions, and recent advances in long-acting drug delivery systems for the treatment of glaucoma.

NCX 470 Restores Ocular Hemodynamics and Retinal Cell Physiology After ET-1-Induced Ischemia/Reperfusion Injury of Optic Nerve and Retina in Rabbits

Purpose: Determine whether NCX 470, a nitric oxide (NO)-donating bimatoprost with clinically demonstrated intraocular pressure (IOP)-lowering effects, improves ocular hemodynamics and retinal physiology. Methods: Endothelin-1 (ET-1)-induced ischemia/reperfusion model in New Zealand white rabbits was used. ET-1 was injected next to the optic nerve twice/week (Monday and Thursday) for 6 weeks. Starting on week 3, animals received NCX 470 (0.1% bid, 6 days/week Monday-Saturday) or vehicle until the end of ET-1 treatment. IOP, ophthalmic artery resistive index (OA-RI) and retina physiology (electroretinogram, ERG) were determined before dosing and at different times post-dosing. All measurements were taken on Mondays before the AM daily dosing (36 h treatment-free). Finally, oxidative stress markers were determined in dissected retina and iris/ciliary body of treated eyes. Results: Injection of ET-1 progressively increased IOP (20.7 ± 0.6, 24.9 ± 1.2, and 27.0 ± 0.6 mmHg at baseline, week 2 and 6, respectively) and OA-RI (0.30 ± 0.02, 0.39 ± 0.02, and 0.42 ± 0.03 at baseline, week 2 and 6, respectively) and reduced rods and/or cones response as indicated by changes in ERG amplitudes under different stimulating conditions. NCX 470 re-established baseline IOP (21.8 ± 1.0 mmHg), OA-RI (0.33 ± 0.02), and ERG amplitude by week 6 (mostly rod response, ^0.01Dark_A_{Veh_6week} = 32.2 ± 3.0 μV and ^0.01Dark_A_{NCX470_6week} 44.3 ± 4.5 μV; mostly cone response, ^3.0Dark_A_{Veh_6week} = 87.6 ± 10.1 μV and ^3.0Dark_A_{NCX470_6week} = 122.8 ± 11.4 μV; combined rod/cone response, ^3.0Light_A_{Veh_6week} = 49.8 ± 6.5 μV and ^3.0Light_A_{NCX470_6week} = 64.2 ± 6.8 μV). NCX 470 also reversed ET-1-induced changes in glutathione and manganese superoxide dismutase (oxidative stress markers) in retina and iris/ciliary body. Conclusions: Repeated ocular topical dosing with NCX 470 reverses ET-1-induced changes in IOP, OA-RI, and ERG suggesting improved ocular hemodynamics and retinal physiology likely independently from its demonstrated IOP-lowering effect.

Hyperspectral Imaging and the Retina: Worth the Wave?

Purpose

Hyperspectral imaging is gaining attention in the biomedical field because it generates additional spectral information to study physiological and clinical processes. Several technologies have been described; however an independent, systematic literature overview is lacking, especially in the field of ophthalmology. This investigation is the first to systematically overview scientific literature specifically regarding retinal hyperspectral imaging.

Methods

A systematic literature review was conducted, in accordance with PRISMA Statement 2009 criteria, in four bibliographic databases: Medline, Embase, Cochrane Database of Systematic Reviews, and Web of Science.

Results

Fifty-six articles were found that meet the review criteria. A range of techniques was reported: Fourier analysis, liquid crystal tunable filters, tunable laser sources, dual-slit monochromators, dispersive prisms and gratings, computed tomography, fiber optics, and Fabry-Perrot cavity filter covered complementary metal oxide semiconductor. We present a narrative synthesis and summary tables of findings of the included articles, because methodologic heterogeneity and diverse research topics prevented a meta-analysis being conducted.

Conclusions

Application in ophthalmology is still in its infancy. Most previous experiments have been performed in the field of retinal oximetry, providing valuable information in the diagnosis and monitoring of various ocular diseases. To date, none of these applications have graduated to clinical practice owing to the lack of sufficiently large validation studies.

Translational Relevance

Given the promising results that smaller studies show for hyperspectral imaging (e.g., in Alzheimer's disease), advanced research in larger validation studies is warranted to determine its true clinical potential.

Increased bioavailability of cyclic guanylate monophosphate prevents retinal ganglion cell degeneration

The nitric oxide - guanylyl cyclase-1 - cyclic guanylate monophosphate (NO-GC-1-cGMP) pathway has emerged as a potential pathogenic mechanism for glaucoma, a common intraocular pressure (IOP)-related optic neuropathy characterized by the degeneration of retinal ganglion cells (RGCs) and their axons in the optic nerve. NO activates GC-1 to increase cGMP levels, which are lowered by cGMP-specific phosphodiesterase (PDE) activity. This pathway appears to play a role in both the regulation of IOP, where reduced cGMP levels in mice leads to elevated IOP and subsequent RGC degeneration. Here, we investigated whether potentiation of cGMP signaling could protect RGCs from glaucomatous degeneration. We administered the PDE5 inhibitor tadalafil orally (10 mg/kg/day) in murine models of two forms of glaucoma - primary open angle glaucoma (POAG; GC-1^-/- mice) and primary angle-closure glaucoma (PACG; Microbead Occlusion Model) - and measured RGC viability at both the soma and axon level. To determine the direct effect of increased cGMP on RGCs in vitro, we treated axotomized whole retina and primary RGC cultures with the cGMP analogue 8-Br-cGMP. Tadalafil treatment increased plasma cGMP levels in both models, but did not alter IOP or mean arterial pressure. Nonetheless, tadalafil treatment prevented degeneration of RGC soma and axons in both disease models. Treatment of whole, axotomized retina and primary RGC cultures with 8-Br-cGMP markedly attenuated both necrotic and apoptotic cell death pathways in RGCs. Our findings suggest that enhancement of the NO-GC-1-cGMP pathway protects the RGC body and axon in murine models of POAG and PACG, and that enhanced signaling through this pathway may serve as a novel glaucoma treatment, acting independently of IOP.

The nitric oxide-guanylate cyclase pathway and glaucoma

Glaucoma is a prevalent optic neuropathy characterized by the progressive dysfunction and loss of retinal ganglion cells (RGCs) and their optic nerve axons, which leads to irreversible visual field loss. Multiple risk factors for the disease have been identified, but elevated intraocular pressure (IOP) remains the primary risk factor amenable to treatment. Reducing IOP however does not always prevent glaucomatous neurodegeneration, and many patients progress with the disease despite having IOP in the normal range. There is increasing evidence that nitric oxide (NO) is a direct regulator of IOP and that dysfunction of the NO-Guanylate Cyclase (GC) pathway is associated with glaucoma incidence. NO has shown promise as a novel therapeutic with targeted effects that: 1) lower IOP; 2) increase ocular blood flow; and 3) confer neuroprotection. The various effects of NO in the eye appear to be mediated through the activation of the GC- guanosine 3:5'-cyclic monophosphate (cGMP) pathway and its effect on downstream targets, such as protein kinases and Ca²⁺ channels. Although NO-donor compounds are promising as therapeutics for IOP regulation, they may not be ideal to harness the neuroprotective potential of NO signaling. Here we review evidence that supports direct targeting of GC as a novel pleiotrophic treatment for the disease, without the need for direct NO application. The identification and targeting of other factors that contribute to glaucoma would be beneficial to patients, particularly those that do not respond well to IOP-dependent interventions.

A Review of Nitric Oxide for the Treatment of Glaucomatous Disease

Glaucoma is the leading cause of irreversible blindness worldwide, affecting 64.3 million people. An estimated 60.5 million people are affected by primary open angle glaucoma globally, and this will increase to 111.8 million by 2040. The definition of glaucoma has evolved greatly over time. Although multiple risk factors such as ischemia, inflammation, myopia, race, age and low ocular perfusion pressure may play a role, intraocular pressure (IOP) is still the main risk factor we can easily identify and modify. Currently, both medical and surgical interventions aim to reduce IOP. Effective IOP reduction controls and prevents the progression in many cases of glaucoma. Although this multifactorial disease's true pathophysiology is difficult to elucidate, physiologic mediators including nitric oxide (NO) are being evaluated as novel ways to impact progression by both lowering IOP and improving optic nerve head perfusion. Latanoprostene bunod 0.024% is an emerging therapeutic agent that has shown promise in clinical trials. As a nitric oxide-donating prostaglandin F2-alpha receptor agonist, it has proven to effectively, and with good tolerability, reduce IOP in glaucoma and ocular hypertensive patients. Latanoprostene bunod capitalizes on NO's ability to modulate the conventional aqueous humor outflow system, directly improving outflow through the trabecular meshwork, Schlemm's canal and distal scleral vessels. Importantly, targeting the conventional outflow tissues with NO-donating drugs represents an opportunity to restore outflow function, which will most likely have a beneficial consequence of additional IOP-lowering effects with dampening of diurnal and other IOP fluctuations, the benefit of a healthy trabecular meshwork.

The Ability of Nitric Oxide to Lower Intraocular Pressure Is Dependent on Guanylyl Cyclase

Purpose

While nitric oxide (NO) donors are emerging as treatments for glaucoma, the mechanism by which NO lowers intraocular pressure (IOP) is unclear. NO activates the enzyme guanylyl cyclase (GC) to produce cyclic guanosine monophosphate. We studied the ocular effects of inhaled and topically applied NO gas in mice and lambs, respectively.

Methods

IOP and aqueous humor (AqH) outflow were measured in WT and GC-1α subunit null (GC-1^−/−) mice. Mice breathed 40 parts per million (ppm) NO in O₂ or control gas (N₂/O₂). We also studied the effect of ocular NO gas exposure (80, 250, 500, and 1000 ppm) on IOP in anesthetized lambs. NO metabolites were measured in AqH and plasma.

Results

In awake WT mice, breathing NO for 40 minutes lowered IOP from 14.4 ± 1.9 mm Hg to 10.9 ± 1.0 mm Hg (n = 11, P < 0.001). Comparable results were obtained in anesthetized WT mice (n = 10, P < 0.001). In awake or anesthetized GC-1^−/− mice, IOP did not change under similar experimental conditions (P ≥ 0.08, n = 20). Breathing NO increased in vivo outflow facility in WT but not GC-1^−/− mice (+13.7 ± 14.6% vs. −12.1 ± 9.4%, n = 4 each, P < 0.05). In lambs, ocular exposure to NO lowered IOP in a dose-dependent manner (−0.43 mm Hg/ppm NO; n = 5 with 40 total measurements; P = 0.04) without producing corneal pathology or altering pulmonary and systemic hemodynamics. After ocular NO exposure, NO metabolites were increased in AqH (n = 8, P < 0.001) but not in plasma.

Conclusions

Breathing NO reduced IOP and increased outflow facility in a GC-dependent manner in mice. Exposure of ovine eyes to NO lowers IOP.

Regulation of vascular tone in rabbit ophthalmic artery: cross talk of endogenous and exogenous gas mediators

Nitric oxide (NO), carbon monoxide (CO) and hydrogen sulphide (H2S) modulate vascular tone. In view of their therapeutic potential for ocular diseases, we examined the effect of exogenous CO and H2S on tone of isolated rabbit ophthalmic artery and their interaction with endogenous and exogenous NO. Ophthalmic artery segments mounted on a wire myograph were challenged with cumulative concentrations of phenylephrine (PE) in the presence or absence of NG-nitro-L-arginine (LNNA) to inhibit production of NO, the CO-releasing molecules CORMs or the H2S-donor GYY4137. The maximal vasoconstriction elicited by PE reached 20-30% of that induced by KCl but was dramatically increased by incubation with LNNA. GYY4137 significantly raised PE-mediated vasoconstriction, but it did not change the response to PE in the presence of LNNA or the relaxation to sodium nitroprusside (SNP). CORMs concentration-dependently inhibited PE-induced constriction, an effect that was synergistic with endogenous NO (reduced by LNNA), but insensitive to blockade of guanylyl cyclase by 1H-[1,2,4]oxadiazolo[4,3,-α]quinoxalin-1-one (ODQ). In vascular tissues cyclic GMP (cGMP) levels seemed reduced by GYY4137 (not significantly), but were not changed by CORM. These data indicate that CO is able per se to relax isolated ophthalmic artery and to synergize with NO, while H2S counteracts the effect of endogenous NO. CO does not stimulate cGMP production in our system, while H2S may reduce cGMP production stimulated by endogenous NO. These findings provide new insights into the complexities of gas interactions in the control of ophthalmic vascular tone, highlighting potential pharmacological targets for ocular diseases.

Regulation of intraocular pressure by soluble and membrane guanylate cyclases and their role in glaucoma

Glaucoma is a progressive optic neuropathy characterized by visual field defects that ultimately lead to irreversible blindness (Alward, 2000; Anderson et al., 2006). By the year 2020, an estimated 80 million people will have glaucoma, 11 million of which will be bilaterally blind. Primary open-angle glaucoma (POAG) is the most common type of glaucoma. Elevated intraocular pressure (IOP) is currently the only risk factor amenable to treatment. How IOP is regulated and can be modulated remains a topic of active investigation. Available therapies, mostly geared toward lowering IOP, offer incomplete protection, and POAG often goes undetected until irreparable damage has been done, highlighting the need for novel therapeutic approaches, drug targets, and biomarkers (Heijl et al., 2002; Quigley, 2011). In this review, the role of soluble (nitric oxide (NO)-activated) and membrane-bound, natriuretic peptide (NP)-activated guanylate cyclases that generate the secondary signaling molecule cyclic guanosine monophosphate (cGMP) in the regulation of IOP and in the pathophysiology of POAG will be discussed.

Soluble guanylate cyclase α1-deficient mice: a novel murine model for primary open angle glaucoma

Primary open angle glaucoma (POAG) is a leading cause of blindness worldwide. The molecular signaling involved in the pathogenesis of POAG remains unknown. Here, we report that mice lacking the α1 subunit of the nitric oxide receptor soluble guanylate cyclase represent a novel and translatable animal model of POAG, characterized by thinning of the retinal nerve fiber layer and loss of optic nerve axons in the context of an open iridocorneal angle. The optic neuropathy associated with soluble guanylate cyclase α1-deficiency was accompanied by modestly increased intraocular pressure and retinal vascular dysfunction. Moreover, data from a candidate gene association study suggests that a variant in the locus containing the genes encoding for the α1 and β1 subunits of soluble guanylate cyclase is associated with POAG in patients presenting with initial paracentral vision loss, a disease subtype thought to be associated with vascular dysregulation. These findings provide new insights into the pathogenesis and genetics of POAG and suggest new therapeutic strategies for POAG.

Retinal oximetry

ABSTRACT.:

PURPOSE

Malfunction of retinal blood flow or oxygenation is believed to be involved in various diseases. Among them are retinal vessel occlusions, diabetic retinopathy and glaucoma. Reliable, non-invasive technology for retinal oxygen measurements has been scarce and most of the knowledge on retinal oxygenation comes from animal studies. This thesis describes human retinal oximetry, performed with novel retinal oximetry technology. The thesis describes studies on retinal vessel oxygen saturation in (1) light and dark in healthy volunteers, (2) central retinal vein occlusion, (3) branch retinal vein occlusion, (4) central retinal artery occlusion, (5) diabetic retinopathy, (6) patients undergoing glaucoma surgery and (7) patients taking glaucoma medication.

METHODS

The retinal oximeter (Oxymap ehf., Reykjavik, Iceland) is based on a fundus camera. An attached image splitter allows the simultaneous capture of four images of the same area of the fundus. Two images are used for further analysis, one acquired with 586 nm light and one with 605 nm light. Light absorbance of retinal vessels is sensitive to oxygen saturation at 605 nm but not at 586 nm. Measurement of reflected light at these wavelengths allows estimation of oxygen saturation in the main retinal vessels. This is performed with custom-made analysis software.

RESULTS

LIGHT AND DARK: After 30 min in the dark, oxygen saturation in retinal arterioles of healthy volunteers was 92 ± 4% (mean ± SD, n = 15). After 5 min in 80 cd/m(2) light, the arteriolar saturation was 89 ± 5%. The decrease was statistically significant (p = 0.008). The corresponding values for retinal venules were 60 ± 5% in the dark and 55 ± 10% in the light (p = 0.020). Similar results were found after alternating 5 min periods of darkness and light. In a second experiment (n = 19), a significant decrease in retinal vessel oxygen saturation was found in 100 cd/m(2) light compared with darkness but 1 and 10 cd/m(2) light had no significant effect. CENTRAL RETINAL VEIN OCCLUSION: In patients with central retinal vein occlusion, the mean saturation in affected retinal venules was 49 ± 12%, while the mean value for venules in the fellow eye was 65 ± 6% (mean ± SD, p = 0.003, n = 8). The retinal arteriolar saturation was the same in affected (99 ± 3%) and the unaffected (99 ± 6%) eyes. The venous oxygen saturation showed much variation between affected eyes. BRANCH RETINAL VEIN OCCLUSION: Median oxygen saturation in venules affected by branch retinal vein occlusion was 59% (range, 12-93%, n = 22), while it was 63% (23-80%) in unaffected venules in the affected eye and 55% (39-80%) in venules in the fellow eye. The difference was not statistically significant (p > 0.05). There was a significant difference between affected arterioles (median 101%; range, 89-115%) and unaffected arterioles (95%, 85-104%) in the affected eye (p < 0.05, n = 18). CENTRAL RETINAL ARTERY OCCLUSION: In a patient with a day's history of central retinal artery occlusion due to temporal arteritis, the mean arteriolar saturation was 71 ± 9% and 63 ± 9% in the venules. One month later, after treatment with prednisolone, the mean arteriolar saturation was 100 ± 4% and the venous saturation 54 ± 5%. DIABETIC RETINOPATHY: When compared with healthy volunteers (n = 31), patients with all categories of diabetic retinopathy had on average 7-10 percentage points higher saturation in retinal arterioles (p < 0.05 for all categories, n = 6-8 in each category). In venules, the saturation was 8-12 percentage points higher (p < 0.05 for all categories). GLAUCOMA SURGERY: Oxygen saturation in retinal arterioles increased by 2 percentage points on average (p = 0.046, n = 19) with surgery, which lowered intraocular pressure from 23 ± 7 mmHg (mean ± SD) to 10 ± 4 mmHg (p < 0.0001). No other significant changes were found (p ≥ 0.35). DORZOLAMIDE: A significant reduction of 3 percentage points was found in arterioles (p < 0.01) and venules (p < 0.05) when patients with glaucoma or ocular hypertension changed from dorzolamide-timolol combination eye drops to timolol alone (n = 6). No change was found in patients, who started on timolol and switched to the combination therapy (p > 0.05, n = 7).

CONCLUSIONS

Dual wavelength oximetry can be used to non-invasively measure retinal vessel oxygen saturation in health and disease. The results indicate that retinal vessel oxygen saturation is (1) increased in the dark, (2) lower in venules affected by central retinal vein occlusions, (3) variable in branch retinal vein occlusion, (4) lower in retinal arterioles in central retinal artery occlusion, (5) increased in diabetic retinopathy, (6-7) mildly affected by glaucoma surgery or dorzolamide.