Suppressive actions of betaxolol on ionic currents in retinal ganglion cells may explain its neuroprotective effects

Use of β‑blockers and risk of age‑related macular degeneration among hypertensive patients: An insight from The National Health and Nutrition Examination Survey

Although age-related macular degeneration (AMD) is the leading cause of legal blindness, the treatment methods for AMD are limited. The aim of the present study was to examine the association between oral β-blockers (BBs) and the risk of developing AMD among hypertensive patients. For this purpose, a total of 3,311 hypertensive patients from the National Health and Nutrition Examination Survey were included in the study. The use of BBs and treatment duration data were collected using a self-reported questionnaire. AMD was diagnosed by gradable retinal images. Multivariate-adjusted survey-weighted univariate logistic regression was used to confirm the association between the use of BBs and the risk of developing AMD. The results revealed that the use of BBs exerted a beneficial effect (odds ratio (OR), 0.34; 95% confidence interval (95% CI, 0.13-0.92; P=0.04) in late-stage AMD in the multivariate adjusted model. When the BBs were classified into non-selective BBs and selective BBs, the protective effect in late-stage AMD was still observed in the non-selective BBs (OR, 0.20; 95% CI, 0.07-0.61; P<0.001). After accounting for treatment duration, long-term treatment with BBs (>6 years) was also found to reduce the risk of late-stage AMD (OR, 0.13; 95% CI, 0.03-0.63; P=0.01). In late-stage AMD, the long-term use of BBs was beneficial for geographic atrophy (OR, 0.07; 95% CI, 0.02-0.28; P<0.001). On the whole, the present study demonstrates that the use of non-selective BBs exerted a beneficial effect against the risk of late-stage AMD among hypertensive patients. Long-term treatment with BBs was also associated with lower risk of developing AMD. These findings may provide novel strategies for the management and treatment of AMD.

Altered ionic currents and amelioration by IGF-1 and PACAP in motoneuron-derived cells modelling SBMA

Spinal and bulbar muscular atrophy (SBMA), also known as Kennedy's disease, is a motor neuron disease caused by the expansion of a polymorphic CAG tandem repeat encoding a polyglutamine (polyQ) tract in the androgen receptor (AR) gene. SBMA is triggered by the binding of mutant AR to its natural ligands, testosterone and dihydrotestosterone (DHT). To investigate the neuronal alterations of motor neuron cell models of SBMA, we applied patch-clamp methods to verify how polyQ expansions in the AR alter cell ionic currents. We used mouse motoneuron-derived MN-1 cells expressing normal AR (MN24Q) and mutant AR (MN100Q treated cells with vehicle EtOH and DHT). We observed a reduction of the current flux mainly at depolarizing potentials in the DHT-treated cells, while the dissection of macroscopic currents showed single different cationic currents belonging to voltage-gated channels. Also, we treated the cells with IGF-1 and PACAP, which have previously been shown to protect MN-1 cells from the toxicity of mutant AR, and we found an amelioration of the altered currents. Our results suggest that the electrophysiological correlate of SBMA is a suitable reference point for the identification of disease symptoms and for future therapeutic targets.

Neuroprotection in Glaucoma

Glaucoma is a degenerative optic neuropathy characterized by retinal ganglion cell (RGC) loss and visual field defects. It is known that in some glaucoma patients, death of RGCs continues despite intraocular pressure (IOP) reduction. Neuroprotection in the field of glaucoma is defined as any treatment, independent of IOP reduction, which prevents RGC death. Glutamate antagonists, ginkgo biloba extract, neurotrophic factors, antioxidants, calcium channel blockers, brimonidine, glaucoma medications with blood regulatory effect and nitric oxide synthase inhibitors are among compounds with possible neuroprotective activity in preclinical studies. A few agents (such as brimonidine or memantine) with neuroprotective effects in experimental studies have advanced to clinical trials; however the results of clinical trials for these agents have not been conclusive. Nevertheless, lack of compelling clinical evidence has not prevented the off-label use of some of these compounds in glaucoma practice. Stem cell transplantation has been reported to halt experimental neurodegenerative disease processes in the absence of cell replacement. It has been hypothesized that transplantation of some types of stem cells activates multiple neuroprotective pathways via secretion of various factors. The advantage of this approach is a prolonged and targeted effect. Important concerns in this field include the secretion of unwanted harmful mediators, graft survival issues and tumorigenesis. Neuroprotection in glaucoma, pharmacologically or by stem cell transplantation, is an interesting subject waiting for broad and multidisciplinary collaborative studies to better clarify its role in clinical practice.

Selectivity of pharmacological tools: implications for use in cell physiology. A review in the theme: Cell signaling: proteins, pathways and mechanisms

Pharmacological inhibitors are frequently used to identify the receptors, receptor subtypes, and associated signaling pathways involved in physiological cell responses. Based on the effects of such inhibitors conclusions are drawn about the involvement of their assumed target or lack thereof. While such inhibitors can be useful tools for a better physiological understanding, their uncritical use can lead to incorrect conclusions. This article reviews the concept of inhibitor selectivity and its implication for cell physiology. Specifically, we discuss the implications of using inhibitor vs. activator approaches, issues of direct vs. indirect pathway modulation, implications of inverse agonism and biased signaling, and those of orthosteric vs. allosteric, competitive vs. noncompetitive, and reversible vs. irreversible inhibition. Additional problems can result from inconsistent estimates of inhibitor potency and differences in potency between cell-free systems and intact cells. These concepts are illustrated by several examples of inhibitors displaying affinity for related but distinct targets or even unrelated targets. Of note, many of the issues being addressed are also applicable to genetic inhibition strategies. The main practical conclusion following from these concepts is that investigators should be critical in the choice of inhibitor, its concentrations, and its mode of application. When this advice is adhered to, small-molecule pharmacological inhibitors can be important experimental tools in the hand of physiologists.

Calcium channels and their blockers in intraocular pressure and glaucoma

Several factors besides high intraocular pressure assumed to be associated with the development and progression of glaucoma, and calcium channel blockers (CCBs) have been an anticipated option for glaucoma treatment by improving ocular perfusion and/or exerting neuroprotective effects on retinal ganglion cells with safety established in wide and long-term usage. Decrease in IOP has been reported after topical application of CCBs, however, the effect is much smaller and almost negligible after systemic application. Various CCBs have been reported to increase posterior ocular blood flow in vivo and to exert direct neuroprotection in neurons in vitro. Distribution of the drug at a pharmacologically active concentration in the posterior ocular tissues across the blood-brain barrier or blood-retina barrier, especially in the optic nerve head and retina where the ganglion cells mainly suffer from glaucomatous damage, is essential for clinical treatment of glaucoma. Improved visual functions such as sensitivity in the visual field test have been reported after administration of CCBs, but evidences from the randomized studies have been limited and effects of CCBs on blood flow and direct neuroprotection are hardly distinguished from each other.

MRI biomarkers for evaluation of treatment efficacy in preclinical diabetic retinopathy

INTRODUCTION

One sober consequence of the current epidemic of diabetes mellitus is that an increasing number of people world-wide will partially or completely lose their sight to diabetic retinopathy. Clinically, the sight-threatening complications of diabetes are diagnosed and treated based on visible retinal lesions (e.g., dot-blot hemorrhages or retinal neovascularization). However, such anatomical microvascular lesions are slow to respond with treatment. Thus, there remains an urgent need for imaging biomarkers that are abnormal before retinal lesions are visibly apparent and are responsive to treatment.

AREAS COVERED

Here, the development of new MRI methods, such as manganese-enhanced MRI, for evaluating early diabetes-evoked retinal pathophysiology, and its usefulness in guiding new treatments for diabetic retinopathy are reviewed.

EXPERT OPINION

In diabetic retinopathy, not all important diagnostic and prognostic needs are well served by optical methods. In the absence of gross anatomy changes, critical times when drug intervention is most likely to be successful at reducing vision loss are missed by most light-based methods and thus provide little help in guiding diagnosis and treatment. For example, before clinical symptoms, is there an optimal time to intervene with drug therapy? Is a drug reaching its target? How does one assess optimal drug dose, schedule, and routes? How well do current experimental models mimic the clinical condition? As discussed herein, MRI is as an analytical tool for addressing these unmet needs. Future clinical applications of MRI can be envisioned such as in clinical trials to assess drug treatment efficacy, or as an adjunct approach to refine or clarify a difficult clinical case. New MRI-generated hypotheses about the pathogenesis of diabetic retinopathy and its treatment are discussed. In the coming years, a substantial growth in the development and application of MRI is expected to address relevant question in both the basic sciences and in the clinic.

Sigma-1 receptor stimulation attenuates calcium influx through activated L-type Voltage Gated Calcium Channels in purified retinal ganglion cells

Sigma-1 receptors (σ-1rs) exert neuroprotective effects on retinal ganglion cells (RGCs) both in vivo and in vitro. This receptor has unique properties through its actions on several voltage-gated and ligand-gated channels. The purpose of this study was to investigate the role that σ-1rs play in regulating cell calcium dynamics through activated L-type Voltage Gated Calcium Channels (L-type VGCCs) in purified RGCs. RGCs were isolated from P3-P7 Sprague-Dawley rats and purified by sequential immunopanning using a Thy1.1 antibody. Calcium imaging was used to measure changes in intracellular calcium after depolarizing the cells with potassium chloride (KCl) in the presence or absence of two σ-1r agonists [(+)-SKF10047 and (+)-Pentazocine], one σ-1r antagonist (BD1047), and one L-type VGCC antagonist (Verapamil). Finally, co-localization studies were completed to assess the proximity of σ-1r with L-type VGCCs in purified RGCs. VGCCs were activated using KCl (20 mM). Pre-treatment with a known L-type VGCC blocker demonstrated a 57% decrease of calcium ion influx through activated VGCCs. Calcium imaging results also demonstrated that σ-1r agonists, (+)-N-allylnormetazocine hydrochloride [(+)-SKF10047] and (+)-Pentazocine, inhibited calcium ion influx through activated VGCCs. Antagonist treatment using BD1047 demonstrated a potentiation of calcium ion influx through activated VGCCs and abolished all inhibitory effects of the σ-1r agonists on VGCCs, implying that these ligands were acting through the σ-1r. An L-type VGCC blocker (Verapamil) also inhibited KCl activated VGCCs and when combined with the σ-1r agonists there was not a further decline in calcium entry suggesting similar mechanisms. Lastly, co-localization studies demonstrated that σ-1rs and L-type VGCCs are co-localized in purified RGCs. Taken together, these results indicated that σ-1r agonists can inhibit KCl induced calcium ion influx through activated L-type VGCCs in purified RGCs. This is the first report of attenuation of L-type VGCC signaling through the activation of σ-1rs in purified RGCs. The ability of σ-1rs to co-localize with L-type VGCCs in purified RGCs implied that these two proteins are in close proximity to each other and that such interactions regulate L-type VGCCs.

Neuroprotection in glaucoma

Glaucoma is a neurodegenerative disease characterized by loss of retinal ganglion cells and their axons. Recent evidence suggests that intraocular pressure (IOP) is only one of the many risk factors for this disease. Current treatment options for this disease have been limited to the reduction of IOP; however, it is clear now that the disease progression continues in many patients despite effective lowering of IOP. In the search for newer modalities in treating this disease, much data have emerged from experimental research the world over, suggesting various pathological processes involved in this disease and newer possible strategies to treat it. This review article looks into the current understanding of the pathophysiology of glaucoma, the importance of neuroprotection, the various possible pharmacological approaches for neuroprotection and evidence of current available medications.

Topical administration of adrenergic receptor pharmaceutics and nerve growth factor

Topical application of nerve growth factor (NGF) and adrenergic receptor pharmaceutics are currently in use for corneal ulcers and glaucoma. A recent interest in the neuroprotective abilities of NGF has led to a renewed interest in NGF as a therapeutic for retinal and choroidal diseases. NGF can promote cell proliferation through actions of the TrkA receptor or promote apoptosis through receptor p75^NTR. This understanding has led to novel interest in the role of NGF for diseases of the posterior eye. The role of β-adrenergic receptor agonists and antagonists for treatments of glaucoma, diabetic retinopathy, and their potential mechanisms of action, are still under investigation. This review discusses the current knowledge and applications of topical NGF and adrenergic receptor drugs for ocular disease.

Application of isoproterenol inhibits diabetic-like changes in the rat retina

Diabetic retinopathy is the leading cause of blindness to working-age adults. We have recently shown that surgical removal or genetic manipulations to eliminate sympathetic neurotransmission produces many of the retinal changes similar to rodent diabetic retinopathy with normal glucose levels. We hypothesized that application of a beta-adrenergic receptor agonist, isoproterenol, could reach the retina to elicit normal cellular signaling and inhibit the functional and morphological markers of early stage diabetic retinopathy in the rat. Rats were made diabetic by injection of 60 mg/kg streptozotocin. Within 3 days of diabetes-induction, rats were placed into 1 of 3 groups (control, diabetes, or diabetic + isoproterenol). Dose and time course studies were done for isoproterenol using a PKA ELISA and CREB analyses. Once the optimal dose and time course were established, electrical activity of the retina was analyzed by electroretinogram each month for the 8-month study. Western blotting was done for insulin receptor signaling and Akt and ELISA analyses for TNFalpha concentration and cleavage of caspase 3 at 2- and 8-months of diabetes. Diabetes-induced degeneration of neural cells and retinal thickness were assessed at 2 months, while degenerate capillaries were quantitated at 8 months of treatment. Daily application of 50 mM isoproterenol was effective in inhibiting the diabetes-induced loss of a- and b-wave and oscillatory potential amplitudes in the electroretinogram. Isoproterenol blocked the increase in TNFalpha and apoptosis in the diabetic retina. The numbers of degenerate capillaries were also reduced in the treated + diabetes retina. These data strongly suggest that loss of beta-adrenergic receptor signaling may be a key factors in early stage diabetic retinopathy. Resolution of this loss of adrenergic receptor signaling can inhibit some of the hallmarks of diabetic retinopathy in the retina.

Systemic propranolol reduces b-wave amplitude in the ERG and increases IGF-1 receptor phosphorylation in rat retina

PURPOSE

To determine whether systemic application of propranolol, a nonselective beta-adrenergic receptor antagonist, with an osmotic pump will decrease the b-wave amplitude of the electroretinogram (ERG) and increase insulin-like growth factor (IGF)-1 receptor signaling.

METHODS

Young rats at 8 weeks of age were treated with saline, phentolamine, a nonselective alpha-adrenergic receptor antagonist, or propranolol, a nonselective beta-adrenergic receptor antagonist, delivered by osmotic pumps for 21 days. On the 21st day, all rats underwent electroretinographic analyses followed by collection of the retinas for protein assessment using Western blot analysis for IGF binding protein 3 (IGFBP3), IGF-1 receptor (IGF-1R), Akt, extracellular signal-related kinases 1 and 2 (ERK1/2), and vascular endothelial cell growth factor (VEGF).

RESULTS

Data indicate that 21 days of propranolol significantly decreased the b-wave amplitude of the ERG. The decrease in the b-wave amplitude occurred concurrently with a decrease in IGFBP3 levels and an increase in tyrosine phosphorylation of IGF-1 receptor on 1135/1136. This phosphorylation of IGF-1 receptor led to increased phosphorylation of Akt and ERK1/2. VEGF protein levels were also increased.

CONCLUSIONS

Overall, beta-adrenergic receptor antagonism produced a dysfunctional ERG, which occurred with an increase in IGF-1R phosphorylation and activation of VEGF. Systemic application of beta-adrenergic receptor antagonists may have detrimental effects on the retina.

Intraocular pressure lowering, change of antiapoptotic molecule expression, and neuroretinal changes by dorzolamide 2%/timolol 0.5% combination in a chronic ocular hypertension rat model

The aim of this study was to examine intraocular pressure lowering, change of antiapoptotic molecules expression, and neuroretinal changes by a commercially available dorzolamide 2%/timolol 0.5% combination in a chronic ocular hypertension rat model. Chronic ocular hypertension was induced by three episcleral vein cauterizations. The expression of antiapoptotic molecules and the effect of dorzolamide 2%/timolol 0.5% combination in chronic ocular hypertensive retina were evaluated. Retinal ganglion cell (RGC) retrograde labeling and quantification with 4-di-10-ASP (DiA) and expression of glial fibrillary acidic protein (GFAP) were detected before and after the administration of dorzolamide 2%/timolol 0.5%. Treatment of ocular hypertensive eyes with dorzolamide 2%/timolol 0.5% significantly reduced, intraocular pressure when compared to the control eyes. Labeling of RGCs with DiA showed a significant decrease in RGC loss after the administration of dorzolamide 2%/timolol 0.5%. GFAP expression revealed a significant decrease in retinal damage after dorzolamide 2%/timolol 0.5% administration. However, dorzolamide 2%/timolol 0.5% did not affect Bcl-2 and Bcl-xL mRNA expression. In conclusion, dorzolamide 2%/timolol 0.5% may have neuroprotective potential in the animal model, which is not mediated by Bcl-2 or Bcl-xL. The mechanism of neuroprotection by dorzolamide 2%/timolol 0.5% in chronic glaucoma models requires further investigation.

Manganese-enhanced MRI of the DBA/2J mouse model of hereditary glaucoma

PURPOSE

To test the hypothesis that manganese-enhanced magnetic resonance imaging (MEMRI) is a sensitive approach for measuring of age-related ocular changes in experimental pigmentary glaucoma.

METHODS

Four groups of light-adapted mice were studied using MEMRI: young (2-3 months), C57BL/6 (negative controls), and DBA/2J mice and aged (10-11 months) C57BL/6 and DBA/2J mice. In all mice, eye perimeter, optic nerve head width, iridocorneal angle, ciliary body area, and total and inner retinal thickness, and a surrogate of retinal ion regulation (intraretinal uptake of manganese) were assessed from MEMRI data and compared. Axon counts were obtained from optic nerves harvested from MEMRI-assessed eyes.

RESULTS

As the C57BL/6 and DBA/2J mice aged, differential and significant changes in ocular perimeter, retinal thickness, iridocorneal angle, ciliary body area, and optic nerve head width were readily measured from MEMRI data (P < 0.05). In C57BL/6 mice, only inner retinal thickness and perimeter were correlated. In DBA/2J mice, ocular perimeter was correlated with total and inner retinal thickness, ciliary body area, optic nerve head width, and iridocorneal angle. Comparison of young and aged mice revealed a subnormal intraretinal manganese uptake (P < 0.05) in aged DBA/2J mice, but not in aged C57BL/6 mice. Manganese uptake did not correlate with the ocular perimeter. Axon density in the optic nerve correlated with MEMRI-measured optic nerve head width (P < 0.05).

CONCLUSIONS

These studies provide a baseline of noninvasive MEMRI-detectable changes associated with age in a common animal model of hereditary glaucoma that may be useful in the longitudinal evaluation of therapeutic success.

Hypoxia-induced retinal ganglion cell death and the neuroprotective effects of beta-adrenergic antagonists

Hypoxia-induced retinal ganglion cell (RGC) death has been implicated in glaucomatous optic neuropathy. However, the precise mechanism of death signaling and how neuroprotective agents affect it are still unclear. The aim of this study is to characterize the mechanisms of hypoxia-induced apoptosis of cultured purified RGCs and to study the neuroprotective effects of beta-adrenergic antagonists. Rat RGCs were purified utilizing a modified two-step immuno-panning procedure. First, the extent of apoptosis in RGCs under hypoxia was quantified. Next, the effects of glutamate-channel antagonists (MK801 or DNQX), Bax inhibiting peptide (BIP), and beta-adrenergic antagonists (betaxolol, nipradilol, timolol or carteolol) on hypoxia-induced RGC death were investigated by the cell viability assay. Third, the effects of beta-adrenergic antagonists on hypoxia-induced increase of intracellular calcium concentrations ([Ca(2+)](i)) and the additional effect of NO scavenger to nipradilol were evaluated. Apoptotic RGC percentages under hypoxia were significantly increased compared to the control. The viability of RGCs under hypoxia was not affected by MK801 or DNQX, whereas it was increased in a dose-dependent manner with exposure to BIP, and to betaxolol, nipradilol, timolol, but not to carteolol. These effective beta-adrenergic antagonists showed no significant change in hypoxia-induced [Ca(2+)](i) levels. The NO scavenger alleviated neuroprotective effect by nipradilol. In conclusion, purified RGC damage induced by hypoxia involves Bax-dependent apoptotic pathway, but mostly independent of glutamate receptor-mediated excitotoxicity. Betaxolol, timolol and nipradilol showed a protective effect against hypoxia-induced RGC death, which was thought to be irrelevant either to calcium channel or beta-adrenoceptor blocking effects.

Nitric oxide synthase in retina and optic nerve head of rat with increased intraocular pressure and effect of timolol

We investigated the expression of nitric oxide synthase (NOS) isoforms -1, -2 and -3 in the retina and optic nerve head (ONH) in an experimental rat model of elevated intraocular pressure (IOP) before and after treatment with timolol, to assess whether its neuroprotective action is associated with the activity of these enzymes. Episcleral vein cauterization in unilateral eyes of Wistar rats was performed to produce elevated IOP. Histological sections of retina and ONH from animals with normal IOP, with elevated IOP, and elevated IOP treated with timolol, were studied by immunohistochemistry with antibodies to NOS-1, NOS-2, and NOS-3. In the control rats, NOS-1 was localized to photoreceptor inner segments, amacrine cells and bipolar cells in the retina, and in astrocytes, pericytes and vascular nitrergic terminals in the ONH. NOS-3 immunostaining localized to the endothelial cells. The rats with elevated IOP showed increased expression of NOS-1 in the plexiform layers of the retina and reactive astrocytes in the ONH. These cells also showed NOS-2 positivity. The rats treated with timolol showed reduced expression of NOS-1 in the retina and ONH. NOS-2 was only detected in a few groups of astrocytes in the ONH. NOS-3 was unchanged in both elevated IOP and timolol-treated groups. These results show that excessive levels of NO synthesized by the NOS-1 and -2 isoforms, considered neurotoxic, might contribute to the progressive lesions of retinal ganglion cell axons. Their reduction after treatment suggests a possible neuroprotective effect of timolol in neurons exposed to excessive amounts of NO.

Protective effects of betaxolol in eyes with kainic acid-induced neuronal death

In the present study, we investigated whether betaxolol, a selective beta1-adrenoceptor antagonist, has neuroprotective effect on kainic acid (KA)-induced retinal damage. Neurotoxicities were induced in adult male rats by intravitreal injection of KA (total amount, 6 nmol). To examine the neuroprotective effects of betaxolol, rats were pretreated with betaxolol topically 60 min before KA injection to the rat eyes and twice daily for 1, 3, and 7 days after KA injection. The neuroprotective effects of betaxolol were estimated by measuring the thickness of the various retinal layers, and by counting the number of choline acetyltransferase (ChAT)- and tyrosine hydroxylase (TH)-positive cells in each retinal layer. The retina is highly vulnerable to KA-induced neuronal damage. Morphometric analysis of retinal damage in KA injected eyes, the thickness of the retinal layers decreased markedly after KA injection period of both 3 and 7 days. Furthermore, the numbers of ChAT- and TH-positive cells were significantly reduced by intravitreal injection of KA. However, when two drops of betaxolol, once before KA injection and twice daily for 7 days after KA injection, were continuously administered, the reductions in the retinal thickness and the retinal ChAT- and TH-positive cells were significantly attenuated. The present study suggests that topically applied betaxolol has neuroprotective effect on the retinal cell damage due to KA-induced neurotoxicity.

Invited Review: Neuroprotective Properties of Certain β-Adrenoceptor Antagonists Used for the Treatment of Glaucoma

Although it is known that ganglion cell death causes loss of vision in glaucoma, the pathogenesis of the disease is complex, probably involving an initial ischemic insult to the ganglion cell axons and glial cells with the ganglion cell bodies eventually being affected. It may therefore be necessary to blunt many stages in the pathogenesis of the disease to obtain a clinically effective neuroprotective strategy. In animal experiments, one cause of ganglion cell death in ischemia is an overactivation of glutamate receptors and a subsequent rise in intracellular levels of sodium and calcium ions as well as a generation of reactive oxygen species. In contrast, optic nerve death in ischemia is mainly caused by an influx of sodium and reversal of the sodium/calcium exchanger, which leads to a rise in intracellular calcium. Thus, a substance that reduces the influx of sodium will protect the ganglion cell axon, and if it also reduces calcium influx and/or acts as an antioxidant it will protect the ganglion cell body in addition. Of all antiglaucoma drugs, only beta-blockers have both calcium and sodium channel blocking activity, with betaxolol being the most efficacious of those analyzed. In addition, of the tested ophthalmic beta-blockers only metipranolol has powerful antioxidant properties. Moreover, laboratory studies on rats have shown that topically applied beta-blockers attenuate ischemic injury to ganglion cells by mechanisms that do not appear to involve an action on beta-receptors. Thus, of the substances used to lower intraocular pressure in glaucoma, beta-blockers have unique additional characteristics that also give them the capacity to act as neuroprotectants.

Advances in glaucoma therapeutics

Glaucoma is a major cause of irreversible blindness in the world. The prevalence of glaucomatous loss in vision will continue to grow as our populations age. Ocular hypertension is a major risk factor for the development of glaucoma and current glaucoma therapy is directed at lowering intraocular pressure. Several new ocular hypotensive agents have been introduced in the past several years providing a variety of treatment options. In addition, various classes of neuroprotective agents demonstrating activity in a wide variety of animal models have been proposed as potential new glaucoma therapeutics. Although these approaches will slow the progression of vision loss, they do not directly intervene in the disease process(es). Advances have been made attempting to understand the pathogenic pathways involved in glaucomatous damage to the eye and in methods to clinically measure glaucoma damage. An increased understanding of the pathophysiology of glaucoma will lead to the development of new therapeutic agents that intervene and perhaps even reverse glaucomatous damage to the eye. There also is a need to develop new methods to clinically measure glaucoma damage because, currently, considerable damage occurs before glaucoma is diagnosed and glaucoma remains underdiagnosed in the general population.

Are there any benefits of Betoptic S (betaxolol HCl ophthalmic suspension) over other beta-blockers in the treatment of glaucoma?

The cardioselective beta-blocker, betaxolol, is an effective ocular antihypertensive agent. Its mode of action in lowering intraocular pressure is similar to that of the nonselective blockers, by suppressing the flow of aqueous humor. The most frequent adverse reaction to betaxolol is stinging upon administration, which is minimised by an ocular suspension with a similarly effective twofold reduced concentration (Betoptic S, 0.25%). The extent of beta 1-adrenoceptor occupancy of topically applied betaxolol in the systemic circulation is less than that of the nonselective blockers and beta 2-receptor occupancy is negligible, providing a better safety profile in patients with cardiopulmonary disease. Experimental studies have revealed that the drug reaches the retina after topical administration and displays a voltage-dependent L-type calcium channel blocking activity, which probably allows betaxolol to improve retinal perfusion and to serve as a neuroprotective agent recommendable in various forms of glaucoma.

Quantification of amino acid neurochemistry secondary to NMDA or betaxolol application

BACKGROUND

Alterations in retinal amino acid neurochemistry are an indicator of metabolic function. Glutamate is the primary excitatory amino acid neurotransmitter within the retina, and excessive levels of glutamate can potentially cause excitotoxicity, in particular, through the N-methyl-D-aspartate (NMDA) subtype of glutamate receptor. Anomalies in NMDA receptor function have been implicated as causing many neurodegenerative disorders, and overactivation leads to neuronal death secondary to metabolic insult. Several pharmaceutical agents have been proposed as potential neuroprotective agents against excitotoxicity (e.g. betaxolol), yet any effects such drugs have on retinal neurochemistry have not been determined. Therefore, the aim of this study was to quantify the changes in retinal amino acid neurochemistry secondary to the application of NMDA with and without betaxolol.

METHODS

Functional NMDA channel activation was confirmed in both amacrine and ganglion cells by quantifying the entry into these neurones of a channel permeable probe (agmatine: 1-amino-4-guanidobutane [AGB]). By probing serial thin sections with immunoglobulins targeting AGB, glutamate, gamma-aminobutyric acid (GABA) and glycine, it was possible to simultaneously study the neurochemical characteristic as well as the NMDA-evoked AGB responses of different neurochemical populations of inner retinal neurones.

RESULTS

The authors have previously shown no accumulation of glutamate or GABA within Muller cells following NMDA application. Herein they report altered GABA and glycine immunoreactivity, but not glutamate immunoreactivity within neurones of the amacrine and ganglion cell layers following NMDA application. Finally, the addition of betaxolol did not significantly alter the normal neurochemistry of the retina.

CONCLUSION

The retina possesses intrinsic mechanisms that allow it to maintain metabolic integrity during short periods of high NMDA application.

Retinal ischemia: mechanisms of damage and potential therapeutic strategies

Retinal ischemia is a common cause of visual impairment and blindness. At the cellular level, ischemic retinal injury consists of a self-reinforcing destructive cascade involving neuronal depolarisation, calcium influx and oxidative stress initiated by energy failure and increased glutamatergic stimulation. There is a cell-specific sensitivity to ischemic injury which may reflect variability in the balance of excitatory and inhibitory neurotransmitter receptors on a given cell. A number of animal models and analytical techniques have been used to study retinal ischemia, and an increasing number of treatments have been shown to interrupt the "ischemic cascade" and attenuate the detrimental effects of retinal ischemia. Thus far, however, success in the laboratory has not been translated to the clinic. Difficulties with the route of administration, dosage, and adverse effects may render certain experimental treatments clinically unusable. Furthermore, neuroprotection-based treatment strategies for stroke have so far been disappointing. However, compared to the brain, the retina exhibits a remarkable natural resistance to ischemic injury, which may reflect its peculiar metabolism and unique environment. Given the increasing understanding of the events involved in ischemic neuronal injury it is hoped that clinically effective treatments for retinal ischemia will soon be available.

Inner retinal neurons display differential responses to N-methyl-D-aspartate receptor activation

The N-methyl-D-aspartate (NMDA) responses of neurons from within the inner rabbit retina were mapped using a channel permeable cation, 1-amino-4-guanidobutane (agmatine, AGB). Serial sections were subsequently probed with immunoglobulins targeting AGB, glutamate, gamma-aminobutyric acid (GABA), and glycine to visualize the NMDA responses of neurochemical subpopulations of neurons. Most inner retinal subpopulations of neurons demonstrated an NMDA concentration-dependent increase in activation. This NMDA-induced activation displayed a distinct pattern, with the most sensitive class to least sensitive class ranking being GC > GABA cAC > GABA/Gly cAC > Gly cAC > GABA dAC (GC, ganglion cells; AC, amacrine cells; c, conventional; d, displaced; Gly, glycine). The variable NMDA response may reflect differences in NMDA receptor subunit disposition or differences in receptor density. In addition to the variable NMDA activation pattern, we found that virtually all ganglion cells (87%) showed NMDA-gated AGB entry, compared with only 58% of amacrine cells. We conclude that a large cohort of amacrine cells do not possess functional NMDA receptors. In addition to most ganglion cells being activated by NMDA, a large subpopulation displayed the highest sensitivity to NMDA application. The functional significance of this finding is that the ganglion cell population will be the first neuronal class to be susceptible to glutamate-induced neurotoxicity mediated through the NMDA receptor. The addition of betaxolol significantly reduced NMDA-mediated AGB entry into most neuronal groups (ganglion cells, GABA, and glycine amacrine cells), with the greatest effect being on ganglion cells. Betaxolol had no significant effect on NMDA-gated entry of AGB on the GABA/Gly amacrine cell population.

Betaxolol attenuates retinal ischemia/reperfusion damage in the rat

This study was performed to elucidate the protection afforded by post-treatment with Betoptic (0.25% betaxolol) against neuronal cell damage after ischemia/reperfusion insult in rats. Betaxolol was applied topically after the start of reperfusion and its effect was evaluated by morphometry and choline acetyltransferase immunoreactivity of retinas at 7 days after reperfusion. In non-treated eyes, the thickness of the inner plexiform layer decreased markedly after a reperfusion period of both 3 and 7 days. However, when eyes were treated with betaxolol after ischemia/reperfusion injury, both the reduction of the inner plexiform layer thickness and the retinal choline acetyltransferase immunoreactivity were significantly attenuated. These findings suggest that betaxolol is an efficient neuroprotective agent and prevents the retinal cell damage induced by ischemic injury in rats.

Beta-adrenergic receptor agonists and antagonists counteract LPS-induced neuronal death in retinal cultures by different mechanisms

Treatment with lipopolysaccharide (LPS) for 72 h was shown to dose-dependently increase nitric oxide production from 6-day-old retinal cultures. Cell death, as determined by lactate dehydrogenase (LDH) release and an increase in neuronal labelling for TUNEL, was elevated concurrently. During treatment there was an increase of both inducible nitric oxide synthase and glial fibrillary acidic protein labelling in glial cells and a reduction in the number of gamma-aminobutyric acid-positive neurones. The NOS inhibitors, N-nitro-L-arginine methyl ester, dexamethasone and indomethacin potently inhibited both nitric oxide stimulation and cell death caused by LPS. In this study, the beta(2)- (ICI-18551), beta(1)- (betaxolol) and mixed beta(1)/beta(2)- (timolol, metipranolol) adrenergic receptor antagonists were all shown to attenuate LPS-induced LDH release from these cultures, but to have no effect on LPS-stimulated nitric oxide production. This effect was mimicked by the calcium channel blocker, nifedipine. Interestingly, the beta-adrenergic receptor agonists, salbutamol, arterenol and isoproterenol were also able to attenuate cell death caused by LPS. Moreover, these compounds also inhibited LPS-stimulated nitric oxide release. These studies suggest that LPS stimulates nitric oxide release from cultured retinal glial cells and that this process leads to neurone death. beta-adrenergic receptor agonists prevent the effects of LPS by inhibiting the stimulation of nitric oxide production. The data also suggest that beta-adrenergic receptor antagonists can attenuate LPS-induced death of neurones, but that these compounds act in a manner that is neurone-dependent, is mimicked by blockade of calcium channels and is independent of the stimulation of nitric oxide release.

Randomized clinical trial of topical betaxolol for persistent macular edema after vitrectomy and epiretinal membrane removal

PURPOSE

To report the efficacy and safety of topical betaxolol for treatment of persistent macular edema.

DESIGN

Randomized clinical trial.

METHODS

Thirty-seven eyes (37 patients) with best-corrected visual acuity between 20/200 and 20/50 and macular edema that remained for 3 months after vitrectomy and removal of epiretinal membrane were prospectively, randomly assigned to receive betaxolol or placebo. Nineteen eyes of 19 patients received betaxolol twice daily, and 18 eyes of 18 patients received placebo as a randomized comparison group. The patients were followed up for 6 months. This study evaluated the effect of betaxolol on best-corrected visual acuity and area of macular edema, which was digitally measured on serial fluorescein angiogram. Calculations of mean best-corrected visual acuity were based on logarithm of the minimal angle of resolution (logMAR). To assess changes in area of edema, the initial (pretreatment) size of the edema was set to 100%, and all posttreatment measurements were normalized relative to the initial size.

RESULTS

Mean best-corrected visual acuity at baseline was 0.216 (20 of 92.6) and 0.244 (20 of 82.0) in the treatment and control group, respectively. Mean area of macular edema was 2.271 +/- 1.629 mm(2) and 2.273 +/- 1.209 mm(2) in the treatment and control group; there was no significant difference. The visual acuity at 6 months after the start of the follow-up was 0.471 (20 of 42.5) in the treatment group and 0.236 (20 of 84.7) in the control group. Mean changes in logMAR of visual acuity for 3- and 6-month follow-up were -0.282 +/- 0.191 and -0.337 +/- 0.197 in the treatment group, and -0.016 +/- 0.186 and +0.015 +/- 0.267 in the control group; a significant difference was found (P <.0001; P <.0001). Areas of macular edema at 6 months after the start of the follow-up were 1.492 +/- 1.357 mm(2) in the treatment group and 2.125 +/- 1.434 mm(2)in the control group. Mean change in area of the edema for 6 months were 76.5% +/- 24.1% and 63.4% +/- 28.3% in the treatment group and 92.9% +/- 15.4% and 87.4% +/- 25.6% in the control group; treated patients showed a significantly larger reduction than untreated patients at each examination (P =.0193; P =.0102). No complication associated with treatment or placebo was found.

CONCLUSIONS

Topical betaxolol appeared to have a favorable treatment effect in eyes with macular edema that remained after vitrectomy and removal of epiretinal membrane. Further investigation of more cases and longer follow-up are needed.

The beta-adrenoceptor antagonists metipranolol and timolol are retinal neuroprotectants: comparison with betaxolol

beta-adrenoceptor antagonists are used clinically to reduce elevated intraocular pressure in glaucoma which is characterised by a loss of retinal ganglion cells. Previous studies have shown that the beta(1)-selective adrenoceptor antagonist, betaxolol, is additionally able to protect retinal neurones in vitro and ganglion cells in vivo from the detrimental effects of either ischemia-reperfusion or from excitotoxicity, after topical application. The neuroprotective effect of betaxolol is thought not to be elicited through an interaction with beta-adrenoceptors, but by its ability to reduce influx of sodium and calcium through voltage-sensitive calcium and sodium channels. In the present study it is shown that the non-selective beta-adrenoceptor antagonists, metipranolol and timolol behave like betaxolol. When topically applied they all attenuate the detrimental effect of ischemia-reperfusion. Protection of the retina was determined by evaluating changes in the electroretinogram and by assessing the loss of mRNA for Thy-1, which is expressed in retinal ganglion cells. In addition, studies conducted on neurones in mixed retinal cultures demonstrated that metipranolol, betaxolol and timolol were all able to partially counteract anoxia-induced cell loss and viability reduction. The influence of timolol was, however, not significant. Within the confines of these investigations, an order of neuroprotective efficacy was delineated for the three beta-adrenoceptor antagonists: betaxolol>metipranolol>timolol. The ability of the beta-adrenoceptor antagonists to attenuate ligand-induced stimulation of calcium and sodium entry into neuronal preparations showed a similar order of effectiveness. In conclusion, the ability to confer neuroprotection to retinal neurones is a common feature of three ophthalmic beta-adrenoceptor antagonists (betaxolol, metipranolol and timolol). A comparison of the effectiveness of the individual compounds in protecting retinal cells in vivo was not possible in these studies. However, in vitro studies show that the capacity of the individual beta-adrenoceptor antagonists to act as neuroprotectants appears to relate to their capacity to attenuate neuronal calcium and sodium influx.

Some current ideas on the pathogenesis and the role of neuroprotection in glaucomatous optic neuropathy

The primary features of glaucomatous optic neuropathy are characteristic changes in the optic nerve head, a decrease in number of surviving ganglion cells and a reduction in vision. It is now generally accepted that a number of factors, including elevated intraocular pressure, could lead to the changes seen in the optic nerve head and to obtain a pharmacological means to treat the causes will vary from patient to patient. In contrast, a cascade of events have been proposed to explain how the changes in the optic nerve head may lead to the slow and differential death of ganglion cells in the disease. It is also proposed that drugs (neuroprotectants) influencing this cascade of events can attenuate ganglion cell death and lead to the treatment of all glaucoma patients.

Effects of beta-adrenergic blockers on glutamate-induced calcium signals in adult mouse retinal ganglion cells

Betaxolol, a selective beta(1)-adrenoceptor antagonist, is an antiglaucoma drug commonly used to lower the intraocular pressure (IOP) in treatment of glaucoma. Recent evidence has also shown that it attenuates ligand- and voltage-gated currents in retinal ganglion cells, which may lead to reduction of intracellular calcium and prevention of glutamate-induced ganglion cell damage in glaucoma. In the present study, we examined the effectiveness of betaxolol and other beta-adrenergic blockers on glutamate-induced calcium signals. Dissociated adult mouse retinal ganglion cells were immuno-labeled with antibody CD90.2 and loaded with Fura-2AM. Calcium signals were recorded with optical recording techniques. Low doses of glutamate cause an increase in intracellular calcium that may result in pathological changes in ganglion cells. The action of glutamate could be reversibly suppressed by beta-adrenergic blockers and the order of inhibitory potency is (s)(-)-propranolol>betaxolol>>timolol, with average IC(50) of 78.05, 235.7 and 2167.05, microM, respectively. Betaxolol compressed the dose-response curve of glutamate. The EC(50) of glutamate was shifted from 6.19 to 23.53 microM, indicating that betaxolol acts as a non-competitive inhibitor of glutamate response in retinal ganglion cells. Our data are consistent with previous reports that betaxolol and other beta-adrenergic blockers may exert its neuroprotective action by suppression of glutamate-induced intracellular calcium increase in retinal ganglion cells.

The Ca(2+) channel antagonists mibefradil and pimozide inhibit cell growth via different cytotoxic mechanisms

We show that mitogenic cells expressing T-type Ca(2+) channels (T-channels) are more sensitive to the antiproliferative effects of the drugs pimozide and mibefradil than cells without significant T-channel expression. The growth of Y79 and WERI-Rb1 retinoblastoma cells, as well as MCF7 breast cancer epithelial cells, all of which express T-channel current and mRNA for T-channel subunits, is inhibited by pimozide and mibefradil with IC(50) values between 0.6 and 1.5 microM. Proliferation of glioma C6 cells, which show little T-channel expression, is less sensitive to these drugs (IC(50) = 8 and 5 microM for pimozide and mibefradil, respectively). Neither drug seems to alter cell cycle or the expression of cyclins. Although this strong correlation between T-channel expression and growth inhibition exists, the following results suggest that the drugs inhibit cell growth via different cytotoxic pathways: 1) pimozide and mibefradil have additive effects on T-channel current inhibition, whereas the antiproliferative activity of the drugs together is synergistic; 2) an increase in the number of apoptotic Y79 and MCF7 cells and a decrease in the mRNA for the antiapoptotic gene Bcl-2 is detected only in pimozide-treated cells, whereas in mibefradil-treated cells, the toxicity is primarily necrotic; and 3) growth inhibition by mibefradil is reduced in Y79 cells transfected with T-channel antisense and in differentiated Y79 cells (which have decreased T-channel expression), but growth inhibition by pimozide is affected to a lesser extent. These results suggest that pimozide and mibefradil inhibit cell proliferation via different cytotoxic pathways and that in the case of pimozide, it is unlikely that this effect is mediated solely by T-channel inhibition.

Adenosine inhibits calcium channel currents via A1 receptors on salamander retinal ganglion cells in a mini-slice preparation

The effects of adenosine on high-voltage-activated calcium channel currents in tiger salamander retinal ganglion cells were investigated in a mini-slice preparation. Adenosine produced a concentration-dependent decrease in the amplitude of calcium channel current with a maximum inhibition of 26%. The effects of adenosine on calcium channel current were both time- and voltage-dependent. In cells dialyzed with GTP-gamma-s, adenosine caused a sustained and irreversible inhibition of calcium channel current, suggesting involvement of a GTP-binding protein. The inhibitory effect of adenosine on calcium channel current was blocked by the A1 antagonist 8-cyclopentyltheophylline (DPCPX, 1-10 microm), but not by the A2 antagonist 3-7-dimethyl-1-propargylxanthine (DMPX, 10 microm), and was mimicked by the A1 agonist N6-cyclohexyladenosine (CHA, 1 microm) but not by the A2 agonist 5'-(N-cyclopropyl) carbox-amidoadenosine (CPCA, 1 microm). Adenosine's inhibition of calcium channel current was not affected by the L-type calcium channel blocker nifedipine (5 microm). However, adenosine's inhibition of calcium channel current was reduced to approximately 10% after application of omega-conotoxin GVIA (1 microm), suggesting that adenosine inhibits N-type calcium channels. These results show that adenosine acts on an A1 adenosine receptor subtype via a G protein-coupled pathway to inhibit the component of calcium channel current carried in N-type calcium channels.

Timolol may inhibit aqueous humor secretion by cAMP-independent action on ciliary epithelial cells

The beta-adrenergic antagonist timolol reduces ciliary epithelial secretion in glaucomatous patients. Whether inhibition is mediated by reducing cAMP is unknown. Elemental composition of rabbit ciliary epithelium was studied by electron probe X-ray microanalysis. Volume of cultured bovine pigmented ciliary epithelial (PE) cells was measured by electronic cell sizing; Ca(2+) activity and pH were monitored with fura 2 and 2',7'-bis(2-carboxyethyl)-5(6)-carboxyfluorescein, respectively. Timolol (10 microM) produced similar K and Cl losses from ciliary epithelia in HCO/CO(2) solution but had no effect in HCO/CO(2)-free solution or in HCO/CO(2) solution containing the carbonic anhydrase inhibitor acetazolamide. Inhibition of Na(+)/H(+) exchange by dimethylamiloride in HCO/CO(2) solution reduced Cl and K comparably to timolol. cAMP did not reverse timolol's effects. Timolol (100 nM, 10 microM) and levobunolol (10 microM) produced cAMP-independent inhibition of the regulatory volume increase (RVI) in PE cells and increased intracellular Ca(2+) and pH. Increasing Ca(2+) with ionomycin also blocked the RVI. The results document a previously unrecognized cAMP-independent transport effect of timolol. Inhibition of Cl(-)/HCO exchange may mediate timolol's inhibition of aqueous humor formation.

Beyond intraocular pressure: neuroprotective strategies for future glaucoma therapy

BACKGROUND

All currently approved glaucoma medications are directed toward lowering intraocular pressure. However, it is apparent that there are pressure-independent mechanisms associated with the development of glaucomatous optic neuropathy. There has been considerable effort to develop therapeutics that rescue the retinal ganglion cells from undergoing secondary degeneration after the original insult has occurred. This therapeutic strategy has been termed neuroprotection.

METHODS

The literature was reviewed to examine the current knowledge of the degenerative cascade involved in glaucomatous damage, with emphasis on potential therapeutic targets for neuroprotective strategies.

RESULTS

There are a number of promising areas of research for new glaucoma therapies including glutamate antagonists, calcium channel blockers, antioxidants, nitric oxide synthase inhibitors, neurotrophins, and anti-apoptotic agents.

CONCLUSIONS

Glaucoma is a complex disease with a number of risk factors and mechanisms leading to ganglion cell death. Future glaucoma therapy will likely include neuroprotectants that could be used as an adjunct therapy with other medications designed to lessen the initial insult (i.e., intraocular pressure-lowering compounds). As the word neuroprotection becomes more popular, care must be taken in evaluating the research literature for clinically effective therapies.