Cone electroretinograms and visual acuities of diabetic patients on sorbinil treatment

Exploring aldose reductase inhibitors as promising therapeutic targets for diabetes-linked disabilities

Diabetes mellitus significantly increases mortality and morbidity rates due to complications like neuropathy and nephropathy. It also leads to retinopathy and cataract formation, which is a leading cause of vision disability. The polyol pathway emerges as a promising therapeutic target among the various pathways associated with diabetic complications. This review focuses on the development of natural and synthetic aldose reductase inhibitors (ARIs), along with recent discoveries in diabetic complication treatment. AR, pivotal in the polyol pathway converting glucose to sorbitol, plays a key role in secondary diabetes complications' pathophysiology. Understanding AR's function and structure lays the groundwork for improving ARIs to mitigate diabetic complications. New developments in ARIs open up exciting possibilities for treating diabetes-related complications. However, it is still challenging to get preclinical successes to clinical effectiveness because of things like differences in how the disease starts, drug specificity, and the complexity of the AR's structure. Addressing these challenges is crucial for developing targeted and efficient ARIs. Continued research into AR's structural features and specific ARIs is essential. Overcoming these challenges could revolutionize diabetic complication treatment, enhance patient outcomes, and reduce the global burden of diabetes-related mortality and morbidity.

Exclusion of aldose reductase as a mediator of ERG deficits in a mouse model of diabetic eye disease

Streptozotocin (STZ)-induced diabetes is associated with reductions in the electrical response of the outer retina and retinal pigment epithelium (RPE) to light. Aldose reductase (AR) is the first enzyme required in the polyol-mediated metabolism of glucose, and AR inhibitors have been shown to improve diabetes-induced electroretinogram (ERG) defects. Here, we used control and AR -/- mice to determine if genetic inactivation of this enzyme likewise inhibits retinal electrophysiological defects observed in a mouse model of type 1 diabetes. STZ was used to induce hyperglycemia and type 1 diabetes. Diabetic and age-matched nondiabetic controls of each genotype were maintained for 22 weeks, after which ERGs were used to measure the light-evoked components of the RPE (dc-ERG) and the neural retina (a-wave, b-wave). In comparison to their nondiabetic controls, wildtype (WT) and AR -/- diabetic mice displayed significant decreases in the c-wave, fast oscillation, and off response components of the dc-ERG but not in the light peak response. Nondiabetic AR -/- mice displayed larger ERG component amplitudes than did nondiabetic WT mice; however, the amplitude of dc-ERG components in diabetic AR -/- animals were similar to WT diabetics. ERG a-wave amplitudes were not reduced in either diabetic group, but b-wave amplitudes were lower in WT and AR -/-diabetic mice. These findings demonstrate that the light-induced responses of the RPE and outer retina are disrupted in diabetic mice, but these defects are not due to photoreceptor dysfunction, nor are they ameliorated by deletion of AR. This latter finding suggests that benefits observed in other studies utilizing pharmacological inhibitors of AR might have been secondary to off-target effects of the drugs.

Electroretinogram in sucrose-fed diabetic rats treated with an aldose reductase inhibitor or an anticoagulant

To investigate the role of increased polyol pathway activity and hemodynamic deficits in the pathogenesis of diabetic retinopathy in non-insulin-dependent diabetes mellitus (NIDDM), Otsuka Long-Evans Tokushima fatty (OLETF) rats, an animal model of human NIDDM, were given water with or without 30% sucrose and some of them were fed laboratory chow containing 0.03% cilostazol, an anticoagulant, or 0.05% [5-(3-thienyl)tetrazol-1-yl] acetic acid monohydrate (TAT), an aldose reductase inhibitor, for 8 wk. Long-Evans Tokushima Otsuka (LETO) rats were used as nondiabetic controls. The peak latencies of oscillatory potentials of the electroretinogram in sucrose-fed OLETF rats were significantly prolonged compared with those in OLETF rats without sucrose feeding and LETO rats. There was a marked increase in platelet aggregability and a significant decrease in erythrocyte 2,3-diphosphoglycerate in sucrose-fed OLETF rats. Cilostazol significantly improved these parameters without changes in retinal levels of sorbitol and fructose. TAT, however, ameliorated all of these parameters. These findings confirm that the sucrose-fed OLETF rat is a useful animal model of retinopathy in human NIDDM and suggest that cilostazol improved diabetic retinopathy by modifying vascular factors, not by altering polyol pathway activity.

An aldose reductase inhibitor, TAT, prevents electroretinographic abnormalities and ADP-induced hyperaggregability in streptozotocin-induced diabetic rats

Rats with streptozotocin-induced diabetes were oral given TAT, a potent aldose reductase inhibitor, at a dose of 10 mg kg-1 day-1 or 40 mg kg-1 day-1 for 30 days. Prolongation of the peak latency of oscillatory potentials in the b-wave of the electroretinogram (ERG), which is associated with retinal Müller cell dysfunction, was significantly improved by treatment with TAT as compared with untreated diabetic rats [sigma(O1 + O2 + O3) was 106.8 +/- 1.8 ms in normal controls (NC), 118.2 +/- 1.1 ms in diabetic controls (DC) (P < 0.001 vs. NC), 110.8 +/- 1.5 ms with 10 mg kg-1 TAT (P < 0.001 vs. DC) and 111.4 +/- 1.6 ms with 40 mg kg-1 TAT (P < 0.01 vs. DC)]. The improvement in ERG abnormalities in diabetic rats was accompanied by partial reduction of elevated sorbitol levels in the retina and erythrocytes, and by correction of platelet hyperaggregability. The authors' findings suggest that a better understanding of the mechanism by which TAT acts may provide new insights into the pathogenesis of hyperglycaemic retinal dysfunction and contribute to establishing effective therapy for diabetic retinopathy.

Diabetic control and progression of retinopathy in elderly patients: five-year follow-up study

OBJECTIVE

To assess whether control of diabetes mellitus is as important in the elderly as in young and middle-aged diabetic patients in terms of progression of retinopathy.

DESIGN

A 5-year longitudinal cohort study.

SETTING

Outpatient diabetic clinic.

PATIENTS

One hundred fourteen non-insulin-dependent diabetic patients (30 males, 84 females) > or = 60 years of age.

MEASUREMENTS

Retinopathy was checked at the beginning and end of the follow-up period. During the 5-year follow-up period, demographic variables, body mass index, HbA1c, blood pressure, and plasma lipids were monitored. Retinopathy was classified as follows: grade 0, no lesion; grade 1, non-proliferative retinopathy; grade 2, pre-proliferative retinopathy; grade 3, proliferative retinopathy. Progression of retinopathy during the 5-year follow-up was defined as an increase in its grade.

RESULTS

At the start of the study, 13% of the patients already had retinopathy, all of grade 1. The 5-year follow-up study showed that progression of retinopathy was 23.6% in all cases, 22.2% in those with grade 0 initially, and 33.3% in those with grade 1 initially. The progression rates of retinopathy as a function of the mean HbA1c during the follow-up were as follows: lower than 7%, 2%; 7-8%, 20%; 8-9%, 40%; more than 9%, 61%. Multiple logistic regression analysis showed that, of the parameters examined, only HbA1c was a significant risk factor for progression of retinopathy.

CONCLUSIONS

Control of diabetes mellitus is the most important factor associated with prevention of progression of retinopathy in elderly patients.

Combined amplitude and phase criteria for evaluation of macular electroretinograms

Focal electroretinograms (ERGs) were obtained from 35 normal eyes and 48 eyes with known macular disease using the MaculoScope stimulator-ophthalmoscope instrument. Response amplitude and phase were combined to permit interpretation of the ERG responses as two-dimensional vectors. This vector interpretation avoids statistical anomalies and distortions inherent in the use of amplitude and phase response parameters. Furthermore, the vector interpretation permits the use of the Hotelling T2 statistic for the assessment of the significance of the differences between ERG responses, providing greater statistical power than simultaneous comparison of amplitude and phase data separately. The distribution of normal responses yielded limiting normal values of 135 nV for the amplitude and -95 degrees for the phase lag of the focal ERG as recorded by the MaculoScope instrument. Significant abnormalities of the focal ERG are illustrated for cases of cilioretinal artery occlusion, Stargardt's disease, idiopathic macular hole, diabetic macular edema, and idiopathic macular dysfunction with normal fundus. This study demonstrates the potential value of the focal ERG in the demonstration of macular disease undetectable by conventional electroretinography.

Recent clinical experience with aldose reductase inhibitors

Since 1981 a number of aldose reductase inhibitors (ARIs) have been extensively investigated in clinical trials for the treatment or prevention of diabetic complications. In general, the results from these trials have varied from no effect to improvement. In part, the inconclusive results are due to differences in the study designs. Investigation of some ARIs has been discontinued because of lack of efficacy (ponalrestat) or major toxicity (sorbinil). Of the ARIs that have been evaluated, only tolrestat is currently undergoing clinical investigation. Although the most recent studies have shown promising results, the role of ARIs in the treatment or prevention of secondary complications of diabetic neuropathy will be determined in ongoing or future clinical trials.

Aldose reductase inhibitors and diabetic complications

Aldose reductase inhibitors impede flux of glucose through the sorbitol pathway in diabetes mellitus. They therefore reduce the accumulation of the pathway metabolites, sorbitol and fructose, reduce the impact of the flux on the cofactors used by the pathway and reduce other derived phenomena, such as osmotic stress and myo-inositol depletion. As drugs, their targets are the chronic complications of diabetes--neuropathy, retinopathy, nephropathy and vasculopathy. In experimental models there is proof of activity against biochemical, functional and structural defects in all of the involved tissues, but we await full clinical verification of this potential.

The clinical utility of the foveal electroretinogram: a review

The historical development of the foveal electroretinogram is reviewed. The factors required to obtain a local cone electroretinogram with a small focal source of illumination against a lighted background are discussed. From these considerations and various studies of macular degeneration, the optimal size of the foveal source is found to be 5 degrees diameter or less. Applications of the foveal electroretinogram in various diseases are summarized. The foveal electroretinogram is abnormal with reduced acuity in age-related macular degeneration, juvenile macular degeneration (Stargardt's disease), retinitis pigmentosa, and diabetic retinopathy. Normal foveal electroretinograms are found in optic atrophy, amblyopia, and optic neuritis. Foveal electroretinograms are normal or abnormal in Best's disease, central serous retinopathy, and several other diseases discussed.